HospitalInspections.org

Based on interview and record review, the governing body failed to track variances (inconsistencies or differences) identified during the Cardiology electrocardiogram (EKG, test that checks for problems with the electrical activity within the heart) overread process (a secondary interpretation and report provided by a specialized physician) for the Emergency Department (ED). The hospital had not taken any action to follow-up or to improve the timeliness of the ED EKG overreads, after they recognized delays in the overread process. The EKG overread process was inconsistent, and the timeliness was determined according to what day of the week the EKG was performed. This had the potential to affect the quality of care and health outcomes for all patients who presented to the hospital's ED and required EKG diagnostic testing. The hospital census was 78.

Findings included:

1. Although requested, on 02/22/21, the hospital was unable to provide a policy related to the ED EKG overread process, any data related to the tracking of variances, any evidence of a process change, performance improvement, or re-education related to the EKG overread process.

During an interview on 02/23/21 at 9:10 AM, Staff B, Cardiac Catheterization (a procedure where a long thin tube is inserted in a blood vessel and threaded through the blood vessels to the heart to examine how well the heart is working) Lab/Cardiopulmonary (relating to the heart and lungs) Department Manager, stated that:
- The ED physician would perform the initial interpretation of an EKG, but the cardiologist would perform and document a final overread.
- Completed EKGs would be transferred in batches from the electronic EKG management system to the cardiologists' queue for review multiple times throughout the day during the week, but only once a day on weekends.
- There was not a specific time designated for the transfer of the batches of EKGs.
- Cardiologists were expected to complete an EKG overread within 24 hours.
- EKG overread times and variances were not tracked.

Review of the hospital's undated document titled, "Cardiology EKG Projects - EKG Overread Process Improvement," provided to the survey team on 02/24/21 at approximately 2:05 PM (about 48 hours after initial request) showed that:
- The Cardiology overreads of the EKGs performed in the ED should be completed within 24 hours.
- From 12/24/20 through 02/24/21, 28% of the total EKG overreads were not completed within 24 hours.
- 18% of EKG overreads on Mondays were not completed within 24 hours.
- 16% of EKG overreads on Tuesdays were not completed within 24 hours.
- 6% of EKG overreads on Wednesdays were not completed within 24 hours.
- 13% of EKG overreads on Thursdays were not completed within 24 hours.
- 38% of EKG overreads on Fridays were not completed within 24 hours.
- 83% of EKG overreads on Saturdays were not completed within 24 hours.
- 45% of EKG overreads on Sundays were not completed within 24 hours.

2. During an interview on 02/24/21 at 9:15 AM, Staff G, ED Director, stated that variances identified with EKG overreads were not tracked and had never been tracked.

During an interview on 02/24/21 at 10:20 AM, Staff K, Physician, ED Medical Director, stated that he had only made minor corrections to the preliminary EKG interpretations of the ED physicians, and he was not aware of any variance tracking.

During an interview on 02/24/21 at 10:30 AM, Staff L, Cardiologist, Former Cardiology Department Head, stated that EKG overread variances were not tracked.

During an interview on 02/24/21 at 9:00 AM, Staff J, Cardiologist, Cardiology Department Head, stated that there were only a small percentage of variances between the ED physicians' interpretation and his overreads that would require him to make a change in the reading, or prompt a change in the treatment of a patient.