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

AUTHORS: DR. KENNETH ORIMMADR. KENNETH ORIMMA ACCIDENT & EMERGENCY DEPARTMENT QUEEN ELIZABETH HOSPITAL - BARBADOS PRINCESS MARGARET HOSPITAL - PRINCESS MARGARET HOSPITAL - BAHAMASBAHAMAS

DR. RAYMOND MASSAYDR. RAYMOND MASSAY CONSULTANT CARDIOLOGIST QUEEN ELIZABETH HOSPITAL - BARBADOS

Background

Study DetailsAimMaterials & MethodsStatistical Analysis & Results

Conclusion / Discussion

Study Limitations & Future Studies

Recommendation

Summary

Acknowledgements & ReferencesMISSED ARRHYTHMIAS - AN ECG AUDIT

The emergency physicians (EP) are the gate-keepers to decide which ED patients presenting with the complaint of chest pain warrants admission or discharge

The ED diagnostic tools (ECG & Cardiac Markers) (ECG & Cardiac Markers)

Correct interpretation is crucial

Determines appropriate management & disposition

Avoid adverse consequencesMISSED ARRHYTHMIAS - AN ECG AUDIT

MISSED ARRHYTHMIAS - AN ECG AUDIT

Prospective double-blinded convenience ECG /Chart Audit

Designed to test accuracy of Emergency Physician (EP) ECG interpretation by comparison with that of the Cardiologist

The study was done over three months period

No ethical approval was required as this was a comparative chart audit & was approved by the ED department


The study was conducted at ED QEH, a 600 bed tertiary facility in Barbados

Inclusion criteriaAll patients >30 years presenting with CP & triaged for ECG

Exclusion criteria All patients with chest pain complaints who were admittedNon-cardiac related chest pain ECGs of poor quality or leads misplaced during tracing


Daily collection of ECGs & review of patient’s A&E charts

Total 152 ECG / ED charts were included in the

study

ECGs were independently reported by both

The EPs were not aware of on-going audit

The cardiologist was not aware of the EP’s report or patient’s history when making his report

Standardized data collection instrument was used to record patient’s age, sex & ECG reports


The reports were divided into 2 groups:

1) Concordant Reports1) Concordant ReportsDefined as an abnormality or normality

reported by both

2) Discordant Reports2) Discordant ReportsDefined as an abnormality or normality

missed by EP in comparison with the Cardiologist’s report


The discordant group was subdivided into 3 groups based on defining parameters of:

I Infarct I Infarct a) Clinically significanta) Clinically significant

II Ischemia II Ischemia b) Indeterminateb) Indeterminatec) Insignificant c) Insignificant

III Arrhythmia III Arrhythmia


Clinically significant discordance included:

Infarct

Ischemia

Atrial fibrillation

Junctional rhythm

Pacemaker rhythm

No report


Indeterminate discordance included:

Interventricular conduction delay

Right bundle branch block

Left bundle branch block

Left ventricular hypertrophy

Right ventricular hypertrophy

Prolonged Q-T interval

Early repolarization


Insignificant Discordance included:

Sinus tachycardia

Sinus bradycardia

First degree AV block

LAD alone

RAD alone

Atrial enlargement

Nonspecific ST-T wave changes



The primary outcome variable was the concordance between the emergency physician & the cardiologist ECG report

Descriptive data entered into excel

Concordance (inter-observer agreement ) was estimated by kappa statistics testing


46%54%

Sex Distribution

MALE FEMALE


N=152

15

48

35

2417

112

0

10

20

30

40

50

60

> 30 36-45 46-55 56-65 66-75 76-85 >85

AGE

Age Distribution Of The Sample


N=152

49%51%

Distribution Of Sample By Report Agreement

ConcordanceDiscordance


N=152Inter-observer Agreement Inter-observer Agreement (K) = 54% (p<0.001)


N=78

The ECG is an important diagnostic tool

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


Morrison WG, Swann IJ study

error rate of 19.8%4.4% graded as Clinically Significant

Snoey ER, et al

discordance of 31%9% graded Clinically Significant

Our study shows a high discordance with clinical significant prevalence of 21%


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


Our study showed poor concordance of ECG report by ED physician compared with the cardiologist’s report

Discordance was significant but no missed MI


1) Study sample size is small A significant number of ECGs were either of poor quality or leads misplaced during tracing

2)2) Different levels of knowledge & experience of Different levels of knowledge & experience of the EP the EP

Significant impact on accuracy of ECG interpretation

3)3) Only one cardiologist was used as goal standard Only one cardiologist was used as goal standard Which may introduce bias


ECG workshops in the ED

ECG quality assurance program

Continuing / Periodic Audits

Trained technicians to do ECGs


PMH, Department of A&E medical staff

QEH, Department of A&E medical staffContributors:Dr. Michelle SweetingDr. Reginald King A&E dept BarbadosDr. Harold Watson Emergency

Medicine program director, Barbados


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

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