Greater San Antonio Emergency Physicians (GSEP). ... and having the ECG vetted in person by a senior doctor, before being able to move on to triage another subse-quent patient. Different EDs, however, have different criteria. 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. Baseline characteristics of patients who had a triage ECG are reported ( Table 1: Baseline characteristics). Save my name, email, and website in this browser for the next time I comment. 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. 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. function() { 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. 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! ekg in triage. 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. 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. How unreliable are computer algorithms in the diagnosis of STEMI? 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. Thanks, Your email address will not be published. st changes = take the pt back immediately for mona, even if it involves sitting them in the hall. 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. display: none !important; — 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 … Results: There was a statistically significant difference between May 2016 and May 2017 (U = 28425, Z=-5.01, p <.001). The 12 Rhythms of Christmas: High-Grade AV-Block. V4 and V5 haveQR-waves, in addition to the STE, which suggests:1. Improving the wait time to triage at the emergency department. no st changes = try and get the patient back asap to a room. Is there a way to maybe minimize the number of interruptions? Discussion: This retrospective study of 538 triage ECG's performed over an 8day period identified no STEMIs and 16 NSTEMIs. streamlined process to improve triage to ECG times. 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. EM. 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. 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. Safety of Computer Interpretation of Normal Triage Electrocardiograms. Type 2 or 3 pattern; even a normal ECG). var notice = document.getElementById("cptch_time_limit_notice_42"); We sought to determine whether the prehospital electrocardiogram (ECG) improves the diagnosis of an acute coronary syndrome. REBEL EM is licensed under a Creative Commons Attribution-NonCommercial-NoDerivs 3.0 Unported License. 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. Work your way through with the accompanying study guides. 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. 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. 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. Hughes KE, Lewis SM, Katz L, Jones J. It would be helpful if you included the findings that lead to diagnosis of STEMI in those “subtle STEMIs” from your collection for us newbies. Triaging of patients at the emergency department (ED) is one of the key steps prior to initiation of doctor consult. 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. At presentation, the patients’ vital signs, serum levels of creatinine, glucose and lipid profiles were similar in both groups. notice.style.display = "block"; Life-threatening hyperkalemia: do you recognize the ECG signs? 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. 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%.  −  Improving the wait time to triage at the emergency department Yuzeng Shen , 1 Lin Hui Lee2 To cite: Shen Y, Lee LH. © 2020 REBEL EM. An exercise in ECG interpretation and triage Home. | Disclaimer | Website by Innov8 Place. 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. 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. }. Acad Emerg Med 2017; 24(1): 120 – 24. — 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. THANKS so much to Dr. Smith for posting this case! EKG at triage slashes door-to-aspirin time. Excellent thoughtful post by Vince DiGiulio. 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. 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. 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.  =  The ECG is the most widely used screening test for evaluating patients with chest pain. 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. 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. The 12‐lead ECG s were acquired in all noncardiology departments of the University Medical Center Utrecht. Safety of Computer Interpretation of Normal Triage Electrocardiograms. 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. Why do we capture a 12-lead ECG with the first set of vital signs? Please reload CAPTCHA. Tweet The aim of this study was to evaluate the existing triage ECG protocol as a means of treatment decision making. The problem regarding the “Triaging of Triage ECGs” is clearly an important one. Join the EMS Safety Culture group on Facebook! 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. 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. Your email address will not be published. Time limit is exhausted. 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. http://traffic.libsyn.com/rebelcast/March_2017_REBEL_Cast_-_Triage_ECGs_-_Reducing_Interruptions_in_a_Busy_ED.m4a. 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. ECG diagnosis remains a time-tested, reliable tool for rapid assessment and triage of cardiac patients. Many of them are performed on low-risk patients. Methods. 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?”. 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. 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. We do EKG's in triage on a regular basis. This video course walks you through from the basics of ECG interpretation to complex topics like subtle signs of ischemia and pesky rhythm problems. "Triage ECGs: Reducing Interruptions in a Busy ED", REBEL EM blog. 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. As a result, OMIs may not declare themselves by as much ST elevation as is written into some “guidelines”. 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. setTimeout( Why do we perform serial 12-lead ECGs on patients with signs and symptoms of ACS? 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%) Hughes KE et al. 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 . 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). 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! My only issue with that approach is that the emergency physicians I’ve work with are always busy. ); })(120000); Is epinephrine harmful in cardiogenic shock? How Unreliable are Computer Algorithms in the Diagnosis of STEMI? 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. 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. Objectives. One advantage that physicians have over ECG interpretation is that we are able to get a history and do a physical exam. 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. The algorithm learned to classify these ECG s into the following 4 triage categories: normal, abnormal not acute, subacute, and acute. 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.”. Triage delays in chest pain evaluation are … Timely diagnosis is critical to achieving timely intervention. 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. All of us have been interrupted by the onslaught of triage ECGs for interpretation. 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. Required fields are marked *, 12-Lead ECG Challenge Smartphone App – $5.99. The most awesome STEMI test on the internet! 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 … Background. We hypothesize that triage ECGs interpreted by the computer as “normal ECG” are unlikely to have clinical significance that would affect triage care. 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. }, Get App Play Online. By recording triage ECGs, we make the early diagnosis of OMI in not just 1 patient, but 35 patients, per year. Dr. Salim Rezaie and Dr. Anand Swaminathan from R.E.B.E.L. Purpose: To evaluate the effect of pre-registration ECGs for walk-in patients with suspected ACS, on door-to-ECG (D2ECG) time. Why do we send so many people to a cardiac arrest? 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. take it immediately to a physician to read. .hide-if-no-js { All rights reserved. T… That the triage ECG must be shown to the physician is demonstrated again by the following ECG, recorded just this week. Background: Lets face it. While the standard is usually to lay the pt down, sometimes that just isn't possible. The Medial Approach to Emergency Medicine. 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. A patient with chest pain: I’d like to confirm my interpretation against yours to make sure I’m seeing it all. 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. 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 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. Chest pain process not without snags. […]. Current AHA/ACC guidelines on the management of ST-elevation myocardial infarction (STEMI) suggest that an ECG is indicated within 10 minutes of arrival for patients arriving to the Emergency Department (ED) with symptoms concerning for STEMI. To improve the overall wait time to consultation, we have identified the need to reduce the wait time to triage for ED patients. The diagnosis of ST‐segment elevation myocardial infarction (STEMI) in the emergency department (ED) is made solely by ECG. 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. Who should receive a prehospital 12-lead ECG? 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. They’re all well thought-out posts with perfectly reasonable conclusions. Very few of those ECGs lead to a change in initial management. 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]. 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. 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). Of the 8 ECGs, I thought only the 4th ECG looked unlikely to be acute (albeit not a “normal” ECG). — 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. timeout Post Peer Reviewed By: Anand Swaminathan (Twitter: @EMSwami), […] Triage ECGs: Reducing Interruptions in a Busy ED by R.E.B.E.L. It’s a lose-lose situation. I’ve spent nine years working in an emergency department, which means I’ve also spent nine years performing electrocardiograms at triage. 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. Join the Advanced Cardiac Life Support group on Facebook! Discriminative performance is presented with overall and category‐specific concordance statistics, polytomous discrimination indexes, sensitivities, … The Medical Approach to Emergency Medicine, Safety of Computer Interpretation of Normal Triage Electrocardiograms, Triage ECGs: Reducing Interruptions in a Busy ED.

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