Pre-hospital interpretation of electrocardiograms (ECG) in ambulance services

We have launched two investigations to help address patient safety risks associated with electrocardiogram (ECG) interpretation by ambulance crews in cases of ST Elevated Myocardial Infarction (StEMI):

• Diagnosis of suspected StEMI
• Paramedic education, training and competence

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.

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.

Diagnosis of suspected StEMI

This investigation will explore:

• The clinical advice and support available to ambulance crews in interpreting ECGs for suspected StEMI.
• The design, functionality and use of auto-diagnostic software to aide in clinical decision making.
• The approach taken in clinical advice, support and auto-diagnostic software in the consideration of ECG interpretation across protected characteristics.

We expect to publish this report in April 2025.

Paramedic education, training and competence

This investigation will explore:

• The undergraduate and vocational training of paramedics in conducting an ECG and interpreting its results.
• The professional training and support available to paramedics in maintaining competence in ECG practise.
• The approach adopted in education and training in considering differences in ECG interpretation across protected characteristics.

We expect to publish this report in October 2025.

We are keen to hear from anybody with an interest in this subject matter. This includes patients, families, carers, and clinical professionals who may wish to share their experiences of care.

If you would like to speak to us about these investigations before we publish the final reports, please email enquiries@hssib.org.uk.