Getting to the heart of the issue: senior emergency resident electrocardiogram interpretation and its impact on quality assurance events

Objective@#Electrocardiogram (ECG) interpretation skills are of critical importance for diagnostic accuracy and patient safety. In our emergency department (ED), senior third-year emergency medicine residents (EM3s) are the initial interpreters of all ED ECGs. While this is an integral part of emergency medicine education, the accuracy of ECG interpretation is unknown. We aimed to review the adverse quality assurance (QA) events associated with ECG interpretation by EM3s. @*Methods@#We conducted a retrospective study of all ED ECGs performed between October 2015 and October 2018, which were read primarily by EM3s, at an urban tertiary care medical center treating 56,000 patients per year. All cases referred to the ED QA committee during this time were reviewed. Cases involving a perceived error were referred to a 20-member committee of ED leadership staff, attendings, residents, and nurses for further consensus review. Ninety-five percent confidence intervals (CIs) were calculated. @*Results@#EM3s read 92,928 ECGs during the study period. Of the 3,983 total ED QA cases reviewed, errors were identified in 268 (6.7%; 95% CI, 6.0%–7.6%). Four of the 268 errors involved ECG misinterpretation or failure to act on an ECG abnormality by a resident (1.5%; 95% CI, 0.0%–2.9%). @*Conclusion@#A small percentage of the cases referred to the QA committee were a result of EM3 misinterpretation of ECGs. The majority of emergency medicine residencies do not include the senior resident as a primary interpreter of ECGs. These findings support the use of EM3s as initial ED ECG interpreters to increase their clinical exposure.

Management pathway for emergency department patients in the setting of the opioid epidemic and emergency department overcrowding

Objective@#The United States is currently in the midst of a major opioid addiction epidemic, of which the primary drivers are a sharp increase in prescription opioid pain medications, their misuse, and the inordinate illicit use of opioids. Declared a national health emergency, the opioid crisis puts enormous pressure on various systems, including increasing overcrowding in emergency departments (EDs) and forced changes in prescribing practices. We are piloting a newlydeveloped ED opiate pathway to streamline ED care for patients who frequently present at the ED for chronic pain management or other recurrent pain-causing medical problems. @*Methods@#Patients at risk of possible opioid addiction are identified and their records are reviewed. If there is no narcotics agreement in place, the ED care team contacts the primary care physician and any other service providers involved in the patient’s care to create a comprehensive pain management program. @*Results@#Our pathway is simple and geared toward streamlining and improving care for patients with opioid addiction and misuse. We looked at seven patients in this pilot study with mixed results regarding decreasing future ED visits. @*Conclusion@#This strategy may both limit opioid usage and abuse as well as limit ED visits and overcrowding by streamlining ED care for patients who frequently present for chronic pain management or other recurrent medical problems.