Dangerous Dysrhythmias in the ED: An Interactive EKG Workshop for Emergency Medicine Clerkship Learners.

AUDIENCE: This guided small group exercise is suitable for medical students who have completed basic lectures on electrocardiogram (EKG) interpretation. This activity was created for use within a third year required Emergency Medicine (EM) clerkship but can be implemented in other undergraduate medical education settings as well.

INTRODUCTION

Electrocardiogram (EKG) interpretation is poorly understood by medical students,1 and trainees display a concordant lack of confidence in their interpretation skills which can carry into fourth year of medical school and residency.2,3,4 Improving learner confidence and competence in identification of arrhythmias is of paramount importance to improve patient care.5,6 Our workshop targets the recognition and management of dangerous arrhythmias frequently seen in the Emergency Department.

EDUCATIONAL

OBJECTIVES

By the end of this session, learners will be able to: 1) identify common tachyarrhythmias and pulseless rhythms using EKGs, 2) differentiate stable from unstable tachyarrhythmias based on hemodynamics, symptoms, and EKG findings in acutely ill ED patients, 3) apply appropriate critical resuscitative actions to manage stable tachyarrhythmias, unstable tachyarrhythmias, and pulseless rhythms during emergency department resuscitations, in accordance with ACLS (Advanced Cardiopulmonary Life Support) principles, and 4) construct a rapid, ED-focused decision-making algorithm to guide the identification and management of tachyarrhythmias and pulseless rhythms.

EDUCATIONAL

METHODS

Learners participated in an interactive EKG workshop interspersed with lectures, EKG interpretation exercises, and case-based learning activities. During the workshop, students constructed a tachyarrhythmia and pulseless algorithm that will enable students in the future to identify and manage sinus tachycardia, supraventricular tachycardia (SVT), atrial fibrillation ( A fib ), atrial flutter, ventricular fibrillation (VF) and ventricular tachycardia (VT). Students collaborated in small groups, receiving real-time feedback from the facilitator on all activities.

RESEARCH

METHODS

Since this curriculum was designed for research purposes, learners completed a pre-test prior to starting this session and a post-test once the session concluded. This EKG pre/post-test was developed alongside the workshop curriculum to address the concerns identified in the needs assessment. The test was validated through testing on PGY1-3 EM residents. Confidence was assessed using Likert-scales of 1 (not at all confident) to 5 (extremely confident). Retention was assessed four weeks after completing the workshop using the same post-test. This study was Institutional Review Board (IRB) exempt.

RESULTS

Pre and post-test results were analyzed for 69 students that were divided across four cohorts. Students averaged a pre-test score of 74% and post-test score of 87.75%. This post-test score was maintained at the four-week reassessment with an average score of 86% (24.6% response rate).Confidence was measured by defining Likert scores of 1-3 as being "not confident" and 4-5 as "confident." On the pre-test, student confidence in identifying ventricular tachycardia was 52%, identifying a shockable rhythm 38%, and identifying features of instability 16%. On the post-test, student's confidence in identifying ventricular tachycardia rose to 96%, shockable rhythms to 93%, and features of instability to 90%.

DISCUSSION: Active small-group EKG workshops enhance learners' confidence and competence in recognizing and managing clinically significant arrhythmias in the emergency department. This learning exercise has become a staple of our required third-year EM clerkship and continues to show high learner satisfaction.

TOPICS: EKG, arrythmias, tachyarrhythmia, atrial fibrillation, ventricular tachycardia, PEA, asystole, ventricular fibrillation, atrial flutter, supraventricular tachycardia, undergraduate medical education, learner confidence, learner competence.