Reducing Electrocardiograms in Sleeping Children

Why is it low-value care?

The VICTOR observation chart used at the RCH is based on a large dataset of hospitalised children. Observations that fall outside of normal ranges result in mandated medical reviews.

Overnight during deep relaxation the heart rate lowers physiologically, known as sleeping bradycardia. Sleeping bradycardia has resulted in a large number of children having heart rates that fall into the ‘rapid review’ criteria. Medical staff respond by ordering ECG to rule out cardiac causes. ECGs cause unnecessary sleep interruption, cost nursing time, require cardiology review and often lead to spurious results.

Based on other large datasets that report on lowest heart rate, there is likely to be a better measure of when further investigation is required. When investigation is required, ECG may not be the most appropriate test. Our recommendation is that ECGs are not ordered for sleeping bradycardia unless indicated.

What were we doing?

Baseline data collected between August 2017 and September 2019, from all overnight inpatients with a heart rate value below the lower limit of normal, based on existing VICTOR observation charts, showed 31.6 per cent of patients had an ECG test.

When assessed against new limits, 26.9 per cent of those with a heart rate above the limit and 68.9 per cent of those with a heart rate below the limit had an ECG performed.

Through this project, our aim is to reduce the ECG to less than five per cent in patients with a heart rate above the new limit. For total rate of ECG in bradycardia, we aim to achieve a rate of less than 15 per cent.

What interventions did we introduce?

A new Clinical Practice Guideline was published and additional education was provided for Junior Medical Officers. Next steps include introducing EMR modifications and review by the Deteriorating Patient Committee.

How effective have we been?

As at March 2020, rates of ECG for sleeping bradycardia have been reduced to 21.3 per cent. Once we achieve our target of 15 per cent, we will convert to a sustainability model to regularly monitor rates and ensure they are maintained.