A young woman with a pained expression lies in an ambulance with her eyes closed while two paramedics treat her.

12-lead electrocardiograms (ECGs) in ambulance services

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Background Intelligence review Safety observations

Background

These investigations will help to address patient safety risks associated with electrocardiogram (ECG) interpretation by ambulance crews in cases of ST Elevated Myocardial Infarction (StEMI).

Summary of investigations

An ECG is a test that records the electrical activity of the heart. ECG results require accurate interpretation by clinicians to determine the condition of the patient. A StEMI is a type of heart attack where there is a long interruption to the heart’s blood supply. This can cause extensive damage to the heart. It requires urgent treatment at a specialist cardiac centre to unblock the artery. An ECG can support the diagnosis of a STEMI.

HSSIB received a prevention of future death (PFD) report from HM Coroner, raising concerns about an incident where an ECG was misinterpreted for a young female patient with chest pain. The PFD highlighted education, training and use of the auto-interpretation function as factors in the patient’s death.

Intelligence review

HSSIB reviewed multiple sources of evidence in progressing the investigation, including:

  • national incident reporting systems
  • academic literature
  • national and international publications.

We have also engaged with a wide range of stakeholders to learn more about the issues surrounding ECG interpretation and identify areas where an investigation could focus to help improve patient safety.

ECG interpretation has been identified as a growing area of concern, with systemic safety risks that can have a significant impact on the outcome for patients. Reliance is placed on ambulance crews to be able to accurately interpret ECGs in critical situations to support their decision making on the treatment of patients with potentially life-threatening conditions.

HSSIB is committed to considering patient equality. We have identified research evidence that suggests the accuracy of an ECG can also be impacted by a range of protected characteristics under the Equality Act 2010, which include age, disability, gender reassignment, pregnancy, race and sex.

Safety observations

12 lead electrocardiograms (ECGs) in ambulance services: paramedic education, training and competence

  • Ambulance services can improve patient safety by including patient protected characteristics, health inequalities and other specific patient factors that can impact on the task of carrying out and interpreting a 12-lead ECG, when developing refresher training.
  • Ambulance services and national organisations can improve patient safety by providing and supporting protected time and resources for paramedic training and continuous professional development, while understanding the potential impact on operational performance.
  • Ambulance services can improve patient safety by providing additional support to paramedic students and paramedics through exposure to a range of clinical scenarios that help develop and maintain 12-lead ECG competency on a regular basis.
  • Acute hospitals and ambulance services can improve patient safety by developing local mechanisms to share information about patient outcomes where paramedics have undertaken a 12-lead ECG. This can help to support learning for paramedics and provide feedback on where their practice may be improved.

12-lead electrocardiograms (ECGs) in ambulance services: diagnosis of suspected ST elevation myocardial infarction (STEMI)

  • Manufacturers can improve patient safety by identifying the potential design barriers and enablers for ambulance crews entering information about a patient’s age or sex into a monitor/defibrillator. This could inform future device design to increase the likelihood that this information is entered when carrying out a 12-lead ECG using auto-interpretation.
  • Algorithm developers can improve patient safety by collecting data from different ethnic groups across different geographical locations to help increase the global representation and accuracy of auto-interpretation algorithms for STEMI.
  • Ambulance services can improve patient safety by informing regulators and manufacturers of instances where the use of monitor/defibrillators has impacted on patient safety.

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Publications

Investigation report: 12-lead electrocardiograms (ECGs) in ambulance services: paramedic education, training and competence Investigation report: Diagnosis of suspected ST elevation myocardial infarction (STEMI)