Okay. You can hear me now because the lights are on me. And I so wish I could sing or dance. That music was nice. But that would clear the room. So I'm Leslie Davis. I think I took Shelly's line. Hello. And welcome to this session titled process improvement initial ECG review and interpretation of guideline recommendations. Dr. Leslie Davis is an associate professor at the University of North Carolina of Chapel Hill. She is a fellow of the American College of Cardiology. And in 2021, Dr. Davis received an ACC distinguished associate award. Dr. Davis currently serves as the chair of the ACC National Cardiovascular Data Registry for the chest pain in my registry steering committee. She has many accomplishments that are outlined in her CV or her biography. Thank you, Shelly. That means I've been around a long time. So we're going to talk about process improvement, initial ECG review and interpretation of guideline recommendations. I learned a long time ago, if you're part of the club, you need the lingo. So it was EKG, but it's ECG, electrocardiogram, if you're in the club. So that's why it says ECG. So I do have some disclosures other than being a chair of the chest pain in my registry. So I'm listening to everything you're saying for improvement of the registry and what should we do differently about definitions, terms, how the evidence matches up. So I'm listening intently. Plus, I am energized by your energy. So in the disclosures, being here has been like a shot of B-12. If you're a Seinfeld fan, Kramer used to get a shot of B-12 and be all energized. That's what it's done for me today. I am a member relevant to this talk. We're going to talk about clinical guidelines. How does that get to help lead what we measure, but we do some of that's based, or a lot, most of it's based on evidence and guidelines. So I am a member of the AHA-ACC Joint Committee on Clinical Practice Guidelines. Not on here. My program of research is with acute coronary syndrome, but I have moved from focusing on time treatment in the hospital to the pre-hospital setting. That is sponsored or paid for or funded by my university and also from the American Association of Nurse Practitioners. So relevant to this. My work is that. Okay. So this is to remind you I'm going to have some polling questions. At lunch they said put some more polling questions in there. So stay tuned for the very last one. That's the one I'm most interested in. But we're going to have some interspersed. So if you didn't get a chance to go ahead and put this QR code in there, my 21-year-old twins have taught me how to do that last year. Just kidding. Yeah, they do teach me most of my technology. So please do that if you haven't already. So the goal for this session is to explore the journey of developing guideline recommendations and how to use them for process improvement. So the objectives that are listed in your program to one, analyze the rationale and evidence backing the guideline recommendations. Why do we do the why? Apply guideline recommendations to clinical scenarios. So we're going to talk about situations. What's your biggest angst? What do you have more issues with at some point? I'll have some polling questions. And really demonstrate when you're done today and I imagine mostly you can do these now, but demonstrate the ability to critically evaluate and incorporate guideline recommendations into clinical decision making. And even beyond clinical decision making, when you're looking at process improvement, how can you use, well, the evidence says this. This is what we do in clinical practice. This is what we're getting from our registry data. And put it all together. And that's why you need a multi-stakeholder panel. All right. So I'm going to give you just a little background about clinical guidelines. You can pull any guidelines that have been published recently. And I'm paraphrasing what they say at the beginning. But this is just to reemphasize. What is the purpose of these clinical guidelines? Now, we hope that many will read it. I mean, I hope the ones, I'm on three writing committees now. I can't tell you which ones. It's not public which ones are coming out and which ones are whose committee members and that sort of thing. But what I'll tell you is, when they come out, we are told our primary audience are cardiovascular clinicians. Now, obviously, there are others that pay attention to these. Those in primary care, internal medicine, surgeons, patients. Most of the guideline committees that I sit on have a patient rep, too. But we're trying to provide recommendations for cardiovascular clinicians, but nonetheless, clinicians who care for those with or at risk for various cardiovascular conditions. All right. We focus on clinical care in the United States. In a minute, I'm going to refer, in a few minutes, to the European guidelines because we're looking. Those guidelines for acute coronary syndrome have come out more recently than we'll see in the ones that are the U.S. guidelines. But our care, you know, once I ask why are there guidelines, Canadian guidelines, European guidelines, you know, U.S. guidelines, well, there's different treatments that are approved in different countries, and also there's different patient populations and the risk factors that get you there for these things. So we focus on clinical care in the United States. The intent is to improve quality of care, not to drive regulations and say, well, what we want insurance or payors to cover. But, you know, that's fresh of mind, too. But what drives the recommendations is the evidence. And sometimes, not often, but sometimes there are recommendations based on expert opinion, the experts at the table that are the writing committee. Now, we meet these recommendations are designed to meet the needs of most, not all patients. In other words, most research is the bell curve. There's going to be some that are over on this side, some on that side that respond to a particular intervention. And when I say intervention, I'm speaking to groups that they think intervention, primary coronary intervention, percutaneous intervention, I'm talking about treatment as an intervention. But it's ultimately just like evidence-based practice is you've got recommendations on the best evidence, you've got a clinician with some very good experience, but there's patient preferences also. So these are designed to give recommendations for most of the patients. All right, so who develops clinical guidelines? I've mentioned a writing committee. A writing committee pretty much is about 15, give or take four or five, that are in the writing committee. Now, and then I'll talk about the joint committee and the peer review committee and then how we get to those. So you have a writing committee. Everything is very structured. There's usually a call for nominations or the American Heart Association and American College of Cardiology, they put in names, but also if they ask for, sometimes you may get emails that say, would you like to nominate someone else or nominate yourself? And I've put my name for those for decades. And, you know, finally I said, all right, I finally broke the glass ceiling. I'm on that. Be careful what you wish for. They meet weekly for a year or so, usually at dinnertime. My family says, what is she doing every Tuesday night at six o'clock for a year and a half? Well, you have these meetings, you need to be on camera. They used to put years ago, I think in the nineties, I was on a pre-hospital ACS thing. They put us in a hotel lobby or a hotel for about three days in your meeting. Nowadays, it's once a week, Tuesdays at six o'clock, for example. That's what I did for a year and a half, but it's sort of fun, but it is work. So that's the writing committee gets together. It's a mix of those with content expertise, different cardiovascular community, which means a different mix, depending on the guidelines. Sometimes, definitely all that I've sat on, there's always a pharmacist, a PharmD, and there's different representation. I represent cardiovascular expertise in the particular topics, but also as a board certified nurse practitioner. A broad variety of backgrounds. That's also with diversity and many ways to define that. And we undergo vetting for relationships with industry. There's a certain percent you can't go over, a certain percent of whether the chair or the vice chair, but that's all vetted. Okay. Then there's the members of the joint committee. So sometimes I wear a member of a joint committee hat and we review and approve a hundred percent of these guidelines. They go through the writing committee that takes about a year or so. The joint committee needs to review and approve this. And then there's also a peer review committee. And some of those things happen simultaneously. So these get quite vetted. And then other organizations, depending on the guidelines, certain organizations will be invited to collaborate and endorse. Collaborate, a member of that organization is on the writing committee. So I want you to say, know that these aren't just thought of in the back room and that's where you get the 10 minutes from. This is based on evidence and lots of vetting, lots of discussion, lots of passionate discussion, lots of poll voting on the Zooms, et cetera. And then we have to like lock our mouth and not say anything until it comes out. And then we're a hundred percent on board. And I think that's the way it should be. It shouldn't be, well, here's what really happened. You know, it has to be where we're a consensus. So they're developed. There's an outline pre-approved. That's usually how we know if a guideline's coming up on the joint committee. And these are not telling tales. This is like you have to approve an outline to begin with. And then writing committee members will get assigned parts. So there's a standard format and that's changed relatively recently. So you'll see the outline's a little bit different, but it's all there. There are rules of brevity. Now I used to think the first time, who's pulled up a clinical guideline and pushed print? You only do that once. Oh, I didn't mean to get 138 pages. So, and that might've been an executive summary way back when. So there are rules of brevity and say, we don't need to give the whole cookbook on how to do X. When it goes, you know, if everybody's writing the same thing to use shared decision making, there shouldn't, which is great. I'm not minimizing the impact of shared decision making, but the same several pages shouldn't be written in every single guideline. Okay. So there are rules of brevity that we're trying to be more efficient and make them live in documents. Writing committee members, once you're on a clinical guideline, you're assigned sections to write. You know those in advance. You're assigned also a primary reviewer for other sections. For example, I might, on one guideline I've written three sections or I've been a reviewer for two or three other sections. They have paid medical librarians. I'm like, where was that during my PhD? Where was that? Or during my NP projects. But they, you give them keywords and that sort of thing, or they'll suggest and nudge you, but they do lit searches. These are very well done. Be careful what you ask for. The first time I said, all right, here's the keywords, here's the journals, last 10 years. Some people, they suggested go back 20 years. I'm like, oh no, 10 years. Well, when I got the 338 citations, I said five years looks good. No, I do like, I review every single abstract and everything, but you give, now it's the PCOT format, the population, the intervention or whatever was being implemented and added, how that was compared to something, comparison group, and an outcome. Timing, if it's important in particular, today we're talking about timing. What you do is you draft that recommendation, and then there's recommendation supportive text, a certain number of words, so it's very brief, and then all these evidence tables to know where we got that information from. You send it in to, quote, the leadership committee. They're very much the leadership committee, some that have been assigned as leaders, and they vet that, and then you bring it to that weekly meeting, and so it's talked about and voted on. Later, about a year later, there's a consensus conference, and every member votes on every particular recommendation. Sometimes something doesn't make it up to be an official recommendation, but there's a nice table or algorithm that we're always keeping that clinician in mind of what's going to be the most useful. I already went through the many, many levels of peer review, and again, the whole process takes a little over a year. We'd like it to be less, but that's what we're working towards. Okay, so how does that? I don't expect you to read every word up there, but you know green is go when you're at a stoplight. That's where you want to be. So there is this class or strength of recommendation, how strong it is, and then you're given verbs that you can use. It really matters if we're saying is recommended versus is useful or may not be helpful, the red. Red means all the way down at the bottom. Class three means it may be harmful. It's not, you know, they're exactly words to use, whereas the level or quality of evidence is more like do we have systematic reviews, lots of randomized clinical trials, all the way down to B, you know, less body of literature and quality randomized controlled trials. They're not going to do a randomized controlled trial relevant to this talk to say, all right, let's do an ECG within one minute. Let's do it within 10 minutes. Let's wait two hours. You know, they're not going to randomize that. Okay, that's unethical. So some things are just not worthy of randomizing. It wouldn't be ethical. So sometimes there's limited data. Sometimes registry data is used. That's observation, the data we get from quality registries. And so all the way down to level C, expert opinion. And the Bs and Cs, sometimes there's different levels within that. Level C could be limited data, but level C can also be expert opinion. All right, so a few questions. How are clinical guidelines then implemented? So we just went 10 or 15 minutes on how do you get those clinical guidelines, because I'm trying to sell that 10 minutes, that 10-minute mark you all are trying to get. Okay, so how are they implemented? Recommendations are only as effective if we use them as intended. So compliance are what clinicians, we look for health care systems and clinicians to be compliant with the recommendation. We use the term adherence for patients. That matters. Clinical care decisions are enhanced if shared decision-making is used based on individual values, preferences. And we need to consider what are those comorbid conditions in context. Is this patient appropriate for that intervention? And again, intervention broadly for the treatment, the plan of care. And patient engagement is a must. So relevant to this talk, what do the guidelines recommend for acute coronary syndrome regarding obtaining and evaluating ECGs for those with ACS symptoms? Drum roll. All right, so we look at AHA and ACC. This is a little old here. 2013, it was the last guideline from the ACC and the AHF for STEMI. 2013, what did it say? Pre-hospital 12-lead ECGs by EMS at site of first medical contact is recommended for patients with symptoms of STEMI. Class 1, we really recommend that. 2, from the evidence, it's right there in the middle. So that's back in 2013, okay? That's where we go. All right, so they had the non-STEMIs. They had their own guideline. 2014, okay, we're getting better. Ten years old. Twelve-lead ECGs should be performed and evaluated. They added a word. So if you just get that EKG and it's sitting over there, that doesn't really drive the care if somebody's done it. So it has to be performed and evaluated for ischemic changes. Okay, it tells you what we do to within ten minutes, not at ten minutes, not a minute before ten, or a second before ten minutes, but within, of their patient's arrival at an emergency facility. Class 1 means the best. We're going to recommend it. Class 1 gets you your verbs. And then level of evidence 3, probably observational stuff. If the initial ECG is non-diagnostic, yet remains symptomatic, the patient remains, the ECG wouldn't be symptomatic. I'm paraphrasing here. Yet the patient remains symptomatic and a high clinical suspicion of ACS. Serial ECGs. Now I put an example in parentheses. That exact timing is not specifically in the recommendation such that it says example, e.g., every 15 to 30 minutes times an hour. Should be, should be performed to detect ischemic changes. Again, should be or is recommended, those are all class 1. Okay, so we'll talk about that. So you're saying is there anything more recent? That was 2013, 2014. Okay, the new ACS guidelines. So they're merging the STEMI and non-STEMI. The new ACS guidelines will come out in the first quarter 2025. We thought they were going to come out in December 2024, holding their breath, maybe, but I suspect it'll be, I looked in this ACC, this is a web link to say when does it say it's coming out. So first quarter, hopefully that'll be like January 1 or something like that. If you click on that link, you're not going to get anything other than that, first quarter. So it's not there yet, but it'll be in the public domain. Do not push print unless you really want to print a lot of pages. I don't know how many pages it'll be, but pay attention. You'll only do that once. So what do we do in the interim? We can look to the 2021 chest pain guidelines. So that was, it's more recent, the last two or three years. This is AHA, ACC, and all the other organizations for the evaluation and diagnosis of chest pain. Now having said that, when the first author presents this they say, if you use the word chest pain, I'm going to wash your mouth out with soap. One time I went to that talk. It's more than chest pain. It's chest symptoms, suspected ischemic symptoms. But for brevity, they say, okay, chest pain guidelines. What I'd say is the first one here is, unless it's a non-cardiac cause is evident. Okay. We're almost at Halloween. If there's a big old knife in your chest and you're having chest symptoms, it's probably not a bad day that you're having an acute MI and acute coronary syndrome, and you've just gotten stabbed here. So if it's a non-cardiac cause is evident of why you're having chest symptoms, then that's going to be a different situation. So if it's non-cardiac cause, and you've taken those to another room, but you suspect chest symptoms, you need an ECG. So that's the first one. If it's unavailable, refer them to the emergency department. So next, patients with clinical evidence of ACS or other life-threatening causes of acute chest pain seen in the office should be transported to the ED, ideally by EMS. Okay. What I put a blue arrow there, in all patients who present with acute chest pain, broadly chest pain, more than just chest pain, regardless of the setting, an ECG should be acquired and reviewed for STEMI within 10 minutes. So that's what we all know. If you're clinicians, you're looking for the STEMI. You're looking for the tombstones. That's what they used to teach people in the 60s and, well, actually, probably in the 70s. Because when we're, all right, raise your hand if you think you know when thrombolytics first came out. So that's when I was an ER nurse. And that's when, wow, that's when we could do something. I have nursing books from the early 80s that say, okay, an acute MITE, you put them in the ICU, bed rest for seven days, bed pan, you know? And all the research was about denial. No wonder people wouldn't come in. You got to be bed rest, nitroglycerin, and say a few prayers. That's what you did. OK, and then we got thrombolytics. And now we know we're trying to look for STEMI because time is muscle. All right, so we do need that 10 minutes. It can go through the rest, but they're here. But we also need troponin. But we're focusing on ECGs. So let's look across the pond in Europe. Their guidelines came out in 2023. What did they say? Darn it, they always get the jump on us. Usually clinical guidelines, they're there a year before us, which is good for the evidence. But the evidence in the body of literature, I said, let's look at what they recommended and what their references say because that might be a preview of what we'll have in our guidelines. Again, they're different. So their recommendations in the chart is to the right. I know it's small. It's hard to see. So I'll paraphrase on the left side of your screen. 12 lead ECGs should be recorded and interpreted as soon as possible. OK, at the first medical contact, target less than 10 minutes. Class 1 should be recommended, those are the verbs, level of evidence B. Serial ECGs, doing more than one, for recurrent symptoms or diagnostic uncertainty. And there's the various charts. So the collective recommendations in the last 10 years and the ones more recently from chest pain MI, or not chest pain MI, see I'm going with the registry, but the chest pain guidelines and the European guidelines are we need to obtain and interpret ECG within 10 minutes of the first medical contact for individuals with suspected ACS symptoms. I'd say think broadly, not just chest pain. They said suspected ischemic symptoms. Now, I used to be a triage nurse. Who works in the ED or in the ER, because that's what we called it before the TV show and everything? So at triage, what do you say? In a sentence or less, why are you here? A sentence or less when it was a busy day. I would say that with a smile. But because they said, well, three years ago, I had this back pain. And then it was here, and then it was there. And you don't say to somebody, what kind of ischemic symptoms are you having today? So you have to translate that. You want to cast a wide net to capture those at highest risk and need of treatment to improve outcomes. So that's my way of saying we do the serial EKGs, which means you do more than one, so that you can pick up on those who didn't declare themselves right away. And also, for those at low risk and a negative EKG and a negative troponin beyond today's talk, we don't really want to expose them. I used to say, why don't you just cath them all? I think I spent a lot of time with interventionists, maybe. But why don't you just cath everybody on the street? Just see who's got it. Let's prevent MIs. Well, that would be too risky. That's way too risky and very costly. All right, so the why behind what we do. Now, one thing Europe does, and their guidelines, they're much longer. But they have the fanciest figures. And so my program of research is really trying to get people off their couch to go in for symptoms. That's what I do. So the symptoms drive the care-seeking decisions. They're not in the first medical contact until somebody gets them up and goes. So symptoms are going to drive the care-seeking decisions. Most of the time we lose to the time of a STEMI patient, ST elevation, opening that vessel, is that pre-hospital setting. So let's acknowledge that. But the ECG is what drives the treatment decisions. It's a big old fork in the road of whether you're going to the cath lab or not. Primary PCI is now the treatment of choice, instead of thrombolytics. Back in the day, I gave thrombolytics. And I think the community hospital I worked at, they must have, or I was helping with the quality improvement. I swear, I think they kept that lytics in their back pocket because they're medium time. I was like, this case, how did they get it within seven minutes? Did they come in with their own EKG? And these were patients in a thrombolytic trial because I was looking at all those forms. So they had to go randomize and even get that. So I was always interviewing. I want to know who those people are that get such great cases because I want to know, how did you get it? And it turned out it was one particular physician. He always wore his cowboy boots. So I just knew he had it in a holster or something. But ECGs do drive decisions. So real time clinical decisions. So I also put on my clinician hat to say, these decisions are real time. They're just not trying to mess with the data abstractor that says, I'm going to get that ECG within two minutes and we're going to get it within three hours over there because I want her to bring the cookies again so they'll emphasize why I need to get my EKGs quicker. They're not trying to game the system. They're trying to do the right thing for the patient. Time to acquire the ECG, time to interpret and act on it. So you're saying, why did 3.1 version? What's the current version? 3.1, the time of interpretation. Some great posters next door that I saw. But time matters. Time is muscle. The less time it takes to get the ECG and interpret and act on it, the shorter time to reperfusion therapy, so whether PCI or thrombolytics, and better outcomes. So what gets in the way? Get ready. If you're falling asleep, I'm getting ready to ask a question. What gets in the way? Time to triage, time to get the ECG, time to interpret the ECG. What gets in the way? Missing documentation, no signature, no time stamp, no something. All right, so I'm trying this out, my patients, for 15 seconds. Choose one, the biggest thing that gets in your way. OK, because I'm really interested in this. I'm a researcher and a clinician. Time to triage, time to get the ECG, 21%. So that's the biggest angst. Time to interpret it. Missing documentation. This is really good. This is really informative. OK, all right. And I would add one for me, time to get from off the couch, or where, and actually, a lot of my research, people do put a lot of mental energy and really trying to sort out symptoms. So I don't want to blame the victim. And it's not about denial. There's a lot that's going on, if you ever want to talk about that. There's a lot of mental and energy and what's going on in your life and your symptoms to make that decision to get in. So I don't want to undermine that. But time to triage, because guess what? There's other people out there, right? And there's what I call the bleeding trauma phenomena. Things in the emergency department, I've been an ER nurse. When there's a bleeding trauma coming in, everybody runs in there. We want to help out, right? And when a patient comes in with an acute MI, ACS, STEMI, once you get the ECG, even symptoms, like I've been there and I'm in a clinical trials perspective where I was the nurse coordinator for that. And everybody goes and helps with that trauma. And I'm waiting for the cath lab to come in and got a defibrillator, I'm ready. And I'm like, how are you doing? Yeah, symptoms are still there. That vessel is not open until that vessel is open. And then they arrest on you, which I love, because I love to shock people. But there you're bleeding trauma. You've got to pay attention to them, too. And everybody doesn't come running when they see all that stuff. So it's time to triage, because they sit out there. So when I took my dad in for suspected ACS, which he had a totally clean cath, by the way. But I took him in. It happened to be snowing that night. Everybody out there, we're all, luckily they registered him. They got his ECG. I think it's standing up somewhere, because there were so many people. But they got it. And I had to look at it real quick. And it was negative. And got his troponins. They got all that. We never made it back to a room. It was snowing so bad. I saw two or three troponin results in the MyChart. And I'm like, we're going home. You got me. We're good. Symptoms had gone away by then. We'd already met everybody from all of Durham, North Carolina coming in with their suitcases. But the point is, triage was rough. It was at a time when COVID was still around at the beginning. So I don't want to undermine that. There's a lot going on back there. All right, so the time it takes to obtain and read an ECG. It's a well-known fact that all time intervals matter. And we've been looking at this issue a long time. So who's that second author? L. Davis. Now, my sisters are both L. Davis. So we all take credit for each other's publications. But anyway, that is me. So back in the 90s, as I was a data abstractor, this was before NCDR, I paid attention to all these time intervals. We didn't have that middle one, time to interpret the ECG. But this was the first of our papers that we did. And there was a second paper that followed this. But I took those case report forms that were three level and interpreted that data with some stats and things. We knew the time to get an ECG. And I'd have to, I can't remember from 1999. So this research was probably 1998. I'm pretty sure the median time was like five minutes, because they were so good at getting ECGs. But we found out, why did it take? And this was a place that didn't have primary PCI. They were giving thrombolytics to everybody. Their median time to thrombolytics, I told you. I look at every chart. And I was like, wow. They amazed me. But women and the elderly took much longer to get thrombolytics. And back then, I was scratching my head of what takes so long. So we weren't looking at time to interpret, because the ECG was in the hands. And it wasn't a metric we paid attention to back then in a data registry. But something was going on. So I hit the books and the literature. It's like, what is going on with women? And now we've seen even women providers with women patients. Is it implicit bias? Now, I said women are 10 years older. Women have more comorbidities. It must be the comorbidities that are related to whether they're eligible. I went to all the literature. But back then, we knew there was different treatment. We weren't collecting interpretation. But we knew the longer it takes to get, we didn't have the decision time. But we knew ECG time drives treatment. There's some other stuff that drives treatment as well. All right, so I'm trying to wake you up. This is like, all right, all you clinicians, we need to see some ECGs. I put some color coding in there to help you. On the next slide, it's going to give you four choices of what this is. So take a look at the yellow and the blue. And if you don't know anything else, you're looking for tombstones if you're worried about stimmies, stuff that looks like that. Usually, we're down near the Riverwalk. And it's around October. I go to another conference. And it's all about that, tombstones. All right, so what does this ECG reveal? All right, you ready? So it doesn't have the picture. All right, 92% say a stimmy. All right, who's that 1% that says it was normal? OK, because you said, all right, it's not normal. And the patient, pay attention to the patient. I have a book, Another Disclosure. But always, it's top secret. It's the first and last secret. Always pay attention to your patient. Of course, if you're a data abstractor, you've got to pay attention to the chart, the electronic health record. But that was not a normal ECG. The stimmy, yes, those tombstones in yellow. It was an anterior lateral MI. Non-stimmy, a friend of mine that used to take an EKG class with me, ECG, back in the late 90s, she really paid attention to ST depression. She was a pulmonary person. And I said, but all this over here, this is ST elevation. Oh, but this is that ST depression you taught me about. I was like, yeah, that's the jealous sister. This is over here. But either way, the patient would have gotten out of her clinic because she saw something. And she said, it sure would help if they would come lit up like this. Maybe that's what AI can do for us. Bundle branch block. Bundle branch blocks are pretty scary. When I teach 12-week classes and I look at a bundle branch block, whoo, those tombstones come out at you. I love rabbits, so right bundle branch blocks are fun, the rabbit ears. But left bundles, they really get your attention. But that, in particular, was a stimmy. All right, I'll keep you active. All right, so serial ECGs, why bother? If the first ECG is negative, you need to obtain more according to the guidelines collectively of what we know. They talk about symptoms are a high index of suspicion for ACS. I always wonder, do they just put the hand over you and say, I just have a feeling? But no, it just looks, it's everything about it. If you're a clinician, you know. If somebody's moving around the bed a lot and very anxious, I know that person's going to cove. They don't have enough oxygen. You know it when you see it. But if there's a high index of suspicion, symptoms are worsening and acute decompensation. Their condition has changed dramatically. Now, if you're an ER nurse and somebody comes, you need to go check on so-and-so. What does that mean? They're coded. They're gone. And you'll never find that text. Somebody that came and told you, go check on so-and-so. You're not waiting until go check on so-and-so because that means they're sort of out. You're going to be doing CPR, not getting an EKG. But in this case, these are the things you're looking at, that that first ECG was negative and you're looking for them to change. And I call them, they haven't declared themselves. And a lot of times, this might happen to an early presenter where they must live next door. They must be on Franklin Street near Chapel Hill. But they just, their first ECG is negative. And who is that likely to happen? The world, for 25, 30 years, we know it takes people on average two and a half to three hours to get to the hospital in whatever means possible. We know that only 40% worldwide use an ambulance, even in some countries where it's free. And so we know. But if you're an early presenter, you're less likely to have it. In my work in the 90s, looking at every single ECG, a 200 a year of these cases after the fact, I know that inferior MIs, those ST elevation in the inferior leads, sometimes they're barely there. One or a millimeter or something in that, one of those two, three are AVFs. And the other one, it's hard, it's not much there. So we keep doing those ECGs in a symptomatic patient. In the pre-hospital setting, they say don't delay if you can't get an ECG. Do it en route, just go, scoop and go. Don't spend an hour or two at the house. All right, this is our question. What percent, if you have a patient and you think they're ACS, and the first ECG's negative, and we're gonna keep doing these for that first hour or so, unless there's a decompensate after an hour, you'll do another, what percent will turn positive when that first one's negative? Because we know about one out of 10, about 11% of people with a STEMI, that first ECG was negative. This question's different. First ECG, negative, what percent will change? Or with serial EKGs, it'll come up. So first ECG's negative. Wow. Wow. Wow. I wish 25% would show up. So, on average, like number one and number two is probably around. Some studies show about 8% that second or third might turn positive. Some say 15%. So the point is, if you say, oh, I better do another one, it might turn positive. It's not going to be 100%. But you're going to get some yield out of it. You keep doing it. 15, usually 15% is about what it is. Some studies 8%. I wish it were one out of four. But that's if these are stats based on if the second or third one would turn positive. So this is an example. I don't know if how easy or hard it is to read. But this is an example, like in the center of your screen, where if it was a green line, that was normal and it might raise. I mean, luckily, those are anterior MIs, like 2, 3, 4, V2, 3, 4. They're really going to get your attention. Those ones, now what happened with lead three? I don't know what's going on there. It probably means nothing if it's just one lead. But something would happen where it's this way and then it goes up. It's going to declare itself. Now, you might ask, we don't have this question. If somebody's a STEMI, so the ST elevation's up, and they've had their ECG, and they're sitting in your waiting room or sitting wherever, and nobody's interpreted this or nobody's done any reperfusion, what's going to happen with that ST segment? Who knows? Is that ST segment going to stay up until something's done? Is the ST segment eventually going to go back down? Or you don't know. So number one, raise your hand if you think the ST segment will go up. I don't know if I remember the same order, but if it goes up and then it'll come back down at a set point. Raise your hand if you think that. Raise your hand if you think it'll go up and it'll just stay up because it hadn't been reperfused. Raise your hand if you don't really know. Okay. So STEMIs, in general, it's a dynamic process because people say they have an acute MI. I teach men and women who have had one. How do we know? When did it happen? It can take up to about 12 hours for the ST elevation to go up. Eventually, it's going to come back down because the damage is done. The vessel is blocked and everything distal to that, you're going to death of the myocardium. Okay. So the ST segment will go up. If they don't have a V-fib arrest and die, it'll come back down, and you'll have Q waves. I'm saying that because I'm saying that seriously in the fact that if they survive, because most people, 50% or so, the first symptom is your acute MI. Okay. Most symptoms don't start until something's 70% or more blocked, and you can have an MI when something's 50% or more blocked. So that's why most of the time your STEMIs are the first time symptoms. Okay. So in this case, if it's normal and it comes in, that ST segment is dynamic. When you present early, it might not show up yet. Just like troponins are going to rule in within a few hours, but not always if they present within 15 minutes. So you're doing those over time. So what gets in the way? What else can make that EKG or ECG look different? STEMIs. So what gets in the way? Posterior MIs. That's the back. We put the leads on the front. Okay. Back in the 80s, the company that made the thrombolytics we were using the most, they were trying to teach us to put them on the front, put them on the back, put them on the right side, or maybe put them on the head, feet, whatever you could do to pick up these MIs. So you give the lytics. I don't know. And so what I'll say is posterior MIs, you could put leads on the back, and there are some studies about that. If you ever do, it's going to be very little ST elevation, very little, because you've got to go through all that stuff to get there. You know, ECGs are in the front there. And so what we look for is V1 and V2 will be ST depressions, because upside down is the version that would be upright on your back. Okay, so posterior mize, the back of the heart, where the vessel goes, those are hard. You have to look at V2, V3, those V leads for ST depression. Right-sided infarcts, we typically don't put leads on the right side of the chest. We do know about 50% of inferior heart attacks on that bottom right of the heart do show up as the right side. The closest you can get to the right side without going in that chest is right-sided leads. So at our place, we make sure if it's an inferior MI that we do leads on the right side before that person leaves that's doing the ECGs. Bundle branch blocks mess it up. I love looking at them, but if it's a new or presumed new bundle branch block, back in the 80s, we would give thrombolytics for that if it's new or presumed new, because you say, have you ever had a bundle branch block? And they say, never had an EKG. Well, one of the complications in a ST segment elevation MI is you can have a bundle branch block and you don't know which came first, but you need clinical correlation with that. 100% paste, it looks like it's a ST segment elevation. Can't say, excuse me, can I cut off your paste maker and we'll see what's happening below that? You can't really do that. There's other things that get in the way with that. Pericarditis, it looks like ST elevation on the whole ECG, and you think, ah, I was having a bad day. It looks like the whole heart. You can't really have that. That could be pericarditis. So there's things that get in the way. All right, and then we learn, so the ECGs, they matter. We look at not only is it ST segment elevation, but we look what type of MI. When you first learn that, you wanna say, ooh, I can use this alphabet suit. They were having an antireceptor lateral, because I had V1 through V6. All you need to know is you have some ST elevation, it looks bad, I need to get them out of my office if I'm a nurse practitioner. There's a gonna kill ya, potentially, and you gotta get them out. Yeah, am I having a heart attack? Yeah, yeah, let's just get you in this ambulance. Let's go. But so that tells them which vessel maybe to squirt with the dye. So that matters. All right, so an anterior STEMI with a left bundle branch block here, this is supposed to be. All these ECGs are available in the public domain that have permission, so I don't go to Wikipedia for my source of evidence, for sure, but that's where you can use free, and then me as a clinician make sure that this is what is an example of, but this is an anterior STEMI with a left bundle branch block where the ST segment elevation, like a tombstone, where it looks at you, V3, V4, V5, with a left bundle branch block. Now that I'm sitting here, I'm arguing that QRS is not that wide. I don't know why Wikipedia called it like that, but this is a teaching point to say that this sometimes can confound it. All right, so back to the registry. You said we're here for a purpose. This is Quality Summit. We're talking about the registry. I'm trying to convince you that ECGs are important and convince you from the guidelines that 10 minutes matters, and more than just getting it, acquiring it, but actually interpreting it, and knowing the time stamp so you know where the process improvement, where you can improve. Okay, so where does the chest pain MI registry data capture this ECG data? So luckily, Shelly helped me find this so I can get a picture, and somebody asked me a question about like data .12278. I don't remember those exact codes because I'm not boots on the ground anymore. We didn't have electronic online stuff, so I didn't remember it, so I had to get a picture of this. So you have where you do more than one ECG. Back when I did it, it was called EKG, so it's ECG date and time, ECG read date and time, and STEMI or non-STEMI or STEMI or STEMI equivalent. On the PCI for acute STEMI, it says it's the first ECG, and so there are places in the data form. So missing data is a problem. Missing data is a bane of my existence because I'm always interested in symptom onset. That's my research, and about half of the charts only have symptom onset in there. Now part of it is documentation is done in real time for clinical purposes. Those clinicians are not thinking about who's going to abstract this later. They might have heard in a meeting and all this, but they are really trying to do the right thing for every patient that they're seeing one at a time. So the primary purpose of documentation in a med record is definitely for clinical purposes. Still, the old saying, if it's not documented, it's not done, so they know that. Yet data collected for performance improvement or research, I'd say, is dependent on complete data. We know, again, like 40 percent of them because I do symptom data. The symptom data's not there. And so you can drill down to the patient level to identify opportunities for improvement. Delays in care, how useful is it to obtain an ECG quickly if no one interprets and acts on it? So again, selling the point of why we have that data capture that point. Do all clinicians practice at the top of their license? Who acquires the ECGs, which means gets them. That's a fancy word in the guidelines. Who reads or interprets these, and who documents these activities? So here's a question for you. Who interprets, and actually we were missing a question, so we were supposed to get, is it not there? Who interprets? There was one supposed to be who gets the ECG, and this one's supposed to be who interprets, so we're leaving off the acquisition. Who interprets ECG? This is actually, I want you to take a different verb here. This is supposed to be who acquires. So that's the question. Who acquires the ECG? An ECG tech, a nurse at the bedside, triage standing like they did with my dad, but he sat down, but they stood, or an emergency department physician, NP or PA or cardiologist. Who acquires the ECG? Okay. This is assuming who acquires it once you get in the hospital because EMS could acquire. So 61 percent of techs, nurse at the bedside, emergency department provider, cardiologist, and this is who then interprets or documents the findings. So let's do this one, and I'll talk. So who do you time stamp them, but it takes a human to do something. Either time stamp it, sign it, something, type in something. So who does that in your place? Is it a scribe? Is it a nurse at the bedside? Is it one of those providers or a cardiologist? Who documents the ECG findings? So one was who obtains it. This is who documents. Okay. So it's, I don't like the word provider. It's a nurse practitioner, and we're trying to get away from that at the college because it's an insurance term that was created. So of that laundry list of number three, you know, there are fast tracks. There are different things in emergency department, but it takes somebody of their scope of practice and their licensure to be able to do that. Luckily, we don't require that a cardiologist comes look to every single ECG. That's not resource allocation, and that would slow care down. We did a study once with Thrombolytics that our institutional review board wanted the chaplain to be a part of all conversations before they went to the cath lab. I'm like, whew, that would scare them, and that would slow things down at 3 a.m. And we had to talk to them. It's like, nobody else does that in the world, and that would be unethical. So the chair of all of IRB said, who thought of that? Where'd that come from? So we do matter who does ECG and who documents it. So I am going to give a shout out to two people because I'm going to give some examples from mine. Lynn did a time to ECG with two other nurses. Is there a Lynn Taggart here? Does anybody see a Lynn Taggart? Or Chris? Okay, so shout out to that poster in there, and then Crystal Payne, be ready. All right, so this was time to get an ECG, and I was very impressed by that poster. We did something similar. I wanted to see the long time. I'm going to paraphrase, and I know I've got 10 minutes and 51 seconds here for the rest of the talk. But you looked at how, in your place, it was taking a while to get ECGs. I'm going to paraphrase this, so go with me and nod. Okay, so it took a while to get them, and then you implemented that you were having somebody write a triage, a nurse that, so this same thing happened to me early days in the 80s. We were calling EKG tech to come down from the academic institution, not UNC Chapel Hill where I work, but somewhere, it would take an hour to get an ECG, and that was separate from registry. That was real clinical time, and we were like, oh, back then, we thought, you better not give a nitro because if it makes the EKG change, then you won't know what it was. That's not good in the early 80s. So then we implemented everybody in the place knows how to do an ECG and doesn't mind doing one. So to make your beautiful poster very simplistic, but you went amazing results that not only changed your time to get an ECG, but also changed all the care in the STEMIs to open those vessels, and yours are crystals. One of you also did cost implications. I mean, it was amazing. Did yours do cost, or was it crystals? Somehow, it was an amazing poster. Three nurses, right? Yeah, the power of three, so it was amazing, and then crystal. Crystal's here. It was about the time stamp. I don't know if crystal's here. Somebody has to tell me because I can't see with the lights, but those two posters, if you haven't gotten a chance, please go see them. So what issues, whatever you face, you tackle one problem at a time. So was that a good shout-out? Did I do it right? It was okay? The poster's great? All right, so finding the data in the health record. That's finding the data. Now, when I did all my stuff, it was hard copies. You had to find the ECGs. There might have been a little spot of blood where they put the IV in or something, and then you had the hard copies. So everything's automated, electronic now. Finding the data, delay between first medical contact and the ECG, this is going to be a polling question, or are you dealing with this delay time to get the ECG and interpretation? That's what Crystal's group was. Or y'all aren't doing the serial ECGs? That's an issue. All right, and I know you don't have that metric as much, but what's your angst? What are you dealing with? All right, 28% said finding stuff. I mean, who's an abstractor here? When you find something that's hard to find, you're like, yes, because you have a personal mission to find that, right? And sometimes, because you're so good, you might find that ECG that was from that volunteer that was on an EMS truck, and they found it, and your data doesn't look so good because they don't totally interpret things and timestamps, and it takes a little bit longer, but it's somebody out there that did it. But you find things. You're the one that can do that. So finding the stuff is hard, and that's when you, if you can talk to the people in your IT or your Epic or whatever vendor you use for electronic health record, just find it and share your secrets. That delay time between first medical contact and ECG acquisition or the delay time, so 40% is that interpretation. Now, Crystal's poster in there was talking about the missing documentation and the timestamp, and that was an amazing poster. I'll shout out those cardiac rehab virtual later. I got you. So there were some very good posters, or not doing the serials. All right, so what I say, local problems require local solutions. If there was one motto for this whole conference is, you've got to get your team together and see what you're doing and what would work. The poster that Crystal and her group did in that, and that I've just looked at during the break in the electronic posters, really showed that they got together and they created a timestamp. Creating stuff that looks great and everybody buying into it. I don't know if I'll get Jason to create a risk stratification model after he told me some people didn't use them before. But whatever you create that works, those solutions come from real places. Local problems require local solutions. But the NCDR has several resources, toolkits, coming to conferences like this every year, looking at these posters. I'm so juiced up about those. They're great things. And what else? So here's your last polling question. Because Shelly, I'm trying to get through. I'm trying not to give you six minutes, because you'll give me hard questions. All right, so take your time. What are your plans for this evening after the networking? Because you'll come to that. I'm going to go put on my tennis shoes. Are you going to hit that lazy river? Are you going to grab the s'mores kit at the front desk at 7 PM? I say, just give me the chocolate. But go get a couple of kits. Go downtown to the Riverwalk. I'm not telling. What happens in the Quality Summit stays in the Quality Summit. What are you going to do? Oh, not telling. Not telling. OK, hit that lazy river. Although I did see what I thought was a squirrel on a branch yesterday. And it turns out it was an iguana. But they hang on to those branches, so it won't fall down on you. The s'mores kit, OK, you already got those last night. Riverwalk, OK, usually I don't like to be the last speaker on the last day. Because usually in New Orleans, I'm the last speaker on the last day. And nobody shows up. So Riverwalk won't be so bad. But not telling. OK, Shelly, I'll take the questions. Be gentle. OK, well, we only have five minutes. So we'll try to get through as many as possible. The first one is, how do we get our busy ED on board with the ECG within 10 minutes? They are too busy to make that happen. Yeah, so one of those two posters talked about, all right, so if I put on my ED nurse hat and knowing that this world has changed since the 80s and 90s, I was there an ED nurse at Duke when we put in bullet-like things that people had to go through the metal detectors. The world changed in the 90s. The world has drastically changed now. I couldn't go, first of all, I couldn't get an IV in if it saved my life. So the world has changed. These are busy clinicians. There's a lot of burden over, like, people leaving. Patients are leaving. It's a harsh condition. I think cookies help a lot. Telling personal stories, talking about this case really. I think when I shared a story, going to somebody and saying, you took care of this patient. Tell me how you knew to do that. Reinforce good things. I really have used those. How did you know that that was a posterior myop in the CCU? I'm like, how did you figure that out? How did you know it was right-sided when they crashed in their jugular vein distension clear line? How did you know? And they were like, oh, we routinely do that. So reinforce really good behaviors. And you've got to have some champions. And once they get that seed and bite it, just like many of you coming here, sharing those stories, and try not to slap hands. You all are going to know better than me. But sharing those stories, beyond today's talk, we've got to do better on what we can do to improve care. The ECG is really about those STEMIs. And today, when Maria this morning shared about the parents with that, we've all had stories. But it makes a difference. Time is muscle. Time is muscle. And regular and often reminders, not a one and done. And cookies. I make a lot of cookies. When I did clinical trials, and we were the top one in the nation of enrolling into these, and putting on ST segment continuous monitors in the 80 and 90, do you think those ER nurses or cath lab nurses wanted those? No. But I was like, here's why we do it. And that was a lot. The why? Now, I'll tell you. I can add to this. We have data. Go to the detail lines within the e-reports dashboard. And there is a detail line that measures ECGs within 10 minutes. You have the data. Take it to your physician champion. Show them. This is how we're doing. How can we improve it? It takes a team. It takes a team to make changes. And actually, at that point, I say boots on the ground, tennis shoes on the ground. It's going to be the people that get the thing. Know in your place who's. We've talked a lot about team approach. Who gets those ECGs? Who makes the difference? One on a shift or on a weekend, you know the people that will make sure it gets done. And they'll get after those people in a good way. Now, if you ask the question of how to timestamp it and do all that, because the posters that talk about the timestamp are finding that time, missing data about 40% of the time, once you get that, of why it matters. And what you're looking for, not just get it. Because you take a person that gets one, and they find a STEMI, and they run it, and they save the day. That's what we live for. It's not to go in and work in the ER and give enemas and take care of the stomach aches. We don't live for that. We like the trauma codes. We like the STEMIs. You found it. OK, so the next one. We are great with ECGs within 10 minutes, but we struggle with interpretation, then activation of the lab. Any ideas to speed this up? Well, one time, they asked me to come talk to the health department where they, and I mean, you can teach anybody how to look for STEMIs. And we want people to overread. So the STEMI one, like anybody that does an EKG, if they see something change, and they'll run it to somebody quickly. Now, what you want to do for the, I'm going off the cuff here, so I'm thinking on these questions. You need that timestamp still. I mean, it's going to take the provider, I don't like that word, but for simplicity, I'm going to use it now. It's going to take the provider, because one issue is documenting the timestamp. The other is, is it actually being interpreted? For care, we need it interpreted to then drive cases. Now, if you see that STEMI, now there is a discussion. I mean, so it's one, if we go to the whole quality summit, you need to pull the team in and see what's happening. Local problems, local solutions. Local problems, local solutions, and then talk to your NCDR people. But I think one thing is training the people on the ground that do the ECGs to know the why. Show them examples. The serial EKGs, that would be a little harder to sell, but you need to keep doing those. I don't know if I've helped with that. Well, we are at time. So thank you so much, Dr. Davis. This has been fabulous. Thank you.

ECG interpretation

acute coronary syndrome

clinical guidelines

process improvement

patient outcomes

serial ECGs

team-based approach

real-world data

healthcare optimization

cardiac guidelines