Key result
Omitting routine preoperative ECGs shows no benefit over routine ECGs in low-risk ophthalmic surgery.
Why the study?
Routine preoperative ECGs remain commonly performed in low-risk ophthalmic surgery despite international guidelines recommending against them, causing unnecessary resource use and patient delays.
Does the removal of routine preoperative ECGs reduce cancellations and resource utilization without increasing adverse medical events in patients undergoing low-risk ophthalmic surgery?
RCT (n=21,246)
Randomized
No
Does the removal of routine preoperative ECGs reduce cancellations and resource utilization without increasing adverse medical events in patients undergoing low-risk ophthalmic surgery?
Absolute Event Rate: 3.2% vs 4%
p-value: p=0.79
Removing routine preoperative ECGs in low-risk ophthalmic surgery safely reduces unnecessary cardiology referrals and costs without increasing perioperative adverse events or cancellations.
Omitting routine ECGs may safely cut referrals and costs in low-risk ophthalmic surgery; supports guideline adherence in real-world practice.
Introduction Despite a mature healthcare system grounded in evidence-based medicine, routine preoperative electrocardiograms (ECG) remain commonly performed in patients undergoing low-risk ophthalmic surgery, contrary to international guidelines. Our institution performs approximately 20,000 cataract surgeries annually. Efforts to remove routine ECG testing encountered significant resistance. Unnecessary ECGs and downstream referrals strain healthcare resources, impair patient experience, and delay sight-restoring surgery, particularly for elderly patients. This quality improvement project reduced routine preoperative ECG use in low-risk ophthalmic surgery, aligning institutional practice with international recommendations. Methods A three-phase quality improvement project was conducted. In phase one, 1,000 patients scheduled for cataract surgery under local anaesthesia with sedation were randomized to either routine preoperative ECG or ECG only if clinically indicated. Primary outcomes were adverse medical events and surgery postponement. Phase two expanded removal of routine ECGs to all cataract surgeries under sedation over six months (10,291 cases), assessing cancellations and adverse events. Phase three involved all low-risk ophthalmic surgeries under sedation, with a six-month audit of 9,955 cases to monitor significant perioperative events. Results Phase one showed no significant difference in cancellation rates, intraoperative events, or unplanned admissions between routine and non-routine ECG groups (4.0% vs 3.2%, p=0.79). In phase two, 10,291 cataract cases had 67 cancellations (0.65%), compared with 3% cancellations during a prior period. Cardiology referrals decreased by 57% (275 to 116, p<0.0001), with estimated cost savings of SGD 733,738. Phase three achieved an 83% reduction in ECG use, with no preventable perioperative events. Conclusion Routine preoperative ECGs offer no clinical benefit in low-risk ophthalmic surgery, and their removal optimises patient care and healthcare resource utilisation.
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Lim et al. (2026) conducted an RCT in Low-risk ophthalmic surgery (cataract surgery) (n=21,246). ECG only if clinically indicated (omission of routine ECG) vs. Routine preoperative ECG was evaluated on Adverse medical events and surgery postponement (cancellation rates, intraoperative events, or unplanned admissions) (p=0.79). Omitting routine preoperative ECGs before low-risk ophthalmic surgery did not significantly change adverse medical events or cancellation rates compared to routine ECGs (3.2% vs 4.0%, p=0.79).
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