VANCOUVER, B.C. – ECG leads were misplaced in 3% of 1,470 pediatric ECGs, based on a review study performed at the Ochsner Medical Center in New Orleans.
Crisscrossed leads were seen in 45 studies; 19 were left arm/left leg reversals, 15 were left arm/right arm reversals, 8 were precordial misplacements, and 3 were right arm/right leg reversals. The majority, 31 of the 45 errors, happened in the pediatric outpatient clinic. Six occurred in the emergency department, and eight in the hospital. While the placements were done by nurses and technicians, pediatric electrophysiologists and other physicians signed off on the reports without catching the mistakes.
Dr. Christopher Snyder
Part of the problem "is the high number of ECGs that you have to read, the low reimbursement rate, and people talking" over your shoulder expecting a quick signature because most pediatric ECGs turn up nothing, said senior investigator Dr. Christopher Snyder, a pediatric cardiologist and electrophysiologist formerly at Ochsner, but now with Case Western Reserve University in Cleveland. "Small chests can also make lead placement tricky; the kids were 10.4 years old on average."
That being said, Dr. Snyder said he reviewed all of these cases "in an hour and 20 minutes. You can pick these out pretty easily" from polarity reversals and other signs.
"I think we need to take maybe 3 seconds to interpret ECGs, as opposed to 1," he remarked.
Dr. Snyder undertook the review after an ECG error resulted in a child being sent to the cath lab at Ochsner with a presumed MI.
"I came in on a Saturday morning and found out that this kid was in the cath lab, and he’d already had his coronaries shot. I ran down there and said ‘this is lead reversal,’ but they didn’t buy into it," even after his coronaries turned out to be normal, Dr. Snyder said. The leads were misplaced; the nurse didn’t understand that "left and right are reversed when you’re looking at someone."
In general, lead misplacement doesn’t result in that much harm, but it does lead to echoes, Holters, and follow-up visits that wouldn’t have happened if ECGs had been done right in the first place, he said.
Dr. Snyder said he had no relevant disclosures.