What adult electrocardiogram (ECG) diagnoses and/or findings do residents in emergency medicine need to know?

The HEARTS ECG workshop: a novel approach to resident and student ECG education

OBJECTIVES

ECG interpretation is a life-saving skill in emergency medicine (EM), and a core competency in undergraduate medical curricula; however, confidence for residents/students is low. We developed a novel educational intervention-the HEARTS ECG workshop-that provides a systematic approach to ECG interpretation, teaches EM residents through the process of teaching medical students and highlights emergency management.

METHODS

We used the Kern Approach to Curriculum Development. A review of ECG education literature and a targeted needs assessment of local students/residents led to goals and objectives including systematic ECG interpretation with clinical relevance. ECGs were selected based on a national consensus of EM program directors and categorized into 5 common emergency presentations. The educational strategy included content based on HEARTS approach (Heart rate/rhythm, Electrical conduction, Axis, R-wave progression, Tall/small voltages, and ST/T changes), and methods including flipped classroom and near-peer teaching. Evaluation and feedback were based on the Kirkpatrick program evaluation. The workshop was piloted with 6 junior EM residents and 58 medical students, and repeated with nine residents and 68 students from four medical schools.

RESULTS

Residents and students agreed or strongly agreed that the workshop improved their perceived ability (100% and 95%, respectively) and confidence (77% and 88%, respectively) in interpreting ECGs. Reports of ECG interpretation causing anxiety declined from pre-workshop (61% and 83% respectively) to post-workshop (38% and 37% respectively). Residents reported behavior change: 3 months after the workshop, 92.3% reported ongoing use of the HEARTS approach clinically and through teaching medical students on shifts. Reported workshop strengths included the pre-workshop material, the clinical application, facilitator-to-learner ratio, interactivity, the ease of remembering and applying the HEARTS mnemonic, and the iterative application of the approach. Suggested changes included longitudinal sessions with graded difficulty, and allocating more time for introductory material for ease of understanding.

CONCLUSION

The HEARTS ECG workshop is an innovative pedagogical method that can be adapted for all levels of training. Future directions include integration in undergraduate medical and EM residency curricula, and workshops for physicians to update ECG interpretation skills.

What Adult Electrocardiogram (ECG) Diagnoses or Findings are Most Important for Advanced Care Paramedics to Know?

Introduction: The interpretation of electrocardiograms (ECGs) is an essential competency in modern paramedicine. Although educational guidelines for paramedic ECG interpretation exist, they are broad, not evidence-based, and lack prioritization in a prehospital clinical context. We conducted this study to gain consensus among stakeholders (EMS physicians, paramedic educators, and paramedic clinicians) regarding which ECG diagnoses or findings are most important for a practising advanced care paramedic to know. 

Methods: This study was an internet-based Delphi survey. We purposefully sampled participants in pairs (physician/paramedic) from all 10 Canadian provinces. Individuals rated a previously developed comprehensive list of emergency ECG diagnoses or findings on the importance of paramedic recognition and impact on prehospital care using a 4-point Likert scale. The consensus was achieved with a minimum of 75% agreement on Likert rating for a single diagnosis or finding during survey rounds one to three. When consensus was not reached, stability was defined as a shift of individual ratings between rounds of 20% or less.

Results: All 20 participants completed the first and second rounds of the survey, and 17 (85%) completed three rounds. Overall, 32 (26.4%) of 121 potentially important ECG diagnoses or findings reached consensus, 2 (1.7%) reached stability and 87 (71.9%) reached neither consensus nor stability. Twenty-one (17.4%) diagnoses or findings were considered “Very Important”, six (4.9%) “Important”, and five (4.1%) “Minimally Important”. In the first round of the survey, the mean rating of the importance of a paramedic knowing a specific ECG diagnosis or finding was lower in the physician group than the paramedic group on 85 (72%) of 118 initial diagnoses or findings.

Conclusion: We have created a list of ECG diagnoses or findings prioritized for the prehospital context that may assist paramedic educators in focusing on educational interventions. Many ECG diagnoses or findings failed to reach consensus or stability, demonstrating potential disagreement regarding clinical expectations for ECG knowledge among paramedics or physicians.

Clinically contextualised ECG interpretation: the impact of prior clinical exposure and case vignettes on ECG diagnostic accuracy

BACKGROUND

ECGs are often taught without clinical context. However, in the clinical setting, ECGs are rarely interpreted without knowing the clinical presentation. We aimed to determine whether ECG diagnostic accuracy was influenced by knowledge of the clinical context and/or prior clinical exposure to the ECG diagnosis.

METHODS

Fourth- (junior) and sixth-year (senior) medical students, as well as medical residents were invited to complete two multiple-choice question (MCQ) tests and a survey. Test 1 comprised 25 ECGs without case vignettes. Test 2, completed immediately thereafter, comprised the same 25 ECGs and MCQs, but with case vignettes for each ECG. Subsequently, participants indicated in the survey when last, during prior clinical clerkships, they have seen each of the 25 conditions tested. Eligible participants completed both tests and survey. We estimated that a minimum sample size of 165 participants would provide 80% power to detect a mean difference of 7% in test scores, considering a type 1 error of 5%.

RESULTS

This study comprised 176 participants (67 [38.1%] junior students, 55 [31.3%] senior students, 54 [30.7%] residents). Prior ECG exposure depended on their level of training, i.e., junior students were exposed to 52% of the conditions tested, senior students 63.4% and residents 96.9%. Overall, there was a marginal improvement in ECG diagnostic accuracy when the clinical context was known (Cohen's d = 0.35, p < 0.001). Gains in diagnostic accuracy were more pronounced amongst residents (Cohen's d = 0.59, p < 0.001), than senior (Cohen's d = 0.38, p < 0.001) or junior students (Cohen's d = 0.29, p < 0.001). All participants were more likely to make a correct ECG diagnosis if they reported having seen the condition during prior clinical training, whether they were provided with a case vignette (odds ratio [OR] 1.46, 95% confidence interval [CI] 1.24-1.71) or not (OR 1.58, 95% CI 1.35-1.84).

CONCLUSION

ECG interpretation using clinical vignettes devoid of real patient experiences does not appear to have as great an impact on ECG diagnostic accuracy as prior clinical exposure. However, exposure to ECGs during clinical training is largely opportunistic and haphazard. ECG training should therefore not rely on experiential learning alone, but instead be supplemented by other formal methods of instruction.

The Development of Visual Expertise in ECG Interpretation: An Eye-Tracking Augmented Re Situ Interview Approach

Phenomenon: Visual expertise in medicine involves a complex interplay between expert visual behavior patterns and higher-level cognitive processes. Previous studies of visual expertise in medicine have centered around traditionally visually intensive disciplines such as radiology and pathology. However, there is limited study of visual expertise in electrocardiogram (ECG) interpretation, a common clinical task that is associated with high error rates. This qualitatively driven multi-methods study aimed to describe differences in cognitive approaches to ECG interpretation between medical students, emergency medicine (EM) residents, and EM attending physicians. Approach: Ten medical students, 10 EM residents, and 10 EM attending physicians were recruited from one tertiary academic center to participate in this study. Participants interpreted 10 ECGs with a screen-based eye-tracking device, then underwent a subjective re situ interview augmented by playback of the participants' own gaze scan-paths via eye-tracking. Interviews were transcribed verbatim and an emergent thematic analysis was performed across participant groups. Diagnostic speed, accuracy, and heat maps of fixation distribution were collected to supplement the qualitative findings. Findings: Qualitative analysis demonstrated differences among the cohorts in three major themes: dual-process reasoning, ability to prioritize, and clinical implications. These qualitative findings were aligned with differences in visual behavior demonstrated by heat maps of fixation distribution across each ECG. More experienced participants completed ECG interpretation significantly faster and more accurately than less experienced participants. Insights: The cognitive processes related to ECG interpretation differed between novices and more experienced providers in EM. Understanding the differences in cognitive approaches to ECG interpretation between these groups may help inform best practices in teaching this ubiquitous diagnostic skill.