EKGs in pre-operative management for OSH transfers
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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
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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
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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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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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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
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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
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Those patient’s 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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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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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
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Of the 6 ordered incorrectly 2 were ordered
by anesthesiology (33%). The remaining 4
were ordered by medicine (66%)
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In total 4/9 patients received appropriate preoperative EKG management
 2 appropriately ordered and 2 appropriately not
ordered
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EKG pre-operative management was done
inappropriately in 56% of studied cases per
the ACC/AHA guidelines.
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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.
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…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
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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.
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Increasing anesthesia and medicine
interaction regarding pre-op
 Pre-Op Clinic together
 Joint lectures
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Pre-Op order set