(function( timeout ) { One advantage that physicians have over ECG interpretation is that we are able to get a history and do a physical exam. Time limit is exhausted. ECG #1 = the initial Triage ECG (TOP) — I repeat below (and illustrate in Figure-1) points made by Dr. Smith above, as well as some additional points: QRST amplitude in the inferior leads is often quite modest. This study did not meet the 379 “normal” ECGs necessary to obtain a NPV of 100% with a lower limit 95% CI of >99%, The incidence of STEMI in this study was low (0.57%), Original interpreting physicians were not blinded to computer interpretation of ECGs, The ECG software used may not be the same ECG software used at other institutions. The Medial Approach to Emergency Medicine. Please reload CAPTCHA. An exercise in ECG interpretation and triage. As part of the Myocardial Infarction Triage and Intervention Project, the investigators found that when compared with a single ECG, serial exams increased the diagnostic sensitivity for acute coronary syndrome from ~34% to 46% with a reduction in specificity from 96% to 93% and positive predictive value from 88% to 84%. }. Alas, nothing is perfect — but I bet adherence to the above principles should greatly expand the “net” of those chest pain patients we seek to capture. Your email address will not be published. Is there a way to maybe minimize the number of interruptions? With a couple thousand waiting-room ECGs under my belt, I’ve noticed a few things: I can’t say I blame them. Please reload CAPTCHA. EM. THANKS so much to Dr. Smith for posting this case! Please provide your Serial Number (located on the underside of your device) in the field provided at Checkout to help facilitate adding this purchase to your device account. We have, when absolutely necessary, done EKG's on pt's while they were in the tripod position, and on two occassions, done the EKG with lead placement on the pt's back. Background: Lets face it. Safety of Computer Interpretation of Normal Triage Electrocardiograms. Many of them are performed on low-risk patients. I will add several points to Vince’s provocative discussion: i) The computerized report should never be looked at until AFTER the screening physician has completed his/her assessment of the ECG to be triaged (Please see below for my Comment that I submitted to Dr. Smith’s blog post that Vince gives the link to above); ii) There are TWO PARTS to ED Triage of patients who present for a potential acute cardiac problem — the 2nd of which is the HISTORY. Discussion: This retrospective study of 538 triage ECG's performed over an 8day period identified no STEMIs and 16 NSTEMIs. Clinical Take Home Point: Although this is a small, single center study, who’s results need to be replicated, this seems like a very feasible intervention to try and reduce one of the most common interruptions encountered by EM physicians at the work place. Except for “true expert interpreters” (ie, clinicians who have read many, many thousands of acute and non-acute tracings over time — NO provider (in my opinion) should ever look at the computerized report BEFORE they have completed their own unbiased ECG interpretation. timeout HERE is MY COMMENT that I added to Dr. Smith’s BLOG: Having been a student of (and author on) computerized ECG interpretations for the past 30 years — I long ago learned that the first priority for providers to master is appreciation of what the computer is good at, and what it is not good at. The primary outcome measured was triage to ECG time for walk-in patients presenting with SICP, and secondarily triage to first-device time for walk-in patients diagnosed with STEMI. In that cohort, the negative LR suggested by this study won’t “rule-out” concerns as well as it would in a general ED population getting ECGs as part of their routine workup. This constant flow of pink paper with black scribble causes frequent task switching, interrupts train of thought, and ultimately can lead to medical errors, which affects the patients in front of us. The goal is to achieve a door‐to‐ECG time of 10 minutes.1The first 10 minutes of an ED visit, however, are administrative. © 2020 REBEL EM. Current institutional ECG billing rates for ECGs performed and interpreted is $125 per ECG, providing an estimated triage ECG charge to detect one STEMI at $54,295. EKG at triage slashes door-to-aspirin time. This is NOT to say that each of the other 7 patients were having an acute event (I have no idea which were and which were not …. ) If such assessment of any of these 7 abnormal ECGs takes more than 10 seconds to know that the patient needs to immediately be seen — then that clinician needs to go back and review the hundreds of wonderful blog posts on Dr. Stephen Smith’s ECG Blog (all of which come with superb clinical correlation to relevant history of these actual cases). st changes = take the pt back immediately for mona, even if it involves sitting them in the hall. if ( notice ) […]. Is epinephrine harmful in cardiogenic shock? The ED staff at Contra Costa Regional Medical Center (CCRMC) in Martinez, CA, has slashed its time to aspirin for chest pain patients from 67 minutes to about eight minutes by completely revamping its triage … Greater San Antonio Emergency Physicians (GSEP). At presentation, the patients’ vital signs, serum levels of creatinine, glucose and lipid profiles were similar in both groups. Acad Emerg Med 2017; 24(1): 120 – 24. Hughes KE, Lewis SM, Katz L, Jones J. | Disclaimer | Website by Innov8 Place. Get App Play Online. Work your way through with the accompanying study guides. The most awesome STEMI test on the internet! The Tele-ECG triage group had a higher percentage of patients reaching the goal of D2BT in less than 90 minutes than the control group (78% vs. 55%; p < 0.001). So it’s understandable why many emergency physicians are rejoicing at the publication of a new study by Hughes, Lewis, Katz, and Jones: “Safety of Computer Interpretation of Normal Triage Electrocardiograms” [1]. T… Game. We hypothesize that triage ECGs interpreted by the computer as “normal ECG” are unlikely to have clinical significance that would affect triage care. Life-threatening hyperkalemia: do you recognize the ECG signs? On the other hand, it is important to avoid delays in care and, in accordance with the American Heart Association guidelines, ECGs in triage should be obtained and interpreted by an attending emergency physician within 10 minutes of arrival to the emergency department for any patients with concerns of acute coronary syndrome. While the standard is usually to lay the pt down, sometimes that just isn't possible. EM also make it clear that they wouldn’t want to eliminate physician over-reads of “normal” triage ECGs, just delay them to reduce interruption. So while still possible that the 4th ECG (which I though was less likely to be acute) might be from a patient evolving an acute event — assuming the HISTORY triage of this patient was unalarming — then the chances are good (if not excellent) that slight delay in reperfusion will probably not alter prognosis of this patient. ECG Interpretation 1 15 March,2015 Antoine Ayer First part of our complete ECG/EKG Interpretation Quiz for physicians, nurses, paramedics, medical and nursing students, among others. In this new approach, patients with suspected STEMI are identified at triage after a brief anamnesis by the PIT, and these patients prioritised for an urgent ECG. http://traffic.libsyn.com/rebelcast/March_2017_REBEL_Cast_-_Triage_ECGs_-_Reducing_Interruptions_in_a_Busy_ED.m4a. This study is not saying that physicians should not review all ECGs, but instead a delayed strategy in “normal” ECGs may be feasible. Triage ECGs: Reducing Interruptions in a Busy ED, Click here for Direct Download of Podcast, Author Conclusion: “Our data suggest that triage ECGs identified by the computer as normal are unlikely to have clinical significance that would change triage care. That the triage ECG must be shown to the physician is demonstrated again by the following ECG, recorded just this week. The ECG is the most widely used screening test for evaluating patients with chest pain. Even as the COVID-19 pandemic pushes medical professionals and facilities across the globe to their limits, patients with cardiac emergencies, regardless of whether or not they have COVID-19, still require timely and effective care. We do EKG's in triage on a regular basis. A new triage process, included a multi-pronged, interdisciplinary approach to obtaining an ECG prior to patients being registered, including educating staff, creating a 7-step process guide, and designating an ECG space. Ten Pre-paid ECG Triage Reports **Please note, prepaid ECG Reports may take up to one business day to show up in the account associated with your HeartCheck device. Triage ECGs interrupt their workflow and, worse than just slowing them down, that distraction can lead to errors. Still, in pre-hospital settings, it remains challenging to adequately identify those patients who require immediate reperfusion therapy when automated ECG analysis provides inconclusive results. This video course walks you through from the basics of ECG interpretation to complex topics like subtle signs of ischemia and pesky rhythm problems. The ECG pattern may vary over time: Patients with symptomatic Brugada syndrome may have a non-diagnostic ECG at the time of assessment (e.g. Finally — it is important to determine the prime purpose of ED ECG Triage — which is namely to rapidly identify those patients likely to be having an acute event, whose outcome can be improved (if not lifesaving) by prompt recognition of the process. Excellent thoughtful post by Vince DiGiulio. display: none !important; I believe a bigger burden comes from ECGs that are read as “abnormal” in some way by the computer but were not indicated in the first place and do not change the patient’s management in the waiting room. This superb case by Dr. Smith illustrates this concept to perfection — as not only are T waves in V2-thru-V4 disproportionately tall and peaked — but there is ST segment straightening that is clearly abnormal in lead V5 and V6 (as well as having inappropriately peaked T waves in those leads) — plus subtle-but-real ST-T wave abnormalities in each of the inferior leads — that in a patient brought by ambulance for chest pain says, “I am an acute or very recent STEMI until you prove otherwise!” Anyone who has studied computerized ECG interpretations will not be surprised by the fact that these clearly abnormal ECG findings were totally missed by the computer report. All of us have been interrupted by the onslaught of triage ECGs for interpretation. Giving all chest pain patients an electrocardiogram (EKG) in triage can significantly improve treatment times and quality of care and it eliminates the need to prioritize patients and takes undue pressure off the nurses, ED managers say. I was at triage when this ECG of a 50-something was handed to me. Though the rate of “normal” ECGs in this study was 26%, in my experience it’s somewhat uncommon to see a tracing with the words “Normal ECG” printed at the top in the ED (I’m just making this up, but I’d guess something < 10% at triage). Regardless of whether the ECG is “normal” or “non-acute”, or not — IF the History is of concern, then THAT patient should be seen promptly! The 12 Rhythms of Christmas: High-Grade AV-Block. It’s not the “normal” ECGs that are weighing on my physicians. Save my name, email, and website in this browser for the next time I comment. Dr. Salim Rezaie and Dr. Anand Swaminathan from R.E.B.E.L. The Medical Approach to Emergency Medicine, Safety of Computer Interpretation of Normal Triage Electrocardiograms, Triage ECGs: Reducing Interruptions in a Busy ED. I’d like to confirm my interpretation against yours to make sure I’m seeing it all. http://ecg-interpretation.blogspot.com/2016/05/ecg-blog-126-computerized-ecg.html, Triage ECGs: Reducing Interruptions in a Busy ED - R.E.B.E.L. function() { While seeing the computer spit out “Normal ECG” certainly stratifies a patient as lower risk, it’s not the same as “no risk.” That’s a problem, because triage ECGs are (or should be) performed in a moderate-to-high risk population with complaints suggestive of an acute cardiac process. Very few of those ECGs lead to a change in initial management. })(120000); Tweet EPs were asked to evaluate the ECG for clinical significance, Clinical Significance: Any change from “normal ECG” computer read that would alter triage care, All patients ≥18 years of age with a triage ECG, 222 (26%) interpreted as “normal ECG” by computer, 13/222 (5.9%) had different interpretation by attending cardiologist, 1/13 (7.7%) found to have clinical significance (EP determined patient should be placed in bed immediately), Patient was ultimately discharged home for a next day stress test which was interpreted as normal, Asks a real-life physician oriented question about interruptions in the ED, Board certified cardiologists and EM physicians interpreting ECGs were blinded to patient presentations, patient care, and goals of the study, ECGs not only read as abnormal, but clinical relevance of abnormality assessed, This was a small sample size. To achieve timely diagnosis of patients with potential STEMI, EDs use early ECG screening criteria for all ED patients on arrival and prior to the physician evaluation. Who should receive a prehospital 12-lead ECG? — but ONLY to say that it was immediately apparent to me (within less than 5-to-10 seconds) that a potential acute event MIGHT be evolving in the other 7 patients, all of whom therefore needed immediately evaluation. REBEL EM is licensed under a Creative Commons Attribution-NonCommercial-NoDerivs 3.0 Unported License. He speaks no English and I really had no idea what his symptoms were, but someone had pointed to his chest, which is why they recorded an ECG.What do you think?I was pretty alarmed by the ST segments in V4 and V5, and the ST segment of the PVC in V3. A diagnostic ECG may be produced in these patients by administration of a sodium-channel blocking agent, typically a class I antiarrhythmic such as flecainide or procainamide. Methods All triage ECGs performed at the University of North Carolina were collected between November 14, 2014, and March 3, 2015, according to a standard nursing triage protocol using GE machines running Marquette 12SL software. It’s not data, and certainly not scientific, but it’s interesting (to the folks who like ECGs, at least). }, Discriminative performance is presented with overall and category‐specific concordance statistics, polytomous discrimination indexes, sensitivities, … "Triage ECGs: Reducing Interruptions in a Busy ED", REBEL EM blog. Time limit is exhausted. As a result, OMIs may not declare themselves by as much ST elevation as is written into some “guidelines”. As Dr. Steve Smith summarizes in his post on the topic, “Computer algorithms that make the diagnosis of ‘normal’ are usually correct, but is usually good enough?”. ); Below are some great opinions on the article from the target demographic: emergency physicians. Join the EMS Safety Culture group on Facebook! Objectives. The most common symptoms prompting an ECG were: chest pain (46.3%), dyspnea (39.4%), nausea and vomiting (34.0%), epigastric pain (18.6%), lightheadedness or dizziness (13.2%); and weakness (12.6%). V4 and V5 haveQR-waves, in addition to the STE, which suggests:1. The diagnosis of ST‐segment elevation myocardial infarction (STEMI) in the emergency department (ED) is made solely by ECG. Computerized ECG interpretations have never been shown to have high enough sensitivity for assessing subtle infarctions to be used as a “stand-alone” tool (http://ecg-interpretation.blogspot.com/2016/05/ecg-blog-126-computerized-ecg.html ). Why do we capture a 12-lead ECG with the first set of vital signs? We don’t have an answer, and I don’t expect to make any headway on that issue with this blog post, but I thought it would be interesting to share a few subtle STEMIs from my collection that were read as normal by the computer. https://rebelem.com/triage-ecgs-reducing-interruptions-busy-ed/, New and Interesting: Timolol Eyedrops to Treat Migraine Headaches, COVID-19 Update: The PlasmAr Trial – Convalescent Plasma vs Placebo, Episode 68 – Ischemic Electrocardiograms | FOAMcast, Creative Commons Attribution-NonCommercial-NoDerivs 3.0 Unported License, Single center, prospective cohort study of all ECGs performed at triage in the ED, Comparison of computer interpretation of “normal ECG” vs attending cardiologist’s final interpretation, Each ECG interpreted as “normal” by the ECG machine were compared to cardiologist’s final interpretation, If cardiologist interpretation differed from “normal,” the ECG was then interpreted by two board certified EM physicians that were blinded to patient presentation, patient care, and the goals of the study. Whether they read a triage ECG now or in fifteen minutes, they’re going to be doing something when I try to slide that paper in front of their screen. How unreliable are computer algorithms in the diagnosis of STEMI? In response, there has been a creep towards performing ECGs more frequently in triage. Chest pain process not without snags. The aim of this study was to evaluate the existing triage ECG protocol as a means of treatment decision making. Join the Resuscitation group on Facebook! By recording triage ECGs, we make the early diagnosis of OMI in not just 1 patient, but 35 patients, per year. Plus, if the signing physician does happen to find something wrong, there’s always a nagging concern that the patient will end up being added to their already full group and need to be seen immediately—further interrupting flow. Methods. Stephen W. Smith at Dr. Smith’s ECG Blog. Timely diagnosis is critical to achieving timely intervention. ekg in triage.  =  Join the Advanced Cardiac Life Support group on Facebook! Improving the wait time to triage at the emergency department Yuzeng Shen , 1 Lin Hui Lee2 To cite: Shen Y, Lee LH. The problem regarding the “Triaging of Triage ECGs” is clearly an important one. — and, the triage clinician who talks to the patient at check-in (be that nurse or other medical personnel) should be sufficiently trained in determining which patients based on history alone should be prioritized — AND — iii) 7 of the 8 ECG examples posted by Vince below should be obviously OF CONCERN (in my opinion) prompting immediate assessment of the patient within NO MORE 5-to-10 seconds by any ECG physician experienced in management of acute cardiac patients. take it immediately to a physician to read. Regardless of whether the ECG is “normal” or “non-acute”, or not — IF the History is of concern, then THAT patient should be seen promptly! The algorithm learned to classify these ECG s into the following 4 triage categories: normal, abnormal not acute, subacute, and acute. The Setting. Background. Such protocols include templated orders for performance of immediate ECGs for clinical triggers; ECG automated and/or rapid manual interpretation of the ECG for ST-segment elevation or acute MI; protocol-driven activation of the STEMI pager, cardiac response team, or on-call cardiologist; and rapid assessment and triage of the patient for reperfusion therapy. Following this simple advice would greatly reduce the chance of overlooking the subtle-but-real series of abnormalities that are clearly present on this initial ECG. ECG diagnosis remains a time-tested, reliable tool for rapid assessment and triage of cardiac patients. setTimeout( ... and having the ECG vetted in person by a senior doctor, before being able to move on to triage another subse-quent patient. Of the 8 ECGs, I thought only the 4th ECG looked unlikely to be acute (albeit not a “normal” ECG). Clinical Significance: Any change from “normal ECG” computer read that would alter triage care; Inclusion: All patients ≥18 years of age with a triage ECG; Exclusion: <18 years of age; Results: 885 triage ECGs collected over 16 weeks 222 (26%) interpreted as “normal ECG” by computer; 5 (0.57%) interpreted as STEMI NPV: 99% (95% CI 97 – 99%) How Unreliable are Computer Algorithms in the Diagnosis of STEMI? Why do we perform serial 12-lead ECGs on patients with signs and symptoms of ACS? We seek to determine if the implementation of a series of plan, do, study, act (PDSA) cycles would improve the wait time to triage within 1 year. An exercise in ECG interpretation and triage Home. six The 12‐lead ECG s were acquired in all noncardiology departments of the University Medical Center Utrecht. ECG Duration 30 Seconds HeartCheck™ ECG Triage Report Gender: Female Import Date: Apr 09 2015 11:15:49 AM Device: HeartCheck PEN 10 Serial Number (SN): 1236103528 Report Generated For: Zohra Test Date of Birth: Jul 28 1992 HR Recording Date: Apr 03 2015 11:43:43 AM Measurements: Rate (BPM): 85 PR: 0.10 QRS: 0.07 QT: 0.32 QTc: 0.39 A patient with chest pain: We sought to determine whether the prehospital electrocardiogram (ECG) improves the diagnosis of an acute coronary syndrome. Eliminating physician review of triage ECGs with a computer interpretation of normal may be a safe way to improve patient care by decreasing physician interruptions.”. As an additional frustration, these patients often end up being seen by a different doctor in the department, and no one likes making diagnostic or treatment decisions that another provider will have to deal with. .hide-if-no-js { Different EDs, however, have different criteria. streamlined process to improve triage to ECG times. It’s a lose-lose situation. Satisfying results have been reported in relation to the implementation of ECG-based triage protocols , also in the Rotterdam-Rijnmond region, the Netherlands, albeit in the thrombolysis era . Objective: The objectives of this study were to investigate if the implementation of a streamlined process at triage for walk-in patients with SICP decreased triage to ECG times, and secondarily if triage to first-device time for walk-in patients diagnosed with STEMI was decreased. The second study of this type showed similar reduced door‐to‐ECG time, but provides no details on how staff identified patients with a “complaint consistent with angina.” 22 Another study showed that adding an ED triage greeter improved ECG time. EM - Emergency Medicine Blog, EMS 12-Lead: Triaging Triage ECGs | The Medial Approach, 6-Step Method for 12-Lead ECG Interpretation, Electrocardiographically Silent High Lateral STEMI Equivalent. no st changes = try and get the patient back asap to a room. notice.style.display = "block"; Baseline characteristics of patients who had a triage ECG are reported ( Table 1: Baseline characteristics). To address the delays in time to ECG and time from ECG to catheterisation, PIT is charged with initiating the treatment for patients presenting with STEMI. They’re all well thought-out posts with perfectly reasonable conclusions. Type 2 or 3 pattern; even a normal ECG). Safety of Computer Interpretation of Normal Triage Electrocardiograms. If we could cut back on the number of triage ECGs that are performed on low-risk patients with non-cardiac complaints, I think that would make a bigger dent in reducing interruptions. Triage delays in chest pain evaluation are … Prehospital and in-hospital ECGs were obtained in 3,027 consecutive patients with symptoms of suspected acute myocardial infarction, 362 … My only issue with that approach is that the emergency physicians I’ve work with are always busy. var notice = document.getElementById("cptch_time_limit_notice_42"); As the only tech at triage, I’ve also got somewhere between one and thirty patients out in the waiting room, so if I don’t get that ECG signed right after it’s performed, I’ll get distracted myself and occasionally forget. Hughes KE et al. Triaging of patients at the emergency department (ED) is one of the key steps prior to initiation of doctor consult. Results: There was a statistically significant difference between May 2016 and May 2017 (U = 28425, Z=-5.01, p <.001). — and, the triage clinician who talks to the patient at check-in (be that nurse or other medical personnel) should be sufficiently trained in determining which patients based on history alone should be prioritized — AND — iii) 7 of the 8 ECG examples posted by … Maybe it’s just the practice at the hospital I worked at, but I think we’d make more progress at reducing interruptions by investigating a stricter triage protocol for ECGs.