A Novel Module Based Method of Teaching Electrocardiogram Interpretation for Emergency Medicine Residents.

Audience: This online learning module is designed for PGY 1-3 emergency medicine (EM) residents.

Introduction: Interpretation of the 12-lead electrocardiogram (ECG) is an essential skill for EM residents. The traditional approach to ECG interpretation in medical school is primarily didactic, teaching: "rate, rhythm, axis," etc. Throughout residency, EM residents continue to receive lectures and practical ECG teaching to independently interpret ECGs with accuracy and efficiency. In addition to basic rhythm interpretation, physicians must be able to identify cardiac ischemia, abnormal rhythms, and subtle ECG findings that could herald sudden death.1 Life-threatening diagnoses such as digitalis toxicity or hyperkalemia can be made promptly through ECG evaluation and catastrophic if missed. If correctly diagnosed through ECG, many channelopathies can be treated and cardiac events can be prevented.2,3 Lecture-based learning is a necessary part of medical education, but there is a need to supplement the traditional teaching approach with online learning modules. Online learning modules provide learners with an accessible and efficient tool that allows them to improve their ECG skills on their own time.

Educational objectives: After completion of the module learners should be able to: 1) correctly recognize and identify ECG abnormalities including but not limited to abnormal or absent P waves, widened QRS intervals, ST elevations, abnormal QT intervals, and dysrhythmias that can lead to sudden cardiac death; and 2) synthesize findings into a succinct but accurate interpretation of the ECG findings.

Educational methods: An online module was developed using Articulate 360 and was implemented with EM residents. The module covers common ECG findings seen in the emergency department including ischemia, atrioventricular blocks, and bundle branch blocks. The module uniquely emphasizes ECG findings of arrythmias that could lead to sudden cardiac death and highlights that diagnosing sudden cardiac death syndromes relies on both clinical presentation and specific ECG findings. Online modules have proven to be as effective as lecture-based learning at improving ECG interpretation among healthcare professionals and are convenient and easily accessible to the busy EM resident.4,5 Additionally, the module is self-paced, can be completed at any time, and includes elements of active learning by incorporating knowledge checks throughout. This allows learners in real time to see where individualized improvement is needed. The ease of embedment of self-paced questions into the module is one of the salient reasons why module-based learning can be superior to lecture-based learning. This allows for real time retrieval practice, feedback, and repetition, all of which can be powerful and effective tools for learning.6.

Research methods: This module was offered at a single academic institution with a 3-year residency program. The investigation was reviewed and approved for exemption by the Institutional Review Board of Sydney Kimmel Medical College. The module was evaluated using survey data; before the module was disseminated, residents were given a pre-module survey. The survey was used to evaluate the methods residents used to interpret ECGs prior to completion of the module and to evaluate their baseline confidence in ECG interpretation. The residents were then given access to the module and had two weeks to complete it. After the two-week period, the post-module survey was used to evaluate resident satisfaction with the delivery of the module, the methods residents used to interpret ECGs after the module, and resident confidence in ECG interpretation. The objective efficacy of the educational content in the module was assessed using a pre- and post-module assessment. The assessments consisted of 15 ECGs.Residents were asked to provide a one-sentence interpretation for each of the 15 ECGs and the final answers were based on interpretation by an electrophysiologist.

Results: A group of 37 EM residents had two weeks to complete the module between pre- and post-tests. There was an 18.2% absolute increase in the mean percent correct after the module, a 42.5% relative increase from pre-test (t= -8.0, p < 0.001). Subjective data demonstrated that after completing the module, residents utilized the novel approach, were more confident in interpreting ECGs, and would use the module as a resource in the future.

Discussion: Most participants were not confident in their ability to interpret an ECG prior to completing the module, despite most of the participants having ECG training in the six months prior to the study. Almost all the participants reported using "rate, rhythm, axis" as their method of ECG interpretation. Even with recent training, and an understanding of "rate, rhythm, axis," there was a very low accuracy on the pre-test and lack of perceived baseline confidence in this skill. These findings highlight the need for a concise, effective supplemental ECG tool that can be incorporated into residency program curricula.The online learning module was effective at increasing confidence of ECG interpretation skills in residents as well as increasing accuracy of interpretation. Overall, participants were satisfied with the module as a resource for practicing their ECG interpretation, and most participants reported that they would use the module in the future as a reference. Implementation of the module as an additional resource in resident education is very simple. It can be accessed through any device that has internet and can be completed in a short period of time. Additionally, most experienced ECG readers will speak about "pattern recognition" as an important tool in ECG interpretation. This ability goes above and beyond the "rate, rhythm, axis" approach, but is acquired over time, often after many years of ECG interpretation. It is possible that the modular method may accelerate such pattern recognition abilities.

Topics: Electrocardiogram, online module, sudden cardiac death, ischemia.