Emergency physician accuracy in interpreting electrocardiograms with potential ST-segment elevation myocardial infarction: Is it enough?

Background: Electrocardiogram (ECG) interpretation is widely performed by emergency physicians. We aimed to determine the accuracy of interpretation of potential ST-segment elevation myocardial infarction (STEMI) ECGs by emergency physicians. Methods: Thirty-six ECGs resulted in putative STEMI diagnoses were selected. Participants were asked to focus on whether or not the ECG in question met the diagnostic criteria for an acutely blocked coronary artery causing a STEMI. Based on the coronary angiogram, a binary outcome of accurate versus inaccurate ECG interpretation was defined. We computed the overall sensitivity, specificity, accuracy and 95% confidence intervals (95%CIs) for ECG interpretation. Data on participant training level, working experience and place were collected. Results: 135 participants interpreted 4603 ECGs. Overall sensitivity to identify ‘true’ STEMI ECGs was 64.5% (95%CI: 62.8–66.3); specificity in determining ‘false’ ECGs was 78% (95%CI: 76–80.1). Overall accuracy was modest (69.1, 95%CI: 67.8–70.4). Higher accuracy in ECG interpretation was observed for attending physicians, participants working in tertiary care hospitals and those more experienced. Conclusion: The accuracy of interpretation of potential STEMI ECGs was modest among emergency physicians. The study supports the notion that ECG interpretation for establishing a STEMI diagnosis lacks the necessary sensitivity and specificity to be considered a reliable ‘stand-alone’ diagnostic test.     

The residency-practice training mismatch. A primary care education dilemma

Primary care practice requires clinical skills and knowledge that differ greatly from those required for successful completion of residency training. Discrepant clinical settings and physician responsibilities have thus created a mismatch between the educational content of residency training and the content of clinical practice, which may result in suboptimal preparation of internists, family practitioners, and pediatricians for patient care. Of equal concern, the psychosocial environment of residency does not prepare physicians for their future community and personal adult roles. Barriers to correcting this worsening mismatch include the following: (1) economic pressures to use house staff to meet service needs of hospitals, (2) changes in patient demographics and the focus of hospital-based medicine that are making hospitals progressively more unsuitable as the principal training site for primary care physicians, (3) the deemphasis of practicing physicians as role models and teachers in postgraduate training, and (4) the often heated disagreement among medical educators regarding the purpose and content of residency training. Efforts to resolve this mismatch should include the following: reexamining the educational objectives of the current system of postgraduate training, better counseling of physicians in training regarding career goals, and emphasizing the primary care physician as role models and faculty.     

Physician assessments of practice patterns in emergency department radiograph interpretation

Emergency and radiology department directors at 517 acute-care US teaching hospitals were sent identical questionnaires surveying practice patterns of ED plain film radiograph interpretation. Fifty-seven percent of ED directors and 51% of radiology department (RD) directors responded. Both groups reported that the most common practice pattern (60%) was alternating responsibility for immediate interpretation between emergency physicians and radiologists during a 168-hour week. Remaining hospitals were nearly equally divided between systems in which radiologists always provided immediate interpretation and those in which the emergency physicians always provided the initial interpretation. In all systems in which emergency physicians provided some immediate radiograph interpretation, radiologists provided subsequent review. Institutions varied as to the level of training of the physician in both the ED and RD who provided immediate radiograph interpretation; at least 30% of the institutions responding were reported to have either emergency physicians or radiologists of resident level providing immediate interpretation at least part of the 24-hour day. Interpretation discrepancy rates between emergency physicians and radiologists were estimated to be 4% to 6%. The large amount of variation among hospitals in ED radiograph interpretation systems suggests that these systems were not designed with quality of care concerns as their primary criterion. As a consequence, objective patient outcome and process measures need to be developed and measured to ensure that a particular internal system for ED radiograph interpretation is providing an acceptably high standard of patient care.     

Interpretation of T-wave inversion in physiological and pathological conditions: Current state and future perspectives

The presence of T-wave inversion (TWI) at 12-lead electrocardiogram (ECG) in competitive athletes is one of the major diagnostic challenges for sports physicians and consulting cardiologists. Indeed, while the presence of TWI may be associated with some benign conditions and it may be occasionally seen in healthy athletes presenting signs of cardiac remodeling, it may also represent an early sign of an underlying, concealed structural heart disease or life-threatening arrhythmogenic cardiomyopathies, which may be responsible for exercise-related sudden cardiac death (SCD). The interpretation of TWI in athletes is complex and the inherent implications for the clinical practice represent a conundrum for physicians. Accordingly, the detection of TWI should be viewed as a potential red flag on the ECG of young and apparently healthy athletes and warrants further investigations because it may represent the initial expression of cardiomyopathies that may not be evident until many years later and that may ultimately be associated with adverse outcomes. The aim of this review is, therefore, to report an update of the literature on TWI in athletes, with a specific focus on the interpretation and management.     

The clinical utility of adenosine in difficult to diagnose tachyarrhythmias.

BACKGROUND: The use of intravenous adenosine to help differentiate the origin of tachyarrhythmias has been suggested to be beneficial. However, the benefit of this intervention to physicians with different levels of training in electrocardiographic (ECG) interpretation is unknown. HYPOTHESIS: The purpose of the study was to determine whether intravenous adenosine improved the diagnostic accuracy of difficult to diagnose tachyarrhythmias when used by physicians with different levels of training in ECG interpretation. METHODS: We studied 28 consecutive patients presenting with wide and narrow complex tachyarrhythmias, in whom adenosine was given specifically for diagnostic purposes. Two groups of physicians, attending (n = 14) and housestaff (n = 10), reviewed each ECG before and after the administration of adenosine. RESULTS: For narrow complex tachyarrhythmias, neither physician group derived diagnostic benefit from the use of adenosine. However, for wide complex tachyarrhythmias, the diagnostic accuracy of the housestaff group significantly improved with the use of adenosine (pre = 54%, post = 70%, p < 0.01), while the attending physician group had no significant improvement (pre = 61%, post = 71%, p = NS). CONCLUSION: This study suggests that adenosine provides useful diagnostic information to physicians less experienced in ECG interpretation when presented with patients having wide complex tachyarrhythmias of uncertain origin.     

Variation in routine electrocardiogram use in academic primary care practice

BACKGROUND: Lack of practical consensus regarding routine electrocardiogram (ECG) ordering in primary care led us to hypothesize that nonclinical variations in ordering would exist among primary care providers. METHODS: We used 2 computerized billing systems to measure ECG ordering at visits to providers in 10 internal medicine group practices affiliated with a large, urban teaching hospital from October 1, 1996, to September 30, 1997. To focus on screening or routine ECGs, patients with known cardiac disease or suggestive symptoms were excluded, as were providers with fewer than 200 annual patient visits. Included were 69 921 patients making 190 238 visits to 125 primary care providers. Adjusted rates of ECG ordering accounted for patient age, sex, and 5 key diagnoses. Logistic regression evaluated additional predictors of ECG ordering. RESULTS: Electrocardiograms were ordered in 4.4% of visits to patients without reported cardiac disease. Among the 10 group practices, ECG ordering varied from 0.5% to 9.6% of visits (adjusted rates, 0.8%-8.6%). Variations between individual providers were even more dramatic: adjusted rates ranged from 0.0% to 24% of visits, with an interquartile range of 1.4% to 4.7% and a coefficient of variation of 88%. Significant predictors of ECG use were older patient age, male sex, and the presence of clinical comorbidities. Additional nonclinical predictors included Medicare as a payment source, older male providers, and providers who billed for ECG interpretation. CONCLUSIONS: Variations in ECG ordering are not explained by patient characteristics. The tremendous nonclinical variations in ECG test ordering suggest a need for greater consensus about use of screening ECGs in primary care.     

Patients' perspectives on physician skill in end-of-life care: differences between patients with COPD,cancer, and AIDS

OBJECTIVES: Patients' views of physician skill in providing end-of-life care may vary across different diseases, and understanding these differences will help physicians improve the quality of care they provide for patients at the end of life. The objective of this study was to examine the perspectives of patients with COPD, cancer, or AIDS regarding important aspects of physician skill in providing end-of-life care. DESIGN: Qualitative study using focus groups and content analysis based on grounded theory. SETTING: Outpatients from multiple medical settings in Seattle, WA. PATIENTS: Eleven focus groups of 79 patients with three diseases: COPD (n = 24), AIDS (n = 36), or cancer (n = 19). RESULTS: We identified, from the perspectives of patients, the important physician skills for high-quality end-of-life care. Remarkable similarities were found in the perspectives of patients with COPD, AIDS, and cancer, including the importance of emotional support, communication, and accessibility and continuity. However, each disease group identified a unique theme that was qualitatively more important to that group. For patients with COPD, the domain concerning physicians' ability to provide patient education stood out as qualitatively and quantitatively more important. Patients with COPD desired patient education in five content areas: diagnosis and disease process, treatment, prognosis, what dying might be like, and advance care planning. For patients with AIDS, the unique theme was pain control; for patients with cancer, the unique theme was maintaining hope despite a terminal diagnosis. CONCLUSIONS: Patients with COPD, AIDS, and cancer demonstrated many similarities in their perspectives on important areas of physician skill in providing end-of-life care, but patients with each disease identified a specific area of end-of-life care that was uniquely important to them. Physicians and educators should target patients with COPD for efforts to improve patient education about their disease and about end-of-life care, especially in the areas defined above. Physicians caring for patients with advanced AIDS should discuss pain control at the end of life, and physicians caring for patients with cancer should be aware of many patients' desires to maintain hope. Physician understanding of these differences will provide insights that allow improvement in the quality of care.     

Palliative and end-of-life care for patients with cardiopulmonary diseases: American College of Chest Physicians position statement

Acute and chronic pulmonary and cardiac diseases often have a high mortality rate, and can be a source of significant suffering. Palliative care, as described by the Institute of Medicine, "seeks to prevent, relieve, reduce or soothe the symptoms of disease or disorder without effecting a cure... Palliative care in this broad sense is not restricted to those who are dying or those enrolled in hospice programs." The American College of Chest Physicians strongly supports the position that such palliative and end-of-life care of the patient with an acute devastating or chronically progressive pulmonary or cardiac disease and his/her family should be an integral part of cardiopulmonary medicine. This care is best provided through an interdisciplinary effort by competent and experienced professionals under the leadership of a knowledgeable and compassionate physician. To that end, it is hoped that this statement will serve as a framework within which physicians may develop their own approach to the management of patients requiring palliative care.     

Classification of cardiac patient states using artificial neural networks

Electrocardiogram (ECG) is a nonstationary signal; therefore, the disease indicators may occur at random in the time scale. This may require the patient be kept under observation for long intervals in the intensive care unit of hospitals for accurate diagnosis. The present study examined the classification of the states of patients with certain diseases in the intensive care unit using their ECG and an Artificial Neural Networks (ANN) classification system. The states were classified into normal, abnormal and life threatening. Seven significant features extracted from the ECG were fed as input parameters to the ANN for classification. Three neural network techniques, namely, back propagation, self-organizing maps and radial basis functions, were used for classification of the patient states. The ANN classifier in this case was observed to be correct in approximately 99% of the test cases. This result was further improved by taking 13 features of the ECG as input for the ANN classifier.     

Training and competency evaluation for interpretation of 12-lead electrocardiograms: recommendations from the American College of Physicians

This paper is part 1 of a 2-part series on interpretation of 12-lead resting electrocardiograms (ECGs). Part 1 is a position paper that presents recommendations for initial competency, competency assessment, and maintenance of competency on ECG interpretation, as well as recommendations for the role of computer-assisted ECG interpretation. Part 2 is a systematic review of detailed supporting evidence for the recommendations. Despite several earlier consensus-based recommendations on ECG interpretation, substantive evidence on the training needed to obtain and maintain ECG interpretation skills is not available. Some studies show that noncardiologist physicians have more ECG interpretation errors than do cardiologists, but the rate of adverse patient outcomes from ECG interpretation errors is low. Computers may decrease the time needed to interpret ECGs and can reduce ECG interpretation errors. However, they have shown less accuracy than physician interpreters and must be relied on only as an adjunct interpretation tool for a trained provider. Interpretation of ECGs varies greatly, even among expert electrocardiographers. Noncardiologists seem to be more influenced by patient history in interpreting ECGs than are cardiologists. Cardiologists also perform better than other specialists on standardized ECG examinations when minimal patient history is provided. Pending more definitive research, residency training in internal medicine with Advanced Cardiac Life Support instruction should continue to be sufficient for bedside interpretation of resting 12-lead ECGs in routine and emergency situations. Additional experience or training in ECG interpretation when the patient's clinical condition is unknown may be useful but requires further study.     

They think you earn too much,but they probably don't care

• A survey of patients and physicians in southern California indicates that patients overestimate Medicare payments to hospitals for elective coronary stenting several‐fold and overestimate Medicare payments to physicians for coronary stenting over 15‐fold. Patients think payments should be less than they erroneously think hospitals and physicians are paid but should be much more than hospitals and physicians are paid.
• The authors hypothesize that patients’ view of physician payments may interfere with the physician–patient relationship, but data from other studies of physician–patient relationships suggest other factors are much more important.
• The importance of patients’ opinions regarding physician payments for procedures could be further assessed by surveying patients about relationships with physicians before versus after information is given about actual payments.

     

A review of Hib epidemiology in Asia.

Meningitis due to an invasive Haemophilus influenzae type b (Hib) infection, has been previously perceived to be relatively uncommon in Asia. However, the incidence of disease and its impact may have been underestimated. In addition to a lack of microbiological facilities in some hospitals, difficulties in culturing the organism and the widespread use of antibiotics may have hidden the true incidence of the disease in some countries. Furthermore, the reported disease burden probably underestimates the incidence of Hib pneumonia. The epidemiology of invasive Hib disease for various Asian nations is reviewed in this paper. Hospital-based studies show that Hib is a major cause of bacterial meningitis and/or pneumonia in the Philippines, India, Thailand, Malaysia, Indonesia and Vietnam. Singapore and Hong Kong have a low incidence of infection compared with Western and other Asian nations. This low incidence is not due to a higher level of natural protective antibodies, but may be related to an interaction between environmental and genetic factors. Therefore the widespread belief that Hib infection is unimportant in Asia does not refer to Asia as a whole and possibly to Chinese patients only, and failure to recognize this has serious implications. The inclusion of Hib vaccine in the routine infant immunization schedule in many industrialized nations has significantly reduced the incidence of invasive disease. Recent studies have shown Hib vaccination is also effective in preventing invasive disease in children in developing countries. While population-based data may be required to confirm the need for public-funded infant Hib immunization in Asia, its introduction in countries with a high incidence of Hib meningitis and/or pneumonia has the potential to significantly improve pediatric health and survival.     

Hospital protocols and policies that may delay early identification and thrombolytic therapy of acute myocardial infarction patients

Despite the compelling relationship between early treatment and outcome from reperfusion therapy in patients with acute myocardial infarction, significant delays in early treatment are imposed by the patient, prehospital systems, and hospital processes and protocols used in the identification and treatment of patients with myocardial infarction. A survey instrument designed to determine the prevalence of hospital policies and protocols that might delay or expedite treatment with thrombolytic therapy in patients with acute myocardial infarction was completed by 524 hospitals participating in the National Registry for Myocardial Infarction (NRMI). Participating hospitals had treated 17,646 patients with tissue plasminogen activator. The door to drug time for the entire population of patients treated at each hospital was available. Door to drug times were compared between those hospitals that had a positive response to a policy and those that had a negative response to that policy. Among respondent hospitals, thrombolysis was excluded by protocol in 34.4% for age above 75 and in 55% for presentation after 6 hours of chest pain onset. Furthermore, 29.4% of hospitals required routine laboratory testing other than electrocardiography (ECG), including chest x-ray, prior to determination of eligibility for thrombolysis. Door to drug times were shorter in those hospitals with prehospital 12-lead ECG availability, assessment of the 12-lead ECG by the emergency department nurse and physician as soon as it was available, and initiation of thrombolysis by the emergency physician (in patients with clear-cut ST elevation myocardial infarction) without bedside cardiology consultation. Door to drug times were longer in those hospitals in which predecision laboratory results were required, written informed consent was mandated, and drug was initiated in the cardiac intensive care unit rather than in the emergency department itself. Door to drug times were not significantly different in those hospitals with a designated chest pain center compared with those operating under a focused patient care protocol. We conclude that the earliest possible hospital treatment of acute myocardial infarction patients may be precluded by multiple components of emergency department policies and process, many of them inappropriate for safe, efficient, and effective identification and management of these patients.This research was presented in part at the Annual Scientific Session, American College of Cardiology, Atlanta, Georgia, March 1994     

Physicians’ knowledge and attitudes in Saudi Arabia regarding implantable cardiac defibrillators

Objectives

To evaluate knowledge and attitude of physicians involved in the management of patients with heart failure regarding implantable cardioverter-defibrillator (ICD).

Pulmonary Hypertension Registry of Kerala (PROKERALA) – Rationale,design and methods

BackgroundPulmonary hypertension (PH) is a disease associated with a high morbidity and mortality. There is paucity of data regarding PH from the developing countries including India.Idiopathic pulmonary arterial hypertension is the most important etiological factor in the western world, but PH secondary to rheumatic heart disease, chronic obstructive pulmonary disease and untreated congenital heart disease could well be the predominant causes in developing countries like India.The main objective of the PROKERALA study – Pulmonary hypertension Registry Of Kerala is to collect data regarding the etiology, practice patterns and one-year outcomes of patients diagnosed to have PH.MethodsThe study is a hospital-based registry in the state of Kerala supported and funded by the Cardiological Society of India, Kerala Chapter. A total of 77 hospitals have agreed to participate in the registry. PH was defined as systolic pulmonary artery pressure derived by echocardiography of more than 50 mmHg (by tricuspid regurgitation jet) or mean PA pressure more than 25 mmHg obtained at cardiac catheterization.A detailed questionnaire is administered which includes the demographic characteristics, risk factors, family history, ECG data, 6 minute walk test distance, chest X ray findings and echocardiographic data. Details of PH specific therapy and one-year follow-up data are collected.From a preliminary survey in the region, we estimated that we will be able to collect 2000 cases over a period of one year.     

Variability in thrombolytic practice in Oregon

STUDY OBJECTIVE: To examine current thrombolytic protocols in Oregon emergency departments with regard to variations in patient evaluation, inclusion and exclusion criteria, initiation of therapy, and available thrombolytic agents. DESIGN: Telephone survey of ED head nurses. SETTING: All acute-care hospital EDs in Oregon. TYPE OF PARTICIPANTS: Of 70 acute-care hospitals contacted, 67 (96%) were included: 61 (87%) have a written ED protocol for thrombolytic agent use. METHODS: Telephone survey of written thrombolytic protocols, with comparison of groups using Kruskal-Wallis test (P less than .05). MEASUREMENTS AND MAIN RESULTS: The primary modes of initiating thrombolytic therapy are at the emergency physician's discretion (32%). after private physician consultation (24%), through the use of an agreement developed by the emergency physicians in conjunction with cardiologists or internists (22%), or after cardiologist or internist consultation (22%). ECG interpretation before drug administration is most often performed by the emergency physician (41%), cardiologist or internist (28%), private physician (6%), or computer (10%). Both tissue plasminogen activator (tPA) and streptokinase are available at 50 hospitals (75%); tPA is used exclusively in ten (15%) and streptokinase in seven (10%) other hospitals. tPA and streptokinase are approved for ED use in 43 (72%) and 46 (81%), respectively, of the hospitals at which these agents are available. In these, the ED is the most frequent site of administration of tPA in only 28 (65%) and of streptokinase in 33 (72%) hospitals; tPA and streptokinase are kept in the ED in only 23 (53%) and 23 (50%) of these hospitals, respectively. There was a significant correlation between thrombolytic administration in the ED and the number of full-time emergency physicians and American Board of Emergency Medicine diplomates. CONCLUSION: Thrombolytic protocols are highly variable in Oregon EDs.     

Design of the Rule Out Myocardial Ischemia/Infarction Using Computer Assisted Tomography: a multicenter randomized comparative effectiveness trial of cardiac computed tomography versus alternative triage strategies in patients with acute chest pain in the emergency department

Although early cardiac computed tomographic angiography (CCTA) might improve the management of emergency department (ED) patients with acute chest pain, it could also result in increased testing, costs, and radiation exposure. ROMICAT II was a randomized comparative effectiveness trial enrolling patients 40 to 74 years old without known coronary artery disease who presented to the ED with chest pain but without ischemic electrocardiographic (ECG) changes or elevated initial troponin and who required further risk stratification. Overall, 1000 patients at 9 sites within the United States were randomized to either CCTA as the first diagnostic test following serial biomarkers or to standard of care, which included no testing or functional testing such as exercise ECG, stress radionuclide imaging, or stress echocardiography. Test results were provided to ED physicians, yet patient management was not driven by a study protocol in either arm. Data were collected on diagnostic testing, cardiac events, and cost of medical care for the index hospitalization and during the following 28 days. The primary end point was length of hospital stay. Secondary end points were cumulative radiation exposure, resource utilization, and costs of competing strategies. Tertiary end points were institutional, physician, and patient characteristics associated with primary and secondary outcomes. Rate of missed acute coronary syndrome within 28 days was the safety end point. The ROMICAT II will provide rigorous data on whether CCTA is more efficient than standard of care in the management of patients with acute chest pain at intermediate risk for acute coronary syndrome.     

Patients Do not Know the Level of Training of Their Doctors Because Doctors Do not Tell Them

Summary Setting Although patients should know the level of training of the physician providing their care in teaching hospitals, many do not. Objective The objective of this study is to determine whether the manner by which physicians introduce themselves to patients is associated with patients’ misperception of the level of training of their physician. Patients/Participants This was an observational study of 100 patient–physician interactions in a teaching emergency department. Measurements and Main Results Residents introduced themselves as a doctor 82% of the time but identified themselves as a resident only 7% of the time. While attending physicians introduced themselves as a “doctor” 64% of the time, only 6% identified themselves as the supervising physician. Patients felt it was very important to know their physicians’ level of training, but most did not. Conclusions Physicians in our sample were rarely specific about their level of training and role in patient care when introducing themselves to patients. This lack of communication may contribute to patients’ lack of knowledge regarding who is caring for them in a teaching hospital.     

Accuracy and variability of medical interpretation of the electrocardiogram]

The accuracy of medical interpretation of the ECG, the variability of electrocardiographic conclusions drawn by different physicians and by a specialist when re-analyzing the same ECG were considered. Three experienced physicians analyzed 700 ECG independently from one another. The electrocardiographic inferences were contrasted against the autopsy, roentgenographic and clinical findings. A paired comparison of electrocardiographic conclusions made by the physicians with respect to the principal groups of these conclusions was undertaken. The mean frequency of complete concurrence of the conclusions varied from 26 to 89 per cent, depending upon the type of the electrocardiographic conclusion. Subject to comparison were also conclusions drawn by a single physician with a two-fold analysis of the same ECG. In this case the frequency of divergent inferences amounted to 43 per cent.