A PROSPECTIVE EVALUATION OF THE UTILITY OF THE PREHOSPITAL
12-LEAD ELECTROCARDIOGRAM TO CHANGE PATIENT MANAGEMENT
IN THE EMERGENCY DEPARTMENT
Matthew Davis, MD, MSc, Michael Lewell, MD, Shelley McLeod, MSc, Adam Dukelow, MD
ABSTRACT
Objective. Retrospective research has shown that 19% of 12-
lead prehospital electrocardiograms (prehospital ECGs) had
Prehosp Emerg Care Downloaded from informahealthcare.com by Northern Alberta Institute of Technology on 02/08/15
clinically significant abnormalities that were not captured on
the initial emergency department (ED) ECG and had the po-
tential to change medical management. The purpose of this
study was to prospectively determine how many prehospi-
tal ECGs had clinically significant abnormalities not present
on the initial ED ECG and determine how many prehospi-
tal ECGs changed physician management. Methods. We con-
ducted a 3-month, prospective cohort study of patients who
had a 12-lead prehospital ECG completed by EMS prior to ar-
riving at one of two tertiary care EDs. STEMI bypass patients
were excluded. Physicians reviewed the prehospital ECG to
determine whether there were any clinically significant ab-
normalities present on the prehospital ECG not captured on
the initial ED ECG. Physicians recorded if and how the pre-
For personal use only.
hospital ECG changed their management. Results. A total of
281 patients were enrolled. Thirty-five (12.5%; 95% CI: 9.1%,
16.8%) prehospital ECGs showed changes that were not cap-
tured on the initial ED ECG (11 ST depression, 5 T-wave in-
version [TWI], 2 ST depression and TWI, 12 arrhythmia, 2
arrhythmia with ST depression, 2 ST elevation, 1 unknown).
Fifty-two (18.5%; 95% CI: 14.4%, 23.5%) prehospital ECGs in-
fluenced physician management. There were 30 (10.7%) in-
stances where physicians were willing to refer the patient to
an inpatient service based on information captured on the
prehospital ECG, regardless if the initial ED ECG was nor-
mal. Conclusions. Prehospital ECGs show clinically signifi-
cant abnormalities that are not always captured on the ini-
tial ED ECG. Prehospital ECGs have the potential to change
the management of patients in the ED. Key words: acute
Received November 23, 2013, from the Division of Emergency
Medicine, Department of Medicine, The University of Western On-
tario (MD, ML, SM, AD), London, Ontario, Canada; and the South-
west Ontario Regional Base Hospital Program (MD, ML, AD), Lon-
don, Ontario, Canada. Revision accepted May 29, 2013; accepted for
publication June 4, 2013.
Study results were presented at NAEMSP January 2012 and the an-
nual conference for the Canadian Association of Emergency Physi-
cians in June 2012.
The authors report no conflicts of interest. The authors alone are re-
sponsible for the content and writing of the paper.
Address correspondence to Matthew Davis, 4056 Meadowbrook
Drive Unit 145, London, ON, Canada N6L 1E5. e-mail: matthew.
davis@lhsc.on.ca
doi: 10.3109/10903127.2013.825350
9
coronary syndrome; electrocardiogram; emergency medical
services; emergency medicine
PREHOSPITAL EMERGENCY CARE 2014;18:9–14
INTRODUCTION
The 2010 American Heart Association guidelines rec-
ommend the implementation of 12-lead electrocar-
diogram (ECG) diagnostic programs with concurrent
medically directed quality assurance (class I LOE B).1
These guidelines also recommend the routine acquisi-
tion of a 12-lead prehospital electrocardiogram (pre-
hospital ECG) by emergency medical service (EMS)
providers as soon as possible for all patients ex-
hibiting signs and symptoms of acute coronary syn-
drome (ACS). The American College of Emergency
Physicians, National Association of EMS Physicians,
and numerous other organizations have made similar
recommendations.2–7
Research has demonstrated that paramedics can ob-
tain diagnostic quality prehospital ECGs without a sig-
nificant increase in on-scene time.8–12 The benefits of
acquiring prehospital ECGs includes a shorter time to
diagnosis and reduced time to reperfusion in patients
with ST elevation myocardial infarction (STEMI), lead-
ing to decreased morbidity and mortality.8,13–15 The
majority of prehospital ECG research has focused on
the role of prehospital ECGs in diagnosing STEMI.
The utility of the prehospital ECG in patients without
STEMI remains to be elucidated.
In patients who are not experiencing a STEMI, im-
portant diagnostic information can be captured by the
prehospital ECG before any prehospital medical inter-
ventions occur.12–18 By the time patients are evaluated
by a physician, their symptoms may have resolved
and their initial emergency department (ED) ECG may
have normalized. Previous retrospective research has
shown that 19% of prehospital ECGs had clinically sig-
nificant abnormalities that were not captured on the
initial ED ECG and had the potential to change emer-
gency management.18
The purpose of this study was to prospectively de-
termine how many prehospital ECGs had clinically
significant abnormalities not present on the initial
ED ECG and determine how many prehospital ECGs
changed emergency physician management.
 10
METHODS
This was a prospective cohort study of adult patients
(≥18 years) transported to 1 of 2 tertiary academic
EDs (combined annual census 150,000) over a three-
month period (February 21, 2011 – May 20, 2011). Pa-
tients were included if they had a 12-lead prehospital
ECG completed by EMS providers prior to hospital ar-
rival. This study was approved by the Health Sciences
Research Ethics Board at The University of Western
Ontario.
This study was conducted in London, Ontario,
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which has a population of approximately 363,000.
EMS in Middlesex County, of which London is a
part, is provided by Middlesex–London Emergency
Medical Services. Middlesex–London EMS is a pri-
vately contracted EMS that has approximately 40,000
patient contacts per year in this county. Paramedics in
Middlesex County complete approximately 2,400 pre-
hospital ECGs per year. Both primary care (PCP) and
advanced care paramedics (ACP) can acquire 12-lead
prehospital ECGs on a battery-powered Zoll M Series
12-lead ECG with an industry standard GE Marquette
12SL Interpretive ECG algorithm. All ambulances
are equipped with these devices. All paramedics
are required to complete a Southwest Ontario Re-
For personal use only.
gional Base Hospital Medical Advisory Committee
12-lead ECG course created by the education sub-
committee and endorsed by the Provincial Medical
Advisory Committee. This program trains paramedics
on how to obtain a 12-lead ECG and in basic ECG
interpretation.
Prior to study initiation, an awareness campaign
was launched to educate paramedics, nurses, physi-
cians, and ED clerical staff about the study in order to
achieve maximum identification and enrolment of pa-
tients. Methods of disseminating this information in-
cluded multiple emails, study posters displayed in the
EDs and paramedic bases and verbal announcement
at academic rounds. Throughout the study, e-mail re-
minders were sent to all involved in order to maximize
enrolment.
Patients were eligible for inclusion if they were
18 years of age or greater and had a 12-lead prehos-
pital ECG completed by paramedics prior to hospital
arrival. Paramedics acquired a prehospital ECG in all
patients weighing ≥40 kg who were alert and experi-
encing chest pain or other symptoms consistent with
those caused by myocardial ischemia, patients expe-
riencing their typical angina or myocardial infarction
pain, or patients with a 3- or 5-lead ECG showing a
rhythm that was difficult to interpret.
Patients were excluded if they met criteria for STEMI
bypass. At our center, when a patient who experi-
ences symptoms consistent with myocardial ischemia
and has a 12-lead ECG that is interpreted as an acute
myocardial infarction by the 12-lead ECG software,
PREHOSPITAL EMERGENCY CARE JANUARY/MARCH 2014 VOLUME 18 / NUMBER 1
paramedics will activate the percutaneous coronary in-
tervention team and the patient is transported directly
to the catheterization lab, bypassing the ED, for treat-
ment. Criteria for STEMI bypass included a prehospi-
tal ECG, which was interpreted as an acute myocar-
dial infarction by the Zoll ECG software and printed as
such on the paper prehospital ECG printout. Patients
were also excluded if they had vital signs absent upon
arrival of paramedics.
After completing a prehospital ECG, paramedics
identified eligible patients by handing a data collec-
tion form to the nurse assuming care for the patient.
Nurses attached the data collection form to the pa-
tient’s ED medical record. The emergency physician
caring for the patient completed the data collection
form after analysis of the prehospital ECG. Physicians
were asked to document if there were any clinically
significant signs of ischemia or arrhythmias (requir-
ing investigation or treatment) present on the prehos-
pital ECG that were not present on the initial ED ECG.
Ischemic changes were defined according to the 2010
AHA Guidelines for Cardiopulmonary Resuscitation
and Emergency Cardiovascular Care (ST-segment de-
pression > 0.5 mm in leads V2 and V3 and 1 mm in
all other leads; T-wave inversion > 2 mm in depth).20
Physicians also recorded whether the prehospital ECG
influenced or changed their management of the pa-
tient in the ED and, if yes, how the prehospital ECG
changed their management. All collected data were en-
tered into a standardized Excel worksheet by a trained
research assistant.
Prior to study initiation, all variables were clearly de-
fined by the research team and a standardized data col-
lection tool was developed. Time to initial ED ECG was
defined as the time interval between ED registration
and the first ECG. Prehospital treatment was defined
as any medication (including oxygen) that was admin-
istered by paramedics prior to patient care handover
to the ED.
Previous retrospective research has shown that 19%
of prehospital ECGs had clinically significant abnor-
malities that were not captured on the initial ED
ECG and had the potential to change emergency
management.19 Therefore, assuming 80% power, an es-
timated prevalence of 19% and a precision level of 5%;
it was estimated that 237 patients were needed to be
95% confident that the true proportion of prehospital
ECGs that had abnormalities that changed ED man-
agement would be between 14% and 24%.21
Data were entered directly into a study-specific
Microsoft Excel database (Microsoft Corporation,
Redmond, Washington). Descriptive statistics were
summarized using means and standard deviations,
medians and interquartile ranges or proportional dif-
ferences where appropriate. Statistical analysis was
conducted using Stata 13.0 (StataCorp LP, College Sta-
tion, TX).
 M. Davis et al. PREHOSPITAL 12-LEAD ECG 11

RESULTS depression and arrhythmia, 12 with an arrhythmia, 2

A total of 562 prehospital ECGs were completed by
paramedics over the three-month study period and 394
patients were identified for enrolment in the study. Of
these, 281 had a data collection form completed by
physicians and were included in the study (Figure 1).
Of the 281 patients enrolled, 149 (53%) were male, 129
(45.9%) were female, and 3 (1.1%) were patients whose
gender was not recorded. The mean (SD) age was 67.8
(17.9) years.
Of the 281 included prehospital ECGs, 35 (12.5%;
Prehosp Emerg Care Downloaded from informahealthcare.com by Northern Alberta Institute of Technology on 02/08/15
with ST elevation, and 1 with an unidentified abnor-
mality that was not recorded by the physician. Of these
35 abnormalities identified on the prehospital ECG
and not captured on the ED ECG, 23 (65.7%) changed
physician management (Table 1). There were 21 (9.0%)
prehospital ECGs that were not different from the ini-
tial ED ECG but did influence ED management prior to
the acquisition of the ED ECG (Table 2). The prehospi-
tal ECG enabled earlier consultation to a specialty ser-
vice and allowed for immediate treatment prior to ED
ECG. In total, 52 (18.5%; 95% CI: 14.4%, 23.5%) of pre-

95% CI: 9.1%, 16.8%) had clinically significant abnor-
malities that were not present on the initial ED ECG.
Of the 35 prehospital ECGs with clinically significant
abnormalities that were not present on the initial ED
ECG, 11 had ST depression, 5 with T-wave inver-
sion (TWI), 2 with ST depression and TWI, 2 with ST
hospital ECGs changed or influenced the management
of the ED physician. There were 30 (10.7%) instances
where ED physicians were willing to refer the patient
to an inpatient service based on information captured
on the prehospital ECG, regardless whether the initial
ED ECG was normal. A total of 57 (20.3%) prehospital

prehospital ECGs
completed by
paramedics during the
study period
(N = 562)
For personal use only.

Missed paents
(n = 168)

prehospital ECGs
idenfied for
enrollment
(n = 394)

Physician forms not Physician forms

completed completed
(n = 113) (n = 281)

prehospital ECGs with Unknown if prehospital

prehospital ECGs that
clinically significant ECGs showed changes
were not different No ED ECG completed
abnormalies not seen that were different
from the inial ED ECG (n = 4)
on inial ED ECG from inial ED ECG
(n = 234)
(n = 35) (n = 8)

prehospital ECGs that prehospital ECGs that prehospital ECGs that prehospital ECGs that
changed ED changed ED changed ED changed ED
management management management management
(n = 21) (n = 23) (n = 3) (n = 5)

FIGURE 1. Flow diagram of prospective findings.

 12
TABLE 1. Abnormalities identified on the prehospital ECG
not captured on the ED ECG that changed physician
management
How ED management was changed
Consultation to specialty service
Immediate treatment prior to formal ECG
Consultation to outpatient service
Laboratory investigation
Physicians were able to select more than one option. ECG, electrocardiogram;
ED, emergency department.
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ECGs were determined to be of poor quality (Table 3).
All were still deemed to be interpretable by physicians
despite the poor quality. The median (IQR) time to ED
ECG was 45 (13, 25 minutes).
DISCUSSION
The prehospital ECG has proven to be a valuable
tool in the early identification, treatment, and man-
agement of patients with STEMI by reducing time
to reperfusion via fibrinolytic or percutaneous coro-
nary intervention.8,13–15 A recent study showed that
prehospital activation of the cardiac catheter labora-
For personal use only.
tory significantly reduced door-to-balloon time when
compared to walk-in STEMI patients and to STEMI
patients arriving by EMS without field activation.16
The majority of prehospital ECG studies focus on this
patient population. The focus of our study was on
patients who had clinically significant abnormalities
recorded on the prehospital ECG that were not cap-
tured on the initial ED ECG and how this influenced
patient management.
EMS providers often evaluate and treat patients who
are experiencing ischemic symptoms. On arrival in the
ED the underlying process causing their symptoms
may have resolved spontaneously or responded to the
symptomatic treatment provided by the paramedics.
The results of our study highlight that paramedics are
in a unique position to capture ECG changes while pa-
tients are experiencing their symptoms. As evidenced
by the number of clinically significant arrhythmias and
ischemic changes that were captured in the prehospital
TABLE 2. Prehospital ECGs that were not different from the
initial ED ECG but did change initial ED management
How ED management was changed
Consultation to specialty service
Immediate treatment prior to formal ECG
Early consultation to outpatient service
Laboratory investigation
Not specified
Code STEMI initiated
Physicians were able to select more than one option. ECG, electrocardiogram;
ED, emergency department; STEMI, ST elevation myocardial infarction.
PREHOSPITAL EMERGENCY CARE JANUARY/MARCH 2014 VOLUME 18 / NUMBER 1
TABLE 3. Characteristics of prehospital ECGs determined to
be of poor quality
Poor-quality characteristics n
n
Wandering baseline 23
16 Wandering baseline and missing lead 1
3 Wandering baseline and artifact 11
2 Artifact 19
2 Unknown 3
Physicians were able to select more than one option.
setting and not in the ED, the prehospital ECG appears
to be a valuable investigation for the non-STEMI pa-
tient. This highlights the value of the prehospital ECG
in emergency medical services regardless of availabil-
ity or timely access to a cardiac catheterization facil-
ity. In our study population, 16.8% of patients had is-
chemic changes on their prehospital ECG. The results
are similar to those found by Turnipseed et al., who re-
ported that 17% of the prehospital ECGs analyzed in
their study showed an injury pattern (ST depression,
TWI, or LBB).12
A recent study examined whether the prehospital
ECG adds supplemental information to the first ECG
obtained in hospital.17 Investigators compared data on
possible myocardial ischemia and arrhythmias by ex-
amining both the prehospital and first ED ECG. It was
discovered that 19% of prehospital ECGs showed ST
depression that was not captured on the first ED ECG,
while 14% of prehospital ECGs showed arrhythmias
that were not captured on the first ED ECG. These find-
ings are in keeping with the results of our study, indi-
cating that transient abnormalities can be captured on
prehospital ECGs that are not seen on initial ED ECGs.
However, our study provided clinical relevance by de-
termining if and how these transient abnormalities in-
fluenced ED patient care.
Of the 281 included prehospital ECGs in our study,
35 (12.5%; 95% CI: 9.1%, 16.8%) had clinically signif-
icant abnormalities that were not apparent on the ini-
tial ED ECG. The majority (62.9%) of these patients had
ischemic changes that were not apparent on the ini-
tial ED ECG. This represents a vulnerable population
whose severity of underlying coronary disease can go
unrecognized if the prehospital ECG is not evaluated
in the ED. This demonstrates the important role that
the prehospital ECG can have as a diagnostic tool in
patients not experiencing a STEMI that may otherwise
be missed if a prehospital ECG is not completed or not
n
analyzed by an ED physician. The presence of these
14 ischemic abnormalities found on the prehospital ECG
8 changed physician management in 65% of cases, high-
1
3 lighting the significant impact it has on providing ap-
2 propriate and timely patient care.
1 The ACC/AHA guidelines recommend that an ECG
should be performed within 10 minutes after ED
arrival in patients whose chief complaint is chest
 M. Davis et al. PREHOSPITAL 12-LEAD ECG
discomfort, angina equivalent, or other symptoms sug-
gestive of ACS.22 However, this standard is not met
in up to 67% of high-risk patients suffering from
non-ST-segment elevation acute coronary syndrome.25
Diercks et al. suggested ED overcrowding, inadequate
operational resources, and logistic challenges may im-
pact the time to initial ED ECG. In our study, the
median time to ED ECG was 45 minutes. The prehos-
pital ECG has the potential to assist in triaging patients
who may be experiencing ACS and can be used to di-
vert ED resources appropriately and earlier, especially
if it demonstrates ischemic changes that may have re-
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solved prior to the initial ED ECG. As demonstrated in
this study, treatment and investigations may be initi-
ated based on the prehospital ECG and not require a
formal ED ECG, such as the management of paroxys-
mal SVT or treatment of rapid atrial fibrillation.
The occurrence of false-negative prehospital ECG
interpretation of STEMIs in patients transported by
EMS highlights the importance of the prehospital ECG
in early STEMI identification. Patients with STEMI
may go undiagnosed either by computer-generated or
paramedic interpretation. A recent study showed that
prehospital computer interpretation is only 58% sen-
sitive in diagnosing STEMI, although the study was
For personal use only.
relatively small and used only one brand of moni-
tor and associated software.23 Additionally, a recent
American study reported that paramedics were able
to identify STEMI with a 75% specificity and a 53%
specificity.24 By having an ED physician review the
prehospital ECG, delays to initiation of reperfusion
strategies may be reduced, which may in turn lead
to more favorable outcomes. In our study population,
two false-negative prehospital ECG interpretations of
prehospital STEMIs (0.7%) were identified by emer-
gency physician interpretation of the prehospital ECG.
Previous false-negative rates have been reported as
high as 20%.26 Considering that the AHA guidelines of
initial ED ECG completion within 10 minutes is often
not met, reviewing the prehospital ECG prior to the ED
ECG can potentially decrease the morbidity associated
with delayed identification of STEMI.
In our study, 12 arrhythmias were identified on the
prehospital ECG that resolved by the time the ED
ECG was performed. The prehospital ECG allowed
for appropriate diagnosis, investigation, and treat-
ment. Atrial fibrillation made up the majority of these
paroxysmal arrhythmias. Identifying these paroxys-
mal rhythms on the prehospital ECG that may other-
wise go undiagnosed on ED ECG can reduce the need
for extended cardiac monitoring or outpatient Holter
monitor investigations. Additionally, relevant inves-
tigations and appropriate treatment can be initiated
sooner, which may lead to reduced morbidity and mor-
tality in this patient population.
Our study demonstrated that the prehospital ECG
changed physician management in 18% of cases, high-
13
lighting the importance of the prehospital ECG in the
ED care of patients. There were 30 (10.7%) instances
where the ED physician deemed there was a signifi-
cant abnormality on the prehospital ECG requiring in-
patient consultation, regardless if the initial ED was
normal. Our findings indicate that the prehospital ECG
can also play a valuable role in the timely and appro-
priate disposition of the patient, which could poten-
tially lead to the reduction of ED overcrowding and
increased departmental flow.
During the study period, 562 prehospital ECGs were
completed by paramedics, but only 394 were identi-
fied for enrolment. Of those, 281 had study forms com-
pleted by physicians. In an attempt to maximize the
number of enrolled patients, various awareness and
education campaigns directed at paramedics, nurses,
physicians, and clerical staff were implemented. De-
spite this, only half of all patients with a prehospital
ECG during the study period were included in the data
analysis. It is unknown if there were unique charac-
teristics or clinically relevant findings of those not en-
rolled that may have altered these study results. Ad-
ditionally, it is unknown whether ED physicians may
have been more likely to report that prehospital ECGs
influenced their management because of the study.
In our study, nearly 20% of the analyzed prehospi-
tal ECGs were of poor quality. This may have resulted
in some subtle changes that may have been missed by
physicians or resulted in overcalling certain positive
findings. Despite the number of poor quality prehos-
pital ECGs, all were deemed to be interpretable by the
emergency physician analyzing the prehospital ECG.
Our study was conducted within a single EMS system
and at two academic tertiary care EDs, and the results
may not be generalizable.
CONCLUSION
In summary, the 12-lead prehospital ECG can reveal
clinically significant abnormalities that are not always
captured on the initial ED ECG. As a result, prehospi-
tal ECGs have the potential to change the management
of patients in the ED. The prehospital ECG may also
lead to a more timely diagnosis, earlier treatment, and
appropriate disposition, potentially leading to reduced
morbidity and mortality among patients.
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