Good afternoon, my name is Heather Rome, and I am the acute cardiovascular emergency coordinator at the Christ Hospital in Cincinnati, Ohio. I am delighted and appreciate the opportunity to present an update on our EKG training program. And I would also like to, on behalf of the Christ Hospital Health Network, thank the ACC Accreditation Foundation for their critical support of the 12-lead EKG training course, which is utilized to ensure the optimal triage and treatment of patients with acute coronary syndrome and life-threatening arrhythmias. I will take a few moments to discuss the significance of the EKG training course, the model for program development, the specific program aims, actions which were implemented to achieve those aims, as well as pre- and post-test data, course user feedback, and future considerations for the program. Cardiovascular disease is the leading cause of death globally, accounting for 17.3 million deaths each year. By year 2030, this number is expected to reach 23.6 million. PCI centers across the U.S. continually seek innovative ways to improve process efficiency and ultimately time to treatment for patients with an acute ST-elevation myocardial infarction, or STEMI. Time is muscle, with primary PCI for STEMI patients considered to be the most complex and time-sensitive intervention in modern medicine. Most PCI centers do report door-to-balloon times less than 90 minutes. However, despite that, challenges and opportunities for continued improvement do persist. STEMI processes and the steps for getting the patient to the cath lab are complex, with room for barriers and unforeseen delays. While PCI centers continually seek processes that are standardized and reliable, EKG interpretation skills vary greatly among healthcare professionals, likely due to the variability in EKG training methods, which include course material, education frequency, competency goals, and processes for ongoing competency and review. There are critical areas in the pre-hospital and early-hospital care of patients with EKG abnormalities, with timely and accurate EKG collection and interpretation of the utmost importance. Failure to recognize high-risk EKG features, specifically ST elevation and critical arrhythmias, compromise the quality of patient care by delaying diagnosis and time to treatment. While the recognition and interventions for critical arrhythmias has been thoroughly addressed by the implementation of the Advanced Cardiac Life Support, ACLS, and Pediatric Advanced Life Support, PALS, pathways, ST elevation has continued to be an area of greater complexity and variability, with ST elevation posing challenges for even the most seasoned physicians. More than two decades ago, the American Heart Association and similar organizations developed the Advanced Cardiac Life Support, ACLS, and Pediatric Advanced Life Support, PALS, algorithms. These are standardized protocols for the care of patients with life-threatening arrhythmias. Today, healthcare professionals must maintain competency of these algorithms as a condition of employment in various departments and specialties, especially critical care. Organizations who adopted these algorithms achieved substantially better patient outcomes. However, the same emphasis has not been placed on EKG interpretation, with organizations and EMS departments across the country all utilizing different education techniques and competency requirements. At the Christ Hospital, we used the ACLS and PALS algorithms as a model for standardizing EKG interpretation and competency. With support from the ACC Accreditation Foundation, the Christ Hospital Health Network aimed to develop, refine, and finalize an EKG training course, focusing on field paramedics with pre- and post-course competency evaluation, and optimizing the program by assessing and utilizing data and user feedback. The 12-lead EKG training course was developed with five training categories, beginning with 12-lead EKG basics, which includes 13 educational videos. Those videos consist of topics such as appropriate lead placement, basics of EKG interpretation, understanding reciprocal and contiguous leads, and why EKGs should be performed with the first set of vital signs. The second category then focuses on STEMI recognition, with seven training videos which assist with identifying ST elevation. The program then provides 20 more training videos, which become a bit more complex, focusing on STEMI equivalence, STEMI mimics, and unique considerations such as the EKG changes that often present with hyperkalemia, Brugada syndrome, Wolff-Parkinson-White syndrome, Wellen syndrome, and of course, aortic dissection. This course was developed to provide the basic fundamentals of EKG collection and interpretation, and then progress into the review of more complex EKG considerations and concepts. After the development of the course curriculum, a website was created which would allow online training for all users, including private login and on-demand short video tutorials with the option to watch and re-watch as often as the user chooses. The program is lengthy, with no limit for completion time frame. Following the course completion, users can even utilize the tutorials for ongoing training and review. At the time that each private login is developed, the account is identified as either being a user or an administrator, with the administrators having access to see both the pre- and post-test results for all users. The course curriculum consists of a 20-question pre-test, which must be completed before the program will launch. Users are not provided with the results of their pre-test until the entire course, including post-test, is completed. After the user completes all 5 modules and 39 training videos, they are given a 20-question post-test. Once they have completed both the post-test and pre-test, they are given the results together, allowing them to see their improvement. Each user is also provided with an evaluation form, as an opportunity to provide valuable feedback which will assist in future considerations and the ongoing development of the EKG training course. Shown here are a few examples taken from the EKG training course. The course begins by providing the basics of EKG collection and interpretation, and then goes into more complex concepts, such as acute coronary syndrome in the presence of left main occlusion, the presence of hyperacute T waves, or left bundle branch block to name a few. The review of complex presentations and STEMI mimics are valuable for enhancing the accuracy of STEMI identification, especially in the field. The program is narrated by a trained EKG moderator, with emphasis on evidence-based practice. This is, however, a lengthy program, which takes approximately 5 hours to complete all 5 modules and 39 training videos, if completed in one session. However, each user has the option to complete the course in small increments. At the Christ Hospital, we recognize that continuing to improve time to intervention can only be achieved through partnership with EMS departments, of which are often our first responders. Therefore, at the Christ Hospital, we have sought to empower field paramedics by providing them the training and resources necessary to activate our STEMI protocol directly from the field, in hopes of continuing to reduce the time to treatment for STEMI patients in our region. When EMS crews respond to a STEMI patient in the middle of the night or the weekend, our goal at the Christ Hospital is to have our team alerted and ready upon patient arrival at the hospital. With that, our focus for our EKG training program was on field paramedics in an effort to further enhance competency of STEMI recognition, comfort level with early team activation, all while maintaining minimal false activation rates. Thirty-four paramedics from nine different EMS departments in the Cincinnati region, as well as three nurse practitioners, completed the EKG training course. Paramedics had an average of 4% improvement in competency after course completion. Nurse practitioners, however, had an average of 13% improvement from their pre-test to post-test scores. The variability in competency improvement between health care providers is a reflection of the potential need to revise the course to meet the learning needs for different types of health care providers and their role in the STEMI activation process. Following the course completion, including the post-test, each user was provided with 13 evaluation questions. Here is an example of two of those questions and the feedback in which we received. Fifty-six percent of users identified the intent to change their practice based on course content. Forty-one percent agreed and 19% of users strongly agreed that the EKG training course material was presented in an effective manner. This feedback was especially valuable to better understand the value and quality of a self-regulated online EKG training program. The course post-test, along with evaluation forms which were completed by each user, have provided valuable information for us to further revise the EKG training course. In an effort to ensure that it is meeting the learning needs of all users, we intend to revise the course to meet the learning needs of different types of health care providers and the role they play in the STEMI activation process. We would also like to incorporate the training course into our organization's onboarding and annual education. We will also begin incorporating the 12-lead EKG training course into the required training for the Christ Hospital's EMS field STEMI activation initiative. In the future, we would also like to further develop a short course which would be available by hard copy or flashcards and consist of 100 consecutive STEMI activation scenarios. The 12-lead EKG training course has been a tremendous asset for continuing to ensure accurate and timely identification of STEMI presentation in our region. Thank you again for your support in this extremely valuable initiative, which is not only improving health care competency, but ultimately health care quality as well. Thank you so much for your time. Thank you.

EKG training program

STEMI recognition

competency improvement

user feedback

healthcare providers