Door-to-Electrocardiogram Time Disparities in Acute Coronary Syndrome: Predictors and Clinical Outcomes in a Contemporary Community Hospital Cohort.

BACKGROUND: Door-to-electrocardiogram (D2E) time is a critical quality metric in evaluating patients with suspected acute coronary syndromes (ACS), yet adherence to the ≤10-minute benchmark remains suboptimal. This study aimed to quantify D2E performance, identify predictors of delayed EKG acquisition, and evaluate associations between D2E delays, in-hospital mortality, and length of stay (LOS). OBJECTIVE: To quantify D2E performance, identify patient- and system-level predictors of delayed EKG acquisition, and evaluate associations between D2E delays, in-hospital mortality, and length of stay (LOS).​. METHODS: This retrospective cohort study included adults presenting to a single community hospital emergency department in 2024 with symptoms suggestive of ACS. The primary outcome was receipt of a 12-lead EKG within 10 minutes of arrival. Secondary outcomes included D2E distribution, in-hospital mortality, and hospital LOS. Multivariable logistic regression examined predictors of D2E >10 minutes. RESULTS: Among 3,435 patients (median age 62 years; 52.3% female), 49.7% achieved D2E ≤10 minutes (median 10.0 minutes). In ACS subgroup analysis, female sex, atypical presentation, lower triage acuity, and afternoon shift were independently associated with D2E >10 minutes. Delayed EKG acquisition correlated with longer LOS, including a higher proportion of stays >4 days and a higher median LOS (3.0 vs. 2.0 days, p<0.01). Overall, in-hospital mortality was 6.5%. CONCLUSION: Fewer than 5 in 10 patients met the 10-minute D2E target. Delays were more frequent among women, patients with atypical presentations, lower triage acuity, and those arriving during afternoon shifts. Delayed EKG acquisition was associated with prolonged hospitalization, underscoring D2E time as a modifiable process measure. ​.