The Medial Approach to Emergency Medicine. They’re all well thought-out posts with perfectly reasonable conclusions. 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. var notice = document.getElementById("cptch_time_limit_notice_42"); Methods. 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. 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.”. Work your way through with the accompanying study guides. 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%). Prehospital and in-hospital ECGs were obtained in 3,027 consecutive patients with symptoms of suspected acute myocardial infarction, 362 … 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. Triage delays in chest pain evaluation are … Very few of those ECGs lead to a change in initial management. Improving the wait time to triage at the emergency department. Results: There was a statistically significant difference between May 2016 and May 2017 (U = 28425, Z=-5.01, p <.001). Life-threatening hyperkalemia: do you recognize the ECG signs? 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. THANKS so much to Dr. Smith for posting this case!, 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. This study is not saying that physicians should not review all ECGs, but instead a delayed strategy in “normal” ECGs may be feasible. All rights reserved. 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. In response, there has been a creep towards performing ECGs more frequently in triage. Who should receive a prehospital 12-lead ECG? Time limit is exhausted. 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%) The diagnosis of ST‐segment elevation myocardial infarction (STEMI) in the emergency department (ED) is made solely by ECG. Why do we perform serial 12-lead ECGs on patients with signs and symptoms of ACS? 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. 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 Thanks, Your email address will not be published. T… It’s not the “normal” ECGs that are weighing on my physicians. Baseline characteristics of patients who had a triage ECG are reported ( Table 1: Baseline characteristics). 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?”. 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. It’s a lose-lose situation. 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. 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). 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. 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. Objectives. EKG at triage slashes door-to-aspirin time. This video course walks you through from the basics of ECG interpretation to complex topics like subtle signs of ischemia and pesky rhythm problems. Tweet Is epinephrine harmful in cardiogenic shock? 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. = "block"; 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. By recording triage ECGs, we make the early diagnosis of OMI in not just 1 patient, but 35 patients, per year. An exercise in ECG interpretation and triage. 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. 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. Join the Resuscitation group on Facebook! 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. Below are some great opinions on the article from the target demographic: emergency physicians. Triage ECGs for which the cardiologist's interpretation differed from the computer interpretation of normal ECG were presented to two emergency physicians (EPs) blinded to the goals of the study. 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. The most awesome STEMI test on the internet! 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. Acad Emerg Med 2017; 24(1): 120 – 24. 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). Computerized ECG interpretations have never been shown to have high enough sensitivity for assessing subtle infarctions to be used as a “stand-alone” tool ( ). Safety of Computer Interpretation of Normal Triage Electrocardiograms. 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 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. How unreliable are computer algorithms in the diagnosis of STEMI? 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). 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. ECG diagnosis remains a time-tested, reliable tool for rapid assessment and triage of cardiac patients. Excellent thoughtful post by Vince DiGiulio. Save my name, email, and website in this browser for the next time I comment. Your email address will not be published. A patient with chest pain: Stephen W. Smith at Dr. Smith’s ECG Blog. Triaging of patients at the emergency department (ED) is one of the key steps prior to initiation of doctor consult. The Setting. Hughes KE, Lewis SM, Katz L, Jones J. Game. I was at triage when this ECG of a 50-something was handed to me. st changes = take the pt back immediately for mona, even if it involves sitting them in the hall. 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. EM. Please reload CAPTCHA. The Medical Approach to Emergency Medicine, Safety of Computer Interpretation of Normal Triage Electrocardiograms, Triage ECGs: Reducing Interruptions in a Busy ED. Background: Lets face it. six 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. REBEL EM is licensed under a Creative Commons Attribution-NonCommercial-NoDerivs 3.0 Unported License.