AUTHORS: DR. KENNETH ORIMMA ACCIDENT & EMERGENCY DEPARTMENT QUEEN ELIZABETH HOSPITAL - BARBADOS PRINCESS MARGARET HOSPITAL...
<ul><li>Background </li></ul><ul><li>Study Details </li></ul><ul><ul><ul><ul><ul><li>Aim </li></ul></ul></ul></ul></ul><ul...
<ul><li>The emergency physicians (EP) are the gate-keepers to decide which ED patients presenting with the complaint of ch...
MISSED ARRHYTHMIAS - AN ECG AUDIT
<ul><li>Prospective double-blinded convenience ECG /Chart Audit  </li></ul><ul><li>Designed to test accuracy of Emergency ...
<ul><ul><ul><li>The study was conducted at ED QEH, a 600 bed tertiary facility in Barbados </li></ul></ul></ul><ul><ul><ul...
<ul><li>Daily collection of ECGs & review of patient’s A&E charts </li></ul><ul><li>Total 152 ECG / ED charts were include...
<ul><li>The reports were divided into 2 groups: </li></ul><ul><ul><li>1)  Concordant Reports </li></ul></ul><ul><ul><ul><u...
<ul><li>The discordant group was subdivided into 3 groups based on defining parameters of: </li></ul><ul><ul><li>I  Infarc...
<ul><li>Clinically significant discordance included: </li></ul><ul><ul><li>Infarct </li></ul></ul><ul><ul><li>Ischemia </l...
<ul><li>Indeterminate discordance included: </li></ul><ul><li>Interventricular conduction delay </li></ul><ul><li>Right bu...
<ul><li>Insignificant Discordance included: </li></ul><ul><li>Sinus tachycardia </li></ul><ul><li>Sinus bradycardia </li><...
MISSED ARRHYTHMIAS - AN ECG AUDIT <ul><li>The primary outcome variable was the  concordance  between the emergency physici...
<ul><li>Descriptive data entered into excel </li></ul><ul><li>Concordance (inter-observer agreement ) was estimated by kap...
MISSED ARRHYTHMIAS - AN ECG AUDIT N=152
MISSED ARRHYTHMIAS - AN ECG AUDIT N=152
MISSED ARRHYTHMIAS - AN ECG AUDIT N=152 Inter-observer Agreement  (K) = 54%  (p<0.001)
MISSED ARRHYTHMIAS - AN ECG AUDIT N=78
MISSED ARRHYTHMIAS - AN ECG AUDIT N=78
<ul><li>The ECG is an important diagnostic tool  </li></ul><ul><li>There are few studies in the literature  that assessed ...
<ul><li>Morrison  WG,  Swann IJ study </li></ul><ul><ul><li>error rate of 19.8% </li></ul></ul><ul><ul><li>4.4%  graded as...
<ul><li>The EP report may be the only available interpretation at the time of disposition of the patient therefore accurat...
<ul><li>Our study showed poor concordance  of  ECG report by  ED physician compared with the cardiologist’s report </li></...
<ul><li>Study sample size is small  </li></ul><ul><ul><li>A significant number of ECGs were either of poor quality or lead...
<ul><ul><li>ECG  workshops in the ED </li></ul></ul><ul><ul><li>ECG quality assurance program  </li></ul></ul><ul><ul><li>...
<ul><li>PMH, Department of  A&E medical staff </li></ul><ul><li>QEH, Department of A&E medical staff </li></ul><ul><li>Con...
<ul><li>Wolfsan  AB, Paris PM. Diagnostic testing in emergency medicine ed 2. WB Saunders Company 1996. P51-60. </li></ul>...
<ul><li>Scarbossa EB, Pinks SL, Barbagelala A, Underwood OA, Gates KB,  </li></ul><ul><li>Topol GE, Califf RM, Wagner GS: ...
<ul><li>11.  Marriott HL: Practical electrocardiography, ed 8. Baltimore, Williams &Wilkins, 1988. </li></ul><ul><li>Edgar...
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missed myocardial infarction among patients discharged with chest pain in the Emergency room: A need for ECG audit

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A prospective ECG/CHART audit designed to test accuracy of ECG interpretation by emergency room Doctors

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missed myocardial infarction among patients discharged with chest pain in the Emergency room: A need for ECG audit

  1. 1. AUTHORS: DR. KENNETH ORIMMA ACCIDENT & EMERGENCY DEPARTMENT QUEEN ELIZABETH HOSPITAL - BARBADOS PRINCESS MARGARET HOSPITAL - BAHAMAS DR. RAYMOND MASSAY CONSULTANT CARDIOLOGIST QUEEN ELIZABETH HOSPITAL - BARBADOS
  2. 2. <ul><li>Background </li></ul><ul><li>Study Details </li></ul><ul><ul><ul><ul><ul><li>Aim </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Materials & Methods </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Statistical Analysis & Results </li></ul></ul></ul></ul></ul><ul><li>Conclusion / Discussion </li></ul><ul><li>Study Limitations & Future Studies Recommendation </li></ul><ul><li>Summary </li></ul><ul><li>Acknowledgements & References </li></ul>MISSED ARRHYTHMIAS - AN ECG AUDIT
  3. 3. <ul><li>The emergency physicians (EP) are the gate-keepers to decide which ED patients presenting with the complaint of chest pain warrants admission or discharge </li></ul><ul><li>The ED diagnostic tools (ECG & Cardiac Markers) </li></ul><ul><li>Correct interpretation is crucial </li></ul><ul><li>Determines appropriate management & disposition </li></ul><ul><li>Avoid adverse consequences </li></ul>MISSED ARRHYTHMIAS - AN ECG AUDIT
  4. 4. MISSED ARRHYTHMIAS - AN ECG AUDIT
  5. 5. <ul><li>Prospective double-blinded convenience ECG /Chart Audit </li></ul><ul><li>Designed to test accuracy of Emergency Physician (EP) ECG interpretation by comparison with that of the Cardiologist </li></ul><ul><li>The study was done over three months period </li></ul><ul><li>No ethical approval was required as this was a comparative chart audit & was approved by the ED department </li></ul>MISSED ARRHYTHMIAS - AN ECG AUDIT
  6. 6. <ul><ul><ul><li>The study was conducted at ED QEH, a 600 bed tertiary facility in Barbados </li></ul></ul></ul><ul><ul><ul><li>Inclusion criteria </li></ul></ul></ul><ul><ul><ul><ul><li>All patients >30 years presenting with CP & triaged for ECG </li></ul></ul></ul></ul><ul><ul><ul><li>Exclusion criteria </li></ul></ul></ul><ul><ul><ul><ul><li>All patients with chest pain complaints who were admitted </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Non-cardiac related chest pain </li></ul></ul></ul></ul><ul><ul><ul><ul><li>ECGs of poor quality or leads misplaced during tracing </li></ul></ul></ul></ul><ul><li>MISSED ARRHYTHMIAS - AN ECG AUDIT </li></ul>
  7. 7. <ul><li>Daily collection of ECGs & review of patient’s A&E charts </li></ul><ul><li>Total 152 ECG / ED charts were included in the study </li></ul><ul><li>ECGs were independently reported by both </li></ul><ul><li>The EPs were not aware of on-going audit </li></ul><ul><li>The cardiologist was not aware of the EP’s report or patient’s history when making his report </li></ul><ul><li>Standardized data collection instrument was used to record patient’s age, sex & ECG reports </li></ul>MISSED ARRHYTHMIAS - AN ECG AUDIT
  8. 8. <ul><li>The reports were divided into 2 groups: </li></ul><ul><ul><li>1) Concordant Reports </li></ul></ul><ul><ul><ul><ul><li>Defined as an abnormality or normality reported by both </li></ul></ul></ul></ul><ul><ul><li>2) Discordant Reports </li></ul></ul><ul><ul><ul><ul><li>Defined as an abnormality or normality missed by EP in comparison with the Cardiologist’s report </li></ul></ul></ul></ul>MISSED ARRHYTHMIAS - AN ECG AUDIT
  9. 9. <ul><li>The discordant group was subdivided into 3 groups based on defining parameters of: </li></ul><ul><ul><li>I Infarct </li></ul></ul><ul><ul><li>a) Clinically significant </li></ul></ul><ul><ul><li>II Ischemia b) Indeterminate </li></ul></ul><ul><ul><li>c) Insignificant </li></ul></ul><ul><ul><li>III Arrhythmia </li></ul></ul>MISSED ARRHYTHMIAS - AN ECG AUDIT
  10. 10. <ul><li>Clinically significant discordance included: </li></ul><ul><ul><li>Infarct </li></ul></ul><ul><ul><li>Ischemia </li></ul></ul><ul><ul><li>Atrial fibrillation </li></ul></ul><ul><ul><li>Junctional rhythm </li></ul></ul><ul><ul><li>Pacemaker rhythm </li></ul></ul><ul><ul><li>No report </li></ul></ul>MISSED ARRHYTHMIAS - AN ECG AUDIT
  11. 11. <ul><li>Indeterminate discordance included: </li></ul><ul><li>Interventricular conduction delay </li></ul><ul><li>Right bundle branch block </li></ul><ul><li>Left bundle branch block </li></ul><ul><li>Left ventricular hypertrophy </li></ul><ul><li>Right ventricular hypertrophy </li></ul><ul><li>Prolonged Q-T interval </li></ul><ul><li>Early repolarization </li></ul>MISSED ARRHYTHMIAS - AN ECG AUDIT
  12. 12. <ul><li>Insignificant Discordance included: </li></ul><ul><li>Sinus tachycardia </li></ul><ul><li>Sinus bradycardia </li></ul><ul><li>First degree AV block </li></ul><ul><li>LAD alone </li></ul><ul><li>RAD alone </li></ul><ul><li>Atrial enlargement </li></ul><ul><li>Nonspecific ST-T wave changes </li></ul>MISSED ARRHYTHMIAS - AN ECG AUDIT
  13. 13. MISSED ARRHYTHMIAS - AN ECG AUDIT <ul><li>The primary outcome variable was the concordance between the emergency physician & the cardiologist ECG report </li></ul>
  14. 14. <ul><li>Descriptive data entered into excel </li></ul><ul><li>Concordance (inter-observer agreement ) was estimated by kappa statistics testing </li></ul>MISSED ARRHYTHMIAS - AN ECG AUDIT
  15. 15. MISSED ARRHYTHMIAS - AN ECG AUDIT N=152
  16. 16. MISSED ARRHYTHMIAS - AN ECG AUDIT N=152
  17. 17. MISSED ARRHYTHMIAS - AN ECG AUDIT N=152 Inter-observer Agreement (K) = 54% (p<0.001)
  18. 18. MISSED ARRHYTHMIAS - AN ECG AUDIT N=78
  19. 19. MISSED ARRHYTHMIAS - AN ECG AUDIT N=78
  20. 20. <ul><li>The ECG is an important diagnostic tool </li></ul><ul><li>There are few studies in the literature that assessed the accuracy of ECG interpretation by EP and how their knowledge affect patient treatment and disposition </li></ul>MISSED ARRHYTHMIAS - AN ECG AUDIT
  21. 21. <ul><li>Morrison WG, Swann IJ study </li></ul><ul><ul><li>error rate of 19.8% </li></ul></ul><ul><ul><li>4.4% graded as Clinically Significant </li></ul></ul><ul><li>Snoey ER, et al </li></ul><ul><ul><li>discordance of 31% </li></ul></ul><ul><ul><li>9% graded Clinically Significant </li></ul></ul><ul><li>Our study shows a high discordance with clinical significant prevalence of 21% </li></ul>MISSED ARRHYTHMIAS - AN ECG AUDIT
  22. 22. <ul><li>The EP report may be the only available interpretation at the time of disposition of the patient therefore accurate interpretation is crucial to ensure appropriate management & disposition </li></ul>MISSED ARRHYTHMIAS - AN ECG AUDIT
  23. 23. <ul><li>Our study showed poor concordance of ECG report by ED physician compared with the cardiologist’s report </li></ul><ul><li>Discordance was significant but no missed MI </li></ul>MISSED ARRHYTHMIAS - AN ECG AUDIT
  24. 24. <ul><li>Study sample size is small </li></ul><ul><ul><li>A significant number of ECGs were either of poor quality or leads misplaced during tracing </li></ul></ul><ul><li>Different levels of knowledge & experience of the EP </li></ul><ul><ul><li>Significant impact on accuracy of ECG interpretation </li></ul></ul><ul><li>Only one cardiologist was used as goal standard </li></ul><ul><li>Which may introduce bias </li></ul>MISSED ARRHYTHMIAS - AN ECG AUDIT
  25. 25. <ul><ul><li>ECG workshops in the ED </li></ul></ul><ul><ul><li>ECG quality assurance program </li></ul></ul><ul><ul><li>Continuing / Periodic Audits </li></ul></ul><ul><ul><li>Trained technicians to do ECGs </li></ul></ul>MISSED ARRHYTHMIAS - AN ECG AUDIT
  26. 26. <ul><li>PMH, Department of A&E medical staff </li></ul><ul><li>QEH, Department of A&E medical staff </li></ul><ul><li>Contributors: </li></ul><ul><li>Dr. Michelle Sweeting </li></ul><ul><li>Dr. Reginald King A&E dept Barbados </li></ul><ul><li>Dr. Harold Watson Emergency Medicine program director, Barbados </li></ul>MISSED ARRHYTHMIAS - AN ECG AUDIT
  27. 27. <ul><li>Wolfsan AB, Paris PM. Diagnostic testing in emergency medicine ed 2. WB Saunders Company 1996. P51-60. </li></ul><ul><li>Hedges JR, Kobernick MS: Detection of myocardial ischemia/infarction in emergency department with chest discomfort. Emerg Med Clin North Am 1988; 6(2) 317-340. </li></ul><ul><li>Storrow AB, Gibler BW: Chest pain centers, diagnosis of acute coronary syndromes. Ann Emerg Med 2000; 35: 449-461. </li></ul><ul><li>Christopher PC, Patrick TO: Critical pathways in cardiology, ed 2. Lippincott Williams & Wilkins 2001 P12-14. </li></ul><ul><li>Theodore CC, William JB, Richard AH, Peter R: ECG in emergency medicine & acute care, ed 2. Elsevier Mosby 2005, P1-5. </li></ul>MISSED ARRHYTHMIAS - AN ECG AUDIT
  28. 28. <ul><li>Scarbossa EB, Pinks SL, Barbagelala A, Underwood OA, Gates KB, </li></ul><ul><li>Topol GE, Califf RM, Wagner GS: Electrocardiographic diagnosis of evolving acute MI in the presence of left bundle branch block, N Eng J Med 1996: 334;481-7. </li></ul><ul><li>Hollander JC: Risk stratification of emergency department patients with chest pain. The need for standard report guidelines. Ann Emerg Med 2004; 43:68-70. </li></ul><ul><li>Heart and Stroke Foundation of Canada: Heart diseases and stroke in Canada. Ottawa. The Foundation 1997. P14-18. </li></ul><ul><li>Jim C. Acute Coronary Syndrome: We must improve diagnostic efficiency in the emergency department. Canad J Emerg.Med Care 1999; 1:22-4. </li></ul><ul><li>Westdorp JE, Gratton MC, Watson WA: Emergency department interpretation of electrocardiograms. Ann Emerg Med 1992; 21:541-44 </li></ul>MISSED ARRHYTHMIAS - AN ECG AUDIT
  29. 29. <ul><li>11. Marriott HL: Practical electrocardiography, ed 8. Baltimore, Williams &Wilkins, 1988. </li></ul><ul><li>Edgar RB, Donald RB, Thomas GT, Robert JP: Diagnostic Strategies for common medical problems, ed 2. American College of Physicians 1998, Philadelphia Pennsylvania. </li></ul><ul><li>Marrison WG, Swann IJ: Electrocardiograph interpretation by junior Doctors in the emergency department. Arch Emerg Med 1990; 7(2): 108-10. </li></ul><ul><li>Todd KH, Hoffman JR, Morgan MT: Effects of cardiologist ECG reviews on emergency department practice. Ann Emerg Med 1996; 27(1): 16-21. </li></ul><ul><li>Snoey ER, Housset B, Guyon P, Elhaddad S, Valty J, Hericord P; Analysis of emergency department interpretation of electrocardiograms. J Accid Emerg Med 1994; 11(3):149-53. </li></ul>MISSED ARRHYTHMIAS - AN ECG AUDIT

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