EFFECT OF CARDIOLOGIST ECG REVIEW ON EMERGENCY DEPARTMENT PRACTICE

Study objective: To determine the effect of cardiology review of ECGs on emergency department practice. Methods: We carried out a prospectiv e cohort study at an urban teaching ED. Our subjects were adult patien ts undergoing electrocardiography. We prospectively collected 1,000 co nsecutive ECGs and classified them by severity according to the follow ing system: class 1, normal or minor abnormalities only; class 2, abno rmalities with potential to alter case management; and class 3, potent ially life-threatening abnormalities. Actual ECG readings by ED physic ians (who had access to computerized interpretations at the time of tr eatment) were compared with those of staff cardiology quality-assuranc e reviewers; if they were not in agreement, an expert cardiology panel blindly chose the superior interpretation. Subsequently, an expert em ergency physician panel reviewed discordant readings for discharged pa tients to determine the need for further action. Results: Of 1,000 ECG s, the readings for 190 (19%) were significantly discordant. The exper t cardiology panel preferred the ED reading in 72 cases (38%) and the staff cardiology reading in 118 (62%). In 30 other cases no ED reading was recorded in the medical record. Of the 148 cases in which the exp ert cardiology panel agreed with the cardiology reading or there was n o ED reading, 102 patients were admitted and 46 discharged. Of the 46 discharges, 8 cardiology readings were categorized as class 1, leaving only 38 cases in which the staff cardiology reading might have affect ed the ED decision to discharge a patient. All of these readings were in class 2, with the exception of one unclassifiable diagnosis. There were no class 3 readings. On expert emergency physician panel review o f these 38 ECGs and interpretations, only 8 (.8%, 95% confidence inter val, .3% to 1.6%) were considered sufficiently important to warrant ch art review. In actual practice, none of these cases was affected by th e ECG quality-assurance (QA) process. Two of these patients died durin g our 1-year follow-up. In one of these cases, the ECG QA process coul d have altered the patient's outcome. Conclusion: The existing ECG rev iew process as mandated by the Joint Commission on Accreditation of He althcare Organizations (JCAHO) will likely have minimal influence on p atient outcomes at our institution. We should establish the effectiven ess of this mandated QA process before committing scarce resources to its performance.