1. EKGs in pre-operative management for OSH transfers

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

3. When to order an EKG

4.  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.  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

7.  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.  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.  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.  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.  In total 4/9 patients received appropriate pre- operative EKG management  2 appropriately ordered and 2 appropriately not ordered

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

14.  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.  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.  Increasing anesthesia and medicine interaction regarding pre-op  Pre-Op Clinic together  Joint lectures  Pre-Op order set