S.T.A.T. ECGs

The Division of Cardiology at the University of Colorado reviewed a “near-miss” patient safety event related to delayed performance of a STAT priority electrocardiogram (ECG) in a floor unit patient with high-risk chest pain. While the importance of prompt ECG completion (<10 mins) during pre-hospital and emergency room care is well-established,1 no similar measures exist for hospitalized patients. Meanwhile, delays in ECG acquisition contribute to delayed diagnosis and treatment of in-hospital STEMI.2. There are few published attempts to improve ECG completion times among hospitalized patients.

Analysis of 25,159 completed, time-stamped inpatient ECGs completed at UCH between 1/1/2018 and 10/30/2018 was completed. Descriptive statistics for ECG volume, ECG completion delays and total AHT staffing levels were calculated and correlations between ECG characteristics and delays were examined. Between February and April 2019, a trained qualitative researcher completed interviews and observations with UCH staff involved in ECG completion, focusing on work processes and the workplace environment. Based on these initial quantitative and qualitative analyses, a simulation model was developed to evaluate changes in 1) technician staffing models; 2) the proportion of STAT orders; and 3) nurse training to help perform ECGs.

ECGs were ordered with a STAT priority in 40% of cases and, among individual providers, use of the STAT priority varied from 7% to 95%. ECG completion was delayed (>15 minutes) for 35% of STAT ECGs, compared to less than 10% of non-stat ECGs. In qualitative interviews, technicians described a “cascade” effect to delays resulting from a compounding effect of a series of late ECGs and supported by the quantitative observation that delays are strongly correlated with STAT ECG volume. Technicians also described spikes in ECG ordering during hours in which staffing levels are low and for non-emergency reasons (such as discharge), a finding again supported by quantitative analysis. Results of discrete event simulation suggest: adding technician staffing hours during the day outperforms reducing the proportion of STAT ECGs; short shifts (4-8 hours) may be a cost effective way to add personnel; ECG training for Cardiology nurses could offload technicians and reduce delays; the negative effect of technician “attrition” – e.g. a technician calls in sick and is not replaced – is more powerful than the positive effect of any intervention.

In light of the above findings, UCH operations leadership trained charge nurses on Cardiology units to perform STAT ECGs and are discussing new ECG technician staffing models. The NavLab plans to create a dashboard for leadership to review ECG timeliness and the performance of ECG technicians.