Training activity information
Details
Perform and interpret the following ECG measurements in a variety of patients –
- 3 lead ECG
- 5 lead ECG
- 12 lead ECG
Type
Entrustable training activity (ETA)
Evidence requirements
Evidence the activity has been undertaken by the trainee repeatedly, consistently, and effectively over time, in a range of situations. This may include occasions where the trainee has not successfully achieved the outcome of the activity themselves. For example, because it was not appropriate to undertake the task in the circumstances or the trainees recognised their own limitations and sought help or advice to ensure the activity reached an appropriate conclusion.
Reflection at multiple timepoints on the trainee learning journey for this activity.
Considerations
- Equipment set up, including calibration
- Preparation of area
- Patient centred care and support
- Communication with patients, relatives and the clinical team
- Connection to patient
- Contraindications
- Troubleshooting
- Risk management
- Infection control
Reflective practice guidance
The guidance below is provided to support reflection at different time points, providing you with questions to aid you to reflect for this training activity. They are provided for guidance and should not be considered as a mandatory checklist. Trainees should not be expected to provide answers to each of the guidance questions listed.
Before action
What does success look like?
- Identify what is expected of you in relation to effectively acquiring, reviewing, and identifying critical changes in 3, 5, and 12-lead ECGs across a variety of patients in critical care.
- Consider how the learning outcomes apply, specifically in relation to applying techniques to manage and monitor cardiac conditions, ensuring patient safety during 12-lead acquisition, and communicating urgent findings to the multi-disciplinary team.
- Discuss with your training officer to gain clarity of what is expected of you in relation to expectations for specific lead placement protocols (e.g., posterior leads), troubleshooting common artifacts, and the expected level of interpretation for acute clinical scenarios.
What is your prior experience of this activity?
- Think about what you already know about performing and interpreting 3, 5, and 12 lead ECGs, including setup, acquisition, and initial review.
- Consider possible challenges you might face during the activity, such as managing electrical artifact in a busy critical care setting, ensuring optimal patient positioning for 12-lead acquisition, or rapidly identifying abnormalities such as ST-segment changes.
- Recognise the scope of your own practice for this activity i.e. know when you will need to seek advice or help, and from whom. You will need to seek advice from your Training Officer when required, for example if you encounter a complex arrhythmia (e.g., VT vs. SVT) or technical issue with the ECG machine that routine troubleshooting cannot resolve.
- Acknowledge how you feel about embarking on this training activity, particularly regarding your confidence in performing and interpreting different lead configurations.
What do you anticipate you will learn from the experience?
- Consider the specific skills you want to develop, such as improving lead placement accuracy for the 12-lead ECG and efficient troubleshooting techniques to eliminate movement or electrical artifact, drawing upon previous experiences.
- Identify the specific insights you hope to gain into the clinical relevance of different ECG findings (e.g., bundle branch blocks or ST elevation/depression) in critical care patients.
What additional considerations do you need to make?
- Consult actions identified following previous experiences of ECGs or similar monitoring activities (if any), such as using specific skin preparation techniques to reduce impedance.
- Identify important information you need to consider before embarking on the activity, such as reviewing the academic content on ECG measurement principles and monitoring, patient history (e.g., recent cardiac events), or current clinical status (e.g., patient is unstable/sedated).
In action
Is anything unexpected occurring?
- Are you noticing anything surprising or different from what you anticipate whilst acquiring the 3, 5, or 12-lead ECG or reviewing the resulting tracing?
- Are you encountering situations such as:
- Technical difficulties arise with electrode application or connection, resulting in persistent high impedance or excessive electrical artifact despite initial setup?
- The patient reports unexpected discomfort or shows signs of distress during lead placement, challenging the acquisition of a clean 12-lead trace?
- The resulting ECG tracing displays unexpected critical changes (e.g., severe dysrhythmia or acute ST elevation/depression) that deviate significantly from the patient’s expected clinical status?
How are you reacting to the unexpected development?
- How is this impacting your actions? For example, are you responding to the situation appropriately? Are you adapting or changing your approach to electrode placement, acquisition parameters, or real-time interpretation?
- Consider the steps you are taking in the moment, such as:
- Immediately halting the acquisition to re-prep, the skin or check connections to resolve technical issues or artifact
- Adapting your communication style to reassure an anxious patient during lead application or quickly communicating an unexpected finding to a clinical colleague
- How are you feeling in that moment? For instance, are you finding it difficult to troubleshoot technical issues in a high-pressure environment? Is it affecting your confidence in accurately interpreting the unexpected critical finding?
What is the conclusion or outcome?
- Identify how you are working within your scope of practice. For example, are you successfully troubleshooting technical issues yourself, maintaining patient dignity, and confidently confirming a diagnosis? Or are you needing support because the critical nature of the finding or unresolvable technical artifact requires senior intervention or immediate expert interpretation?
- What are you learning as a result of the unexpected development? For example, are you mastering a more efficient troubleshooting technique for 5-lead monitoring? Or gaining insight into the specific ECG patterns associated with acute presentations in critical care?
On action
What happened?
- Begin by summarising the key steps you took when performing and interpreting the ECG measurements (3, 5, and 12-lead) for the variety of patients encountered.
- Consider specific events, actions, or interactions which felt important, such as how you managed the acquisition in a challenging environment (e.g., patient movement or electrical interference) or how you communicated a potentially critical finding (e.g., ST elevation) to the multidisciplinary team.
- Include any ‘reflect-in-action’ moments where you had to adapt to the situation as it unfolded, for instance, immediately troubleshooting an ECG with a clinical colleague when persistent artifact compromised the signal quality.
- How did you feel during this experience, e.g., did you feel confident in your technical ability or stressed by the clinical urgency of the finding?
How has this experience contributed to your developing practice?
- Identify what learning you can take from this experience regarding performing and interpreting ECG measurements. What strengths did you demonstrate, e.g., meticulous adherence to lead placement protocol?
- What skills and/or knowledge gaps were evident, e.g., unfamiliarity with the differential diagnosis for a complex arrhythmia?
- Compare this experience against previous engagement with similar activities – were any previously identified actions for development achieved? Has your practice improved in efficiently distinguishing non-pathological variations from acute findings?
- Identify any challenges you experienced, such as needing to seek advice or clarification on scope of practice regarding the expected level of certainty required to report an equivocal T-wave inversion, and how you reacted to this.
- Acknowledge any changes in your own feelings now that you are looking back on the experience.
What will you take from the experience moving forward?
- Identify the actions or ‘next steps’ you will now take to support the assimilation of what you have learnt, including from any feedback you have received, with regards to improving your rapid interpretation skills for specific acute coronary syndromes.
- What will you do differently next time you approach performing and interpreting ECG measurements, for instance, by proactively consulting the patient’s history for known cardiac issues before initiating the study?
- Do you need to practise any aspect of the activity further, such as troubleshooting electrical noise or key learning outcomes related to applying techniques to manage and monitor cardiac conditions?
Beyond action
Have you revisited the experiences?
- How have your subsequent experiences of performing and interpreting more complex or critical ECGs (e.g., those involving complex blocks or acute ischaemia) since completing this specific training activity led you to revisit your initial approach or decisions during that activity? For example, seeing several cases of Brugada syndrome or challenging STEMI mimics forced you to re-evaluate the rigidity of your interpretation checklist for subtle ischaemic findings during your first attempt at this training activity.
- Considering what you understand about pattern recognition and acute cardiac conditions now, were the actions or considerations you identified after your initial reflection on this training activity sufficient? How have you since implemented or adapted improvements in your systematic approach to ECG acquisition and interpretation based on further learning and experiences? For example, how you proactively reviewed and integrated the modified Sgarbossa criteria for LBBB with suspected Acute Myocardial Infarction (AMI) based on further learning.
- Has discussing equivocal ST changes or the impact of non-cardiac factors (e.g., electrolyte imbalance) on the ECG with colleagues, peers, or supervisors changed how you now view your initial experience in this training activity? For example, how professional storytelling with a senior colleague about a misclassified STEMI in a patient with pericarditis refined your understanding of the critical nature of correlating clinical history with ECG findings.
How have these experiences impacted upon current practice?
- How has the learning from this initial training activity, in combination with subsequent ECG performance and interpretation experiences, contributed to your overall confidence and ability in efficiently and accurately interpreting critical ECG changes, particularly in preparing for assessments like DOPS (Direct Observation of Practical Skills) or OCEs (Observed Communication Events)? For example, how your accumulated ability in rapid pattern recognition and communication of urgent findings now enables you to confidently present a 12-lead ECG tracing and articulate necessary clinical correlations during an OCE assessment.
- How has reflecting back on this specific training activity, combined with everything you’ve learned since, shaped your current approach to ECG acquisition, analysis, and clinical correlation? How does this evolved understanding help you identify when something is beyond your scope of practice or requires escalation? For example, how your evolved approach means you now routinely seek advice from your Training Officer or Senior Clinician immediately when a complex or life-threatening finding (e.g., unstable ventricular tachycardia or new complete heart block) is noted, recognising this requires immediate clinical intervention and not merely technical reporting.
- Looking holistically at your training journey, how has this initial ECG performance and interpretation experience, revisited with your current perspective, contributed to your development in meeting the learning outcomes related to applying techniques to manage and monitor cardiac conditions and practising safely? For example, how this foundational experience has supported your development in applying systematic analysis and troubleshooting techniques necessary for other cardiac monitoring activities.
Relevant learning outcomes
| # | Outcome |
|---|---|
| # 1 |
Outcome
Apply techniques to manage and monitor cardiac conditions. |
| # 5 |
Outcome
Communicate effectively with the patient and the multi-disciplinary team. |
| # 6 |
Outcome
Practice safely, managing risk in all elements of patient care. |