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When doctors in the emergency department (ED) miss a diagnosis of heart attack (acute myocardial infarction, AMI) or unstable angina, they put the patient at risk and open the door to a possible malpractice suit. Physician use of an electrocardiograph-based ED risk management tool, which predicts the probability of acute ischemia (AMI or unstable angina), substantially reduces malpractice costs, according to a study supported by the Agency for Healthcare Research and Quality (HS07360). A second AHRQ-supported study (HS08212) shows that a suspected heart attack patient who is identified in the ED is more likely to receive potentially lifesaving thrombolytic (clot dissolving) therapy or angioplasty when another ECG-based predictive instrument indicates the benefits of thrombolytic therapy for the patient at the time of the ECG. Both studies, which were led by Harry P. Selker, M.D., M.S.P.H., of Tufts-New England Medical Center, are summarized here.
Selker, H.P., Beshansky, J.R., Pozen, J.D., and others. (2002, winter). "An electrocardiograph-based emergency department risk management tool based on the acute cardiac ischemia time-insensitive predictive instrument (ACI-TIPI): Potential impact on care and on the occurrence and outcomes of malpractice claims." Journal of Healthcare Risk Management pp. 11-18.
An ED risk management form automatically generated by electrocardiographs that include an ECG-based acute cardiac ischemia time-insensitive predictive instrument (ACI-TIPI) could reduce malpractice costs nationally by $1.2 billion a year, concludes this study. The ACI-TIPI generates a 0-100 percent probability that the ED patient has acute cardiac ischemia and may prompt doctors to consider and document key clinical factors for each ED patient with chest pain or related symptoms. It reduces the likelihood of malpractice suits because it helps ED doctors appreciate the importance of ECG abnormalities, the need to hospitalize certain patients, and the need to document appropriate care, suggest the researchers.
For 20 closed cases of malpractice litigation for missed AMI, six expert reviewers determined the likely impact of the ACI-TIPI if filled out by the physician during patient ED evaluations and if automatically generated with the initial electrocardiogram, on the case's likelihood of litigation and the outcome of litigation, if litigated. Both the manually completed and electrocardiograph-generated forms were judged to reduce the likelihood of litigation, respectively, for 65 percent and 83 percent of cases, including 38 percent judged "very much less likely" and 61 percent judged "almost certain not" to come to litigation.
Assuming that the cases were litigated, reviewers determined that there would have been a different litigation outcome supporting the physician's care for 62 percent of cases had the physician-completed form been used and for 80 percent of cases had the electrocardiograph-generated version been used. Review of cases with complete financial data projected a mean savings per case for physician-generated forms of $356,052, compared with $470,288 for the electrocardiograph-generated forms. This would translate into annual savings in the United States of $1.2 billion.
Selker, H.P., Beshansky, J.R., and Griffith, J.L. (2002, July 16). "Use of the electrocardiograph-based thrombolytic predictive instrument (TPI) to assist thrombolytic and reperfusion therapy for acute myocardial infarction: A multicenter randomized clinical effectiveness trial." Annals of Internal Medicine 137(2), pp. 87-95.
As electrocardiograph-based decision support to help ED physicians recognize the need for thrombolytic (clot dissolving) therapy for suspected heart attack patients, the Thrombolytic Predictive Instrument (TPI), incorporated into conventional computerized electro-cardiographs, provides patient-specific predictions of the benefit of thrombolytic therapy for individual patients. When this prediction was printed on the text header of the ED electro-cardiograph, the percentage of patients treated with thrombolytic therapy over a 22-month period increased at the EDs of 28 urban, suburban, and rural hospitals.
The researchers randomly assigned 1,197 ED patients with ST elevations on the ECG to either the control (587 patients) or intervention group (610 patients). If assigned to the intervention group, the ECG automatically prompted the user to enter information needed to compute the TPI predictions: age, sex, history of hypertension or diabetes, blood pressure, and time since ischemic symptom onset. The remaining variables, based on measurements of ECG waveforms, were automatically acquired by the electrocardiograph. Then the ECG was printed with the TPI prediction on its header. For patients assigned to the control group, the ECG was automatically printed with the standard header text used in that ED.
The ECG-TIPI increased use of thrombolytic therapy for patients with ECG detection of ST elevation characteristic of AMI, as well as use within 1 hour when it is most beneficial for preventing heart damage. The ECG-TIPI also increased overall reperfusion therapy (by thrombolytics or angioplasty) by 11-12 percent for inferior AMI (which is less classically targeted for reperfusion therapy and more likely to be missed than anterior AMI). It also increased overall reperfusion therapy by 18-22 percent for women (who are less likely to have classic signs of heart attack than men), by 30-34 percent when consultation with an off-site physician was required, and by 44-53 percent for patients who were seen at hospitals with no on-site ED physician. Thus, its impact was greatest for those patients in settings less likely to receive needed reperfusion therapy. The next area of application for this technology could be in ambulances.
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