Article

Electrocardiogram interpretation: Emergency medicine residents on the front lines

1000 Correspondence / American Journal of Emergency Medicine 37 (2019) 9721004

Theresa A. Bacon-Baguley1

College of Health Professions, Grand Valley State University, Grand Rapids,

MI, United States of America

Jeffrey Jones

Department of Emergency Medicine, Spectrum Health Hospitals, Grand

Rapids, MI, United States of America

Corresponding author at: 15 Michigan St NE Suite 701, Grand Rapids, MI

49503, United States of America.

E-mail address: [email protected]. https://doi.org/10.1016/j.ajem.2018.10.015

References

  1. Zink TM, Fargo JD, Baker RB, Buschur C, Fisher BS, Sommers MS. Comparison of methods for identifying ano-genital injury after consensual intercourse. J Emerg Med 2010;39(1):113-8.
  2. Slaughter L, Brown CRV. Colposcopy to establish physical findings in rape victims. Am J Obstet Gynecol 1992;166(1):83-6.
  3. Lenahan L, Ernst A, Johnson B. Colposcopy in evaluation of the adult sexual assault victim. Am J Emerg Med 1998;16(2):183-4.
  4. Jones JS, Dunnuck C, Rossman L, Wynn BN, Nelson-Horan C. Significance of toluidine

    blue positive findings after speculum examination for sexual assault. Am J Emerg Med 2004;22(3):201-3.

    Slaughter L, Brown CRV, Crowley S, Peck R. Patterns of genital injury in female sexual assault victims. Am J Obstet Gynecol 1997;176(3):609-16.

  5. Teixeira RG. Hymenal colposcopic examination in sexual offenses. Am J Forensic Med

    Pathol 1981;2(3):209-12.

    Sommers MS. Defining patterns of genital injury from sexual assault: a review. Trauma Violence Abuse 2007;8(3):270-80.

  6. McGregor MJ, Le G, Marion SA, Wiebe E. Examination for sexual assault: is the docu- mentation of Physical injury associated with the laying of charges? A retrospective cohort study. CMAJ 1999;160(11):1565-9.

    Electrocardiogram interpretation: Emergency medicine residents on the front lines

    Electrocardiogram (ECG) interpretation skills represent an impor- tant diagnostic tool we impart to new generations of trainees. It is es- sential to patient care, diagnostic treatment plans and national hospital quality metrics [1,2]. This burden lies heavily on emergency medicine (EM) physicians, thus, ECG interpretation./a> skills are an essen- tial component of EM residency education.

    The American College of Cardiology (ACC) and American Heart Association (AHA) have developed curricula regarding ECG competency within cardiology [3]. Although the Accreditation Council for Graduate Medical Education (ACGME) and American Board of Emergency Medicine (ABEM) created twenty-three EM sub- competencies, none of these specifically refer to ECG interpretation requirements [4]. The EM Council of Residency Directors (CORD) includes ECG interpretation as part of its curricular model but without specific metrics [5].

    While efforts have been made to improve ECG interpretation train- ing, EM literature provides little guidance regarding the optimization of ECG curricula [6-9]. We sought to profile the current ECG interpreta- tion curricula and clinical practice patterns, specifically the role of the resident as ECG interpreter.

    At the time of survey initiation, there were 166 allopathic EM resi- dency programs within the United States. Program directors (PD) were asked to complete a de-identified questionnaire via a secure appli- cation called Research Electronic Data Capture (REDCap; Vanderbilt University, TN). REDCap allowed for response tracking and three addi- tional reminder emails were sent. Participants provided program demo- graphics, geographic location as defined by the Society of Academic Emergency Medicine (SAEM) Regions, and additional information re- garding their ECG curriculum and primary rapid ECG interpreter. Per

    Fig. 1. Geographical distribution of participating emergency medicine residencies as defined by SAEM Regions.

    ACC and AHA guidelines, rapid ECGs are performed within 10 min of presentation concerning for acute coronary syndrome [10]. Four senior faculty members, two junior faculty members and one second-year EM resident internally validated the survey questions at our academic insti- tution. The study met exempteion criteria per the Institutional Review Board.

    Frequencies and proportions were calculated to determine the most common responses. Fisher’s exact tests were performed to assess associ- ations between variables. All analyses were two-sided, with a significant level of <=0.05. SAS version 9.4 (SAS Institute, Cary, NC) was used for analyses.

    Of 166 programs, 102 (61%) participated from various regions of the United States (Fig. 1). Of the responding programs, 71 (70%) are three- year programs and 30 (30%) are four-year programs. Eighty-nine pro- grams (87%) reported an attending as primary ECG interpreter, while only thirteen institutions (13%) allowed the senior resident to perform primary interpretation. Of these thirteen programs, nine (69%) require at- tending interpretation within 11-30 min and the other four programs (31%) state the attending will review the ECG interpretation at another time during the shift.

    Seventy-one programs (70%) provided information regarding re- quired and elective ECG curriculum models (Fig. 2). We found that most programs utilize mandatory didactic lectures, while a smaller portion use innovative teaching modalities such as the flipped classroom model in which learners prepare at home for in-class problem solving [11].

    There were important trends in the relationship between [1] geo- graphic location or [2] ECG curriculum and the primary ECG interpreter (Table 1). Midwest programs were more likely to have an attending as primary ECG interpreter (22%, p-value = 0.01). Southeastern and West- ern programs were more likely to have a resident as primary interpreter (31% for each region, p-value = 0.01). Programs that allowed resident as primary interpreter were more likely to have implemented elective one-on-one training (75% versus 38%, p-value = 0.03).

    Our findings expand on previous studies that highlighted ECG cur- ricula as an area for improvement. Over ten years ago, a similar study of EM PDs demonstrated that only half of the residencies queried had a formal ECG curriculum and even fewer had a way to assess compe- tency [12,13]. Since that time, there remains no standardization of the ECG interpretation curricula within EM graduate medical education nor has an optimal teaching method been identified [14].

    Correspondence / American Journal of Emergency Medicine 37 (2019) 9721004 1001

    Fig. 2. Required versus elective teaching modalities.

    Table 1

    Associations between the primary ECG interpreter and other variables.

    N (%)

    Primary ECG interpreter

    P-value

    Attending

    Resident

    Geographic location

    Great Plains

    2 (2%)

    2 (15%)

    0.01

    New England

    6 (7%)

    2 (15%)

    Mid Atlantic

    16 (18%)

    0 (0%)

    New York State

    16 (18%)

    1 (8%)

    Western

    14 (16%)

    4 (31%)

    Southeastern

    15 (17%)

    4 (31%)

    Midwest

    Elective OneonOne Teaching

    Yes

    20 (22%)

    22 (38%)

    0 (0%)

    9 (75%)

    0.03

    No

    36 (62%)

    3 (25%)

    Unlike previous publications, our study explicitly investigated the role of the resident in clinical ECG interpretation. Our survey demon- strated that attending physicians are the primary interpreters of ECGs at the majority of programs. Only 13% of the participants utilize senior residents as the primary interpreter. Our institution’s educational model allows senior residents (post-graduate year three) to perform pri- mary ECG interpretation. This deliberate practice (DP) model allows for performance of repetitive skills followed by assessment and constructive feedback [15]. DP has been demonstrated to be a powerful method to im- prove clinical skills and to have a positive impact on patient care [16,17]. While we cannot definitively ascertain the optimal ECG teaching method, our study highlights areas for potential growth such as an em- phasis on innovative educational methods and deliberate practice in the clinical setting. Limitations include the 61% response rate as well as pos- sible reporting bias due to PD discretion in choosing whether to partic- ipate in the survey. Additional research is required to determine the optimal method by which to teach and assess ECG interpretation skills.

    Leslie A. Bilello*, 1 Celine Pascheles2 Shamai A. Grossman1

    David T. Chiu1 Jennifer M. Singleton1

    Carlo L. Rosen1 Beth Israel Deaconess Medical Center, Department of Emergency Medicine, One Deaconess Rd, 2nd Floor, Boston, MA 02215, United States of America

    *Corresponding author at: Department of Emergency Medicine, One Deaconess Road, 2nd Floor, Boston, MA 02215, United States of America.

    1 Harvard Medical School.

    2 Harvard Affiliated Emergency Medicine Residency.

    E-mail address: [email protected] (L.A. Bilello), [email protected] (C. Pascheles), [email protected] (S.A. Grossman), [email protected] (D.T. Chiu), [email protected] (J.M. Singleton), [email protected] (C.L. Rosen).

    https://doi.org/10.1016/j.ajem.2018.10.019

    References

    Coyne CJ, Testa N, Desai S, et al. Improving Door-to-balloon time by decreasing door- to-ECG time for walk-in STEMI patients. West J Emerg Med 2015;16(1):184-9.

  7. Yiadom MY, Baugh CW, Mcwade CM, et al. Performance of emergency department screening criteria for an early ECG to identify ST-segment elevation myocardial in- farction. J Am Heart Assoc 2017;6(3).
  8. Zipes DP, Calkins H, Daubert JP, et al. 2015 ACC/AHA/HRS advanced training statement on clinical Cardiac electrophysiology (a revision of the ACC/AHA 2006 update of the clinical competence statement on invasive electrophysiology studies, Catheter ablation, and cardioversion). J Am Coll Cardiol 2015;66(24): 2767-802.
  9. The Emergency Medicine Milestone Project. www.abem.org, Accessed date: 25 Jan- uary 2018.
  10. 2013 Model of the Clinical Practice of Emergency Medicine. www.cordem.org, Accessed date: 25 January 2018.
  11. Berger JS, Eisen L, Nozad V, et al. Competency in electrocardiogram interpretation among internal medicine and emergency medicine residents. Am J Med 2005;118 (8):873-80.
  12. Hoyle RJ, Walker KJ, Thomson G, et al. Accuracy of electrocardiogram interpretation improves with emergency medicine training. Emerg Med Australas 2007;19(2): 143-50.
  13. Pourmand A, Tanski M, Davis S, et al. Educational technology improves ECG inter- pretation of acute myocardial infarction among medical students and emergency medicine residents. West J Emerg Med 2015;16(1):133-7.
  14. Pourmand A, Lucas R, Nouraie M. Asynchronous web-based learning, a practical

    method to enhance teaching in emergency medicine. Telemed J E Health 2013;19

    (3):169-72 (23).

    Amsterdam EA, Wenger NK, Brindis RG, et al. 2014 AHA/ACC guideline for the man- agement of patients with non-ST-elevation acute coronary syndromes: a report of the American College of Cardiology/American Heart Association Task Force on Prac- tice Guidelines. J Am Coll Cardiol 2014;64(24):e139-228.

  15. Prober CG, Heath C. Lecture halls without lectures–a proposal for medical education.

    N Engl J Med 2012;366(18):1657-9.

    Ginde AA, Char DM. Emergency medicine residency training in electrocardiogram interpretation. Acad Emerg Med 2003;10(7):738-42.

  16. Pines JM, Perina DG, Brady WJ. Electrocardiogram interpretation training and com- petency assessment in emergency medicine residency programs. Acad Emerg Med 2004;11(9):982-4.
  17. Fent G, Gosai J, Purva M. Teaching the interpretation of electrocardiograms: which method is best? J Electrocardiol 2015;48(2):190-3.
  18. Duvivier RJ, Van Dalen J, Muijtjens AM, et al. The role of deliberate practice in the ac- quisition of clinical skills. BMC Med Educ 2011;11:101.
  19. Hatala RM, Brooks LR, Norman GR. Practice makes perfect: the critical role of mixed practice in the acquisition of ECG interpretation skills. Adv Health Sci Educ Theory Pract 2003;8(1):17-26.
  20. Mcgaghie WC, Issenberg SB, Cohen ER, et al. Medical education featuring mastery learning with deliberate practice can lead to better health for individuals and popu- lations. Acad Med 2011;86(11):e8-9.

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