Elucidating system-level interdependence in electronic health record data: What are the ramifications for trainee assessment?

CONTEXT: The electronic health record (EHR) has been identified as a potential site for gathering data about trainees' clinical performance, but these data are not collected or organised for this purpose. Therefore, a careful and rigorous approach is required to explore how EHR data could be meaningfully used for assessment purposes. The purpose of this study was to identify EHR performance metrics that represent both the independent and interdependent clinical performance of emergency medicine (EM) trainees and explore how they might be meaningfully used for assessment and feedback. METHODS: Using constructivist grounded theory, we conducted 21 semi-structured interviews with EM faculty members and residents. Participants were asked to identify the clinical actions of trainees that would be valuable for assessment and feedback and describe how those activities are represented in the EHR. Data collection and analysis, which consisted of three stages of coding, occurred iteratively. RESULTS: When faculty members and trainees in EM were asked to reflect on the usefulness of using EHR performance metrics for resident assessment and feedback they expressed both widespread support for the idea in principle and hesitation that aspects of clinical performance captured in the data would not be representative of residents' individual performance, but would rather reflect their interdependence with other team members and the systems in which they work. We highlight three categorisations of system-level interdependence - medical directives, technological systems and organisational systems - identified by our participants, and discuss strategies participants employed to navigate these forms of interdependence within the health care system. CONCLUSIONS: System-level interdependence shapes physicians' performances, and yet, this impact is rarely corrected for or noted within clinical performance data. Educators have a responsibility to recognise system-level interdependence when teaching and consider system-level interdependence when assessing the performance of trainees in order to most effectively and fairly utilise the EHR as a source of assessment data.

Evaluation of the Uptake of a Prehospital Cardiac Arrest Termination of Resuscitation Rule.

BACKGROUND: Previous research has focused on creation and validation of a basic life support rule for termination of resuscitation (TOR) in nontraumatic out-of-hospital cardiac arrest (OHCA) to identify patients who will not be successfully resuscitated or will not have a favorable outcome. Although now widely implemented, translational research regarding in-field compliance with TOR criteria and barriers to use is scarce. OBJECTIVES: This project aimed to assess compliance rates, barriers to use, and effect on ambulance transport rates after implementing TOR criteria for OHCA. METHODS: Retrospective chart review of patients ≥ 18 years with OHCA. Data from regional Emergency Medical Services agencies were collected to determine TOR rule compliance for patients meeting criteria, barriers to use, and effect of a TOR rule on ambulance transport. RESULTS: There were 552 patients with OHCAs identified. Ninety-one patients met TOR criteria, with paramedics requesting TOR in 81 (89%) cases and physicians granting requests in 65 (80.2%) cases. Perceived barriers to TOR compliance included distraught families, nearby advanced-care paramedics, and unusual circumstances. Reasons for physician refusal of TOR requests included hospital proximity, patient not receiving epinephrine, and poor communication connection to paramedics. Total high priority transports decreased 15.6% after implementation of a TOR rule. CONCLUSIONS: The study found high compliance after implementation of a TOR rule and identified potentially addressable barriers to TOR use. Appropriate application of a TOR rule led to reduction in high-priority ambulance transports, potentially reducing futile use of health care resources and risk of ambulance motor vehicle collisions.

Morbidity and Mortality Associated with Prehospital "Lift-assist" Calls.

INTRODUCTION: When an individual requires assistance with mobilization, emergency medical services (EMS) may be called. If a patient does not receive treatment on scene and is not transported to hospital, these are referred to as "Lift Assist" (LA) calls. It is possible this need for assistance represents a subtle onset of a disease process or decline in function. Without recognition or treatment, the patient may be at risk for recurrent falls, repeat EMS visits or worsening illness. OBJECTIVE: To examine the 14-day morbidity and mortality associated with LA calls and determine factors that are associated with increased risk of these outcomes. METHODS: All LA calls from a single EMS agency were collected over a one year study period (January-December 2013). Calls were linked with hospital records to determine if LA patients had a subsequent visit to the emergency department (ED), admission, or death within 14 days of the LA call. Logistic regression analyses were completed to determine factors predicting ED visit or hospital admission within 14 days of the LA call. RESULTS: Of 42,055 EMS calls, 804 (1.9%) were LAs. These calls were for 414 individuals; 298 (72%) patients had 1 LA, and 116 (28%) patients had >1 LA call. There were 169 (21%) ED visits, 93 (11.6%) hospital admissions and 9 (1.1%) deaths within 14 days of a LA call. Patient age (p = 0.025) significantly predicted ED visit. Patient age (p = 0.006) and an Ambulance Call Record missing at least 1 vital sign (p = 0.038) significantly predicted hospital admission. CONCLUSIONS: LA calls are associated with short-term morbidity and mortality. Patient age was found to be associated with these outcomes. These calls may be early indicators of problems requiring comprehensive medical evaluation and thus further factors associated with poor outcomes should be determined.

Effect of out-of-hospital noninvasive positive-pressure support ventilation in adult patients with severe respiratory distress: a systematic review and meta-analysis.

STUDY OBJECTIVE: Noninvasive positive-pressure ventilation (NIPPV) is increasingly being used by emergency medical services (EMS) for treatment of patients in respiratory distress. The primary objective of this systematic review is to determine whether out-of-hospital NIPPV for treatment of adults with severe respiratory distress reduces inhospital mortality compared with "standard" therapy. Secondary objectives are to examine the need for invasive ventilation, hospital and ICU length of stay, and complications. METHODS: Electronic searches of MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, and Cumulative Index to Nursing and Allied Health Literature were conducted and reference lists of relevant articles hand searched. Randomized controlled trials comparing out-of-hospital NIPPV with standard therapy in adults (aged ≥16 years) with severe respiratory distress published in English were included. Two reviewers independently screened abstracts, assessed quality of the studies, and extracted data. Data were pooled with random-effects models and reported as risk ratios (RRs) with 95% confidence intervals (CIs) and number needed to treat (NNT). RESULTS: Seven randomized controlled trials were included, with a combined total of 632 patients; 313 in the standard therapy group and 319 in the NIPPV group. In patients treated with NIPPV, the pooled estimate showed a reduction in both inhospital mortality (RR 0.58; 95% CI 0.35 to 0.95; NNT=18) and need for invasive ventilation (RR 0.37; 95% CI 0.24 to 0.58; NNT=8). There was no difference in ICU or hospital length of stay. CONCLUSION: Out-of-hospital administration of NIPPV appears to be an effective therapy for adult patients with severe respiratory distress.

A prospective evaluation of the utility of the prehospital 12-lead electrocardiogram to change patient management in the emergency department.

OBJECTIVE: Retrospective research has shown that 19% of 12-lead prehospital electrocardiograms (prehospital ECGs) had clinically significant abnormalities that were not captured on the initial emergency department (ED) ECG and had the potential to change medical management. The purpose of this study was to prospectively determine how many prehospital ECGs had clinically significant abnormalities not present on the initial ED ECG and determine how many prehospital ECGs changed physician management. METHODS: We conducted a 3-month, prospective cohort study of patients who had a 12-lead prehospital ECG completed by EMS prior to arriving at one of two tertiary care EDs. STEMI bypass patients were excluded. Physicians reviewed the prehospital ECG to determine whether there were any clinically significant abnormalities present on the prehospital ECG not captured on the initial ED ECG. Physicians recorded if and how the prehospital ECG changed their management. RESULTS: A total of 281 patients were enrolled. Thirty-five (12.5%; 95% CI: 9.1%, 16.8%) prehospital ECGs showed changes that were not captured on the initial ED ECG (11 ST depression, 5 T-wave inversion [TWI], 2 ST depression and TWI, 12 arrhythmia, 2 arrhythmia with ST depression, 2 ST elevation, 1 unknown). Fifty-two (18.5%; 95% CI: 14.4%, 23.5%) prehospital ECGs influenced physician management. There were 30 (10.7%) instances where physicians were willing to refer the patient to an inpatient service based on information captured on the prehospital ECG, regardless if the initial ED ECG was normal. CONCLUSIONS: Prehospital ECGs show clinically significant abnormalities that are not always captured on the initial ED ECG. Prehospital ECGs have the potential to change the management of patients in the ED.

Developing and authenticating an electronic health record-based report card for assessing residents' clinical performance.

Purpose: The electronic health record (EHR) is frequently identified as a source of assessment data regarding residents' clinical performance. To better understand how to harness EHR data for education purposes, the authors developed and authenticated a prototype resident report card. This report card used EHR data exclusively and was authenticated with various stakeholders to understand individuals' reactions to and interpretations of EHR data when presented in this way. Methods: Using principles derived from participatory action research and participatory evaluation, this study brought together residents, faculty, a program director, and medical education researchers (n = 19) to develop and authenticate a prototype report card for residents. From February to September 2019, participants were invited to take part in a semistructured interview that explored their reactions to the prototype and provided insights about how they interpreted the EHR data. Results: Our results highlighted three themes: data representation, data value, and data literacy. Participants varied in terms of the best way to present the various EHR metrics and felt pertinent contextual information should be included. All participants agreed that the EHR data presented were valuable, but most had concerns about using it for assessment. Finally, participants had difficulties interpreting the data, suggesting that these data could be presented more intuitively and that residents and faculty may require additional training to fully appreciate these EHR data. Conclusions: This work demonstrated how EHR data could be used to assess residents' clinical performance, but it also identified areas that warrant further consideration, especially pertaining to data representation and subsequent interpretation. Providing residents and faculty with EHR data in a resident report card was viewed as most valuable when used to guide feedback and coaching conversations.

Provision of immobilization or ice by paramedics in Southwestern Ontario.

OBJECTIVES: Pain is the most common reason for prehospital transport. As emergency wait times increase, timely pain management is essential. In children, there is abundant evidence that prehospital pharmacologic analgesia is suboptimal, but little is known about non-pharmacologic therapies. We sought to characterize documentation by paramedics of non-pharmacologic (immobilization and ice) and pharmacologic analgesia in children with musculoskeletal injuries. METHODS: We reviewed all ambulance call reports for children 0-17 years transported to Southwestern Ontario regional hospitals from January 1, 2017, to December 31, 2019, with a musculoskeletal injury (Ontario Ministry of Health and Long-Term Care problem codes 66 and 67). Primary and secondary outcomes were documented immobilization or ice and pharmacologic analgesia, respectively. In a multivariable analysis, we explored the relationship between immobilization or ice and the following a priori covariates: age, sex, visible deformity, crew type, pain severity, and analgesia. RESULTS: Of 40,692 ambulance call reports reviewed, 4445 met inclusion criteria. There were 2584/4441 (58.2%) males, with a median (IQR) age of 14 (10, 16) years. In ambulance call reports with documented pain scores, 2106/3048 (69.1%) ambulance call reports reported "moderate or severe" pain. Immobilization or ice were documented in 1605/4445 (36.1%) and 385/4445 (8.7%) of ambulance call reports. Pharmacologic analgesia was documented in 275/1983 (13.9%) and 125/991 (12.6%) of ambulance call reports for primary care paramedics and advanced care paramedics, respectively. An increased odds of documented immobilization or ice was associated with moderate or severe pain [OR: 2.4; 95% CI 1.84-3.17; p < 0.01] and visible deformity [OR: 2.5; 95% CI 1.97-3.12; p < 0.01]. CONCLUSIONS: Documented immobilization and ice and pharmacologic analgesia to children by paramedics is suboptimal. Our findings underscore an important need for enhanced education surrounding the benefits of non-pharmacologic options for children with musculoskeletal injuries.

RéSUMé: OBJECTIFS: La douleur est le motif le plus fréquent de transport préhospitalier. À mesure que les temps d'attente aux urgences augmentent, la gestion de la douleur en temps opportun est essentielle. Chez les enfants, il existe de nombreuses preuves que l'analgésie pharmacologique préhospitalière est sous-optimale, mais on sait peu de choses sur les thérapies non pharmacologiques. Nous avons cherché à caractériser la documentation par les ambulanciers paramédicaux de l'analgésie non pharmacologique (immobilisation et glace) et pharmacologique chez les enfants souffrant de lésions musculo-squelettiques. MéTHODES: Nous avons examiné tous les rapports d'appels d'ambulance pour les enfants de 0 à 17 ans transportés vers les hôpitaux régionaux du Sud-Ouest de l'Ontario du 1er janvier 2017 au 31 décembre 2019, avec une blessure musculo-squelettique (codes de problèmes 66 et 67 du ministère de la Santé et des Soins de longue durée de l'Ontario). Les résultats primaires et secondaires étaient l'immobilisation documentée ou la glace et l'analgésie pharmacologique, respectivement. Dans une analyse multivariable, nous avons exploré la relation entre l'immobilisation ou la glace et les covariables a priori suivantes: âge, sexe, déformation visible, type d'équipage, intensité de la douleur et analgésie. RéSULTATS: Sur les 40 692 rapports d'appels d'ambulance examinés, 4 445 répondaient aux critères d'inclusion. Il y avait 2584/4441 (58,2 %) hommes, avec un âge médian (IQR) de 14 (10,16) ans. Dans les rapports d'appel d'ambulance avec des scores de douleur documentés, 2106/3048 (69,1 %) rapports d'appel d'ambulance ont signalé une douleur "modérée ou sévère". L'immobilisation ou la glace ont été documentées dans 1605/4445 (36,1 %) et 385/4445 (8,7 %) des rapports d'appel d'ambulance. L'analgésie pharmacologique a été documentée dans 275/1983 (13,9 %) et 125/991 (12,6 %) des rapports d'appel d'ambulance pour les ambulanciers de soins primaires et les ambulanciers de soins avancés, respectivement. Une probabilité accrue d'immobilisation documentée ou de glace était associée à une douleur modérée ou intense [OR: 2,4; IC à 95 %: 1,84-3,17; p < 0,01] et déformation visible [OR: 2,5; IC à 95 %: 1,97-3,12; p < 0,01]. CONCLUSIONS: L'immobilisation documentée et l'administration de glace et d'analgésie pharmacologique aux enfants par les ambulanciers est sous-optimale. Nos résultats soulignent le besoin important de renforcer l'éducation concernant les avantages des options non pharmacologiques pour les enfants souffrant de blessures musculo-squelettiques.

Facilitating Residents' Understanding of Electronic Health Record Report Card Data Using Faculty Feedback and Coaching.

PURPOSE: Feedback continues to present a challenge for competency-based medical education. Clear, consistent, and credible feedback is vital to supporting one's ongoing development, yet it can be difficult to gather clinical performance data about residents. This study sought to determine whether providing residents with electronic health record (EHR)-based report cards, as well as an opportunity to discuss these data with faculty trained using the R2C2 model, can help residents understand and interpret their clinical performance metrics. METHOD: Using action research methodology, the author team collected EHR data from July 2017 to February 2020, for all residents (n = 21) in one 5-year Emergency Medicine program and created personalized report cards for each resident. During October 6-17, 2020, 8 out of 17 eligible residents agreed to have their feedback conversations recorded and participate in a subsequent interview with a nonphysician member of the research team. Data were analyzed using thematic analysis, and the authors used inductive analysis to identify themes in the data. RESULTS: In analyzing both the feedback conversations as well as the individual interviews with faculty and residents, the authors identified 2 main themes: (1) Reactions and responses to receiving personalized EHR data and (2) The value of EHR data for assessment and feedback purposes. All participants believed that EHR data metrics are useful for prompting self-reflection, and many pointed to their utility in providing suggestions for actionable changes in their clinical practice. For faculty, having a tool through which underperforming residents can be shown "objective" data about their clinical performance helps underscore the need for improvement, particularly when residents are resistant. CONCLUSIONS: The EHR is a valuable source of educational data, and this study demonstrates one of the many thoughtful ways it can be used for assessment and feedback purposes.

"EMERGing" Electronic Health Record Data Metrics: Insights and Implications for Assessing Residents' Clinical Performance in Emergency Medicine.

OBJECTIVES: Competency-based medical education requires that residents are provided with frequent opportunities to demonstrate competence as well as receive effective feedback about their clinical performance. To meet this goal, we investigated how data collected by the electronic health record (EHR) might be used to assess emergency medicine (EM) residents' independent and interdependent clinical performance and how such information could be represented in an EM resident report card. METHODS: Following constructivist grounded theory methodology, individual semistructured interviews were conducted in 2017 with 10 EM faculty and 11 EM residents across all 5 postgraduate years. In addition to open-ended questions, participants were presented with an emerging list of EM practice metrics and asked to comment on how valuable each would be in assessing resident performance. Additionally, we asked participants the extent to which each metric captured independent or interdependent performance. Data collection and analysis were iterative; analysis employed constant comparative inductive methods. RESULTS: Participants refined and eliminated metrics as well as added new metrics specific to the assessment of EM residents (e.g., time between signup and first orders). These clinical practice metrics based on data from our EHR database were organized along a spectrum of independent/interdependent performance. We conclude with discussions about the relationship among these metrics, issues in interpretation, and implications of using EHR for assessment purposes. CONCLUSIONS: Our findings document a systematic approach for developing EM resident assessments, based on EHR data, which incorporate the perspectives of both clinical faculty and residents. Our work has important implications for capturing residents' contributions to clinical performances and distinguishing between independent and interdependent metrics in collaborative workplace-based settings.

How do emergency departments and emergency leaders catalyze positive change through quality improvement collaborations?

OBJECTIVES: Quality Improvement and Patient Safety (QIPS) plays an important role in addressing shortcomings in optimal healthcare delivery. However, there is little published guidance available for emergency department (ED) teams with respect to developing their own QIPS programs. We sought to create recommendations for established and aspiring ED leaders to use as a pathway to better patient care through programmatic QIPS activities, starting internally and working towards interdepartmental collaboration. METHODS: An expert panel comprised of ten ED clinicians with QIPS and leadership expertise was established. A scoping review was conducted to identify published literature on establishing QIPS programs and frameworks in healthcare. Stakeholder consultations were conducted among Canadian healthcare leaders, and recommendations were drafted by the expert panel based on all the accumulated information. These were reviewed and refined at the 2018 CAEP Academic Symposium in Calgary using in-person and technologically-supported feedback. RESULTS: Recommendations include: creating a sense of urgency for improvement; engaging relevant stakeholders and leaders; creating a formal local QIPS Committee; securing funding and resources; obtaining local data to guide the work; supporting QIPS training for team members; encouraging interprofessional, cross-departmental, and patient collaborations; using an established QIPS framework to guide the work; developing reward mechanisms and incentive structures; and considering to start small by focusing on a project rather than a program. CONCLUSION: A list of 10 recommendations is presented as guiding principles for the establishment and sustainable deployment of QIPS activities in EDs throughout Canada and abroad. ED leaders are encouraged to implement our recommendations in an effort to improve patient care.

OBJECTIF: L'amélioration de la qualité et la sécurité des patients (AQSP) joue un rôle important dans la correction des lacunes observées dans la prestation optimale de soins. Toutefois, les équipes de soins au service des urgences (SU) disposent de peu de documentation sur la conception de leurs propres programmes d'AQSP. L'étude avait donc pour objectif l'élaboration de recommandations conçues à l'intention des chefs de file, nouveaux ou confirmés, au SU, et présentées comme une voie à emprunter pour améliorer les soins aux patients, par l'application d'activités programmatiques d'AQSP, tout d'abord au sein du service, puis entre services, grâce à la collaboration. MÉTHODE: Un groupe d'experts composé de 10 cliniciens en médecine d'urgence, ayant des compétences particulières en AQSP et en pouvoir d'influence, a été mis sur pied. Un examen de cadrage a été entrepris à la recherche de publications sur l'établissement de programmes d'AQSP et de cadres de travail s'y rapportant, en soins de santé. Des consultations ont été menées avec les parties intéressées parmi les chefs de file en soins de santé au Canada, et le groupe d'experts a rédigé une version préliminaire de recommandations fondées sur l'ensemble de l'information recueillie. Celles-ci ont été examinées et améliorées durant le Symposium sur les affaires universitaires 2018 de l'ACMU, à Calgary, à la suite de rétroactions communiquées en personne ou par voie électronique. RÉSULTATS: Les recommandations portaient sur : l'éveil d'un sentiment d'urgence à l'égard de l'amélioration; la mobilisation d'intervenants et de chefs de file compétents; la mise sur pied d'un comité local structuré d'AQSP; l'obtention de financement et de ressources; la disponibilité de données locales pour orienter le travail; le soutien de la formation des membres d'équipe en AQSP; la promotion de la collaboration entre professions, entre services et avec les patients; l'utilisation d'un cadre de travail d'AQSP déjà établi afin d'orienter le travail; l'élaboration d'un système de récompenses et de structures incitatives; la possibilité d'entreprendre, au début, des initiatives à petite échelle, soit des projets plutôt que des programmes. CONCLUSION: Les dix recommandations ont été présentées à titre de principes directeurs en vue de l'élaboration d'activités d'AQSP et de leur mise en œuvre durable dans les SU, au Canada et ailleurs dans le monde. Les chefs de file dans les SU sont invités à appliquer ces recommandations dans le but d'améliorer les soins aux patients.

Emergency overcrowding and access block: A smaller problem than we think.

OBJECTIVES: Emergency department (ED) access block, the inability to provide timely care for high acuity patients, is the leading safety concern in First World EDs. The main cause of ED access block is hospital access block with prolonged boarding of inpatients in emergency stretchers. Cumulative emergency access gap, the product of the number of arriving high acuity patients and their average delay to reach a care space, is a novel access measure that provides a facility-level estimate of total emergency care delays. Many health leaders believe these delays are too large to be solved without substantial increases in hospital capacity. Our objective was to quantify cumulative emergency access blocks (the problem) as a fraction of inpatient capacity (the potential solution) at a large sample of Canadian hospitals. METHODS: In this cross-sectional study, we collated 2015 administrative data from 25 Canadian hospitals summarizing patient inflow and delays to ED care space. Cumulative access gap for high acuity patients was calculated by multiplying the number of Canadian Triage Acuity Scale (CTAS) 1-3 patients by their average delay to reach a care space. We compared cumulative ED access gap to available inpatient bed hours to estimate fractional access gap. RESULTS: Study sites included 16 tertiary and 9 community EDs in 12 cities, representing 1.79 million patient visits. Median ED census (interquartile range) was 66,300 visits per year (58,700-80,600). High acuity patients accounted for 70.7% of visits (60.9%-79.0%). The mean (SD) cumulative ED access gap was 46,000 stretcher hours per site per year (± 19,900), which was 1.14% (± 0.45%) of inpatient capacity. CONCLUSION: ED access gaps are large and jeopardize care for high acuity patients, but they are small relative to hospital operating capacity. If access block were viewed as a "whole hospital" problem, capacity or efficiency improvements in the range of 1% to 3% could profoundly mitigate emergency care delays.

Effects of nebulized diethylenetetraamine-NONOate in a mouse model of acute Pseudomonas aeruginosa pneumonia.

OBJECTIVE: Endogenous and exogenous nitric oxide (NO) may have important antibacterial effects in patients with pneumonia. NO administration has been limited to the continuous inhalation of gas-phase NO (ie, inhaled NO [iNO]). Intermittent nebulization of NONOates, novel NO donors, may permit the continuous intrapulmonary delivery of NO. Thus, we assessed the effects of nebulized diethylenetetraamine-NONOate (DETA-NO) in a model of acute Pseudomonas aeruginosa pneumonia. DESIGN: Randomized, controlled study. SUBJECTS: Male C57Bl/6 mice. INTERVENTIONS: Pneumonia was induced by intratracheal instillation of P aeruginosa (3 x 10(7) CFU in 50 microL). Pneumonia and sham mice were randomized to receive no treatment, nebulized DETA-NO (12.5 or 125 micromol) at 4 h and 12 h, or continuous iNO for 24 h (10 or 40 ppm) until they were killed at 24 h. MAIN RESULTS: The nebulization of DETA-NO was associated with a marked increase in mean (+/- SEM) exhaled NO levels (after nebulization, 484 +/- 34 parts per billion [ppb]; baseline, 13.4 +/- 0.4 ppb; p < 0.01) and plasma levels of nitrites/nitrates (after nebulization, 73 +/- 28 microM; at baseline, 14 +/- 3 microM; p < 0.05). Nebulized DETA-NO decreased the pulmonary bacterial load in mice with pneumonia by 65 +/- 19% (p < 0.05 vs untreated mice) but had no effect on pulmonary leukocyte infiltration. Although the growth of P aeruginosa colonies in vitro was impaired on exposure to DETA-NO, growth was similarly impaired by exposure to DETA nucleophile/backbone alone. CONCLUSIONS: The nebulization of DETA-NO provides a method for the prolonged intrapulmonary delivery of NO. The antibacterial effect of DETA-NO in vivo and in vitro is due, in large part, to the DETA nucleophile moiety and is independent of NO, suggesting a limited therapeutic role for exogenous NO in pneumonia.

The utility of the prehospital electrocardiogram.

OBJECTIVES: The 12-lead electrocardiogram (ECG) can capture valuable information in the prehospital setting. By the time patients are assessed by an emergency department (ED) physician, their symptoms and any ECG changes may have resolved. We sought to determine whether the prehospital electrocardiogram (pECG) could influence ED management and how often the pECG was available to and reviewed by the ED physician. METHODS: A retrospective medical record review was conducted on a random sample of patients ≥ 18 years who had a prehospital 12-lead ECG and were transported to one of two tertiary care centres. Data were recorded onto a standardized data extraction tool. Three investigators independently compared the pECG to the first ECG obtained in the ED after patient arrival at the hospital. Any abnormalities not present on the ED ECG were adjudicated to ascertain whether they had the potential to change ED management. RESULTS: Of 115 ambulance runs selected, 47 had no pECG attached to the ambulance call record (ACR) and another 5 were excluded (one ST elevation myocardial infarction, one cardiac arrest, three ACR missing). Of the 63 pECGs reviewed, 16 (25%) showed changes not apparent on the initial ED ECG (κ  =  0.83; 95% CI 0.74-0.93), of which 12 had differences that might influence ED management (κ  =  0.76; 95% CI 0.72-0.82). Only one hospital record contained a copy of the pECG, despite the current protocol that paramedics print two copies of the pECG on arrival in the ED (one copy for the ACR and one to be handed to the medical personnel). None of 110 ED charts documented that the pECG was reviewed by the ED physician. CONCLUSION: The pECG has the potential to influence ED management. Improvement in paramedic and physician documentation and a formal pECG handover process appear necessary.