Attitude of Emergency Medical Technicians Toward Electrocardiogram　― Needs of Electrocardiogram Training Courses and Other Learning Opportunities ―

Abstract

Background: Early intervention in prehospital settings is important for treating patients with acute coronary syndrome (ACS). Emergency medical technicians (EMTs) are the essential first responders who treat these patients, and their current attitudes towards electrocardiograms (ECGs) have not been identified. This study investigated the awareness of EMTs of ECGs to shorten hospital arrival time, improving patient prognosis.

Methods and Results: An anonymous questionnaire survey, with 27 statements about ECG and ACS response, was administered to 395 EMTs. The statements were related to interest, motivation, learning status, confidence, and norms pertaining to ECGs, a sense of perceived behavioral control, and training courses. The primary outcome was the perception of EMTs that their interpretation of an ECG affected patient prognosis (Statement [S] 1). Participants assigned scores for each statement using a scale ranging from 1 (strongly disagree) to 10 (strongly agree). The mean score for S1 was 7.09. Mean scores for statements regarding confidence and learning status were 3.96 and 3.53, respectively. The participants had a positive impression of training courses (score >5.5).

Conclusions: The EMTs experience was that their interpretation of an ECG could affect the prognosis of patients with ACS. Conversely, they lacked confidence reading ECGs, but were willing to attend ECG training courses. Therefore, efficient training programs need to be established to achieve a better prognosis for ACS patients.

Ischemic heart disease is the leading cause of mortality worldwide, accounting for 16% of all deaths worldwide.¹ Acute coronary syndrome (ACS) is the most common cause of mortality from ischemic heart disease, and the appropriate management of ACS is an urgent global issue. Various factors can help determine ACS prognosis, including age, sex, time to reperfusion, cardiac arrest, infarction site, and diabetes.^2–6 Of these factors, time from ACS onset to coronary reperfusion, particularly in the case of ST-elevation myocardial infarction (STEMI), has a significant effect on prognosis. The immediate restoration of coronary artery blood flow without complications is the key treatment.³ Primary percutaneous coronary intervention (PCI) has become the mainstay of reperfusion therapy in recent years, and its goal is to achieve balloon dilation within ≤90 min from the time of the first medical contact and reperfusion within 120 min of symptom onset.^7,8 Further, the Japanese Circulation Society guideline states that a door-to-balloon-time (DTBT; from hospital arrival to reperfusion) of 90 min is the minimum acceptable time; however, a DTBT of 60 min should be targeted.³

Before 2015, in Nagasaki Prefecture the median time from symptom onset to coronary reperfusion was 182 min. Although there is a need to shorten the DTBT to improve the prognosis of patients with ACS, there is a limit to how much the PCI procedure can be shortened to reduce the DTBT. Furthermore, a reduction in DTBT alone does not contribute to a better prognosis, and the most effective strategy to improve prognosis is to significantly shorten the total ischemic time from ACS onset to reperfusion.³ Therefore, there must also be an efficient reduction in prehospital time to reduce total ischemic time. However, there is insufficient information on prehospital activities to help achieve this.

Emergency medical technicians (EMTs) are among the most important first responders to patients with out-of-hospital ACS. The Japan Resuscitation Council (JRC) guidelines recommend a prehospital 12-lead electrocardiogram (ECG) for patients with ACS to reduce prehospital time,⁸ thereby indicating the importance of intervention in prehospital settings. Although, recently, automatic 12-lead ECG analysis has become available, previous studies consider it insufficient and indicate that a negative ACS statement should not be solely based on the automated analysis of a 12-lead ECG.⁹ Although it is best to have an experienced cardiologist evaluate the 12-lead ECG, systems for transmitting 12-lead ECGs to hospitals are not yet widely used throughout Japan. Furthermore, the installation rate of 12-lead ECGs in ambulances is low, with only 55 (23%) of 240 regions in Japan having 12-lead ECGs installed in all ambulances.¹⁰ The JRC guideline suggests, rather than recommends, that EMTs must read the 12-lead ECG, with the level of evidence for this suggestion found to be low.⁸ Therefore, establishing education programs for EMTs in the interpretation of 12-lead ECGs in each region could be a future issue.⁸ In addition, the current attitudes of local EMTs towards 12-lead ECGs have not been validated.

There is no evidence regarding the attitude of EMTs to 12-lead ECG in Japan, and dissemination of new evidence is desired in the guidelines.⁸ Because prehospital activities by EMTs can affect the total ischemic time from the onset of ACS, improving their awareness and ability to read 12-lead ECGs may reduce the prehospital time. Therefore, we investigated the attitudes of EMTs regarding reading 12-lead ECGs. This information could ultimately improve the prognosis of patients with ACS by shortening the time required for EMTs to arrive at the hospital or to call the emergency cardiac catheterization team.

Methods

An anonymous questionnaire survey was administered to all 395 EMTs in 10 fire departments in Nagasaki Prefecture, Japan, in March 2022. Participants were informed about the study and the submission of questionnaire responses, and informed consent was obtained. The participants who provided complete responses for all questions were included in the analysis. The questionnaire on 12-lead ECGs and the ACS response was developed on the basis of a previous disaster awareness survey that was conducted with EMTs by Iyama et al.¹¹ For the present study, the questionnaire was modified and created specifically to reflect 12-lead ECGs and ACS response. The questionnaire comprised statements regarding the following items: interest, motivation, learning status, confidence, and norms pertaining to ECGs, a sense of perceived behavioral control, and training courses. The primary outcome of this study was the perception of EMTs that their own ability to read a 12-lead ECG can affect the prognosis of patients with ACS (Statement [S] 1). The statements in the questionnaire are presented in Table 1. S2–S4 investigated interest; S5–S6 investigated motivation; S7–S8 investigated learning status; S9–S13 investigated confidence; S14–S17 investigated social norms; S18–S20 investigated the sense of perceived behavioral control; and S21–S27 investigated training courses. Participants assigned a score to each statement ranging from 1 (strongly disagree) to 10 (strongly agree). A mean score of >5.5 indicated that the EMTs agreed with the statement, whereas a mean value of <5.5 showed that they disagreed with the statement. A mean value of 5.5 suggested that the EMTs neither agreed nor disagreed with the statement. The scores obtained based on questionnaire responses were compared with the previous 12-lead ECG training course experience using a t-test (Table 2).

Table 1. Statements Included in the Questionnaire

S1	EMTs’ ability to read a 12-lead ECG affects the prognosis of patients with ACS.
S2	I am interested in cardiovascular diseases.
S3	I am interested in 12-lead ECGs.
S4	I am interested in a training course about 12-lead ECGs.
S5	I would like to actively engage in self-directed study about 12-lead ECGs.
S6	I would like to attend a training course on 12-lead ECGs.
S7	I have learned enough about 12-lead ECGs.
S8	Self-directed study about 12-lead ECGs has limitations.
S9	I am confident in my basic knowledge of 12-lead ECGs.
S10	I am confident in my ability to read 12-lead ECGs.
S11	I am anxious in my ability to read 12-lead ECGs.
S12	I can predict ischemic areas and urgency based on a 12-lead ECG.
S13	I can accurately convey the information from the 12-lead ECG results to the hospital.
S14	The ability to read a 12-lead ECG is a necessary basic skill for EMTs.
S15	Education and training to read 12-lead ECGs are essential.
S16	If my colleagues are studying to prepare for ACS response, I should take action as well.
S17	EMTs should be routinely educated and trained to meet the expectations of citizens.
S18	At my own workplace, it is easy to obtain information about seminars for 12-lead ECGs.
S19	At my own workplace, there is an opportunity to learn about 12-lead ECGs.
S20	I would like to receive feedback on my 12-lead ECG assessment from the hospital.
S21	I would like to attend a 12-lead ECG training course if it is free to attend.
S22	I would like to attend a 12-lead ECG training course, even if there is a fee to attend.
S23	I would like to attend a 12-lead ECG training course, if it is within the re-education training* period.
S24	I would like to attend a 12-lead ECG training course, if it will lead to a promotion or a salary increase.
S25	I would like to attend a 12-lead ECG training course, even if it is unrelated to a promotion or salary increase.
S26	If I were to take a training course on 12-lead ECGs, I would like to take only a classroom lecture.
S27	If I were to take a training course on 12-lead ECGs, I would like to have practical training.

The questionnaire asked study participants to rate each statement using a scale of 1 (strongly disagree) to 10 (strongly agree). *Re-education training: In Japan, EMTs are required to have 40 hours training in hospital every 2 years to maintain their emergency medical skills. ACS, acute coronary syndrome; ECG, electrocardiogram; EMT, emergency medical technician.

Table 2. Characteristics of Study Participants (n=327)

Age group (years)
20s	40 (12.2)
30s	156 (47.7)
40s	87 (26.6)
50s	41 (12.5)
60s	3 (1)
Work experience (years)
<5	85 (26)
5–9	91 (27.8)
10–14	79 (24.2)
15–19	47 (14.4)
≥20	25 (7.6)
Experience of 12-lead ECG training course
Yes	139 (42.5)
No	188 (57.5)

Data are presented as n (%). ECG, electrocardiogram.

This study was conducted in accordance with the Declaration of Helsinki and was approved by the Ethics Committee of Nagasaki University Graduate School of Biomedical Sciences (Approval no. 20103001).

Results

The questionnaires were administered to 395 EMTs, with responses obtained from 389 EMTs (response rate 98.5%). Responses from the 327 EMTs (effective response rate 82.8%) who provided complete responses to all questions were included in the subsequent analysis (Figure 1).

Figure 1.

Flowchart of participant selection. The questionnaire was administered to all emergency medical technicians (EMTs) in Nagasaki Prefecture (Pref.); 389 EMTs answered the questionnaire. After excluding 62 participants with incomplete response data, 327 were finally included in the analysis.

The background characteristics of the EMTs are presented in Table 2. The participants were commonly aged in their 30s. In all, 139 (42.5%) EMTs had previously attended a 12-lead ECG training course. Questionnaire responses are summarized in Table 3 and Figure 2. The mean score for the primary outcome, namely the ability of EMTs to read a 12-lead ECG affecting the prognosis of patients with ACS (S1), was 7.09. This score being >5.5 indicated that the EMTs felt that their own 12-lead ECG readings were important. Further, the scores for the remaining statements indicated that the EMTs were interested in cardiovascular disease and 12-lead ECG (S2: 7.81; S3: 7.74; and S4: 7.65) and were willing to engage in self-directed study (S5: 7.56). The EMTs were highly interested in attending a training course (S6: 7.87). Their learning status was low (S7: 3.53), and they felt that self-study had limitations (S8: 7.67). They were anxious rather confident about reading 12-lead ECGs (S9: 4.15; S10: 3.96; S11: 7.19; S12: 5.15; and S13: 4.60). Further, they observed that their 12-lead ECG reading ability is an important basic skill (S14: 7.31). In addition, education and training should be addressed (S15: 7.87; S16: 7.68; and S17: 8.19). The EMTs felt they did not have enough opportunities to learn in their own workplace, and they wanted feedback for their own assessments to be provided (S18: 4.40; S19: 3.93; and S20: 7.41). Finally, EMTs were willing to take 12-lead ECG training courses, with and without fees (S21: 8.35; S22: 6.17), and wanted to attend a course even if it was unrelated to salary increase (S25: 7.27). The EMTs preferred that courses were held during the re-education training period (S23: 7.63). Moreover, they requested that the training course included practical examinations rather than lectures alone (S26: 5.77; and S27: 7.29). Compared with the group without 12-lead ECG training, the group with training and experience in reading 12-lead ECGs scored significantly higher on S5, S9, S10, S13, S22, and S27 (P=0.01, 0.02, 0.03, 0.01, and 0.00, respectively; Table 3).

Table 3. Results of the Questionnaire Survey

Statement	Total (n=327)			Experienced 12-lead ECG training (n=139)			No 12-lead ECG training (n=188)			P value
	Mean	SD	95% CI	Mean	SD	95% CI	Mean	SD	95% CI
S1	7.09	1.92	6.89–7.30	7.24	1.97	6.92–7.56	6.99	1.88	6.72–7.26	0.2476
S2	7.81	1.76	7.61–8.00	7.96	1.80	7.66–8.25	7.70	1.72	7.45–7.95	0.1859
S3	7.74	1.83	7.54–7.94	7.84	1.83	7.54–8.15	7.67	1.83	7.41–7.93	0.4027
S4	7.65	1.97	7.44–7.87	7.89	2.00	7.56–8.22	7.48	1.94	7.20–7.76	0.0607
S5	7.56	1.84	7.36–7.76	7.86	1.77	7.57–8.16	7.34	1.86	7.07–7.61	0.0108*
S6	7.87	1.90	7.66–8.07	8.09	1.90	7.77–8.40	7.70	1.91	7.43–7.98	0.0719
S7	3.53	1.80	3.33–3.73	3.64	1.82	3.33–3.95	3.45	1.79	3.19–3.70	0.3386
S8	7.67	1.95	7.46–7.88	7.64	1.94	7.31–7.97	7.69	1.96	7.41–7.97	0.8147
S9	4.15	1.89	3.94–4.36	4.42	1.96	4.10–4.75	3.95	1.82	3.68–4.21	0.0240*
S10	3.96	1.87	3.75–4.16	4.22	1.86	3.90–4.53	3.77	1.86	3.50–4.03	0.0310*
S11	7.19	2.17	6.96–7.43	6.96	2.16	6.60–7.33	7.36	2.16	7.05–7.67	0.1010
S12	5.15	2.46	4.88–5.42	5.40	2.50	4.99–5.81	4.97	2.43	4.62–5.32	0.1208
S13	4.60	2.15	4.37–4.84	4.90	2.08	4.55–5.25	4.38	2.17	4.07–4.70	0.0312*
S14	7.31	2.07	7.09–7.54	7.46	2.11	7.11–7.81	7.21	2.04	6.91–7.50	0.2756
S15	7.87	1.78	7.68–8.07	7.95	1.79	7.65–8.25	7.81	1.78	7.56–8.07	0.4968
S16	7.68	1.94	7.47–7.89	7.72	2.04	7.38–8.06	7.64	1.86	7.38–7.91	0.7269
S17	8.19	1.65	8.01–8.37	8.24	1.67	7.96–8.52	8.16	1.64	7.92–8.40	0.6745
S18	4.40	2.11	4.17–4.63	4.54	2.21	4.17–4.91	4.30	2.03	4.01–4.59	0.3166
S19	3.93	2.14	3.69–4.16	4.17	2.31	3.78–4.56	3.74	1.99	3.46–4.03	0.0735
S20	7.41	1.85	7.21–7.61	7.53	1.99	7.20–7.87	7.32	1.73	7.07–7.57	0.3034
S21	8.35	2.01	8.13–8.57	8.41	2.16	8.05–8.77	8.31	1.89	8.04–8.58	0.6516
S22	6.17	2.17	5.93–6.40	6.55	2.19	6.19–6.92	5.88	2.12	5.58–6.19	0.0056*
S23	7.63	2.22	7.39–7.87	7.51	2.48	7.09–7.93	7.71	2.01	7.42–8.00	0.4169
S24	5.68	3.15	5.33–6.02	5.33	3.36	4.77–5.89	5.93	2.97	5.50–6.36	0.0885
S25	7.27	2.28	7.02–7.52	7.42	2.41	7.01–7.82	7.16	2.17	6.85–7.48	0.3226
S26	5.77	2.17	5.53–6.00	5.59	2.23	5.22–5.96	5.9	2.12	5.59–6.20	0.2031
S27	7.29	2.04	7.07–7.51	7.76	1.95	7.43–8.09	6.94	2.04	6.65–7.24	0.0003*

Data show mean scores for each of the statements in the questionnaire survey. A mean score >5.5 indicates that the emergency medical technician agreed with the statement, whereas a mean score <5.5 indicates that they disagreed with the statement; a mean score of 5.5 indicates that they neither agreed nor disagreed with the statement. *P<0.05. CI, confidence interval; ECG, electrocardiogram.

Figure 2.

Mean scores for each statement in the questionnaire. Error bars indicate 95% confidence intervals. A mean score >5.5 indicates that the emergency medical technicians agree with the statement, whereas a mean score <5.5 suggests that they disagree with the statement. Statements are presented in Table 1.

Discussion

Previous studies have recommended a DTBT of 120 min in the past.¹² However, over time, the DTBT has gradually shortened, with a DTBT or the time from first medical contact to implantation of a device <90 min having become the global standard. Currently, a target time of <60 min is recommended.^3,7,12,13 However, a recent study suggested that reducing DTBT alone does not contribute to a better prognosis, and significantly shortening the total ischemic time from ACS onset to reperfusion is the most effective strategy for improving prognosis.³ Furthermore, in some local medical area in Japan, a network has been established between out-of-hospital and coronary care unit specialists, which can provide information prior to patient delivery. This network helps receiving hospitals to secure a catheterization laboratory and staff in advance, thereby reducing PCI time by 18–30 min.^14–16 Considering that the time from the initial emergency call to hospital arrival is increasing every year (with a mean time of 40 min in Japan),¹⁷ EMTs must read a 12-lead ECG on-site and forward the data to hospitals to shorten the treatment time. Therefore, in this study we surveyed EMTs to determine their attitude towards reading 12-lead ECGs.

EMTs felt that their own 12-lead ECG readings are important (S1: 7.09). They also believed that their ability to read a 12-lead ECG is an important basic skill (S14: 7.31) and that education and training should be provided (S15: 7.87; S16: 7.68; and S17: 8.19). Therefore, they have a high social norm, interest in cardiovascular disease and 12-lead ECGs (S2: 7.81; S3: 7.74; and S4: 7.65), and willingness to undertake self-directed study (S5: 7.56). In contrast, the EMTs were not confident, instead rather anxious, about interpreting 12-lead ECG findings (S9: 4.15; S10: 3.96; S11: 7.19; S12: 5.15; and S13: 4.60), and their learning status is also insufficient (S7: 3.53). Therefore, contrary to their ideals, they have not completely achieved their goals. They need to be prepared to dispel their anxiety and acquire confidence. However, they are limited by self-study (S8: 7.67). Therefore, concrete measures to solve these issue are urgently required.

Based on the theory of planned behavior, 3 factors influence a person’s willingness to act: attitude towards the behavior, subjective norms, and perceived behavioral control (Figure 3).^18–20 When discussing the actions that EMTs should take to improve their own ability to read 12-lead ECGs, 2 of the 3 factors in the theory of planned behavior are already at a high level. Specifically, EMTs understand that their attitude towards this action is related to improvements in patient outcome (attitude towards behavior), and fire department personnel, including EMTs, are a group with originally high norms (subjective norms).^20,21 Therefore, the absence of a perceived behavioral control is one of the reasons for the lack of direct linkage to this behavior (improving their own 12-lead ECG reading ability). In fact, EMTs feel the limitation of self-study, and they do not have opportunities to learn in their own workplace (S8: 7.67; S18: 4.40; and S19: 3.93). Therefore, a sufficient learning environment (i.e., holding regular training courses) will directly solve the current issue.

Figure 3.

Diagram of the theory of planned behavior. Behavioral intention is the most important determinant factor of behavior. There are 3 factors that can affect behavioral intention: attitude towards the behavior, subjective norms, and perceived behavioral control. Among participants in the present study, attitude towards the behavior and subjective norms were high (solid arrows). However, the perceived behavioral control was low (dashed arrow).

EMTs were highly interested in attending a training course (S6: 7.87) and were willing to take courses with and without fees (S21: 8.35; and S22: 6.17). The course did not need to be related to a salary increase (S25: 7.27) and ideally would be held during re-education training (In Japan, EMTs are required to have 40 hours training in hospital every 2 years to maintain their emergency medical skills) periods (S23: 7.63). EMTs lacked confidence in identifying ischemic areas on 12-lead ECGs and in providing information to the hospital (S12: 5.15; and S13: 4.6). Further, the course ideally would include practical demonstrations (S27: 7.29) rather than lectures alone. Therefore, the development of a training program that covers practical training in predicting the ischemic area on 12-lead ECGs and providing information to the hospital could be a step towards resolving these issues.

EMTs who had attended some type of 12-lead ECG training course in the past were more willing to engage in self-study than those who had not (S5: 7.86 vs. 7.34, respectively; P=0.01). EMTs with training course experience were also more confident (S9: 4.42 vs. 3.95 [P=0.02]; S10: 4.22 vs. 3.77 [P=0.03]) and felt they could accurately provide information from a 12-lead ECG to the hospital (S13: 4.90 vs. 4.38; P=0.03). It is thought that having attended at least one course in the past can positively affect the EMTs’ self-confidence and motivation. However, despite having previously taken the course, EMTs felt that they had not learned enough (S7: 3.64) and did not have adequate confidence in their ability to read 12-lead ECGs (S9: 4.42; and S10: 4.22). Although the type of training courses they had attended in the past was unclear, these courses were probably classroom-based interactive lectures without the opportunity for practical exposure. Those who had taken a course preferred a more practical format (S27: 7.76 vs. 6.94; P<0.01), suggesting the importance of incorporating a practical component, such as hands-on training based on actual field activities, while planning future 12-lead ECG training courses. Moreover, those who had taken a course were willing to take another 12-lead ECG training course even if they had to pay for it (S22: 6.55 vs. 5.88; P=0.01), suggesting that taking a course at least once may be a stepping stone to further improvement of awareness and motivation for training about ECGs. Reports from other countries have shown that paramedics who underwent 12-lead ECG training could diagnose STEMI with high sensitivity and specificity.²² Conversely, the number of false-positive STEMI readings varied from 0% to 51% depending on the study,²³ which may be attributed to variations in healthcare systems and prevalence rates across different countries or regions. Therefore, the accuracy of EMTs in diagnosing a condition based on 12-lead ECG readings should be evaluated in each healthcare system. Methods to evaluate the diagnostic abilities of future EMTs must be considered while conducting training programs for them.

In only 23% of fire departments in Japan are all ambulances equipped with a 12-lead ECG.¹⁰ However, 87% of ambulances equipped with a 12-lead ECG were used occasionally or frequently, thereby indicating a high utilization rate of prehospital 12-lead ECG.¹⁰ Ambulances in 39 of the 240 regions in Japan were not equipped with any 12-lead ECG, and this was most commonly attributed to financial issues.¹⁰ The guidelines recommend a prehospital 12-lead ECG, and there is no scientific objection to its introduction.⁸ Most regions that have not yet introduced 12-lead ECG in ambulances have financial constraints. Even in these regions, the introduction of 12-lead ECG in ambulances and the contribution of 12-lead ECG interpretation by EMTs could lead to better transport and therapeutic interventions before patients become critically ill. Preventing patients from becoming critically ill could reduce the subsequent length of hospital stay and rehabilitation, as well as the amount of medical equipment and materials used. Overall, this may be advantageous to the local healthcare economy. We hope this paper encourages areas with few ambulances equipped with 12-lead ECGs to reconsider the introduction of 12-lead ECG in all ambulances.

In areas where a 12-lead ECG has already been introduced in ambulances, the improved 12-lead ECG reading skills of EMTs will help them make comprehensive decisions and select hospitals based on the patient’s condition and its urgency. Furthermore, hospital selection negotiations can be effectively performed by providing information to the hospital in a concise, clear, and appropriately timed manner during patient acceptance negotiations. Therefore, it is important to design a 12-lead ECG training course that includes not only the reading of 12-lead ECGs, but also methods to evaluate clinical findings, education using simulators, and training in the selection of hospitals and reporting to transport destinations.

Study Limitations

The present study has several limitations. Nagasaki Prefecture has the largest number of remote islands in Japan. Ten fire departments in Nagasaki Prefecture were included in this study. Some fire departments, particularly those in remote islands, only have one medical facility to which patients can be transported. Therefore, there may be regional bias; that is, there is no need for 12-lead ECG reading in actual clinical practice in some areas.

The effective response rate for this study was 82.2%, with 62 EMTs providing incomplete responses. Some EMTs did not respond as required to some items or provided multiple responses where only a single response was required; we believe the reasons are the exploratory nature of this study and the fact that the questionnaire contained numerous statements. It is evident that the response rate decreases as the number of questions increases, which we consider a limitation of this study.²⁴ We believe that a more targeted survey with a higher completion rate can be conducted in the future by reducing the number of question items.

Because the actual ECG reading ability of the EMTs was not investigated in this study, their ability to interpret ECGs remains unclear. However, when 29 of the 327 EMTs who attended a training course were given a pretest, 28 (96.6%) could accurately diagnose STEMI and 22 (75.9%) could predict the presence of an inferior myocardial infarction on a 12-lead ECG. Considering that no reports are available on the ability of EMTs in Japan to read 12-lead ECGs, future surveys in this area are warranted.²³

Conclusions

EMTs felt that their own abilities to interpret 12-lead ECG were related to a better prognosis for patients with ACS. EMTs lacked confidence in reading 12-lead ECGs, and their knowledge of 12-lead ECGs is insufficient. Hence, they were willing to attend 12-lead ECG training courses, and programs should include practical training. A 12-lead ECG training program with a practical format, such as hands-on training, that is based on actual field activities may be effective. We believe that EMTs who attend such a course to improve their ability to interpret 12-lead ECG findings can facilitate the smooth conduction of prehospital activities, which may reduce the prehospital time and ultimately improve the prognosis of patients with ACS.

Acknowledgment

The authors are extremely grateful to the study participants and all the staff involved in conducting the survey.

Sources of Funding

This study was supported by the Japan Health Academy.

Disclosures

K.M. is a member of Circulation Journal’s Editorial Team. All remaining authors declare no conflicts of interest.

IRB Information

This study was conducted in accordance with the principles of the Declaration of Helsinki and was approved by the Ethics Committee of Nagasaki University Graduate School of Biomedical Sciences (Approval no. 20103001).

Data Availability

The unidentified participant data from the study can be requested by contacting the corresponding author directly. The raw survey data are available for sharing; however, other related documents are not accessible. Please note that the data will be made available immediately following publication, ending 10 years after publication. Data sharing is intended solely for the purposes of meta-analyses and the data will be shared as Excel files via email.

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