Effects of Use of Primary Care Checklists and of Extent of Clinical Experience on Performance in Interpreting Paediatric ECGs Linked to Risk of Sudden Cardiac Death

Introduction: Sudden cardiac death in children and adolescents is a devastating yet potentially preventable event. There is, therefore, an urgent need for early recognition of young patients at elevated cardiac risk. Electrocardiographic screening may play a central role in this effort. However, interpreting paediatric ECGs requires advanced diagnostic skills. Checklists have been advocated to mitigate errors in a number of complex fields, both medical and non-medical; however, their effectiveness in interpreting paediatric ECGs remains uncertain. Objective: To evaluate whether the use of a structured checklist improves primary care paediatricians’ performance in interpreting paediatric ECGs, and to assess the influence of professional experience on diagnostic accuracy. Methods: We conducted a prospective, parallel-group study involving primary care paediatricians in the Balearic Islands (Spain). Participants were randomly assigned to interpret paediatric ECGs, either using routine unstructured interpretation or with checklist support. Outcomes included diagnostic validity ratios, and appropriateness of referral to paediatric cardiologists. Performance was analysed according to checklist use or years of clinical experience. It was also analysed whether diagnostic accuracy varied according to whether the ECG was classified as normal, or abnormal with or without an increased risk of sudden cardiac death. Results: Thirty-one paediatricians completed the study, generating 310 ECG interpretations. Checklist use did not significantly improve sensitivity, specificity, or likelihood ratios for detecting ECG abnormalities associated with sudden cardiac death risk, nor did it increase appropriate referral rates. We report a trend towards higher specificity and likelihood ratios among paediatricians with fewer than 20 years of professional experience than among their more senior counterparts. Significantly, this study found true positive rates of normal ECGs, and of abnormal ECGs with risk of sudden cardiac death, to be around 90%, as opposed to true positive rates of around 60% for abnormal ECGs without risk of sudden cardiac death (91% vs. 85% vs. 59%, respectively). Conclusions: In this study, checklist support did not enhance diagnostic performance in paediatric ECG interpretation. This finding highlights the need for targeted efforts to improve diagnostic accuracy in this sensitive subset. We also report that mid-career paediatricians appear to achieve the highest ECG diagnostic accuracy, and we show a particularly high rate of correct interpretation of both simple ECGs and high-risk abnormal ECGs.