Triaging Triage ECGs

I’ve spent nine years working in an emergency department, which means I’ve also spent nine years performing electrocardiograms at triage. With a couple thousand waiting-room ECGs under my belt, I’ve noticed a few things:

  • A lot of ECGs are ordered at triage.
  • Many of them are performed on low-risk patients.
  • Very few of those ECGs lead to a change in initial management.

Oh, and one more thing:

  • Most physicians hate signing triage ECGs.

I can’t say I blame them. Triage ECGs interrupt their workflow and, worse than just slowing them down, that distraction can lead to errors. 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. 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.

Triage ECGs bring work and distraction.

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].

Below are some great opinions on the article from the target demographic: emergency physicians.

They’re all well thought-out posts with perfectly reasonable conclusions. Dr. Salim Rezaie and Dr. Anand Swaminathan from R.E.B.E.L. 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.

My only issue with that approach is that the emergency physicians I’ve work with are always busy. 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.

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. It’s a lose-lose situation.

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. 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).

It’s not the “normal” ECGs that are weighing on my physicians.

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. 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.

But I digress…

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. 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.

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?”

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.

It’s not data, and certainly not scientific, but it’s interesting (to the folks who like ECGs, at least).

Enjoy!

 

References

  1. Hughes KE, Lewis SM, Katz L, Jones J. Safety of Computer Interpretation of Normal Triage Electrocardiograms. Acad Emerg Med. 2017;24(1):120-124. doi: 10.1111/acem.13067

2 Comments

  • Excellent thoughtful post by Vince DiGiulio. The problem regarding the “Triaging of Triage ECGs” is clearly an important one. 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. 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! — 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. 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). Of the 8 ECGs, I thought only the 4th ECG looked unlikely to be acute (albeit not a “normal” ECG). 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 …. ) — 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.

    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. 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. 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.

    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. 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 ). 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. 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. 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. THANKS so much to Dr. Smith for posting this case!

  • Tom says:

    Hey Vince,

    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. I’d like to confirm my interpretation against yours to make sure I’m seeing it all. Thanks

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