Report highlights concerning variation in paramedic ECG education and training

The report charts the first of two investigations exploring the use of 12-lead electrocardiograms (ECGs) in ambulance services. A 12-lead ECG usually involves using 10 electrodes to record 12 different views of the heart’s electrical activity so it is more comprehensive than other ECGs that use fewer electrodes for monitoring purposes.

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. 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.

Variation in teaching

Our investigation emphasises that completing a 12-lead ECG is a complex task and there is variation in the way 12-lead ECG skills are taught across different higher education institutions (HEIs), 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.

During the investigation, we spoke to students, new qualified paramedics (NQPs), and experienced paramedics. Those conversations often reinforced the lack of consistency. For example, some felt they had a good level of ECG training at HEIs, whilst 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, i.e. placing electrodes correctly, could be limited.

Key findings

In response to the analysis, the report sets out a number of key findings in relation to education and training:

• 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 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 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.

Safety recommendation

The report makes its 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.