Investigation Report: 12-lead electrocardiograms (ECGs) in ambulance services: paramedic education, training and competence.
Authors: Bancroft, A. and Phillips, P.
Publisher: The Health Services Safety Investigation Body
Abstract:Executive summary Background
This is the first of two investigation reports exploring the use of 12-lead electrocardiograms (ECGs) in ambulance services. An ECG is a test that records the electrical activity of a patient’s heart. It needs to be correctly carried out and accurately interpreted by clinicians to determine the patient’s condition and potential diagnosis. This investigation looked at paramedic education, training and competence in ECG practice, and the task of carrying out and interpreting an ECG in the context of the patient’s clinical signs and symptoms.
The second investigation report, which is due to be published in October 2025, will consider how patients with suspected ST elevation myocardial infarction (STEMI) (a type of heart attack) are diagnosed. It will explore the clinical advice and support available to paramedics, including the design, functionality and use of ECG equipment to aid in clinical decision making.
The investigation HSSIB received a prevention of future deaths (PFD) report, issued by HM Coroner in November 2023, which raised concerns about an incident involving a female patient aged 29 with chest pain. An ECG was reported as being misinterpreted and the patient later died of an acute myocardial infarction (heart attack). The PFD highlighted paramedic education, training, and competence in ECG interpretation as factors in the patient’s death.
The investigation spoke to key stakeholders to understand the safety risks that may be present in this area. The way 12-lead ECGs are undertaken and interpreted was identified as a growing area of concern, with systemic safety risks that can have a significant impact on the outcome for patients.
Findings The task of carrying out and interpreting a 12-lead ECG is an important skill for paramedics. It is a complex task involving multiple factors that can impact on its accuracy.
There is confusion about the level of specialist knowledge paramedics may be expected to have about 12-lead ECGs. This has created challenges in understanding and implementing the required level of education, training, competence, and professional expectations of paramedics in this area.
Paramedics are generalist clinicians who are required to have a broad knowledge base to respond to many different emergency and non-emergency situations. Any expectations for paramedics to have more specialist knowledge of 12-lead ECGs would need to be balanced with the need to support specialist knowledge in other areas.
Paramedics and student paramedics often lacked confidence in their ability to accurately interpret more complex 12-lead ECG and patient presentations.
There is no formal national requirement setting out if, how and to what standard 12-lead ECG competency should be assessed by higher education institutions (HEIs) and ambulance services.
There was variation in the way 12-lead ECG skills were taught across different HEIs, including variation in the time and level of detail, assessment methods, and the subject matter knowledge of lecturers involved in teaching about ECGs.
ECG refresher training does not always form part of paramedic annual training.
Practice-based learning about undertaking 12-lead ECGs for student paramedics could be limited by the range of clinical scenarios they encountered and the 12- lead ECG skills of their placement supervisors.
There was variability in the level of support and training provided to newly qualified paramedics in 12-lead ECGs via preceptorship programmes.
There was a lack of consistency in feedback mechanisms between higher education institution’s and ambulance services which limited the ability to address any 12-lead ECG learning needs.
There was a lack of feedback provided by hospitals to ambulance services and paramedic crews about their 12-lead ECG interpretation once patients had been taken to hospital. This limited the opportunity for paramedics to learn about ECG interpretation.
Some ambulance services and hospitals had been able to develop data sharing agreements feeding back information on patient diagnostics and outcomes to support learning.
There was variability in the approach to supporting protected time for training for staff within ambulance services. Pressure on ambulance services and paramedics meant that time for annual training and continuous professional development was often sacrificed to ensure operational demands could be met.
There was variability in the education and training provided by HEIs and ambulance services around patient protected characteristics, health inequalities and other specific patient factors, and how this may impact on 12-lead ECGs and decisions about patient care.
HSSIB makes the following safety recommendation Safety recommendation R/2025/058:
HSSIB recommends that the Health and Care Professions Council and the College of Paramedics work in collaboration with relevant stakeholders to improve the undergraduate teaching of 12-lead electrocardiograms by reviewing and updating any relevant standards, guidance, and curricula to provide clarification on:
the level of education and expected level of competency and assessment required of student paramedics in relation to electrocardiograms
any minimum expected standards for electrocardiogram education in higher education institutions, including the time spent on electrocardiogram learning, methods used, and subject matter expertise required of teaching staff
how patient protected characteristics, health inequalities and other specific patient factors are taught in relation to electrocardiograms
how effective feedback mechanisms can be developed between higher education institutions and ambulance services
This is to help improve consistency in the way paramedic students are educated about electrocardiograms.
Source: Manual
