Quality Assurance of Prehospital 12-Lead ECG Programs

I’m going to share with you my thoughts on quality assurance of prehospital 12-lead ECG programs.

This is a excerpt from one of my posts in the current discussion called EMS Role in Reducing the Symptom to Reflow Interval for AMI at the National Association of EMS Physicians Dialog Group.

I strongly believe that we need to start with:

1.) Making sure that the patients who are supposed to be getting a 12-lead ECG are getting one.

2.) Making sure that the ECG is captured early on in the patient care encounter, preferably with the first set of vital signs and within 5 minutes of arriving at the patient’s side (unless there is a very good reason as opposed to an excuse).

3.) Making sure that the ECG is captured with *excellent* data quality! There is a lot of room for improvement here.

4.) Making sure that the appropriate actions are taken when the patient meets the stated criteria of the EMS system (whether that is a “STEMI Alert”, transmitting the ECG to a decision maker, or both).

5.) Making sure that serial ECGs are captured (one of which should be captured on arrival at the receiving hospital).

Sometimes asynchronous clocks can cause problems, but they are solvable problems. For example, we can mandate that the cardiac monitor be “powered on” when the EMS crew arrives at the patient’s side so we can calculate the “time to ECG”.

All of the rest can generally be QA/QI’d through retrospective case reviews or abstracted from ePCR. For example, patients who are diagnosed with ACS at the hospital and were transported by EMS but did not receive a 12-lead ECG in the field. We should find out why and use it as a learning opportunity.

We should also have regular meetings with the stakeholders on STEMI care so the people on the receiving end understand management’s expectations of patients who receiving a 12-lead ECG in the field (in other words, that they should be gowned and our approach is very standardized in the field).

Any STEMI Alerts that were called based on incorrect interpretation of the 12-lead ECG are learning opportunities and should be fed back to the line personnel as case reviews, along with tips for identifying that particular mimic in the future.

Often (but not always) what you’ll see is that poor data quality was a major factor. Sometimes it’s poor lead placement (limb leads on the chest) and sometimes it’s a very good mimic like an atypical strain pattern from left ventricular hypertrophy.

If the paramedics in the field are doing their part and the E2B/D2B times “fall out” then a problem on the hospital’s side of the fence. Sometimes there are legitimate reasons for this (marginal cases, an unstable patient, another STEMI patient already on the cath table) but our attention should be on system failures where EMS failed to act appropriately.

It doesn’t take long to figure out if the problems encountered are training-related versus compliance-related. If you have paramedics out there who just “don’t believe in 12-leads” or “don’t need a 12-lead to tell them who’s having a heart attack” you need to find that out and address it.

It also doesn’t take long to figure out who the problem physicians are. If you plot out all of your acute STEMI cases for a year on a time graph you might be surprised to see that the same ED physician was on duty for all of the “fall out” cases and a different ED physician was on duty for all of the D2B times < 60 minutes. That’s a problem that the hospital needs to address through peer review.

What are your thoughts?


  • Christopher says:

    Perhaps even review of 3L/12L from a random selection of calls to ensure interpretation is accurate.I know it would be met with huge resistance, but adding data fields to ePCR systems for 12L's to gather additional information, such as Wide or Narrow complexes, electrical axis, does the medic believe there is LVH.Then those fields could be QA'd to see if certain 12L skills were adequate or needed improvement. And it would be interesting from a data-mining perspective!

  • Anonymous says:

    Hey. Thanks for a greate blogg. What's the different by putting the limb leads on the cheast? In our system we don't have the possibility to put them on the legs (the electrodes don't reach the legs).Sry for bad English.Daniel, German emt.

  • Tom B says:

    Christopher -I do believe that someone who is qualified should over-read 100% of prehospital 12-lead ECGs, and I think they should all be "stored" within the ePCR.However, it shouldn't be a painful process for the paramedic in charge of the call.Why not just "pluck" interesting ECGs and make case studies out of them for continuing education?Tom

  • Tom B says:

    Daniel – Talk a look at this case study:23 year old male CC: Chest painThe clinic placed the limb leads on the chest and abdomen which shifted the frontal plane axis and created a pseudo-reciprocal change in lead aVL.Tom

  • Your position is right on…To ensure that the highest qaulity of care is being delivered it is imperative that all representatives from the system are active and meet regularly to analyze the processes and to ensure that each piece works and fits with another. If you removed one or two spokes form a wheel the entire function is weakened and the wheel will not function properly; conversely when all the spokes are carrying equal weight, the wheel moves faster, more efficiently. In STEMI systems if one group or piece of the system is absent or does not do their part, it puts the entire process in jeopardy impacting the care the patient receives.

  • If only we could create our own system Tom. The NAEMP discussion has been great. I love talking about solutions as opposed to complaining about problems. This is a great post.

  • emt161 says:

    Most of the busiest services in my area don't even bring a bag to the patient's side, never mind a monitor that they're going to use as a timestamp. If they were even doing 12-leads that would be an improvement. Sorry to be Debbie Downer, its just increadibly frustrating to see systems that are trying to implement best practices on top of their already squared-away programs, and then go out in the streets and see almost a million people not getting the care they deserve.

  • Tom B says:

    BarefootNurse -Great analogy! I hope that we in EMS start to take patient safety and best practices seriously like they do inside the hospital. It's going to essential in order for us to move forward as a profession.Tom

  • Tom B says:

    Adam -Thanks, bro! Sometimes I wish I could build an EMS system from the ground-up, but since that's not currently possible, the next best thing is brining positive change to my own organization.There are a lot of barriers in the way of quality patient care. The only way to remove them is to win the hearts and minds of people in positions of authority.Raising the bar means that quality patient care needs to become an expectation.Tom

  • Tom B says:

    emt161 -Hang in there! Sometimes change happens very slowly (or not at all). I hope that some day you are able to experience transformational leadership. Good luck! Tom

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