Asynchronous learning for EKG’s

 

Problem Identification and Needs Assessment

It seems a crime to me that students finish medical school without the basic skills to read an EKG. No one volunteers this deficiency, but when asked the majority of students admit to it. This is in the fourth year, prior to their graduation. We need to do better by them. 

Targeted Needs Assessment

When I speak with students individually or in small groups, I find that they are all at differing levels of familiarity with EKG’s. Those who took a CCU rotation are more comfortable than those who didn’t. Yet when challenged with the task of reading an EKG while working shifts, nearly all have a disorganized approach – some more than others.

Goals and Objectives

The goal of this curriculum would be to give students the tools they need to interpret basic EKG’s they encounter. After they master the basic skills, then they can work on more complex EKG’s. The objectives are as follows:

By the end of this module, given an EKG the student will be able to:

1. Calculate the rate without referring to the computer generated number
2. Determine the rhythm and axis
3. Interpret the intervals (PR, QRS, QTc) and their significance
4. Interpret ST segments and T waves and their anatomical significance
5. Synthesize the above and the clinical presentation of the patient into their interpretation of the EKG

Educational Strategies

Since each student starts with a different level of understanding, an asynchronous model in which each student can progress at their own pace seems most appropriate. I can create a video for each of the objectives and pair it with exercises (blank EKG’s) for the student to read.

Additionally, during their ER rotation, the students will be challenged to bring in interesting EKG’s they’ve found and guide their fellow students through that EKG’s interpretation.

Should start with a challenge. Provide the students with an EKG and see if they can read it. Then have them do the course. Then we can see how they perform with real EKG’s and how it would affect their management of the patient.

Implementation

Would need to make the videos and collect representative EKG’s. Then I’d need to strip out all patient identifiers and arrange them into a packet (downloadable PDF) on which they can practice.

Here are the EKG’s I’ll need:

1. Rate: tachycardia, bradycardia
2. Rhythm: atrial fibrillation, atrial flutter, PSVT, junctional rhythm, AV-blocks (1, 2.1, 2.2, 3),
3. Axis: left, normal, right, normal in the upper-left quadrant
4. Intervals:
   1. PR – short (WPW) and long (1st degree block)
   2. QRS – LBBB and RBBB (leave the hemi-blocks for another course)
   3. QTc – prolonged QT
5. ST segments
   1. Anterior, Inferior, Lateral, Posterior and Right sided MI’s
   2. Same but ischemic changes
6. An advanced module can cover electrolyte abnormalities, digoxin, hypothermia and difficult rhythms (fusion beats, etc)

Evaluation and Feedback

Evaluation of the students can be done by a test of several EKG’s set aside to quiz them. To evaluate the curriculum, students can provide their comments. Ultimately I can study this and so my evaluation should be based on the modified Kirkpatrick hierarchy:

• Level 1: participation/satisfaction – post-course survey: did students enjoy this experience or find it helpful?
• Level 2a: change in attitudes/perceptions –
• Level 2b: change in knowledge/skills – a pre-test and post-test comparison
• Level 3: change in an individual’s behaviors – maybe can ask attendings if the students are more readily reading EKG’s.
• Level 4a: change in an organization’s practice
• Level 4b: benefits to patients – hmm…

Scholarship?

Always start with the end in mind, so how can this be studied?

• Can compare two groups, one getting asynchronous and one getting normal. This would really compare asynchronous learning to non-asynchronous. 
• Just see how students do after this and then see how much they retain, given that they always have access to these videos. Can also ask them later if they still use the videos.