ECG Educational Standards for Prehospital Providers

The level of knowledge pertaining to electrocardiogram (ECG) interpretation among prehospital healthcare providers undoubtedly impacts patient outcomes. EMS personnel from EMRs to EMTs, AEMTs and paramedics play a critical role in the care of acutely ill and injured patients. First responders make critical decisions regarding initial assessment, intervention and transport. They must do so expeditiously. Such decisions have profound implications on quality and continuity of care. The importance of such actions becomes especially evident in regard to on-scene ECG interpretation.

The prehospital providers’ ECG interpretation often determines where the patient will be transported, and may set in motion activation of special personnel and resources at the receiving hospital (e.g., in the case of suspected stroke or ST-elevation myocardial infarction).

A position statement published in 2009 by the National EMS Advisory Council states that, “The EMS interventions that have been demonstrated to contribute most significantly to improved outcomes are those that result in earlier diagnosis and more timely reperfusion, specifically the capture and interpretation of 12-lead ECGs, notification of the receiving hospital and activation of coronary care or catheter lab teams, triage directly to a percutaneous intervention (PCI) center, and administration of thrombolytic agents during transport”.1

Such recommendations make it imperative that EMS educational institutions examine the extent to which they provide training in ECG interpretation for first responders. This research may identify areas of instructional strengths and weaknesses, thereby providing valuable information to guide future revisions for prehospital protocols and procedures.

The American Heart Association (AHA) reports that roughly 790,000 Americans suffer a heart attack every year.2 A longstanding adage from the AHA that’s popular among EMS providers is, “time is muscle” (i.e., the shorter the transport time the more vital muscle can be salvaged in a cardiac emergency such as myocardial infarction (MI).

The AHA recommends a medical contact-to-balloon or door-to-balloon time (D2BT) within 90 minutes;3 where “balloon” refers to percutaneous coronary intervention (PCI). Therefore, EMS personnel must make decisions expeditiously that decrease both time on-scene and transit time to a facility with PCI capabilities.

No Minimum Standard Exists

EMS regulations and oversight fall under the National Highway Traffic Safety Administration (NHTSA) Office of EMS in the U.S. Department of Transportation (DOT). This agency provides suggested guidelines for EMS education programs that target different levels of providers (e.g., EMT, paramedic, etc.) and were last updated in January 2009.4

Documents pertaining to each respective provider level contain a section on cardiovascular education. However, any specific mention of ECG interpretation appears only in paramedic instructional guidelines. Such guidelines are appropriate for EMS systems that utilize paramedics exclusively.

On the other hand, many systems throughout the country utilize varying combinations of prehospital providers to staff ambulances and fire apparatuses. To our knowledge, research has yet to demonstrate the impact on patient care attributable to the omission of specific educational guidelines in basic ECG interpretation appropriate for these first responders.

The Office of EMS recommendations identify specific arrhythmias and life-threatening cardiac emergencies paramedics should be able to identify and treat. Though being nearly a decade old, they may not adequately reflect current staffing models and best practices.

Moreover, they contain no hard-and-fast requirements to adhere to these guidelines. For example, those seeking paramedic licensure are required to apply for certification through the National Registry of Emergency Medical Technicians (NREMT). As of January 1, 2013, all applicants must have completed their education at an institution currently accredited or in the process of becoming accredited by the Commission on Accreditation of Allied Health Education Programs (CAAHEP).5

Programs not fully accredited must hold a Letter of Review (LOR) from the Committee of Educational Programs for the Emergency Medical Services Professions (CoAEMSP). Although CAAHEP is ultimately the final authority on accreditation, the CoAEMSP has an important role to play. This includes forming an on-site advisory committee, evaluating paperwork, and conducting site visits.6

CAAHEP’s “Standards and Guidelines for the Accreditation of Educational Programs in the Emergency Medical Services Professions” fail to mention training standards for basic ECG interpretation.7 Although this provides curricular autonomy for individual programs, it also suggests there’s no minimum standard of ECG interpretation that must be taught to all EMS professionals.

A Starting Place

Although recommendations for such training must take into account EMS provider scope of practice, an obvious starting point would be instruction in the mechanics of obtaining an ECG, and recognition of STEMI and non-STEMI abnormalities. This enables EMS providers to radio alerts to receiving hospitals which can immediately mobilize appropriate resources for reperfusion therapies, and most importantly, catheterization suites. This is consistent with the AHA’s admonition that “time is muscle” in treating heart attack victims.  

Within every EMS system, associated educational programs should teach standards that reflect system-specific protocols. The position of EMS medical director represents a potential safeguard to ensure that best practices in education are in fact being met. For this reason, medical directors play a significant role in determining expected educational outcomes for EMS professionals.

CAAHEP standards and guidelines state that the medical director is responsible for “review and approval of the educational content of the program curriculum to certify its ongoing appropriateness and medical accuracy.”7

In a policy statement, the American College of Emergency Physicians states that, “the 12-lead ECG in the out-of-hospital setting should be obtained as part of the initial vital signs for patients presenting with potential acute coronary syndrome. Use and transmission of this ECG should be defined by local protocol under appropriate EMS physician medical direction.”8

In this way, the EMS medical director maintains vital quality control for ECG education. The individual medical director and EMS system determine to what extent they exercise this authority.


As the role of evidence-based medicine becomes more prominent in the field of emergency medicine, a clear view of the current state of ECG education and platform from which to implement uniform standards becomes increasingly essential; especially as research expands into the prehospital setting.

Further research into EMS education may identify both strengths and weaknesses in basic ECG interpretation appropriate for first responders.

Implementing minimum ECG interpretation standards for EMS personnel nationwide is one potential option to ensure prehospital educational institutions stay responsive to current scientific knowledge and best practice recommendations. This in turn may result in increased competency among prehospital providers and, by extension, better patient outcomes.


1. National Highway Traffic Safety Administration. EMS makes a difference: Improved clinical outcomes and downstream healthcare savings. A position statement of the National EMS Advisory Council. Ann Emerg Med. 2011;57(2):170.

2. Benjamin EJ, Blaha MJ, Chiuve SE, et al. Heart disease and stroke statistics–2017 update: A report from the American Heart Association. 2017;135(10):e146—e603.

3. Antman EM, Anbe DT, Armstrong PW, et al. ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction: Executive summary: A report of the ACC/AHA Task Force on Practice Guidelines (Writing Committee to Revise the 1999 Guidelines on the Management of Patients With Acute Myocardial Infarction). Circulation. 2004;110(5):588—636.

4. National Highway Traffic Safety Administration. (January 2009.) National Emergency Medical Services Education Standards: Paramedic Instructional Guidelines. 2009. Retrieved June 5, 2018, from

5. National Registry of Emergency Medical Technicians. (2018.) Paramedic Program Accreditation Policy. Retrieved June 78, 2018, from

6. Committee on Accreditation of Educational Programs for the Emergency Medical Services Professions. (2015.) Letter of Review Self Study Report (LSSR). Retrieved June 15, 2018, from

7. Commission on Accreditation of Allied Health Education Programs. (2005.) Standards and Guidelines for the Accreditation of Educational Programs in the Emergency Medical Services Professions. Committee on Accreditation of Educational Programs for the Emergency Medical Services Professions. Retrieved June 15, 2018, from

8. American College of Emergency Physicians (ACEP). Out-of-hospital 12-lead ECG. Policy Statement. Ann Emerg Med. 2013;62(4):447.


  • J. William Hayden, MD, EdD, FACEP, has practiced emergency medicine for more than 28 years in rural and urban hospitals, university medical centers, and single as well as large group practices. He's a graduate of the University of Michigan Medical School and holds a doctorate in education from the University of Memphis. He is also a professor of medicine at the American University of the Caribbean School of Medicine.

  • Jonathan Barney, MD, BA, EMT-B, is a graduate of the American University of the Caribbean, School of Medicine. Prior to medical school, he attained his Bachelor of Arts degree from California State University at San Marcos and gained experience working in a variety of healthcare settings in Southern California, including working as an EMT, ER-Tech, and AHA Instructor.

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