Physician electrocardiogram reading in the emergency department—Accuracy and effect on triage decisions

Objective:To determine how well physicians in emergency departments read electrocardiographic (ECG) ST-segment and T-wave changes and how this affects triage decisions. Methods:In the emergency departments of six teaching and nonteaching hospitals, the authors prospectively collected physicians’ ECG readings and clinical data for 2,320 patients presenting with possible acute cardiac ischemia from 1979 to 1981. Results:Compared with electrocardiographers, the study physicians misread as normal41% of abnormal ST segments and 36% of abnormal T waves, and misread as abnormal14% of normal ST segments and 17% of normal T waves. Trainees were significantly more sensitive readers of T-wave changes but less specific readers of both ST-segment and T-wave changes when compared with other physicians. Suboptimal triage was more likely when abnormal ST segments or T waves were misread as normal (22% vs. 11% p<0.01, and 18% vs. 14%, p=0.08, respectively). Conversely, coronary care unit (CCU) admission for patients withoutacute cardiac ischemia was more likely when normal ST segments were misread as abnormal (23% vs. 13%, p<0.0001). Conclusions:Physicians in emergency departments often misread the ST segments and T waves of patients with possible acute cardiac ischemia. Misreading is related to suboptimal triage and unnecessary CCU admission. Training emergency physicians to make these distinctions more accurately could improve medical care and hospital utilization. Received from the Center for Cardiovascular Health Services Research, Divisions of Clinical Decision Making and General Medicine, Department of Medicine, New England Medical Center, Boston, Massachusetts. Supported by Agency for Health Care Policy and Research and Technology Assessment grants R01 HS02068 and R01 HS0554901, and by the National Library of Medicine Medical Information Program training grant LM7044 and research grant LM4493.