It’s not uncommon for EPs to be presented with dozens of ECGs during a shift. “In a lot of EDs, when someone walks in with any symptom that is at all suspicious, an ECG is done at triage,” says Arlo F. Weltge, MD, MPH, FACEP, clinical professor of emergency medicine at McGovern Medical School at the University of Texas at Houston.
Criteria for ECGs vary depending on the ED. Many are performed on low-risk patients. “Some EDs will do it on anybody with a fast heart rate, any shortness of breath, or anything related to the chest and even part of the abdomen,” Weltge explains.
The large number of ECGs performed at triage could lead to an unintended legal consequence: increasing the possibility of missed ST-elevation myocardial infarction (STEMI), especially those that are subtle or atypical presentations.
“If you have an ED full of sick patients, there is the very real potential you will miss a subtle STEMI,” Weltge says. When handed a patient’s ECG, the EP’s goal is very specific: He or she must answer the question, “Is this a STEMI?”
“Our goal at that point is not to do a full cardiology interpretation of the ECG,” Weltge says. Rather, an immediate decision must be made about whether the patient should go straight to the cardiac catheterization lab.
Many ECGs are abnormal, but there is no evidence of STEMI. A conscientious EP may note the abnormality in the ED chart, and later find themselves named as a defendant in a malpractice lawsuit because an adverse outcome occurred later.
“The responsibility is really not to do a full interpretation,” Weltge says. “But because the EP laid eyes on it and commented on the fact that the ECG is abnormal, it creates the possibility of a liability risk.”
If the goal of the EP is to determine if a STEMI is present, and the answer is no, Weltge says the EP probably is best off simply documenting, “No STEMI” without additional commentary. “Otherwise, the argument can be made, ‘If you looked at the ECG, and it was abnormal, why didn’t you act on it?’” he explains.
The statement “No STEMI” makes it clear that the EP was focused specifically on determining if a STEMI existed at that point, not whether the ECG was completely normal. “The more one can define what question they are being asked and what question they are responding to, the better one is able to defend their actions if it’s ever challenged,” Weltge notes.
An abnormal ECG in and of itself doesn’t necessarily indicate a problem, Weltge says. Unless the EP has previous ECGs for comparison, it’s unknown if the abnormality is new or old. Thus, offering additional comments about the abnormalities on the ECG can mislead any subsequent reviewers of the ED chart.
“If you give a more robust explanation, it can imply you had a more robust relationship with the patient, placing you at risk for something that is beyond one’s control,” Weltge warns.
With so many low-risk patients undergoing ECGs at triage, delays can occur in obtaining ECGs for higher-risk patients who are brought back immediately. “This is one of the unanticipated consequences of doing ECGs on so many people at triage,” Weltge says. “For the person who needs it the most, it doesn’t always get done quickly.”
Weltge is aware of several malpractice claims involving delayed ECGs for ED patients who were brought back directly and worked up for non-cardiac conditions who actually had STEMIs. “Any slip up or delay becomes another target for the plaintiff to attack,” he says.
If there is an abnormality noted on the ECG that might affect the subsequent care that’s provided, the ED has a responsibility to be sure it gets communicated to the subsequent treater, Weltge explains. This might be the oncoming EP, or a cardiologist in the outpatient setting, depending on the specifics of the case.
Another legal landmine: Some ECGs are not documented by the triage nurse. Therefore, the EP never sees the ECG. “Then, you’ve got an ECG that hasn’t been interpreted,” Weltge says. “There are obvious liability issues involved in failing to close that loop.” The triage nurse might later document the ECG was done, so the ED chart is complete. “But if that happens after the EP sees the patient, it leaves a potential gap,” says Weltge.
Overreliance on Normal ECGs
Failure to diagnose a STEMI on initial ED presentation can lead to a post-ED discharge out-of-hospital cardiac arrest and death, or permanent disability, warns Charles A. Eckerline, Jr., MD, FACEP, vice chairman in the department of emergency medicine at the University of Kentucky Medical Center.
Eckerline says these two factors are the most frequent causes of missed myocardial infarction:
- Failure to recognize atypical presentations, particularly in women and diabetics;
- Overreliance on normal or nondiagnostic ECGs and normal enzymes.
A recent malpractice case involved both these issues. A woman with type 2 diabetes presented to an ED with transient sharp chest pain, dizziness, numbness, and hyperventilation.
“These symptoms were clearly atypical, and were believed to be due to anxiety and hyperventilation,” says Eckerline, who reviewed the case. The patient’s ECG was non-diagnostic, and two cardiac troponins were negative. Her symptoms resolved promptly without treatment, and she was discharged from the ED. “She suffered a cardiac arrest a short time later at home due to a critical coronary lesion,” Eckerline says.
The patient died at home within 24 hours of the ED discharge. A lawsuit, which was settled for an undisclosed amount, included these allegations:
- The EP failed to diagnose a STEMI or acute coronary syndrome;
- The standard of care required the patient to be admitted for observation and a stress test or cardiac catheterization.
“The lawsuit alleged that if these things had been done, her critical and ultimately fatal coronary artery lesion would have been diagnosed, stented, and her death prevented,” Eckerline says.
- Charles A. Eckerline, Jr., MD, FACEP, Vice Chairman, Department of Emergency Medicine, University of Kentucky, Lexington. Email: firstname.lastname@example.org.
- Arlo F. Weltge, MD, MPH, FACEP, Clinical Professor, Emergency Medicine, Department of Emergency Medicine, McGovern Medical School, University of Texas, Houston. Phone: (713) 667-4113. Email: Arlo.F.Weltge@uth.tmc.edu.