EKGs in pre-operative management for OSH transfers

Assess if EKG’s are ordered appropriately on patients who are transferred from OSH to undergo Dr. John Lee endoscopic procedures

When to order an 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

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

Patient’s 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

Information regarding the patient’s 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 EKG’s preformed for any symptomatic heart

disease was also deemed appropriate Those patient’s who did not require and EKG

and did not receive an EKG were also noted to be appropriate Pre-Operative management

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

In total 8/9 pts had EKG’s ordered after transfer.

Of those 8 pt’s, 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%)

In total 4/9 patients received appropriate pre-operative EKG management 2 appropriately ordered and 2

appropriately not ordered

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

It’s hard to say… The study was retrospective/cross-sectional and

those physicians who ordered the EKG’s 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 patient’s aren’t delayed

for procedures Pressure from anesthesia to obtain these EKG’s

regardless of indications Education/Culture of both anesthesia and

medicine

Medicare reimbursement = $68 / EKG interpreted

# of incorrectly ordered EKG’s over 4 weeks: 6

Assuming accurate cross-section Average cost: $408/mo $4,896 of Medicare

waste per year on one subset of patients.

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

Pre-Op order set