The report from the Health Services Safety Investigations Body (HSSIB) explores the use of 12-lead ECGs in ambulance services.

The investigation focused on 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 investigation spoke to key stakeholders to understand the safety risks that may be present in this area. 

HSSIB was prompted to examine this topic after receiving a Prevention of Future Deaths report. The coroner had highlighted paramedic education, training and competence as factors in the death of a 29-year-old woman who suffered a heart attack.

The report emphasises that there is variation in the way 12-lead ECG skills are taught across different higher education institutions, including variation in the time spent teaching and the level of detail, assessment methods and the subject matter expertise of lecturers involved in teaching about ECGs.

The investigation also found 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.

Some students felt they had a good level of ECG training at higher education institutions, while others felt limited time was spent on this during their degrees. Others commented that sometimes training tended to be via presentation, and therefore the practical application could be limited.

The report sets out a number of key findings in relation to education and training:

• 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 HEIs and ambulance services
• 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 education and training 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.

The report makes one safety recommendation to the Health and Care Professions Council and the College of Paramedics to improve the undergraduate teaching of 12-lead ECGs by reviewing and updating any relevant standards, guidance and curricula to provide clarification on a number of areas.

This includes:

• The level of education and expected level of competency and assessment required by student paramedics
• Any minimum standards expected for ECG education, including the time spent on learning, methods used, and subject matter expertise required of teaching staff
• How patient protected characteristics, health inequalities and other specific patient factors are taught
• How effective feedback mechanisms can be developed between HEIs and ambulance services.

Deinniol Owens, deputy director of investigations, said: ‘Carrying out and interpreting an ECG is an important skill for paramedics. It is crucial to the time-critical care of patients, but is a complex task with many factors that impact its accuracy. From our conversations with HEIs, paramedics and national organisations, there was no indication that the importance of ECG skills are underestimated. However, our investigation emphasised that there is still a concerning level of variation in the quality of paramedic ECG education and training across England.

‘Our recommendation and other learning in our report is aimed at improving paramedic education and training through consistency and clarity; paramedics should be able to feel confident when interpreting ECGs to ensure the best outcome for patients who may need life-saving treatment.'