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135/A review of quality control in electrocardiography and the need for focused training and continuing education of professionals involved in the recording of routine ECGs

European Journal of Arrhythmia & Electrophysiology. 2019;5(Suppl. 1):abstr135

Introduction: The 12-lead electrocardiogram (ECG) is currently one of the most widely used, operator-dependent investigations in healthcare. To acquire an ECG, six recording electrodes are placed at precise anatomical locations on a person’s chest, and one electrode on each wrist and ankle. These are identified by palpation of standardised bony landmarks and in certain clinical circumstances can prove challenging to complete correctly. Incorrect positioning of ECG electrodes, erroneous connection of ECG leads and varying patient postures during ECG acquisition can significantly impact an ECG recording by falsely indicating an emergent abnormality or the requirement to administer therapeutic interventions. The literature suggests that up to 33% of ECG interpretations have some error when compared to the expert reference and consequently up to 11% resulted in inappropriate management.

Most textbooks and ECG learning media devote little attention to inadequate ECG recordings, meaning the first encounter a novice experiences of challenges to ECG interpretation is during clinical scenarios with actual patients. ECG related errors are mitigated through quality control measures and the need for focused training and continuing education of professionals involved in the recording of routine ECGs. Healthcare systems that enable reporting and discussion of challenges to ECG acquisition and interpretation are recommended to avoid risking patient safety through errors in interpretation.

Method: A review of the published literature surrounding teaching, learning and assessment of ECG describes the challenges of ECG acquisition and how patient care may be affected.

Results: ECG interpretation requires rapid decision making to support patient care. Analysing 12 ECG signal patterns, each comprising of multiple complexes and deflections, as well as integrating interval and segment metrics and relating these findings to physiological processes of myocardial contraction can overload the cognitive capacity of the interpreter and result in erroneous findings. It is therefore paramount correct ECG lead connection are established to minimise the detection of erroneous ECG signals that could ascribe pathology where there is none. It has been reported in clinical trials that up to 4% of all 12-lead ECG’s acquired in various clinical settings have been recorded incorrectly, with electrodes positioned either too high or too low to the correct anatomical bony landmark (9).

Conclusion/implication: These findings highlight the constant need for quality control in electrocardiography and the need for focused training and continuing education of professionals involved in the recording of routine ECGs.

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