Implementing Prehospital Evidence-Based Guidelines: A Systematic Literature Review

Prehospital care for traumatic brain injuries: A review of U.S. state emergency medical services protocols

Traumatic brain injury (TBIs) necessitates a rapid and comprehensive medical response to minimize secondary brain injury and reduce mortality. Emergency medical services (EMS) clinicians serve a critical role in the management of prehospital TBI, responding during an initial phase of care with significant impact on patient outcomes. We used versions two and three of the Brain Trauma Foundation (BTF) Prehospital Guidelines for the Management of Traumatic Brain Injury and the NASEMSO National Model Clinical Guidelines to determine key elements for a TBI prehospital protocol and included common factors across sources such as recommendations concerning patient monitoring, hypoxia, hypotension, hyperventilation, cerebral herniation, airway management, hyperosmolar therapy, and transport destination. We then conducted a cross-sectional evaluation of publicly available statewide EMS clinical protocols in the US to determine the degree of alignment with national guidelines. We calculated descriptive statistics for each factor in the state protocols. Despite adoption of some evidence-based recommendations for a standard approach to the prehospital management of patients with TBI, we found significant variability in statewide EMS treatment protocols for management of severe TBI, especially in the recommended frequency of patient reassessment and for the management of suspected herniation. Most statewide protocols provided guidance regarding oxygenation, ventilation, and blood pressure management that aligned with evidence-based guidelines. While most protocols did address management of oxygenation and ventilation, one in four protocols had no specific guidance for managing hypoxia and only 31% of protocols recommended avoiding hyperventilation. For the management of suspected cerebral herniation, over half of statewide protocols recommended hyperventilation, whereas only 31% explicitly advised against hyperventilation regardless of TBI severity. Interestingly, 94% of protocols do not mention the use of hyperosmolar therapy for TBI patients, neither recommending use or avoidance of hyperosmolar therapy. In conclusion, we found inconsistent adoption of national recommendations in available statewide protocols for prehospital TBI management. We identified significant gaps and variation in statewide protocols regarding patient monitoring and reassessment, as well as in several key areas of severe TBI management.

The Influencing Factors of Implementation in Emergency Medical Service Systems - A Scoping Review

OBJECTIVES: Emergency medical services (EMS) provide health care in situations with limited time and resources. Challenges arise when introducing novel medications, treatments, or technologies or modifying existing practices in these settings. Effective implementation strategies are pivotal for their success. This study aims to identify and categorize potential facilitators and barriers in the implementation of prehospital EMS through a review of relevant research articles.METHODS: We searched PubMed and EMbase to identify studies published before December 2023, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines for our search strategy and scoping review. We included original articles written in English that report on the factors that influence the implementation in prehospital settings. We extracted and categorized the factors into different themes.RESULTS: Out of the 371 retrieved papers, we selected 19 (5%) for inclusion in this review. We extracted 46 influencing factors from the selected articles and categorized them into ten themes: (1) Outer system, (2) Inner system, (3) Practitioner characteristics, (4) Resources, (5) Communication and collaboration, (6) Patient factors, (7) Intervention characteristics, (8) De-implementation of prior practices, (9) Logistical issues, and (10) Quality improvement.CONCLUSIONS: This study examined the literature on EMS implementation factors and proposed a 10-theme EMS model framework. Key factors include training/education, equipment/tools, communication with hospitals, and practitioners' attitudes.

Mapping the processes and information flows of a prehospital emergency care system in Rwanda: a process mapping exercise

OBJECTIVE

A vital component of a prehospital emergency care system is getting an injured patient to the right hospital at the right time. Process and information flow mapping are recognised methods to show where efficiencies can be made. We aimed to understand the process and information flows used by the prehospital emergency service in transporting community emergencies in Rwanda in order to identify areas for improvement.

DESIGN

Two facilitated process/information mapping workshops were conducted. Process maps were produced in real time during discussions and shared with participants for their agreement. They were further validated by field observations.

SETTING

The study took place in two prehospital care settings serving predominantly rural and predominantly urban patients.

PARTICIPANTS

24 healthcare professionals from various cadres. Field observations were done on 49 emergencies across both sites.

RESULTS

Two maps were produced, and four main process stages were described: (1) call triage by the dispatch/call centre team, (2) scene triage by the ambulance team, (3) patient monitoring by the ambulance team on the way to the health facility and (4) handover process at the health facility. The first key finding was that the rural site had multiple points of entry into the system for emergency patients, whereas the urban system had one point of entry (the national emergency number); processes were otherwise similar between sites. The second was that although large amounts of information were collected to inform decision-making about which health facility to transfer patients to, participants found it challenging to articulate the intellectual process by which they used this to make decisions; guidelines were not used for decision-making.

DISCUSSION

We have identified several areas of the prehospital care processes where there can be efficiencies. To make efficiencies in the decision-making process and produce a standard approach for all patients will require protocolising care pathways.

Evaluation of the implementation of evidence-based pediatric asthma exacerbation treatments in a regional consortium of emergency medical Services Agencies

OBJECTIVE

Asthma exacerbations are a frequent reason for pediatric emergency medical services (EMS) encounters. The objective of this study was to examine the implementation of evidence-based treatments for pediatric asthma in a regional consortium of EMS agencies.

METHODS

This retrospective study applied the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) implementation framework to data from an EMS agency consortium in the Cincinnati, Ohio region. The study analyzed one year before an oral systemic corticosteroid (OCS) option was added to the agencies' protocol, and five years after the protocol change. We constructed logistic regression models for the primary outcome of Reach, defined as the proportion of pediatric asthma patients who received a systemic corticosteroid. We modeled Maintenance (Reach measured monthly over time) using time series models.

RESULTS

A total of 713 patients were included, 133 pre- and 580 post-protocol change. In terms of Reach, 3% (n = 4) of eligible patients received a systemic corticosteroid pre-OCS versus 20% (n = 116) post-OCS. Multivariable modeling of Reach revealed the study period, EMS transport time, months since implementation of OCS, and number of bronchodilators administered by EMS as significant covariates for the administration of a systemic corticosteroid. For Maintenance, it took approximately two years to reach maximal administration of systemic corticosteroids.

CONCLUSIONS

Indicators of asthma severity and time since the protocol change were significantly associated with EMS administration of systemic corticosteroids to pediatric asthma patients. The two-year time for maximal Reach suggests further work is required to understand how to best implement evidence-based pediatric asthma treatments in EMS.

Early Administration of Steroids in the Ambulance Setting: An Observational Design Trial (EASI-AS-ODT)

BACKGROUND

In the emergency department (ED), prompt administration of systemic corticosteroids for pediatric asthma exacerbations decreases hospital admission rates. However, there is sparse evidence for whether earlier administration of systemic corticosteroids by emergency medical services (EMS) clinicians, prior to ED arrival, further improves pediatric asthma outcomes.

METHODS

Early Administration of Steroids in the Ambulance Setting: An Observational Design Trial is a multicenter, observational, nonrandomized stepped-wedge design study with seven participating EMS agencies who adopted an oral systemic corticosteroid (OCS) into their protocols for pediatric asthma treatment. Using univariate analyses and multivariable mixed-effects models, we compared hospital admission rates for pediatric asthma patients ages 2-18 years before and after the introduction of a prehospital OCS and for those who did and did not receive a systemic corticosteroid from EMS.

RESULTS

A total of 834 patients were included, 21% of whom received a systemic corticosteroid from EMS. EMS administration of systemic corticosteroids increased after the introduction of an OCS from 14.7% to 28.1% (p < 0.001). However, there was no significant difference between hospital admission rates and ED length of stay before and after the introduction of OCS or between patients who did and did not receive a systemic corticosteroid from EMS. Mixed-effects models revealed that age 14-18 years (coefficient -0.83, p = 0.002), EMS administration of magnesium (coefficient 1.22, p = 0.04), and initial EMS respiratory severity score (coefficient 0.40, p < 0.001) were significantly associated with hospital admission.

CONCLUSIONS

In this multicenter study, the addition of an OCS into EMS agency protocols for pediatric asthma exacerbations significantly increased systemic corticosteroid administration but did not significantly decrease hospital admission rates. As overall EMS systemic corticosteroid administration rates were low, further work is required to understand optimal implementation of EMS protocol changes to better assess potential benefits to patients.

Electronic field protocols for prehospital care quality improvement in Lithuania: a randomized simulation-based study

BACKGROUND

Prehospital emergency care is complex and influenced by various factors, leading to the need for decision-support tools. Studies suggest that cognitive aids improve provider performance and patient outcomes in clinical emergencies. Electronic cognitive aids have rarely been investigated in prehospital care. Therefore, this study aimed to evaluate the effects of the electronic field protocol (eFP) module on performance, adherence to the standard of care, and satisfaction of prehospital care providers in a simulated environment.

METHODS

This randomised simulation-based study was conducted at the Lithuanian University of Health Sciences in Kaunas, Lithuania. The simulation scenarios were developed to test 12 eFPs: adult resuscitation, pediatric resuscitation, delivery and postpartum care, seizures in pregnancy, stroke, anaphylaxis, acute chest pain, acute abdominal pain, respiratory distress in children, severe trauma, severe infection and sepsis, and initial neonatal evaluation and resuscitation. Sixteen prehospital practitioners with at least 3 years of clinical experience were randomly assigned to either use the eFP module or perform without it in each of the 12 simulated scenarios. Participant scores and adherence to standardised checklists were compared between the two performance modes. Participant satisfaction was measured through a post-simulation survey.

RESULTS

A total of 190 simulation sessions were conducted. Compared to the use of memory alone, the use of the eFP module significantly improved participants' performance in 10 out of the 12 simulation scenarios. Adherence to the standardised checklist increased from 60 to 85% (p < 0.001). Post-simulation survey results indicate that participants found the eFP module easy to use and relevant to prehospital clinical practice.

CONCLUSIONS

The study findings suggest that the eFP module as a cognitive aid can enhance prehospital practitioners' performance and adherence to the standard of care in simulated scenarios. These results highlight the potential of standardised eFPs as a quality improvement step in prehospital care in Lithuania.

The barriers and facilitators for the implementation of clinical practice guidelines in healthcare: an umbrella review of qualitative and quantitative literature

OBJECTIVES

To identify barriers and facilitators of clinical practice guidelines (CPGs) implementation, and map those factors to the theoretical domains framework (TDF) and behavior change wheel (BCW).

METHODS

We conducted an umbrella review of systematic reviews. PubMed, Embase, and the Cochrane Library were searched. Two investigators independently screened the studies, extracted the data, and assessed the methodological quality. The identified barriers and facilitators of CPG implementation were categorized and mapped to the TDF domains and BCW components.

RESULTS

Thirty-seven studies were included, and 193 barriers and 140 facilitators were identified. Intrinsic aspects (35 barriers and 28 facilitators) mainly included the CPGs' impracticality, complexity, and inaccessibility. Extrinsic aspects (158 barriers and 113 facilitators) mainly included lack of resources, training, funding, or awareness of CPG content in barriers; audits and feedback; strong leadership and management support; and educating and training about CPGs in facilitators. Environmental context and resources (n = 97, 19.48%) were the most reported barriers in TDF domains. Physical opportunity and social opportunity were the most frequently mentioned models in BCW.

CONCLUSION

Multiple barriers and facilitators for healthcare CPG implementation are identified, with further links to TDF and BCW. Future knowledge translation strategies should be developed accordingly in specified health care settings.

Prehospital Stroke Care Part 2: On-Scene Evaluation and Management by Emergency Medical Services Practitioners

The prehospital phase is a critical component of delivering high-quality acute stroke care. This topical review discusses the current state of prehospital acute stroke screening and transport, as well as new and emerging advances in prehospital diagnosis and treatment of acute stroke. Topics include prehospital stroke screening, stroke severity screening, emerging technologies to aid in the identification and diagnosis of acute stroke in the prehospital setting, prenotification of receiving emergency departments, decision support for destination determination, and the capabilities and opportunities for prehospital stroke treatment in mobile stroke units. Further evidence-based guideline development and implementation of new technologies are critical for ongoing improvements in prehospital stroke care.

Multifaceted implementation and sustainability of a protocol for prehospital anaesthesia: a retrospective analysis of 2115 patients from helicopter emergency medical services

BACKGROUND

Prehospital emergency anaesthesia (PHEA) is a high-risk procedure. We developed a prehospital anaesthesia protocol for helicopter emergency medical services (HEMS) that standardises the process and involves ambulance crews as active team members to increase efficiency and patient safety. The aim of the current study was to evaluate this change and its sustainability in (i) on-scene time, (ii) intubation first-pass success rate, and (iii) protocol compliance after a multifaceted implementation process.

METHODS

The protocol was implemented in 2015 in a HEMS unit and collaborating emergency medical service systems. The implementation comprised dissemination of information, lectures, simulations, skill stations, academic detailing, and cognitive aids. The methods were tailored based on implementation science frameworks. Data from missions were gathered from mission databases and patient records.

RESULTS

During the study period (2012-2020), 2381 adults underwent PHEA. The implementation year was excluded; 656 patients were analysed before and 1459 patients after implementation of the protocol. Baseline characteristics and patient categories were similar. On-scene time was significantly redused after the implementation (median 32 [IQR 25-42] vs. 29 [IQR 21-39] minutes, p < 0.001). First pass success rate increased constantly during the follow-up period from 74.4% (95% CI 70.7-77.8%) to 97.6% (95% CI 96.7-98.3%), p = 0.0001. Use of mechanical ventilation increased from 70.6% (95% CI 67.0-73.9%) to 93.4% (95% CI 92.3-94.8%), p = 0.0001, and use of rocuronium increased from 86.4% (95% CI 83.6-88.9%) to 98.5% (95% CI 97.7-99.0%), respectively. Deterioration in compliance indicators was not observed.

CONCLUSIONS

We concluded that clinical performance in PHEA can be significantly improved through multifaceted implementation strategies.

Measuring the Implementation Preferences of Emergency Medical Services Clinicians Using Discrete Choice Experiments

INTRODUCTION

Prehospital research and evidence-based guidelines (EBGs) have grown in recent decades, yet there is still a paucity of prehospital implementation research. While recent studies have revealed EMS agency leadership perspectives on implementation, the important perspectives and opinions of frontline EMS clinicians regarding implementation have yet to be explored in a systematic approach. The objective of this study was to measure the preferences of EMS clinicians for the process of EBG implementation and whether current agency practices align with those preferences.

METHODS

This study was a cross-sectional survey of National Registry of Emergency Medical Technicians registrants. Eligible participants were certified paramedics who were actively practicing EMS clinicians. The survey contained discrete choice experiments (DCEs) for three EBG implementation scenarios and questions about rank order preferences for various aspects of the implementation process. For the DCEs, we used multinomial logistic regression to analyze the implementation preference choices of EMS clinicians, and latent class analysis to classify respondents into groups by their preferences.

RESULTS

A total of 183 respondents completed the survey. Respondents had a median age of 39 years, were 74.9% male, 89.6% White, and 93.4% of non-Hispanic ethnicity. For all three DCE scenarios, respondents were significantly more likely to choose options with hospital feedback and individual-level feedback from EMS agencies. Respondents were significantly less likely to choose options with email/online only education, no feedback from hospitals, and no EMS agency feedback to clinicians. In general, respondents' preferences favored classroom-based training over in-person simulation. For all DCE questions, most respondents (66.2%-77.1%) preferred their survey DCE choice to their agency's current implementation practices. In the rank order preferences, most participants selected "knowledge of the underlying evidence behind the change" as the most important component of the process of implementation.

CONCLUSIONS

In this study of EMS clinicians' implementation preferences using DCEs, respondents preferred in-person education, feedback on hospital outcomes, and feedback on their individual performance. However, current practice at EMS agencies rarely matched those expressed EMS clinician preferences. Collectively, these results present opportunities for improving EMS implementation from the EMS clinician perspective.

2022 Systematic Review of Evidence-Based Guidelines for Prehospital Care

INTRODUCTION

Multiple national organizations and federal agencies have promoted the development, implementation, and evaluation of evidence-based guidelines (EBGs) for prehospital care. Previous efforts have identified opportunities to improve the quality of prehospital guidelines and highlighted the value of high-quality EBGs to inform initial certification and continued competency activities for EMS personnel.

OBJECTIVES

We aimed to perform a systematic review of prehospital guidelines published from January 2018 to April 2021, evaluate guideline quality, and identify top-scoring guidelines to facilitate dissemination and educational activities for EMS personnel.

METHODS

We searched the literature in Ovid Medline and EMBASE from January 2018 to April 2021, excluding guidelines identified in a prior systematic review. Publications were retained if they were relevant to prehospital care, based on organized reviews of the literature, and focused on providing recommendations for clinical care or operations. Included guidelines were appraised to identify if they met the National Academy of Medicine (NAM) criteria for high-quality guidelines and scored across the six domains of the Appraisal of Guidelines for Research and Evaluation (AGREE) II tool.

RESULTS

We identified 75 guidelines addressing a variety of clinical and operational aspects of EMS medicine. About half (n = 39, 52%) addressed time/life-critical conditions and 33 (44%) contained recommendations relevant to non-clinical/operational topics. Fewer than half (n = 35, 47%) were based on systematic reviews of the literature. Nearly one-third (n = 24, 32%) met all NAM criteria for clinical practice guidelines. Only 27 (38%) guidelines scored an average of >75% across AGREE II domains, with content relevant to guideline implementation most commonly missing.

CONCLUSIONS

This interval systematic review of prehospital EBGs identified many new guidelines relevant to prehospital care; more than all guidelines reported in a prior systematic review. Our review reveals important gaps in the quality of guideline development and the content in their publications, evidenced by the low proportion of guidelines meeting NAM criteria and the scores across AGREE II domains. Efforts to increase guideline dissemination, implementation, and related education may be best focused around the highest quality guidelines identified in this review.

Recommendations for Improving the Quality of Prehospital Evidence-Based Guidelines

Evidence-based guidelines that provide recommendations for clinical care or operations are increasingly being published to inform the EMS community. The quality of evidence evaluation and methodological rigor undertaken to develop and publish these recommendations vary. This can negatively affect dissemination, education, and implementation efforts. Guideline developers and end users could be better informed by efforts across medical specialties to improve the quality of guidelines, including the use of specific criteria that have been identified within the highest quality guidelines. In this special contribution, we aim to describe the current state of published guidelines available to the EMS community informed by two recent systematic reviews of existing prehospital evidenced based guidelines (EBGs). We further aim to provide a description of key elements of EBGs, methods that can be used to assess their quality, and concrete recommendations for guideline developers to improve the quality of evidence evaluation, guideline development, and reporting. Finally, we outline six key recommendations for improving prehospital EBGs, informed by systematic reviews of prehospital guidelines performed by the Prehospital Guidelines Consortium.

Looking back to inform the future: a review of published paramedicine research

OBJECTIVE

Paramedicine has evolved in ways that may outpace the science informing these changes. Examining the scholarly pursuits of paramedicine may provide insights into the historical academic focus, which may inform future endeavors and evolution of paramedicine. The objective of this study was to explore the existing discourse in paramedicine research to reflect on the academic pursuits of this community.

METHODS

We searched Medline, Embase, CINAHL, Google Scholar and Web of Science from January, 2006 to April, 2019. We further refined the yield using a ranking formula that prioritized journals most relevant to paramedicine, then sampled randomly in two-year clusters for full text review. We extracted literature type, study topic and context, then used elements of qualitative content, thematic, and discourse analysis to further describe the sample.

RESULTS

The initial search yielded 99,124 citations, leaving 54,638 after removing duplicates and 7084 relevant articles from nine journals after ranking. Subsequently, 2058 articles were included for topic categorization, and 241 papers were included for full text analysis after random sampling. Overall, this literature reveals: 1) a relatively narrow topic focus, given the majority of research has concentrated on general operational activities and specific clinical conditions and interventions (e.g., resuscitation, airway management, etc.); 2) a limited methodological (and possibly philosophical) focus, given that most were observational studies (e.g., cohort, case control, and case series) or editorial/commentary; 3) a variety of observed trajectories of academic attention, indicating where the evolution of paramedicine is evident, areas where scope of practice is uncertain, and areas that aim to improve skills historically considered core to paramedic clinical practice.

CONCLUSIONS

Included articles suggest a relatively narrow topic focus, a limited methodological focus, and observed trajectories of academic attention indicating where research pursuits and priorities are shifting. We have highlighted that the academic focus may require an alignment with aspirational and direction setting documents aimed at developing paramedicine. This review may be a snapshot of scholarly activity that reflects a young medically directed profession and systems focusing on a few high acuity conditions, with aspirations of professional autonomy contributing to the health and social well-being of communities.

Emergency Medical Services Leadership Perspectives on Implementation of Evidence-Based Guidelines: A Qualitative Study

Introduction: Prehospital evidence-based guidelines (EBGs) are developed to optimize clinical outcomes for emergency medical services (EMS) patients. However, widespread implementation of EBGs is often inconsistent. Therefore, this study aimed to assess the baseline knowledge and practices of EMS leaders related to EBG implementation.Methods: This was a qualitative study using focus groups to assess prehospital implementation awareness and knowledge. Participants were EMS EBG authors, EMS medical directors, and EMS professional organization leaders. Focus groups were held via video conference, audio recorded, and transcribed. Thematic coding used domains and constructs of the Consolidated Framework for Implementation Research (CFIR).Results: Six focus groups were conducted with a total of 18 participants. A total of 1,044 codes were analyzed. "Process" was the CFIR domain with the most codes (n = 350, 33.5%), followed by the "inner setting" (the EMS agency; n = 250, 23.9%), "characteristics of the intervention" (n = 203, 19.4%), "outer setting" (the health care system and community the EMS agency serves, and the broader national EMS professional context; n = 141, 13.5%), and "characteristics of individuals" (n = 100, 9.6%). The ten most frequent constructs across all domains were: reflecting and evaluating, executing, cosmopolitanism, planning, external policy and incentives, design quality and packaging, learning climate, culture, complexity, and other personal attributes.Conclusion: EMS leadership and stakeholder views on EBG implementation identified dominant themes related to the process of implementation and the culture and learning/implementation climate of EMS agencies. Opinions were mixed on the utility of the CFIR as a potential guide for EMS implementation. Further work is required to gain the frontline EMS clinician perspective on implementation and tie key themes to quantitative prehospital implementation outcomes.

Novel Prehospital Phenotypes and Outcomes in Adult-Patients with Acute Disease

An early identification of prehospital phenotypes may allow health care workers to speed up and improve patients’ treatment. To determine emergency phenotypes by exclusively using prehospital clinical data, a multicenter, prospective, and observational ambulance-based study was conducted with a cohort of 3,853 adult patients treated consecutively and transferred with high priority from the scene to the hospital emergency department. Cluster analysis determined three clusters with highly different outcome scores and pathological characteristics. The first cluster presented a 30-day mortality after the index event of 45.9%. The second cluster presented a mortality of 26.3%, while mortality of the third cluster was 5.1%. This study supports the detection of three phenotypes with different risk stages and with different clinical, therapeutic, and prognostic considerations. This evidence could allow adapting treatment to each phenotype thereby helping in the decision-making process.

Identification and Treatment of Opioid-Associated Out-of-Hospital Cardiac Arrest in Emergency Medical Service Protocols

This cross-sectional study reviews emergency medical services (EMS) treatment protocols for adults presenting with cardiac arrest or overdose to evaluate whether current protocols include the consideration of opioid overdose for patients with possible out-of-hospital cardiac arrest.

State emergency medical services guidance and protocol changes in response to the COVID-19 pandemic: A national investigation

OBJECTIVES

The COVID-19 pandemic has had an impact on emergency medical services (EMS) and its guidelines, which aid in patient care. This study characterizes state and territory EMS office recommendations to EMS statewide operational and clinical guidelines and describes the mechanisms of distribution and implementation during the COVID-19 pandemic.

METHODS

A mixed-methods study was conducted in 2 phases. In phase 1, changes and development of COVID-19 guidance and protocols for EMS clinical management and operations were identified among 50 states, the District of Columbia, and 5 territories in publicly available online documents and information. In phase 2, structured interviews were conducted with state/territory EMS officials to confirm the protocol changes or guidance and assess dissemination and implementation strategies for COVID-19.

RESULTS

In phase 1, publicly available online documents for 52 states/territories regarding EMS protocols and COVID-19 guidance were identified and reviewed. Of 52 (33/52) states/territories, 33 had either formal protocol changes or specific guidance for the pandemic. In phase 2, 2 state and territory EMS officials were interviewed regarding their protocols or guidance for COVID-19 and the dissemination and implementation practices they used to reach EMS agencies (response rate = 65%). Of the 34 state/territory officials interviewed, 22 had publicly available online COVID-19 protocols or guidance. Of the 22 officials with online COVID-19 protocols, all reported providing operational direction, and 19 of 22 officials reported providing clinical direction.

CONCLUSIONS

Most states provided guidance to EMS agencies and/or updated protocols in response to the COVID-19 pandemic.

Sex and Gender Equity in Prehospital Electrocardiogram Acquisition

INTRODUCTION

Research in cardiac care has identified significant gender-based differences across many outcomes. Women with heart disease are less likely both to be diagnosed and to receive standard care. Gender-based disparities in the prehospital setting are under-researched, but they were found to exist within rates of 12-lead electrocardiogram (ECG) acquisition within one urban Emergency Medical Services (EMS) agency.

STUDY OBJECTIVE

This study evaluates the quality improvement (QI) initiative that was implemented in that agency to raise overall rates of 12-lead ECG acquisition and reduce the gap in acquisition rates between men and women.

METHODS

This QI project included two interventions: revised indications for 12-lead acquisition, and training that highlighted sex- and gender-based differences relevant to patient care. To evaluate this project, a retrospective database review identified all patient contacts that potentially involved cardiac assessment over 18 months. The primary outcome was the rate of 12-lead acquisition among patients with qualifying complaints. This was assessed by mean rates of acquisition in before and after periods, as well as segmented regression in an interrupted time series. Secondary outcomes included differences in rates of 12-lead acquisition, both overall and in individual complaint categories, each compared between men/women and before/after the interventions.

RESULTS

Among patients with qualifying complaints, the mean rate of 12-lead acquisition in the lead-in period was 22.5% (95% CI, 21.8% - 23.2%) with no discernible trend. The protocol change and training were each associated with a significant absolute level increase in the acquisition rate: 2.09% (95% CI, 0.21% - 4.0%; P = .03) and 3.2% (95% CI, 1.18% - 5.22%; P = .003), respectively. When compared by gender and time period, women received fewer 12-leads than men overall, and more 12-leads were acquired after the interventions than before. There were also significant interactions between gender and period, both overall (2.8%; 95% CI, 1.9% - 3.6%; P < .0001) and in all complaint categories except falls and heart problems.

CONCLUSION

This QI project resulted in an increase in 12-leads acquired. Pre-existing gaps in rates of acquisition between men and women were reduced but did not disappear. On-going research is examining the reasons behind these differences from the perspective of prehospital providers.

Protocol for a scoping review on the development of policy, guidelines and protocols within emergency medical services

Introduction

Emergency medical services (EMS) use a combination of policy, clinical practice guidelines and protocols to set out their expectations for service delivery and to inform patient care. While these are integral to how EMS now operate, relatively little is known about how they are developed, or the processes involved. Therefore, the aim of this scoping review is to understand what is known in the literature about the development of policy, guidelines and protocols within EMS.

Methods

This scoping review will follow the Arksey and O'Malley (2005) methodological framework for scoping reviews. A search strategy has been developed using index term definitions, building from authors' knowledge of the field. The following electronic databases will be searched from 2002 to 2021 for all types of publication: CINAHL, Medline, Academic Search Complete and PsycINFO, EMBASE, Nursing and Allied Health, the Cochrane library, NICE Evidence, Scopus, OpenGrey, EThOS, Google Scholar, Google search and key EMS journal websites. The results will be downloaded using EndNoteX9 reference management software and duplicates will be removed. Titles and abstracts of the results will be independently screened for their relevance to the research question, and the full text of each selected publication will be assessed against pre-determined inclusion and exclusion criteria to determine its eligibility. The reference list and forward citations will be searched for articles meeting the eligibility criteria. A second researcher will independently assess a 10% sample of results to allow for validation of this assessment. Data will be extracted and charted on the characteristics of the publications and the knowledge they contribute on the development of policy, guidelines or protocols. Accompanying narratives will be presented to identify themes and gaps in the available evidence. A critical appraisal will be undertaken of the included publications, where empirical research is presented.

Priorities for Prehospital Evidence-Based Guideline Development: A Modified Delphi Analysis

Objective: Few areas of prehospital care are supported by evidence-based guidelines (EBGs). We aimed to identify gaps in clinical and operational prehospital EBGs to prioritize future EBG development and research funding. Methods: Using modified Delphi methodology, we sought consensus among experts in prehospital care and EBG development. Five rounds of surveys were administered between October 2019 and February 2020. Round 1 asked participants to list the top three gaps in prehospital clinical guidelines and top three gaps in operational guidelines that should be prioritized for guideline development and research funding. Based on responses, 3 reviewers performed thematic analysis to develop a list of prehospital EBG gaps, with participant feedback in Round 2. In Round 3, participants rated each gap's importance using a 5-point Likert scale, and participants' responses were averaged. In Round 4, participants rank-ordered 10 gaps with the highest mean scores identified in Round 3. In Round 5, participants indicated their agreement with sets of the highest ranked gaps. Results: Of 23 invited participants, 14 completed all 5 rounds. In Rounds 1 and 2, participants submitted 65 clinical and 58 operational gaps, and thematic analysis identified 23 unique clinical gaps and 28 unique operational gaps. The final prioritized list of clinical EBG gaps was: 1) airway management in adult and pediatric patients, 2) care of the pediatric patient, and 3) management of prehospital behavioral health emergencies, with 79% of participants agreeing. The final prioritized list of operational EBG gaps was: 1) define and measure the impact of EMS care on patient outcomes, 2) practitioner wellness, and 3) practitioner safety in the out-of-hospital environment, with 86% of participants agreeing. Conclusions: This modified Delphi study identifies gaps in prehospital EBGs that, if prioritized for development and research funding, would be expected to have the greatest impact on prehospital clinical care and operations.

Early administration of steroids in the ambulance setting: Protocol for a type I hybrid effectiveness-implementation trial with a stepped wedge design

BACKGROUND

Pediatric asthma exacerbations are a frequent reason for emergency care. Early administration of oral systemic corticosteroids (OCS) in the emergency department (ED) decreases hospitalization rates and ED length-of-stay (LOS). However, it is unknown whether even earlier OCS administration by emergency medical services (EMS) in the prehospital setting further improves outcomes.

PURPOSE

To describe the background and methods of a type 1 hybrid effectiveness-implementation trial of EMS-administered OCS for pediatric asthma patients incorporating a stepped wedge design and the RE-AIM framework.

METHODS

The study employs a non-randomized stepped wedge design where multiple EMS agencies adopt OCS as a treatment for pediatric asthma exacerbations at varying times. This design accommodates ethical considerations of studying pediatric subjects in the prehospital setting where informed consent is not feasible. We will compare hospitalization rates, ED LOS, and short-term healthcare costs between pediatric asthma patients who do and do not receive OCS from EMS. Using geographic information systems (GIS), we will measure how differences in outcomes scale with increasing EMS transport time. We will use the RE-AIM framework to guide a mixed methods analysis of barriers and enablers to EMS administration of OCS for pediatric asthma patients, including quantitative measures of adoption and uptake and qualitative EMS provider focus group data.

CONCLUSION

This trial will determine if earlier EMS administration of OCS to pediatric asthma patients decreases hospitalizations, ED LOS, and short-term healthcare costs, and if those outcomes scale with longer EMS transport times. We will identify barriers and enablers to implementing EMS-administered OCS for pediatric asthma patients.

Brief Educational Intervention Improves Emergency Medical Services Stroke Recognition

Background and Purpose- Recognition of stroke symptoms and hospital prenotification by emergency medical services (EMS) facilitate rapid stroke treatment; however, one-third of patients with stroke are unrecognized by EMS. To promote stroke recognition and quality measure compliant prehospital stroke care, we deployed a 30-minute online EMS educational module coupled with a performance feedback system in a single Michigan county. Methods- During a 24-month study period, a registry of consecutive EMS-transported suspected or unrecognized stroke cases was utilized to perform an interrupted time series analysis of the impact of the EMS education and feedback intervention. For each agency, we compared EMS stroke recognition and quality measure compliance rates, as well as emergency department performance and hospital outcomes during 12 preintervention months with performance in the remaining study months. Results- A total of 1805 EMS-transported cases met inclusion criteria; 1235 (68.4%) of these had ischemic or hemorrhagic strokes or transient ischemic attacks. There were no trends toward improvement in any outcome before the intervention. After the intervention, the EMS stroke recognition rate increased from 63.8% to 69.5% ( P=0.037). Prenotification increased from 60.9% to 77.3% ( P<0.001). Among patients with ischemic stroke/transient ischemic attack, there was a trend toward higher rates of tPA (tissue-type plasminogen activator) delivery (13.9%-17.7%; P=0.096) and a significant increase in tPA delivery within 45 minutes (5.7%-8.9%; P=0.042) after intervention. However, improvements in EMS recognition were limited to the first 3 months following intervention. Conclusions- A brief educational intervention was associated with improved EMS stroke recognition, hospital prenotification, and faster tPA delivery. Gains were primarily observed immediately following education and were not sustained through provision of performance feedback to paramedics.

Emergency Medical Services Protocols for Generalized Convulsive Status Epilepticus

This study reviews protocols for treating convulsive status epilepticus from 33 emergency medical services systems in California to determine if they had incorporated updated evidence-based guidelines.

Effectiveness of implementation strategies for the improvement of guideline and protocol adherence in emergency care: a systematic review

OBJECTIVE

Guideline and protocol adherence in prehospital and in-hospital emergency departments (EDs) is suboptimal. Therefore, the objective of this systematic review was to identify effective strategies for improving guideline and protocol adherence in prehospital and ED settings.

DESIGN

Systematic review.

DATA SOURCES

PubMed (including MEDLINE), CINAHL, EMBASE and Cochrane.

METHODS

We selected (quasi) experimental studies published between 2004 and 2018 that used strategies to increase guideline and protocol adherence in prehospital and in-hospital emergency care. Pairs of two independent reviewers performed the selection process, quality assessment and data extraction.

RESULTS

Eleven studies were included, nine of which were performed in the ED setting and two studies were performed in a combined prehospital and ED setting. For the ED setting, the studies indicated that educational strategies as sole intervention, and educational strategies in combination with audit and feedback, are probably effective in improving guideline adherence. Sole use of reminders in the ED setting also showed positive effects. The two studies in the combined prehospital and ED setting showed similar results for the sole use of educational interventions.

CONCLUSIONS

Our review does not allow firm conclusion on how to promote guideline and protocol adherence in prehospital emergency care, or the combination of prehospital and ED care. For ED settings, the sole use of reminders or educational interventions and the use of multifaceted strategies of education combined with audit and feedback are all likely to be effective in improving guideline adherence.