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For patients presenting to emergency departments (ED) with a suspected acute coronary syndrome, time of arrival until an electrocardiogram is performed is an important quality metric. In our ED routine quality monitoring found that mean door-to-electrocardiogram (D2ECG) time did not meet our goal and national benchmark of 10 minutes. We describe the use of quality improvement tools to assess and decrease our D2ECG time. The ED quality improvement committee identified 2 main causes of D2ECG >10 minutes: (1) priority delay (eg, completing triage and registration data entry tasks before ECG), and (2) failure to recognize patients with nonchest pain ST Elevation Myocardial Infarction (STEMI) symptoms. Interventions included are-designed patient prioritization process for triage, staff assignment to provide immediate ECG testing, continuous feedback and a triage staff educational initiative to identify high risk patients. Mean time to ECG before intervention was 21.28 ± 5.49 minutes. After the intervention period, the mean D2ECG for STEMI decreased to 9.47 ± 2.48 minutes representing a 55% improvement. A D2ECG time of less than 10 minutes time can be achieved by the implementation of patient prioritization triage process changes, assigning specific personnel to obtain the ECG, continuous feedback by reviewing cases that fall outside the 10-minute goal and by ED staff education regarding STEMI symptoms other than chest pain.