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Pediatric ECG Interpretation: An Illustrative Guide
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Between June and December of , a convenience sample of pediatric residents from the Johns Hopkins Children's Center were surveyed to evaluate their ability to interpret ECGs. We included the PGY 4 group to represent those residents who had completed their training.
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The initial component of the survey asked the participating residents if they had completed a pediatric cardiology rotation, how well they would rate their ability to read and interpret pediatric ECGs, how much training they had received regarding the reading and interpreting of pediatric ECGs, how important is the ECG when addressing pediatric cardiology issues, and would they routinely obtain an ECG as part of the evaluation for ADHD, chest pain, sports participation, murmur, acute life threatening event ALTE , syncope, drug ingestion, and new onset seizures.
Answers to the questions regarding ability and training to read and interpret ECGs as well as the importance of the ECG when addressing pediatric cardiology issues were based on a Likert scale of 1 not well, none, or not at all important to 5 excellent, more than enough, or extremely important. The vignettes were written by the authors to represent typical case scenarios where an ECG may be indicated. An example is shown in Appendix 1. ECG findings and cardiac diagnoses included in the study were based on the cardiovascular disorders content specifications from the American Board of Pediatrics and opinions of the pediatric cardiology faculty at the Johns Hopkins Children's Center.
Prior to the start of the study, the survey was completed by two pediatric cardiology fellows and one faculty member to test for content and validity. The institutional review board at the Johns Hopkins Bayview Medical Center approved the study and a consent recruitment statement was supplied to all participants. The primary outcome was the resident's ability to pair the ECG finding with the cardiac diagnosis.
Secondary outcomes included the affect of resident's self rated ability to read ECGs, training received in reading ECGs, the importance of obtaining an ECG when dealing with cardiac issues, and selected indications for obtaining an ECG on the primary outcome. Means were calculated for continuous variables. Simple and multiple linear regression was used to estimate the magnitude and significance of any association between total points given for ECG finding and cardiac diagnosis pairs correctly identified and resident year, completion of a pediatric cardiology rotation, self-rated ability to read ECGs, and training received in reading ECGs.
PGY 1 was used as the reference resident year.
The number of residents who identified the correct ECG finding and cardiac diagnosis based on the 10 vignettes is shown in Table 1. The most identifiable cardiac diagnoses were WPW syndrome, ventricular tachycardia VT , and cor pulmonale. Additionally, those who completed a pediatric cardiology rotation correctly identified 2.
For each point increase in the Likert scale for selfrated ability and received training in reading and interpreting ECGs the residents correctly identified 1 additional pairing. Adjusting for resident year, completed pediatric cardiology rotation, selfrated ability to read and interpret ECGs, and received training in reading and interpreting ECGs, only those residents completing a pediatric cardiology rotation were better at identifying correct pairings coefficient 2.
This study indicates that pediatric residents' ability to read and interpret ECGs improves significantly from PGY 1 to PGY 3 and among those who complete a pediatric cardiology rotation. Additionally and not surprisingly, those residents who received more training and rated their ability to read and interpret ECGs higher were better able to correctly identify ECG findings and cardiac diagnosis pairs. Of all of the variables completing a pediatric cardiology rotation was the strongest predictor of ECG reading and interpreting ability [ Table 2 ].
Incorporating a cardiology rotation into all pediatric residency training programs may have the potential to significantly improve trainees' ability to read and interpret ECGs. Additionally, residents completing a cardiology rotation will have opportunities to discuss the indications for obtaining an ECG and learn about those cardiac conditions with moderate to high clinical severity that require cardiology consultation. Indications for obtaining an ECG in children have traditionally included chest pain, heart murmur, ALTE, new onset seizures, syncope, and drug ingestion.
Guidelines from academies such as the AAP, AHA, and American College of Cardiology ACC that outline specific indications for obtaining ECGs in children may enhance the training of pediatric residents and help to focus teaching on those cardiac conditions with identifiable ECG abnormalities and moderate to high clinical severity. In a prior study, a grading system for pediatric ECG findings was developed to designate clinical severity. Educational programs involving ECG interpretation should target those diagnoses with high clinical severity and average to poor resident knowledge such as those identified in this study.
Residents who go on to work in ambulatory settings that care for children will have numerous opportunities to order ECGs and initially review and interpret the findings.
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Most of these opportunities will likely come in acute care settings such as urgent care centers and emergency departments where findings will often direct patient care, disposition, and follow up. There were limitations to this study that warrant further discussion. We conducted a cross-sectional survey at one institution and results may not be generalizable across all pediatric resident training programs.
The response rate in this study was low raising the possibility of reporting bias. Such a bias could potentially skew the results to show no difference among the groups if those completing the survey had an interest in cardiology and had increased competence in interpreting ECGs. Additionally, the small sample size may have affected our ability to observe meaningful differences in the adjusted analysis among resident groups.
However, despite the small sample size, the number of residents participating in the study was distributed evenly by year of training and we were able to demonstrate a statistically significant improvement in ECG interpretation skill from PGY 1 to PGY 3. Finally, the vignettes were limited in scope and were not representative of other serious cardiac conditions that may present with subtle ECG findings.
More than half of the residents surveyed in this study rate their training and ability to interpret ECGs as low. Pediatric guidelines on indications for obtaining an ECG and maintaining clinical competence may be needed for residents in training. These identified areas of strengths and weaknesses may help guide resident educational interventions for ECG interpretation.
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Source of Support: Nil. Conflict of Interest: None declared. National Center for Biotechnology Information , U. Journal List Ann Pediatr Cardiol v. Ann Pediatr Cardiol. Michael Crocetti and Reid Thompson 1. Author information Copyright and License information Disclaimer. Address for correspondence: Dr. E-mail: ude.