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

Summary

This report is intended for healthcare organisations, healthcare staff, policymakers, higher education institutions and the public to help improve patient safety in how 12-lead electrocardiograms (ECGs) are carried out in ambulance services. It shares findings and recommendations from an investigation that considered the use of ECGs to help identify ST elevation myocardial infarction (a type of heart attack) and the support available to ambulance crews in making this identification.

Content

This report focuses on the equipment and support systems that are used by and assist ambulance crews in diagnosing a STEMI. The findings highlight key issues concerning not only the ECG equipment’s ability to recognise a STEMI, but also the ambulance crews’ recognition and the level of clinical support available to them during interpretation. HSSIB heard from ambulance crews that it was easy to interpret an obvious or “barn door” STEMI from a 12 lead ECG. However, it was more challenging to identify one where patients had less obvious signs and symptoms.

Safety recommendations

• HSSIB recommends that NHS Supply Chain reviews and amends the procurement framework for monitors/defibrillators to help ambulance services ensure they are fully considering the defibrillation/monitoring and cardiac diagnostic functions of the device when making purchasing decisions, to better reflect how these devices are used in practice.
• HSSIB recommends that NHS England/Department of Health and Social Care reviews and amends the service specification for primary percutaneous coronary intervention (PPCI) centres, to include a requirement for a function enabling two-way communication with ambulance crews for shared decision making about patients with a suspected STEMI. This is to ensure that patients are taken to the correct place of care and PPCI teams are responding to confirmed STEMI cases.

Safety observations

• Regulatory bodies can improve patient safety by supporting standardisation across manufacturers in how information from ECG traces is displayed.
• 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.