Dr. Lee and the EKG

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Dr. Lee and the EKG

• EKGs in pre-operative management for OSH transfers

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Goal

• Assess if EKGs are ordered appropriately on
  patients who are transferred from OSH to undergo
  Dr. John Lee endoscopic procedures

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Background information

• When to order an EKG

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Indications for Pre-Operative EKG

• ACC/AHA recommends preoperative EKG in patients
• at least one clinical risk factor scheduled to
  undergo vascular surgery
• patients scheduled to undergo intermediate-risk
  surgery with known cardiovascular disease,
  peripheral artery disease, or cerebrovascular
  disease
• They do not recommend preoperative EKGs in
  asymptomatic patients undergoing low-risk
  surgical procedures.
• There is a recommendations for further work up on
  any patient with symptomatic heart disease

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QED

• Thus any asymptomatic patient that is transferred
  for an endoscopic procedure does not warrant a
  pre-operative EKG
• However, if a patient shows symptoms of ACS, CAD,
  CHF, or arrhythmia getting an EKG would be
  appropriate

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The Study
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Population

• Patients were all transferred from an OSH for a
  potential procedure to be done by Dr. Lee.
• 10 total patients
• Male 3 Females 7
• Patients selected from the online Hospitalist
  Transfer Webpage. Patients were the last 10 John
  Lee acceptances as of 4/16/13. Admission occurred
  over the course of 1 month
• Inclusion criteria is acceptance of patient by
  Dr. Lee. Exclusion criteria was any patient who
  did not have an endoscopy preformed

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Methods

• Information regarding the patients stay was
  obtained from a retrospective search of the
  patient's online chart and orders from that
  hospitalization.
• EKG appropriateness was determined as per the
  above descriptors.
• All EKGs for endoscopic procedures of
  asymptomatic patients were deemed inappropriate
• All EKGs preformed for any symptomatic heart
  disease was also deemed appropriate
• Those patients who did not require and EKG and
  did not receive an EKG were also noted to be
  appropriate Pre-Operative management

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Results

• 9/10 patients underwent endoscopic procedure
• 1 patient was found not to be a candidate for an
  endoscopic procedure on transfer and underwent
  surgical management by Gyn/Onc

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Results

• In total 8/9 pts had EKGs ordered after
  transfer.
• Of those 8 pts, 2 EKGs were appropriately
  ordered for pre-operative reasons
• Pt showing signs of symptomatic tachycardia/heart
  failure
• Pt with abdominal pain and recent hx of meth use
• Of the 6 ordered incorrectly 2 were ordered by
  anesthesiology (33). The remaining 4 were
  ordered by medicine (66)

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RESULTS

• In total 4/9 patients received appropriate
  pre-operative EKG management
• 2 appropriately ordered and 2 appropriately not
  ordered

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Conclusions and discussion
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Conclusion

• EKG pre-operative management was done
  inappropriately in 56 of studied cases per the
  ACC/AHA guidelines.

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But Why?

• Its hard to say
• The study was retrospective/cross-sectional and
  those physicians who ordered the EKGs were not
  surveyed as to why they ordered EKG was ordered.
  
• A future study that surveyed these physicians
  would be a more informative study.
• but if you ask me
• Pressure to make sure patients arent delayed
  for procedures
• Pressure from anesthesia to obtain these EKGs
  regardless of indications
• Education/Culture of both anesthesia and medicine

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Cost

• Medicare reimbursement 68 / EKG interpreted
• of incorrectly ordered EKGs over 4 weeks 6
• Assuming accurate cross-section
• Average cost 408/mo
• 4,896 of Medicare waste per year on one subset
  of patients.

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Solutions?

• Increasing anesthesia and medicine interaction
  regarding pre-op
• Pre-Op Clinic together
• Joint lectures
• Pre-Op order set