Do you read EKGs for STEMI for floor patients?

[thegenius]

There is a lot of gruff among some of the ER doctors where I work (and I'm one of them) that somehow our group got snookered into reading "rapid response" EKGs from hospitalized patients after hours. If a floor patient has acute SOB or chest pain after hours (say 12a - 8a), the EKG gets sent to the ER for the ER doc to determine if it's a STEMI.

Whoa, what's the problem you might say? Why yes we have 24 hr cardiology and interventional cardiology coverage. But somehow they requested not to be called for these EKGs. They are making money taking call and not wanting to be woken up overnight.

Do any of you guys have similar arrangements?

---

Members don't see this ad.

 

[Dr Mantis Toboggan]

There is a lot of gruff among some of the ER doctors where I work (and I'm one of them) that somehow our group got snookered into reading "rapid response" EKGs from hospitalized patients after hours. If a floor patient has acute SOB or chest pain after hours (say 12a - 8a), the EKG gets sent to the ER for the ER doc to determine if it's a STEMI.

Whoa, what's the problem you might say? Why yes we have 24 hr cardiology and interventional cardiology coverage. But somehow they requested not to be called for these EKGs. They are making money taking call and not wanting to be woken up overnight.

Do any of you guys have similar arrangements?

No that’s bad. We do way more than average upstairs but not that fortunately.

 

[southerndoc]

Who gets paid for interpreting them? If I'm reimbursed for the interpretation, then I wouldn't mind it. Most likely it's cardiology, so cardiology should review them or the admitting attending of record should review them.

Who reviews the stat x-rays done on the floor?

 

[turkeyjerky]

Never been handed an EKG from the floor. That's really strange. Once or twice, I've had a hospitalist come down and curbside me on an EKG, which I was happy to help out, but that's it.

Honestly, though, if I was getting paid, I'd be happy to do it. 8 bucks for like 20 secs of thinking.

 

[gamerEMdoc]

I bet Cardiology still reads them later and bills for the official read.

 

[RustedFox]

We have a policy to explicitly NOT do this.

 

[BoardingDoc]

There is a lot of gruff among some of the ER doctors where I work (and I'm one of them) that somehow our group got snookered into reading "rapid response" EKGs from hospitalized patients after hours. If a floor patient has acute SOB or chest pain after hours (say 12a - 8a), the EKG gets sent to the ER for the ER doc to determine if it's a STEMI.

Whoa, what's the problem you might say? Why yes we have 24 hr cardiology and interventional cardiology coverage. But somehow they requested not to be called for these EKGs. They are making money taking call and not wanting to be woken up overnight.

Do any of you guys have similar arrangements?

Weird. We bill for our own EKGs that we read in the ED. That was a fight we won with cards a long time ago. If the patient is still in the ED waiting to go up and gets an EKG, I generally read it. Otherwise, we don't get these.

If you're not explicitly getting paid to read these EKGs, I wouldn't be onboard with that.

 

[DeadCactus]

The problem is you're not really responsible for just seeing if it meets STEMI criteria; you're now responsible for any cardiac issues that patient may be having and, in my experience, be expected to do so off a random EKG shoved in your face with literally no backstory on why the patient is there or what symptoms prompted the EKG. Frustrating enough with a patient in my department but doesn't sound worth it for a patient somewhere else in the hospital and definitely not if someone else is going to "read it" while sipping coffee the next morning and bill for it.

 

[bravotwozero]

Nope, never had to do this at any hospital

 

[Mount Asclepius]

Your group and medical director need to fight this battle. You are taking on unnecessary liability and I suspect not being compensated for this work. Entirely inappropriate to have EPs reading EKGs for patients not under their care located somewhere else in the hospital. Either Cardiology needs to read them in real time (suspect unlikely to happen) or the inpatient physicians who are taking care of the patients need to take responsibility of reading the EKGs overnight.

 

[Vandalia]

Agree with the above. In this scenario, you will be held to the standard of a cardiologist interpreting an EKG, not an EM physician treating a patient.

There is a simple way to address this problem: Remind the hospital administration that if there is an adverse event and the patient alleges malpractice in the interpretation, they are not going to go after the physician, they are going to go after the deep pockets of the hospital. That can mess with the CEO's bonus.

 

[emergentmd]

Hard stop on this. No way. The small amount of money to read the EKGs are not worth it. When we were a SDG we were asked to and refused to do these.

1. Intubate non arrest pts on the floor b/c anesthesiology was too busy
2. Deliver emergent babies on the flood b/c OB was not in house sometimes
3. Put in Central lines on floor patients


They are floor patients, they are not ER patients. You give them EKG reads, then you will be the stat Xray read, central line, intubation team, delivery team. Bad medicine all around.

I do not understand how anyone could think this is good medicine when the ER is packed for the most part. Its just admin wanting to get things covered and not willing to pay the specialist.

Now, I have gone to the floor to put in a central line prob 3 times in my 20 yr career WHEN the specialists calls and asks me specifically with a good reason. I would even do it if asked nicely by a good consultant who was at dinner with their family. But now way should you be part of any floor teams.

 

[Cinclus]

Nope. Happy to say I've never seen this done.

 

[Brigade4Radiant]

Yeah at one of the hospitals I work for. I said no. EM is treated like the dog who bit the baby. All sorts of stuff could go wrong. The patient crashes then what?

You have to leave the department for no money and all the liability.

 

[RustedFox]

Hard stop on this. No way. The small amount of money to read the EKGs are not worth it. When we were a SDG we were asked to and refused to do these.

1. Intubate non arrest pts on the floor b/c anesthesiology was too busy
2. Deliver emergent babies on the flood b/c OB was not in house sometimes
3. Put in Central lines on floor patients


They are floor patients, they are not ER patients. You give them EKG reads, then you will be the stat Xray read, central line, intubation team, delivery team. Bad medicine all around.

I do not understand how anyone could think this is good medicine when the ER is packed for the most part. Its just admin wanting to get things covered and not willing to pay the specialist.

Now, I have gone to the floor to put in a central line prob 3 times in my 20 yr career WHEN the specialists calls and asks me specifically with a good reason. I would even do it if asked nicely by a good consultant who was at dinner with their family. But now way should you be part of any floor teams.

After the third time I was asked to put in a central line in the stepdown unit for one of the OBGYN's (Dr. Ripsaw, as she was known to the nursing staff) patients, it got escalated and the problem was solved.

 

[thegenius]

The problem is that a year or two ago a hospitalist misread an STEMI EKG as something else and I think there was a bad, or semi-bad outcome. Somehow out of admin meetings we were assigned to first read EKGs overnight and to escalate as needed. I don't even think we bill for reading the EKG. We don't even put in a note. It's absolutely terrible and the majority of our group doesn't want this responsibility yet I don't know why it hasn't changed.

Why is it that I'm allowed to wake up the cardiologist at 2:00 AM to determine if an EKG for an ER patient is a STEMI, but the hospitalist cannot wake up the same cardiologist at 2:00 AM to determine if an EKG for a hospitalized patient is a STEMI?

 

[thegenius]

Who gets paid for interpreting them? If I'm reimbursed for the interpretation, then I wouldn't mind it. Most likely it's cardiology, so cardiology should review them or the admitting attending of record should review them.

Who reviews the stat x-rays done on the floor?

Thankfully we have 24-7 rads reading all imaging studies

 

[thegenius]

Agree with the above. In this scenario, you will be held to the standard of a cardiologist interpreting an EKG, not an EM physician treating a patient.

There is a simple way to address this problem: Remind the hospital administration that if there is an adverse event and the patient alleges malpractice in the interpretation, they are not going to go after the physician, they are going to go after the deep pockets of the hospital. That can mess with the CEO's bonus.

Precisely. Someone said that we are experts reading EKGs, and while I think we are very good at it, the experts are actually Cardiologists. That's why we consult them when we have difficult EKGs taken in the ED.

 

[Mount Asclepius]

The problem is that a year or two ago a hospitalist misread an STEMI EKG as something else and I think there was a bad, or semi-bad outcome. Somehow out of admin meetings we were assigned to first read EKGs overnight and to escalate as needed.

It often seems that bad policy comes from an overly reactionary response to an isolated bad incident …or it’s just non-clinical administrators making decisions without all of the clinical stakeholders in the room giving valuable input.

 

[Tenk]

Your Hospitalists should be reading these.

 

[BAM!]

The problem is that a year or two ago a hospitalist misread an STEMI EKG as something else and I think there was a bad, or semi-bad outcome. Somehow out of admin meetings we were assigned to first read EKGs overnight and to escalate as needed. I don't even think we bill for reading the EKG. We don't even put in a note. It's absolutely terrible and the majority of our group doesn't want this responsibility yet I don't know why it hasn't changed.

Why is it that I'm allowed to wake up the cardiologist at 2:00 AM to determine if an EKG for an ER patient is a STEMI, but the hospitalist cannot wake up the same cardiologist at 2:00 AM to determine if an EKG for a hospitalized patient is a STEMI?

This is where one hospitalist needs remediation.

However, I live in reality and some of this may depend on how far up the chain the case went. For example, if a complaint was filed to CMS, sometimes this can result in a mandatory regulatory action plan. I know.... That said, you definitely should lobby to come up with a different regulatory action plan, such as hospitalist texts the cardiologist, or all hospitalists have to take an online learning module on identifying STEMIs to, you know, learn how to doctor.

 

[turkeyjerky]

This is where one hospitalist needs remediation.

However, I live in reality and some of this may depend on how far up the chain the case went. For example, if a complaint was filed to CMS, sometimes this can result in a mandatory regulatory action plan. I know.... That said, you definitely should lobby to come up with a different regulatory action plan, such as hospitalist texts the cardiologist, or all hospitalists have to take an online learning module on identifying STEMIs to, you know, learn how to doctor.

Omg, could you imagine a hospital-created online ekg learning module? A bunch of screen shots from dubin combined w/ some old dude blathering on for 30 mins about ACC stemi guidelines. And we'd all have to do it every single year.

 

[emergentmd]

Hospitalist are doctors who should be able to read ekgs. That is what they were trained to do. It was either a bad outcome or at worse an incompetent hospitalist.

Either way, not much yo fix. If hospitalist are not able to read EKGs then training must have changed.

 

[bravotwozero]

Your hospital might be the only one in the country with this arrangement. This is the proverbial hill to die on and push back.

 

[Groove]

There is a lot of gruff among some of the ER doctors where I work (and I'm one of them) that somehow our group got snookered into reading "rapid response" EKGs from hospitalized patients after hours. If a floor patient has acute SOB or chest pain after hours (say 12a - 8a), the EKG gets sent to the ER for the ER doc to determine if it's a STEMI.

Whoa, what's the problem you might say? Why yes we have 24 hr cardiology and interventional cardiology coverage. But somehow they requested not to be called for these EKGs. They are making money taking call and not wanting to be woken up overnight.

Do any of you guys have similar arrangements?

I've worked at two hospitals (same system) where this was a policy in place. Luckily, I don't have to deal with it anymore in my current hospital system. I would often just sign them as "No STEMI, alert admitting doc for STAT bedside eval" or something to that effect. If it makes you feel any better, I probably signed those things for 7+ years and never got a lawsuit from my "name" being on an EKG (knock on wood). I think it's an abuse of ED physicians but it may not be as uncommon as you think or maybe I was just unlucky. I didn't like the policy....but I don't know if I'd quit over it assuming everything else about the gig is copacetic.

 

[Groove]

Thankfully we have 24-7 rads reading all imaging studies

You're lucky. I don't know what it is about my region in SE but I've never been able to get a formal radiology read overnight. Currently they are preliminary reports from radiology residents that get over read in the a.m. Plain films don't get read at all. That's actually an improvement, believe it or not, from my last hospital where they had a "wet read" from a radiologist at home reading on his PC without dictation where the read would go something like this... "NAF" a.k.a. "No acute finding". It was miserable. The best gig in this area was years ago and that was with a formal nighthawk service. Even then, the local radiology group still didn't have to work at night. It must be nice.

 

[d2305]

I wonder if there was a NP on the floor trying to decipher the STs?

 

[Angry Birds]

I wonder if there was a NP on the floor trying to decipher the STs?

Well, at my hospital, the NP usually comes down and asks us for help to read the EKG and determine this.
This may just be with me, I'm not sure. I might be less scary than their own on-call hospitalist.

 

[Splenda88]

Hospitalist are doctors who should be able to read ekgs. That is what they were trained to do. It was either a bad outcome or at worse an incompetent hospitalist.

Either way, not much yo fix. If hospitalist are not able to read EKGs then training must have changed.

We are trained to read EKG, especially the ones that can lead to bad outcomes, but ED docs have more training than us in reading EKG. Therefore, it might make sense to put the responsibility on the ED docs if cardiology service/department dont want to do it. We all know how things work in medicine; the services or departments that bring the most $$$ can get away with a lot of things.

However, it seems strange that an IM hospitalist (could have been FM) missed a STEMI. If not sure, why not go down to the ED and ask an ED doc what he/she thinks.

 

[Lexdiamondz]

Nope...I don't even read EKGs for boarders in the ED.

Save for imaging studies, the ordering physician/PA/NP should be able to within reason interpret the results of a test that they ordered. If I didn't order a study and I don't get to bill for interpreting it, why am I being held responsible for it?

If a hospitalist misses a STEMI the problem is with that hospitalist, not necessarily with the entire medicine service.

 

[dadaddadaBATMAN]

We are trained to read EKG, especially the ones that can lead to bad outcomes, but ED docs have more training than us in reading EKG. Therefore, it might make sense to put the responsibility on the ED docs if cardiology service/department dont want to do it. We all know how things work in medicine; the services or departments that bring the most $$$ can get away with a lot of things.

However, it seems strange that an IM hospitalist (could have been FM) missed a STEMI. If not sure, why not go down to the ED and ask an ED doc what he/she thinks.

Yeah. I know plenty of internists who are great with ekgs, but the reality is after a few years you tend to be good at what you do.

My guess is that you guys see a few ekgs a shift.

I get handed one every 10-20 minutes and the main question that can screw me is

STEMI???!??

So I view them primarily through that lens. A subtle 2nd type 2 block or something could burn me, but stemi and equivalent things are really my main job. I also get regular emails on different ways ed docs got burned by stemi presentations they missed.

The point is, hospitalist in general shouldn’t be as good as we are at that, similar to how they should be more intelligent when talking about aki or electrolytes or management >4 hrs.

Also if I call cards at 2am, they curse my name and go back to sleep, cus it’s expected behavior from us. When im does it I imagine they are more pissy

 

[thegenius]

I get handed one every 10-20 minutes and the main question that can screw me is

STEMI???!??

So I view them primarily through that lens. A subtle 2nd type 2 block or something could burn me, but stemi and equivalent things are really my main job. I also get regular emails on different ways ed docs got burned by stemi presentations they missed.

The difference here is that ER patients are brand new. I initially look at the EKG as STEMI/NOSTEMI as well, I don't study it too much. But when I see the patient 30 minutes later then I look at it more carefully and am able to pick up on important features.

Inpatients tend to be stable, they already have EKGs done on most, if not all, of them, and it would be rare for things like someone to develop asymptomatic 3rd degree heart block while admitted.

 

[dadaddadaBATMAN]

The difference here is that ER patients are brand new. I initially look at the EKG as STEMI/NOSTEMI as well, I don't study it too much. But when I see the patient 30 minutes later then I look at it more carefully and am able to pick up on important features.

Inpatients tend to be stable, they already have EKGs done on most, if not all, of them, and it would be rare for things like someone to develop asymptomatic 3rd degree heart block while admitted.

That’s true. If I pick an ekg up a second time I probably have a directed question I’m answering, unless they’re just sick and I have no idea why/going over it again. E.g. peaked ts, absent p, wide qrs, what was qt interval? Was there a subtle st change I filtered out? Etc

However, would point out it sounds like you guys are getting handed ekgs from rapids which are a higher risk group for all sorts of crap.

Glad I don’t have to do this at my job, and if I did I would clarify if I’m also expected to pick up on the other 100 things an ekg can show you without clinical context. While it would be ridiculous to say I should have called the hospitalist about the new low voltage (and perhaps some retrospective hallucinated electrical alternans) and suspected tamponade, or a borderline peaked t wave for hyperk, I wouldn’t put it past a lawyer to try it. Would make me nervous

 

[emergentmd]

We are trained to read EKG, especially the ones that can lead to bad outcomes, but ED docs have more training than us in reading EKG. Therefore, it might make sense to put the responsibility on the ED docs if cardiology service/department dont want to do it. We all know how things work in medicine; the services or departments that bring the most $$$ can get away with a lot of things.

However, it seems strange that an IM hospitalist (could have been FM) missed a STEMI. If not sure, why not go down to the ED and ask an ED doc what he/she thinks.

Fair enough. If the hospitalist is not comfortable, they can look at the EKG, come down to the ER, discuss the case with me and I would gladly look at it.

I would help any colleague out who needs my help, more so than many of my partners. But I say full stop to doing inpatient care, other than codes, when I have no clue about the pts history.

An anesthesiologist is better than me at intubations, so if I miss one with a bad outcome, does that mean that they should do all intubations? I doubt that would fly.