Electrocardiogram interpretation by Canadian general paediatricians: Examining practice, accuracy and confidence

pECGreview: Assessment of a Novel Tool to Evaluate the Accuracy of Pediatric ECG Interpretation Skills

The skill of interpretation of the electrocardiogram (ECG) remains poor despite existing educational initiatives. We sought to evaluate the validity of using a subjective scoring system to assess the accuracy of ECG interpretations submitted by pediatric cardiology fellows, trainees, and faculty to the Pediatric ECG Review (pECGreview), a web-based ECG interpretation training program. We conducted a retrospective, cross-sectional study of responses submitted to pECGreview. ECG interpretations were assessed independently by four individuals with a range of experience. Accuracy was assessed using a 3-point scale: 100% for generally correct interpretations, 50% for over- or underdiagnosis of minor ECG abnormalities, and 0% for over- or underdiagnosis of major ECG abnormalities. Inter-rater agreement was assessed using expanded Bland-Altman plots, Pearson correlation coefficients, and Intraclass Correlation Coefficients (ICC). 1460 ECG interpretations by 192 participants were analyzed. 107 participants interpreted at least five ECGs. The mean accuracy score was 76.6 ± 13.7%. Participants were correct in 66.1 ± 5.1%, had minor over- or underdiagnosis in 21.5 ± 4.6% and major over- or underdiagnosis in 12.3 ± 3.9% of interpretations. Validation of agreement between evaluators demonstrated limits of agreement of 11.3%. Inter-rater agreement exhibited consistent patterns (all correlations ≥ 0.75). Absolute agreement was 0.74 (95% CI 0.69-0.80), and average measures agreement was 0.92 (95% CI 0.89-0.94). Accuracy score analysis of as few as five ECG interpretations submitted to pECGreview yielded good inter-rater reliability for assessing and ranking ECG interpretation skills in pediatric cardiology fellows in training.

Pediatric Electrocardiography Interpretation: Where We Are Now?

OBJECTIVE

Electrocardiography (ECG) is an important diagnostic tool used in the early diagnosis and treatment of arrhythmias and conduction disorders. Pediatricians need to interpret the ECGs correctly and be able to decide the situations that require pediatric cardiology consultation. In this study, we aimed to determine the ECG evaluation competencies of pediatricians. The obtained data will serve as a guide for the development of a training module.

MATERIALS AND METHODS

Pediatric residents and specialists were included in the study. A questionnaire was sent to the participants via Google Forms. In this questionnaire, participants were asked to evaluate whether 10 ECG samples were normal or abnormal, detect the abnormality in the ECGs, define the specific diagnosis, and indicate how confident they were in their evaluation. A total of 242 participants, 160 of whom were pediatric residents and 82 were pediatricians, were included in the study.

RESULTS

The mean knowledge level of the participants was 17 ± 4.1 out of 30 points. Electrocardiography knowledge score increased with increasing age, increasing experience after graduation from medical school, increasing seniority during residency training, and increasing self-confidence in ECG interpretation. A significant difference was found between the ECG knowledge scores of those who attended an ECG course after graduation and those who did not. The rate of correctly defining the distinction between normal and abnormal was 93.7%. The rate of detecting pathologies in ECGs accurately and correct identification of specific diagnosis was 56.7%.

CONCLUSION

The accuracy level of pediatricians in ECG evaluation is low. Electrocardiography trainings are needed to develop ECG assessment skills.

EKG Acquisition Curriculum for Pediatric Trainees

OBJECTIVES

Pediatric residency trainees interface with electrocardiograms (EKG) as part of routine clinical care. Depending on workflow and availability of support staff, trainees may be required to obtain EKGs on patients, though training on this skill varies. Our intervention seeks to train incoming pediatric residents on obtaining EKGs from pediatric patients and identifying common problems that may result in acquisition of low-fidelity EKGs.

METHODS

A team of physicians, EKG technicians, and simulation educators designed a 30-min didactic and experiential learning opportunity for incoming pediatric trainees held prior to their start of clinical responsibilities. During the session, trainees were introduced to the basics of EKG acquisition and common quality issues that arise. Afterwards, they practiced placing EKG leads on a mannequin and a live model. A pre- and post-session survey was utilized to assess the session's utility and participant's learning.

RESULTS

The intervention was perceived as a valuable experience by participants over the course of 2 years. We found increased participant comfort with performing and troubleshooting EKGs (P<.001). There was a 33% improvement in quality assessment of EKG rhythm strips after the session (P<.001).

CONCLUSION

Given the importance of EKGs to the care of pediatric patients, it is essential that pediatricians receive adequate training in acquiring and assessing EKG quality. This intervention was deemed to be highly useful with a demonstrated improvement in EKG troubleshooting skills among first year pediatric residents. This session improves learner comfort with essential clinical responsibilities and identification of low-quality EKGs that often warrant repeat testing.

Electrocardiogram interpretation among pediatricians: Assessing knowledge, attitudes, and practice

Objectives:

This study assesses the competency of pediatricians in interpreting electrocardiograms (ECGs).

Methods:

A cross-sectional study involving 125 pediatricians comprised of 71 general pediatricians, 15 pediatric cardiologists, and 39 other subspecialists recruited from all public hospitals and two specialty centers. Participants completed a questionnaire that included 10 ECGs and questions regarding backgrounds, attitudes, and practices. The ECGs were graded to obtain a knowledge score out of 30 points. Mann–Whitney U test and Kruskal-Wallis test with post hoc analysis and Bonferroni adjustment were used to compare groups.

Results:

The mean knowledge score ranged from 47.7% to 69.7% among various pediatric specialties (P = 0.006). Age, increasing years of experience, confidence level, number of cardiology referrals, and perceived importance of having good ECG interpretation skills were significantly related to the knowledge score (P ≤ 0.05). Accuracy was highest in identifying normal ECGs (76.8%), supraventricular tachycardia (64.8%), along with long QT interval (58.4%), and was lowest for right bundle branch block (RBBB) (10.4%), 2:1 atrioventricular conduction (10.4%), and atrial tachycardia (AT) (4.8%). Accuracy among pediatric cardiologists was highest for long QT interval (100%), normal ECG (80%), as well as Wolff-Parkinson-White syndrome (80%), and lowest for RBBB (13.3%) and AT (0%). Most pediatricians believe that ECGs are “useful” (78.4%) and that having good interpretation skill is “important” (80.6%).

Conclusions:

Pediatricians recognize the importance of ECGs. However, their skill and level of accuracy at interpretation is suboptimal, including cardiologists, and may affect patient care. Thus, efforts should be made to improve ECG understanding to provide better service to patients.