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Dr. Lee and the EKG

EKGs in pre-operative management for OSH transfers. Dr. Lee and the EKG. Goal. Assess if EKG’s are ordered appropriately on patients who are transferred from OSH to undergo Dr. John Lee endoscopic procedures. Background information. When to order an EKG. Indications for Pre-Operative EKG.

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Dr. Lee and the EKG

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  1. EKGs in pre-operative management for OSH transfers Dr. Lee and the EKG

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

  3. Background information When to order an EKG

  4. 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

  5. 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

  6. The Study

  7. Population • 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

  8. Methods • 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. 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

  10. Results • 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%)

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

  12. Conclusions and discussion

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

  14. But Why? • 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

  15. Cost • 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.

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

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