550 Making paediatric ECG interpretation in the paediatric emergencydepartment easier and safer by introduction of an ECG checklist

Abstract

<h3>Background</h3> The accuracy of reporting electrocardiograms by trainees in paediatric emergency medicine has been shown to increase with experience. However, most paediatric trainees will only spend 3–6 months in the emergency department with limited opportunity to improve skills in electrocardiogram reporting. Interpretation in the emergency department has been shown to be relatively inaccurate and additional reporting of emergency department electrocardiograms by a consultant paediatric cardiologist increases the diagnostic accuracy. As a result, in many paediatric cardiac units the burden of electrocardiogram reporting is placed on the cardiology team, resulting in a significant workload. In addition, time taken for electrocardiograms to be reviewed by reporting teams may result in delay to clinic referral for patients with electrocardiogram abnormality. A previous study has shown that even amongst paediatricians, accuracy at interpreting paediatric ECGs is only around 60%. Although, there are accepted normal ranges and values for paediatric electrocardiograms, these are often presented in busy tables that can be complex and daunting to use, especially in a time pressured clinical environment. We hypothesised that a diagnostic aid, in the form of an electrocardiogram checklist, could assist in electrocardiogram interpretation, helping to screen for electrocardiograms that needed to be reviewed by a cardiologist and reducing the time to cardiology review for patients with electrocardiogram abnormalities. <h3>Objectives</h3> We set out to assess the use of a simple checklist and guideline to aid interpretation of paediatric electrocardiograms in the paediatric emergency department. <h3>Methods</h3> An electrocardiogram interpretation checklist and guideline were implemented in the emergency department. Abnormal electrocardiograms identified by the checklist were reviewed by a paediatric cardiologist and patients appointed to a cardiology outpatient clinic. The process was prospectively evaluated over six months to determine the ability of the checklist to detect abnormal electrocardiograms. The emergency department clinicians were sent a questionnaire to evaluate their experience with the checklist. <h3>Results</h3> Between May and November 2018, 600 electrocardiograms were performed in paediatric emergency department. 48 electrocardiograms of patients known to cardiology services or discussed with the on-call team were excluded. Of the remaining 552 electrocardiograms, 30 were identified by the emergency clinicians as abnormal and sent for cardiology review. 13/30 of these were considered normal by the consultant cardiologist and the patients discharged. The other 17 patients were allocated to cardiology outpatient clinic. Only 3/17 required ongoing follow-up. Of the 522 electrocardiograms deemed normal by the emergency department clinicians, cardiology disagreed in 8 (1.4%). In these cases, there was either incorrect lead placement or the checklist had been applied incorrectly. All 8 patients were seen in cardiology outpatient clinic but subsequently discharged. Use of the checklist demonstrated an excellent negative predictive value of 98.47% [CI 97.32% to 99.13%]. Following implementation, time from emergency department attendance to outpatient clinic decreased from a median of 89 to 45 days (P&lt;0.001) and survey respondents reported increased confidence in interpreting paediatric electrocardiograms. <h3>Conclusions</h3> The use of a simple checklist and guideline allows confident and accurate detection of electrocardiogram abnormality by emergency department staff and speeds referral to cardiology clinic for patients with electrocardiogram abnormalities.