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Richards CT, Oostema JA, Chapman SN, Mamer LE, Brandler ES, Alexandrov AW, Czap AL, Martinez-Gutierrez JC, Martin-Gill C, Panchal AR, McMullan JT, Zachrison KS. Prehospital Stroke Care Part 2: On-Scene Evaluation and Management by Emergency Medical Services Practitioners. Stroke 2023; 54:1416-1425. [PMID: 36866672 PMCID: PMC10133016 DOI: 10.1161/strokeaha.123.039792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Accepted: 02/02/2023] [Indexed: 03/04/2023]
Abstract
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.
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Affiliation(s)
- Christopher T. Richards
- Department of Emergency Medicine, University of Cincinnati College of Medicine, Cincinnati, OH
| | - J. Adam Oostema
- Department of Emergency Medicine, Michigan State University College of Human Medicine, Grand Rapids, MI
| | | | - Lauren E. Mamer
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI
| | - Ethan S. Brandler
- Department of Emergency Medicine, Renaissance School of Medicine at Stony Brook University, Stony Brook, NY
| | - Anne W. Alexandrov
- College of Nursing, University of Tennessee Health Science Center, Memphis, TN
| | - Alexandra L. Czap
- Department of Neurology, University of Texas Houston McGovern Medical School, Houston, TX
| | | | | | - Ashish R. Panchal
- Department of Emergency Medicine, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Jason T. McMullan
- Department of Emergency Medicine, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Kori S. Zachrison
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA
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2
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Powell JR, Browne LR, Guild K, Shah MI, Crowe RP, Lindbeck G, Braithwaite S, Lang ES, Panchal AR. Evidence-Based Guidelines for Prehospital Pain Management: Literature and Methods. PREHOSP EMERG CARE 2023; 27:154-161. [PMID: 34928783 DOI: 10.1080/10903127.2021.2018074] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Emergency Medical Services (EMS) clinicians commonly encounter patients with acute pain. A new set of evidence-based guidelines (EBG) was developed to assist in the prehospital management of pain. Our objective was to describe the methods used to develop these evidence-based guidelines for prehospital pain management. METHODS The EBG development process was supported by a previous systematic review conducted by the Agency for Healthcare Research and Quality (AHRQ) covering nine different population, intervention, comparison, and outcome (PICO) questions. A technical expert panel (TEP) was formed and added an additional pediatric-specific PICO question. Identified evidence was evaluated using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) framework and tabulated into Summary of Findings tables. The TEP then utilized a rigorous systematic method, including the PanelVoice function, for recommendation development which was applied to generate Evidence to Decision Tables (EtD). This process involved review of the Summary of Findings tables, asynchronous member judging, and facilitated panel discussion to generate final consensus-based recommendations. RESULTS The work product described above was completed by the TEP panel from September 2020 to April 2021. For these recommendations, the overall certainty of evidence was very low or low, data for decisions on cost effectiveness and equity were lacking, and feasibility was rated well across all categories. Based on the evidence, one strong and seven conditional recommendations were made, with two PICO questions lacking sufficient evidence to generate a recommendation. CONCLUSION We describe a protocol that leveraged established EBG development techniques, the GRADE framework in conjunction with a previous AHRQ systematic review to develop treatment recommendations for prehospital pain management. This process allowed for mitigation of many confounders due to the use of virtual and electronic communication. Our approach may inform future guideline development and increase transparency in the prehospital recommendations development processes.
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Affiliation(s)
- Jonathan R Powell
- National Registry of Emergency Medical Technicians, Columbus, Ohio.,Division of Epidemiology, The Ohio State University College of Public Health, Columbus, Ohio
| | - Lorin R Browne
- Medical College of Wisconsin, Milwaukee County EMS, Milwaukee, Wisconsin
| | - Kyle Guild
- Cumming School of Medicine, University of Calgary, Calgary, Alberta
| | - Manish I Shah
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | | | - George Lindbeck
- Office of Emergency Medical Services, Virginia Department of Health, and the Department of Emergency Medicine, University of Virginia School of Medicine, Charlottesville, Virginia
| | - Sabina Braithwaite
- Missouri Department of Health and Senior Services, and the Washington University in St Louis School of Medicine, St Louis, Missouri
| | - Eddy S Lang
- Cumming School of Medicine, University of Calgary, Calgary, Alberta
| | - Ashish R Panchal
- National Registry of Emergency Medical Technicians, Columbus, Ohio.,Division of Epidemiology, The Ohio State University College of Public Health, Columbus, Ohio.,Department of Emergency Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio
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3
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Martin-Gill C, Panchal AR, Cash RE, Richards CT, Brown KM, Patterson PD. Recommendations for Improving the Quality of Prehospital Evidence-Based Guidelines. PREHOSP EMERG CARE 2023; 27:121-130. [PMID: 36369888 DOI: 10.1080/10903127.2022.2142992] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
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.
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Affiliation(s)
- Christian Martin-Gill
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Ashish R Panchal
- Department of Emergency Medicine, The Ohio State University, Columbus, Ohio
| | - Rebecca E Cash
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | | | - Kathleen M Brown
- Division of Emergency Medicine, Children's National Hospital, Washington, DC
| | - P Daniel Patterson
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
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4
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Guerrier C, Brailsford J, Patel S, Burcham S, Salloum RG, Martin-Gill C, Richards CT, Panchal AR, Fishe J. Emergency Medical Services Leadership Perspectives on Implementation of Evidence-Based Guidelines: A Qualitative Study. PREHOSP EMERG CARE 2022; 27:946-954. [PMID: 36149372 PMCID: PMC10060435 DOI: 10.1080/10903127.2022.2128484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Revised: 09/04/2022] [Accepted: 09/21/2022] [Indexed: 10/14/2022]
Abstract
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.
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Affiliation(s)
- Christina Guerrier
- Center for Data Solutions, University of Florida College of Medicine - Jacksonville, Jacksonville, Florida
| | - Jennifer Brailsford
- Center for Data Solutions, University of Florida College of Medicine - Jacksonville, Jacksonville, Florida
| | - Shama Patel
- Department of Emergency Medicine, University of Florida College of Medicine - Jacksonville, Jacksonville, Florida
| | - Shannon Burcham
- Department of Pediatrics, University of Florida College of Medicine, Gainesville, Florida
| | - Ramzi G Salloum
- Department of Health Outcomes and Biomedical Informatics, University of Florida College of Medicine, Gainesville, Florida
| | - Christian Martin-Gill
- Department of Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Prehospital Guidelines Consortium
| | - Christopher T Richards
- Prehospital Guidelines Consortium
- Department of Emergency Medicine, School of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Ashish R Panchal
- Prehospital Guidelines Consortium
- Department of Emergency Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Jennifer Fishe
- Center for Data Solutions, University of Florida College of Medicine - Jacksonville, Jacksonville, Florida
- Department of Emergency Medicine, University of Florida College of Medicine - Jacksonville, Jacksonville, Florida
- Prehospital Guidelines Consortium
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5
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Anders JF, Fishe JN, Fratta KA, Katznelson JH, Levy MJ, Lichenstein R, Milin MG, Simpson JN, Walls TA, Winger HL. Creating a Pediatric Prehospital Destination Decision Tool Using a Modified Delphi Method. CHILDREN-BASEL 2021; 8:children8080658. [PMID: 34438548 PMCID: PMC8394584 DOI: 10.3390/children8080658] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 07/26/2021] [Accepted: 07/26/2021] [Indexed: 11/16/2022]
Abstract
Decisions for patient transport by emergency medical services (EMS) are individualized; while established guidelines help direct adult patients to specialty hospitals, no such pediatric equivalents are in wide use. When children are transported to a hospital that cannot provide definitive care, care is delayed and may cause adverse events. Therefore, we created a novel evidence-based decision tool to support EMS destination choice. A multidisciplinary expert panel (EP) of stakeholders reviewed published literature. Four facility capability levels for pediatric care were defined. Using a modified Delphi method, the EP matched specific conditions to a facility pediatric-capability level in a draft tool. The literature review and EP recommendations identified seventeen pediatric medical conditions at risk for secondary transport. In the first voting round, two were rejected, nine met consensus for a specific facility capability level, and six did not reach consensus on the destination facility level. A second round reached consensus on a facility level for the six conditions as well as revision of one previously rejected condition. In the third round, the panel selected a visual display format. Finally, the panel unanimously approved the PDTree. Using a modified Delphi technique, we developed the PDTree EMS destination decision tool by incorporating existing evidence and the expertise of a multidisciplinary panel.
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Affiliation(s)
- Jennifer F. Anders
- Department of Pediatrics, Johns Hopkins University, Baltimore, MD 21287, USA; (K.A.F.); (J.H.K.)
- Correspondence: ; Tel.: +1-410-955-6143
| | - Jennifer N. Fishe
- Department of Emergency Medicine, University of Florida–Jacksonville, Jacksonville, FL 32224, USA;
| | - Kyle A. Fratta
- Department of Pediatrics, Johns Hopkins University, Baltimore, MD 21287, USA; (K.A.F.); (J.H.K.)
- Department of Emergency Medicine, University of Pittsburgh Medical Center-Harrisburg, Harrisburg, PA 15213, USA
| | - Jessica H. Katznelson
- Department of Pediatrics, Johns Hopkins University, Baltimore, MD 21287, USA; (K.A.F.); (J.H.K.)
| | - Matthew J. Levy
- Department of Emergency Medicine, Johns Hopkins University, Baltimore, MD 21287, USA; (M.J.L.); (M.G.M.)
| | - Richard Lichenstein
- Division of Pediatric Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD 21201, USA;
| | - Michael G. Milin
- Department of Emergency Medicine, Johns Hopkins University, Baltimore, MD 21287, USA; (M.J.L.); (M.G.M.)
| | - Joelle N. Simpson
- Department of Emergency Medicine, Children’s National Hospital, Washington, DC 20010, USA;
| | - Theresa A. Walls
- Division of Emergency Medicine, Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA;
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Patterson PD, Martin-Gill C, Buysse DJ. Commentary on Dawson et al.: Fatigue risk management in emergency services personnel. Sleep Med Rev 2021; 57:101484. [PMID: 33865012 DOI: 10.1016/j.smrv.2021.101484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 02/13/2021] [Indexed: 11/29/2022]
Affiliation(s)
- Paul D Patterson
- University of Pittsburgh, School of Medicine, Department of Emergency Medicine, Pittsburgh, PA, 15261, USA; University of Pittsburgh, School of Health and Rehabilitation Sciences, Division of Community Health Services, Emergency Medicine Program, Pittsburgh, PA, 15261, USA.
| | - Christian Martin-Gill
- University of Pittsburgh, School of Medicine, Department of Emergency Medicine, Pittsburgh, PA, 15261, USA
| | - Daniel J Buysse
- University of Pittsburgh, Department of Psychiatry, Pittsburgh, PA, 15261, USA
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Fratta KA, Fishe JN, Anders PD, Anders JF. Improving EMS destination choice for pediatrics: Results of a novel pediatric destination decision tool pilot test. Am J Emerg Med 2020; 46:769-771. [PMID: 33039231 DOI: 10.1016/j.ajem.2020.09.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Revised: 09/02/2020] [Accepted: 09/10/2020] [Indexed: 11/30/2022] Open
Affiliation(s)
- Kyle A Fratta
- Johns Hopkins University, School of Medicine, Department of Pediatrics, Division of Pediatric Emergency Medicine, Baltimore, MD, USA; Campbell University, Jerry M. Wallace School of Osteopathic Medicine, Lillington, NC, USA.
| | - Jennifer N Fishe
- University of Florida College of Medicine - Jacksonville, Department of Emergency Medicine, Jacksonville, FL, USA.
| | | | - Jennifer F Anders
- Johns Hopkins University, School of Medicine, Department of Pediatrics, Division of Pediatric Emergency Medicine, Baltimore, MD, USA.
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8
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Fishe JN, Hendry P, Brailsford J, Salloum RG, Vogel B, Finlay E, Palmer S, Datta S, Hendeles L, Blake K. Early administration of steroids in the ambulance setting: Protocol for a type I hybrid effectiveness-implementation trial with a stepped wedge design. Contemp Clin Trials 2020; 97:106141. [PMID: 32931918 DOI: 10.1016/j.cct.2020.106141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 08/17/2020] [Accepted: 09/07/2020] [Indexed: 11/16/2022]
Abstract
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.
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Affiliation(s)
- Jennifer N Fishe
- Department of Emergency Medicine, Division of Research, University of Florida College of Medicine, Jacksonville. 655 W. 8(th) St., Jacksonville, FL 32209, United States of America; Center for Data Solutions, University of Florida College of Medicine - Jacksonville, 655 W. 11(th) St., Jacksonville, FL 32209, United States of America.
| | - Phyllis Hendry
- Department of Emergency Medicine, Division of Research, University of Florida College of Medicine, Jacksonville. 655 W. 8(th) St., Jacksonville, FL 32209, United States of America.
| | - Jennifer Brailsford
- Center for Data Solutions, University of Florida College of Medicine - Jacksonville, 655 W. 11(th) St., Jacksonville, FL 32209, United States of America.
| | - Ramzi G Salloum
- Department of Health Outcomes and Bioinformatics, University of Florida College of Medicine, 2004 Mowry Road, Gainesville, FL 32610, United States of America.
| | - Bruce Vogel
- Department of Health Outcomes and Bioinformatics, University of Florida College of Medicine, 2004 Mowry Road, Gainesville, FL 32610, United States of America.
| | - Erik Finlay
- GeoPlan Center, University of Florida College of Design, Construction, and Planning. 1480 Inner Rd, Gainesivlle, FL 32601, United States of America.
| | - Sam Palmer
- GeoPlan Center, University of Florida College of Design, Construction, and Planning. 1480 Inner Rd, Gainesivlle, FL 32601, United States of America.
| | - Susmita Datta
- Department of Biostatistics, University of Florida. 2004 Mowry Road, 5(th) Floor CTRB, Gainesville, FL 32611, United States of America.
| | - Leslie Hendeles
- Department of Pediatrics, Pediatric Pulmonary Division, University of Florida College of Medicine, 1600 SW Archer Rd, Ste HD-506, Gainesville, FL 32610, United States of America
| | - Kathryn Blake
- Nemours Center for Pharmacogenomics and Translational Research, 807 Children's Way, Jacksonville, FL 32207, United States of America.
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Shah MI, Ostermayer DG, Browne LR, Studnek JR, Carey JM, Stanford C, Fumo N, Lerner EB. Multicenter Evaluation of Prehospital Seizure Management in Children. PREHOSP EMERG CARE 2020; 25:475-486. [PMID: 32589502 DOI: 10.1080/10903127.2020.1788194] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
BACKGROUND Seizures are a common reason why emergency medical services (EMS) transports children by ambulance. Timely seizure cessation prevents neurologic morbidity, respiratory compromise, and mortality. Implementing recommendations from an evidence-based pediatric prehospital guideline may enhance timeliness of seizure cessation and optimize medication dosing. OBJECTIVE We compared management of pediatric prehospital seizures across several EMS systems after protocol revision consistent with an evidence-based guideline. METHODS Using a retrospective, cross-sectional approach, we evaluated actively seizing patients (0-17 years old) EMS transported to a hospital before and after modifying local protocols to include evidence-based recommendations for seizure management in three EMS agencies. We electronically queried and manually abstracted both EMS and hospital data at each site to obtain information about patient demographics, medications given, seizure cessation and recurrence, airway interventions, access obtained, and timeliness of care. The primary outcome of the study was the appropriate administration of midazolam based on route and dose. We analyzed these secondary outcomes: frequency of seizure activity upon emergency department (ED) arrival, frequency of respiratory failure, and timeliness of care. RESULTS We analyzed data for 533 actively seizing patients. Paramedics were more likely to administer at least one dose of midazolam after the protocol updates [127/208 (61%) vs. 232/325 (71%), p = 0.01, OR = 1.60 (95% CI: 1.10-2.30)]. Paramedics were also more likely to administer the first midazolam dose via the preferred intranasal (IN) or intramuscular (IM) routes after the protocol change [(63/208 (49%) vs. 179/325 (77%), p < 0.001, OR = 3.24 (2.01-5.21)]. Overall, paramedics administered midazolam approximately 14 min after their arrival, gave an incorrect weight-based dose to 130/359 (36%) patients, and gave a lower than recommended dose to 94/130 (72%) patients. Upon ED arrival, 152/533 (29%) patients had a recurrent or persistent seizure. Respiratory failure during EMS care or subsequently in the ED occurred in 90/533 (17%) patients. CONCLUSIONS Implementation of an evidence-based seizure protocol for EMS increased midazolam administration. Patients frequently received an incorrect weight-based dose. Future research should focus on optimizing administration of the correct dose of midazolam to improve seizure cessation.
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Turner S, Lang ES, Brown K, Franke J, Workun-Hill M, Jackson C, Roberts L, Leyton C, Bulger EM, Censullo EM, Martin-Gill C. Systematic Review of Evidence-Based Guidelines for Prehospital Care. PREHOSP EMERG CARE 2020; 25:221-234. [PMID: 32286899 DOI: 10.1080/10903127.2020.1754978] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Introduction: Multiple national organizations have identified a need to incorporate more evidence-based medicine in emergency medical services (EMS) through the creation of evidence-based guidelines (EBGs). Tools like the Appraisal of Guidelines for Research and Evaluation (AGREE) II and criteria outlined by the National Academy of Medicine (NAM) have established concrete recommendations for the development of high-quality guidelines. While many guidelines have been created that address topics within EMS medicine, neither the quantity nor quality of prehospital EBGs have been previously reported. Objectives: To perform a systematic review to identify existing EBGs related to prehospital care and evaluate the quality of these guidelines using the AGREE II tool and criteria for clinical guidelines described by the NAM. Methods: We performed a systematic search of the literature in MEDLINE, EMBASE, PubMED, Trip, and guidelines.gov, through September 2018. Guideline topics were categorized based on the 2019 Core Content of EMS Medicine. Two independent reviewers screened titles for relevance and then abstracts for essential guideline features. Included guidelines were appraised with the AGREE II tool across 6 domains by 3 independent reviewers and scores averaged. Two additional reviewers determined if each guideline reported the key elements of clinical practice guidelines recommended by the NAM via consensus. Results: We identified 71 guidelines, of which 89% addressed clinical aspects of EMS medicine. Only 9 guidelines scored >75% across AGREE II domains and most (63%) scored between 50 and 75%. Domain 4 (Clarity of Presentation) had the highest (79.7%) and domain 5 (Applicability) had the lowest average score across EMS guidelines. Only 38% of EMS guidelines included a reporting of all criteria identified by the NAM for clinical practice guidelines, with elements of a systematic review of the literature most commonly missing. Conclusions: EBGs exist addressing a variety of topics in EMS medicine. This systematic review and appraisal of EMS guidelines identified a wide range in the quality of these guidelines and variable reporting of key elements of clinical guidelines. Future guideline developers should consider established methodological and reporting recommendations to improve the quality of EMS guidelines.
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11
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Most guideline organizations lack explicit guidance in how to incorporate cost considerations. J Clin Epidemiol 2019; 116:72-83. [DOI: 10.1016/j.jclinepi.2019.08.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2019] [Revised: 07/26/2019] [Accepted: 08/14/2019] [Indexed: 11/21/2022]
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Thorvaldsen NØ, Flingtorp LD, Wisborg T, Jeppesen E. Implementation of new guidelines in the prehospital services: a nationwide survey of Norway. Scand J Trauma Resusc Emerg Med 2019; 27:83. [PMID: 31464620 PMCID: PMC6716817 DOI: 10.1186/s13049-019-0660-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Accepted: 08/20/2019] [Indexed: 12/01/2022] Open
Abstract
Background A debate regarding the potential harmful effects of rigid neck collar and backboard usage among prehospital and hospital care providers in Norway provoked the development of an evidence-based guideline. “The Norwegian guideline for the prehospital management of adult trauma patients with potential spinal injury” was developed with rigorous scientific methods and published in 2016. An e-learning course was developed in parallel. The aim of this study is to explore whether emergency medical services personnel in Norway have implemented the guideline, and to what extent the e-learning course was applied during the implementation process. Method An electronic survey was distributed individually to registered prehospital personnel in Norway 18 months after publication of the guideline. Results In all, 938 of 5500 (17%) EMS personnel responded to the survey. More than one-half confirmed knowledge of the guideline; among these, 56% claimed that the guideline was implemented in the service they work. Not having responded to trauma cases in real life was the main reason for not having executed the guideline. The e-learning course had been completed by 18% of respondents. Conclusion Although the guideline has not been authorized or made compulsory by national authorities, one-half of respondents with knowledge of the guideline reported it as implemented. E-learning did not seem to have affected the implementation. The guideline was developed based on perceived needs among care providers, and this probably facilitated implementation of the guideline. Electronic supplementary material The online version of this article (10.1186/s13049-019-0660-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Nina Øye Thorvaldsen
- Emergency Medical Services, Division of Prehospital Services, Oslo University Hospital, Oslo, Norway. .,Faculty of Health Science, University of Stavanger, Stavanger, Norway.
| | - Lars Didrik Flingtorp
- Norwegian National Advisory Unit on Prehospital Emergency Medicine (NAKOS), Oslo, Norway
| | - Torben Wisborg
- Norwegian National Advisory Unit on Trauma, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway.,Anesthesia and Critical Care Research Group, Faculty of Health Sciences, University of Tromsø - the Arctic University of Norway, Tromsø, Norway
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13
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Moesker MJ, de Groot JF, Damen NL, Huisman MV, de Bruijne MC, Wagner C. How reliable is perioperative anticoagulant management? Determining guideline compliance and practice variation by a retrospective patient record review. BMJ Open 2019; 9:e029879. [PMID: 31320357 PMCID: PMC6661608 DOI: 10.1136/bmjopen-2019-029879] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
OBJECTIVES Surgery in patients on anticoagulants requires careful monitoring and risk assessment to prevent harm. Required interruptions of anticoagulants and deciding whether to use bridging anticoagulation add further complexity. This process, known as perioperative anticoagulant management (PAM), is optimised by using guidelines. Optimal PAM prevents thromboembolic and bleeding complications. The purpose of this study was to assess the reliability of PAM practice in Dutch hospitals. Additionally, the variations between hospitals and different bridging dosages were studied. DESIGN A multicentre retrospective patient record review. SETTING AND PARTICIPANTS Records from 268 patients using vitamin-K antagonist (VKA) anticoagulants who underwent surgery in a representative random sample of 13 Dutch hospitals were reviewed, 259 were analysed. PRIMARY AND SECONDARY OUTCOME MEASURES Our primary outcome measure was the reliability of PAM expressed as the percentage of patients receiving guideline compliant care. Seven PAM steps were included. Secondary outcome measures included different bridging dosages used and an analysis of practice variation on the hospital level. RESULTS Preoperative compliance was lowest for timely VKA interruptions: 58.8% (95% CI 50.0% to 67.7%) and highest for timely preoperative assessments: 81% (95% CI 75.0% to 86.5%). Postoperative compliance was lowest for timely VKA restarts: 39.9% (95% CI 33.1% to 46.7%) and highest for the decision to apply bridging: 68.5% (95% CI 62.3% to 74.8%). Variation in compliance between hospitals was present for the timely preoperative assessment (range 41%-100%), international normalised ratio testing (range 21%-94%) and postoperative bridging (range 20%-88%). Subtherapeutic bridging was used in 50.5% of patients and increased with patients' weight. CONCLUSIONS Unsatisfying compliance for most PAM steps, reflect suboptimal reliability of PAM. Furthermore, the hospital performance varied. This increases the risk for adverse events, warranting quality improvement. The development of process measures can help but will be complicated by the availability of a strong supporting evidence base and integrated care delivery regarding PAM.
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Affiliation(s)
- Marco J Moesker
- Department of Public and Occupational Health, Amsterdam Public Health Research Institute, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Janke F de Groot
- Netherlands Institute for Health Services Research (NIVEL), Utrecht, The Netherlands
| | - Nikki L Damen
- Departmentof Quality and Safety, Elisabeth-TweeSteden Ziekenhuis, Tilburg, The Netherlands
| | - Menno V Huisman
- Department of Thrombosis and Hemostasis, Leids Universitair Medisch Centrum, Leiden, The Netherlands
| | - Martine C de Bruijne
- Department of Public and Occupational Health, Amsterdam Public Health Research Institute, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Cordula Wagner
- Department of Public and Occupational Health, Amsterdam Public Health Research Institute, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Netherlands Institute for Health Services Research (NIVEL), Utrecht, The Netherlands
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Williams K, Lang ES, Panchal AR, Gasper JJ, Taillac P, Gouda J, Lyng JW, Goodloe JM, Hedges M. Evidence-Based Guidelines for EMS Administration of Naloxone. PREHOSP EMERG CARE 2019; 23:749-763. [DOI: 10.1080/10903127.2019.1597955] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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Adelgais KM, Hansen M, Lerner EB, Donofrio JJ, Yadav K, Brown K, Liu YT, Denslow P, Denninghoff K, Ishimine P, Olson LM. Establishing the Key Outcomes for Pediatric Emergency Medical Services Research. Acad Emerg Med 2018; 25:1345-1354. [PMID: 30312993 DOI: 10.1111/acem.13637] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Revised: 10/01/2018] [Accepted: 10/06/2018] [Indexed: 11/28/2022]
Abstract
The evidence supporting best practices when treating children in the prehospital setting or even the effect emergency medical services (EMS) has on patient outcomes is limited. Standardizing the critical outcomes for EMS research will allow for focused and comparable effort among the small but growing group of pediatric EMS investigators on specific topics. Standardized outcomes will also provide the opportunity to collectively advance the science of EMS for children and demonstrate the effect of EMS on patient outcomes. This article describes a consensus process among stakeholders in the pediatric emergency medicine and EMS community that identified the critical outcomes for EMS care in five clinical areas (traumatic brain injury, general injury, respiratory disease/failure, sepsis, and seizures). These areas were selected based on both their known public health importance and their commonality in EMS encounters. Key research outcomes identified by participating stakeholders using a modified nominal group technique for consensus building, which included small group brainstorming and independent voting for ranking outcomes that were feasible and/or important for the field.
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Affiliation(s)
| | - Kathleen M. Adelgais
- Department of Pediatrics Section of Pediatric Emergency Medicine University of Colorado School of Medicine Aurora CO
| | - Matthew Hansen
- Department of Emergency Medicine Oregon Health Sciences University PortlandOR
| | - E. Brooke Lerner
- Departments of Emergency Medicine and Pediatrics Medical College of Wisconsin Milwaukee WI
| | - J. Joelle Donofrio
- Departments of Emergency Medicine and Pediatrics University of California San Diego Rady Children's Hospital San Diego CA
| | - Kabir Yadav
- Department of Emergency Medicine Harbor‐UCLA Medical Center Torrance CA
| | - Kathleen Brown
- Department of Emergency Medicine The George Washington University School of Medicine and Children's National Medical Center Washington DC
| | - Yiju T. Liu
- Department of Emergency Medicine Harbor‐UCLA Medical Center Torrance CA
| | | | - Kurt Denninghoff
- Department of Emergency Medicine University of Arizona School of Medicine Tucson AZ
| | - Paul Ishimine
- Departments of Emergency Medicine and Pediatrics University of California San Diego Rady Children's Hospital San Diego CA
| | - Lenora M. Olson
- Division of Pediatric Critical Care Department of Pediatrics University of Utah School of Medicine Salt Lake City UT
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Adelgais KM, Sholl JM, Alter R, Gurley KL, Broadwater-Hollifield C, Taillac P. Challenges in Statewide Implementation of a Prehospital Evidence-Based Guideline: An Assessment of Barriers and Enablers in Five States. PREHOSP EMERG CARE 2018; 23:167-178. [PMID: 30118367 DOI: 10.1080/10903127.2018.1495284] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
BACKGROUND Individual states, regions, and local emergency medical service (EMS) agencies are responsible for the development and implementation of prehospital patient care protocols. Many states lack model prehospital guidelines for managing common conditions. Recently developed national evidence-based guidelines (EBGs) may address this gap. Barriers to statewide dissemination and implementation of model guidelines have not been studied. The objective of this study was to examine barriers and enablers to dissemination and implementation of an evidence-based guideline for traumatic pain management across 5 states. METHODS This study used mixed methods to evaluate the statewide dissemination and implementation of a prehospital EBG. The guideline provided pain assessment tools, recommended opiate medication dosing, and indications and contraindications for analgesia. Participating states were provided an implementation toolkit, standardized training materials, and a state-specific implementation plan. Outcomes were assessed via an electronic self-assessment tool in which states reported barriers and enablers to dissemination and implementation and information about changes in pain management practices in their states after implementation of the EBG. RESULTS Of the 5 participating states, 3 reported dissemination of the guideline, one through a state model guideline process and 2 through regional EMS systems. Two states did not disseminate or implement the guideline. Of these, one state chose to utilize a locally developed guideline, and the other state did not perform guideline dissemination at the state level. Barriers to state implementation were the lack of authority at the state level to mandate protocols, technical challenges with learning management systems, and inability to track and monitor training and implementation at the agency level. Enablers included having a state/regional EMS office champion and the availability of an implementation toolkit. No participating states demonstrated an increase in opioid delivery to patients during the study period. CONCLUSION Statewide dissemination and implementation of an EBG is complex with many challenges. Future efforts should consider the advantages of having statewide model or mandatory guidelines and the value of local champions and be aware of the challenges of a statewide learning management system and of tracking the success of implementation efforts.
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Improving Prehospital Management of Children With Respiratory Distress. CLINICAL PEDIATRIC EMERGENCY MEDICINE 2018. [DOI: 10.1016/j.cpem.2018.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Patterson PD, Martin-Gill C. Absence and Need for Fatigue Risk Management in Emergency Medical Services. PREHOSP EMERG CARE 2018; 22:6-8. [PMID: 29324169 DOI: 10.1080/10903127.2017.1380101] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Marino MC, Ostermayer DG, Mondragon JA, Camp EA, Keating EM, Fornage LB, Brown CA, Shah MI. Improving Prehospital Protocol Adherence Using Bundled Educational Interventions. PREHOSP EMERG CARE 2018; 22:361-369. [PMID: 29364730 DOI: 10.1080/10903127.2017.1399182] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND Seizures and anaphylaxis are life-threatening conditions that require immediate treatment in the prehospital setting. There is variation in treatment of pediatric prehospital patients for both anaphylaxis and seizures. This educational study was done to improve compliance with pediatric prehospital protocols, educate prehospital providers and decrease variation in care. OBJECTIVE To improve the quality of care for children with seizures and anaphylaxis in the prehospital setting using a bundled, multifaceted educational intervention. METHODS Evidence-based pediatric prehospital guidelines for seizures and anaphylaxis were used to create a curriculum for the paramedics in the EMS system. The curriculum included in-person training, videos, distribution of decision support tools, and a targeted social media campaign to reinforce the evidence-based guidelines. Prehospital charts were reviewed for pediatric patients with a chief complaint of anaphylaxis or seizures who were transported by paramedics to one of ten hospitals, including three children's hospitals, for 8 months prior to the intervention and eight months following the intervention. The primary outcome for seizures was whether midazolam was given via the preferred intranasal (IN) or intramuscular (IM) routes. The primary outcome for anaphylaxis was whether IM epinephrine was given. RESULTS A total of 1,402 pediatric patients were transported for seizures by paramedics to during the study period. A total of 88 patients were actively seizing pre-intervention and 93 post-intervention. Of the actively seizing patients, 52 were given midazolam pre-intervention and 62 were given midazolam post-intervention. Pre-intervention, 29% (15/52) of the seizing patients received midazolam via the preferred IM or IN routes, compared to 74% (46/62) of the seizing patients post-intervention. A total of 45 patients with anaphylaxis were transported by paramedics, 30 pre-intervention and 15 post-intervention. Paramedics administered epinephrine to 17% (5/30) patients pre-intervention and 67% (10/15) patients post-intervention. CONCLUSION The use of a bundled, multifaceted educational intervention including in-person training, decision support tools, and social media improved adherence to updated evidence-based pediatric prehospital protocols.
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Fishe JN, Crowe RP, Cash RE, Nudell NG, Martin-Gill C, Richards CT. Implementing Prehospital Evidence-Based Guidelines: A Systematic Literature Review. PREHOSP EMERG CARE 2018; 22:511-519. [PMID: 29351495 DOI: 10.1080/10903127.2017.1413466] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
OBJECTIVE As prehospital research advances, more evidence-based guidelines (EBGs) are implemented into emergency medical services (EMS) practice. However, incomplete or suboptimal prehospital EBG implementation may hinder improvement in patient outcomes. To inform future efforts, this study's objective was to review existing evidence pertaining to prehospital EBG implementation methods. METHODS This study was a systematic literature review and evaluation following the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology. PubMed, EMBASE, Scopus, and Google Advanced Search were searched without language or publication date filters for articles addressing prehospital EBG implementation. Conference proceedings, textbooks, and non-English articles were excluded. GRADE was applied to the remaining articles independently by three of five study investigators. Study characteristics and salient findings from the included articles are reported. RESULTS The systematic literature review identified 1,367 articles, with 41 meeting inclusion criteria. Most articles described prehospital EBG implementation (n = 24, 59%), or implementation barriers (n = 13, 32%). Common study designs were statement documents (n = 12, 29%), retrospective cohort studies (n = 12, 29%), and cross-sectional studies (n = 9, 22%). Using GRADE, evidence quality was rated low (n = 18, 44%), or very low (n = 23, 56%). Salient findings from the articles included: (i) EBG adherence and patient outcomes depend upon successful implementation, (ii) published studies generally lack detailed implementation methods, (iii) EBG implementation takes longer than planned (mostly for EMS education), (iv) EMS systems' heterogeneity affects EBG implementation, and (v) multiple barriers limit successful implementation (e.g., financial constraints, equipment purchasing, coordination with hospitals, and regulatory agencies). This review found no direct evidence for best prehospital EBG implementation practices. There were no studies comparing implementation methods or implementation in different prehospital settings (e.g., urban vs. rural, advanced vs. basic life support). CONCLUSIONS While prehospital EBG implementation barriers are well described, there is a paucity of evidence for optimal implementation methods. For scientific advances to reach prehospital patients, EBG development efforts must translate into EMS practice. Future research should consider comparing implementation methodologies in different prehospital settings, with a goal of defining detailed, reproducible best practices.
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Martin-Gill C, Higgins JS, Van Dongen HPA, Buysse DJ, Thackery RW, Kupas DF, Becker DS, Dean BE, Lindbeck GH, Guyette FX, Penner JH, Violanti JM, Lang ES, Patterson PD. Proposed Performance Measures and Strategies for Implementation of the Fatigue Risk Management Guidelines for Emergency Medical Services. PREHOSP EMERG CARE 2018; 22:102-109. [DOI: 10.1080/10903127.2017.1381791] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Patterson PD, Higgins JS, Weiss PM, Lang E, Martin-Gill C. Systematic Review Methodology for the Fatigue in Emergency Medical Services Project. PREHOSP EMERG CARE 2018; 22:9-16. [PMID: 29324053 DOI: 10.1080/10903127.2017.1380096] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND Guidance for managing fatigue in the Emergency Medical Services (EMS) setting is limited. The Fatigue in EMS Project sought to complete multiple systematic reviews guided by seven explicit research questions, assemble the best available evidence, and rate the quality of that evidence for purposes of producing an Evidence Based Guideline (EBG) for fatigue risk management in EMS operations. METHODS We completed seven systematic reviews that involved searches of six databases for literature relevant to seven research questions. These questions were developed a priori by an expert panel and framed in the Population, Intervention, Comparison, and Outcome (PICO) format and pre-registered with PROSPERO. Our target population was defined as persons 18 years of age and older classified as EMS personnel or similar shift worker groups. A panel of experts selected outcomes for each PICO question as prescribed by the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology. We pooled findings, stratified by study design (experimental vs. observational) and presented results of each systematic review in narrative and quantitative form. We used meta-analyses of select outcomes to generate pooled effects. We used the GRADE methodology and the GRADEpro software to designate a quality of evidence rating for each outcome. RESULTS We present the results for each systematic review in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA). More than 38,000 records were screened across seven systematic reviews. The median, minimum, and maximum inter-rater agreements (Kappa) between screeners for our seven systematic reviews were 0.66, 0.49, and 0.88, respectively. The median, minimum, and maximum number of records retained for the seven systematic reviews was 13, 1, and 100, respectively. We present key findings in GRADE Evidence Profile Tables in separate publications for each systematic review. CONCLUSIONS We describe a protocol for conducting multiple, simultaneous systematic reviews connected to fatigue with the goal of creating an EBG for fatigue risk management in the EMS setting. Our approach may be informative to others challenged with the creation of EBGs that address multiple, inter-related systematic reviews with overlapping outcomes.
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Patterson PD, Higgins JS, Van Dongen HPA, Buysse DJ, Thackery RW, Kupas DF, Becker DS, Dean BE, Lindbeck GH, Guyette FX, Penner JH, Violanti JM, Lang ES, Martin-Gill C. Evidence-Based Guidelines for Fatigue Risk Management in Emergency Medical Services. PREHOSP EMERG CARE 2018; 22:89-101. [DOI: 10.1080/10903127.2017.1376137] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Patterson PD, Higgins JS, Lang ES, Runyon MS, Barger LK, Studnek JR, Moore CG, Robinson K, Gainor D, Infinger A, Weiss PM, Sequeira DJ, Martin-Gill C. Evidence-Based Guidelines for Fatigue Risk Management in EMS: Formulating Research Questions and Selecting Outcomes. PREHOSP EMERG CARE 2016; 21:149-156. [PMID: 27858581 DOI: 10.1080/10903127.2016.1241329] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND Greater than half of Emergency Medical Services (EMS) personnel report work-related fatigue, yet there are no guidelines for the management of fatigue in EMS. A novel process has been established for evidence-based guideline (EBG) development germane to clinical EMS questions. This process has not yet been applied to operational EMS questions like fatigue risk management. The objective of this study was to develop content valid research questions in the Population, Intervention, Comparison, and Outcome (PICO) framework, and select outcomes to guide systematic reviews and development of EBGs for EMS fatigue risk management. METHODS We adopted the National Prehospital EBG Model Process and Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework for developing, implementing, and evaluating EBGs in the prehospital care setting. In accordance with steps one and two of the Model Process, we searched for existing EBGs, developed a multi-disciplinary expert panel and received external input. Panelists completed an iterative process to formulate research questions. We used the Content Validity Index (CVI) to score relevance and clarity of candidate PICO questions. The panel completed multiple rounds of question editing and used a CVI benchmark of ≥0.78 to indicate acceptable levels of clarity and relevance. Outcomes for each PICO question were rated from 1 = less important to 9 = critical. RESULTS Panelists formulated 13 candidate PICO questions, of which 6 were eliminated or merged with other questions. Panelists reached consensus on seven PICO questions (n = 1 diagnosis and n = 6 intervention). Final CVI scores of relevance ranged from 0.81 to 1.00. Final CVI scores of clarity ranged from 0.88 to 1.00. The mean number of outcomes rated as critical, important, and less important by PICO question was 0.7 (SD 0.7), 5.4 (SD 1.4), and 3.6 (SD 1.9), respectively. Patient and personnel safety were rated as critical for most PICO questions. PICO questions and outcomes were registered with PROSPERO, an international database of prospectively registered systematic reviews. CONCLUSIONS We describe formulating and refining research questions and selection of outcomes to guide systematic reviews germane to EMS fatigue risk management. We outline a protocol for applying the Model Process and GRADE framework to create evidence-based guidelines.
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Contemporary evidence-based practice in Canadian emergency medical services: a vision for integrating evidence into clinical and policy decision-making. CAN J EMERG MED 2016; 19:220-229. [PMID: 27658352 DOI: 10.1017/cem.2016.364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Nationally, emphasis on the importance of evidence-based practice (EBP) in emergency medicine and emergency medical services (EMS) has continuously increased. However, meaningful incorporation of effective and sustainable EBP into clinical and administrative decision-making remains a challenge. We propose a vision for EBP in EMS: Canadian EMS clinicians and leaders will understand and use the best available evidence for clinical and administrative decision-making, to improve patient health outcomes, the capability and quality of EMS systems of care, and safety of patients and EMS professionals. This vision can be implemented with the use of a structure, process, system, and outcome taxonomy to identify current barriers to true EBP, to recognize the opportunities that exist, and propose corresponding recommended strategies for local EMS agencies and at the national level. Framing local and national discussions with this approach will be useful for developing a cohesive and collaborative Canadian EBP strategy.
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Browne LR, Shah MI, Studnek JR, Ostermayer DG, Reynolds S, Guse CE, Brousseau DC, Lerner EB. Multicenter Evaluation of Prehospital Opioid Pain Management in Injured Children. PREHOSP EMERG CARE 2016; 20:759-767. [DOI: 10.1080/10903127.2016.1194931] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Shah MI, Carey JM, Rapp SE, Masciale M, Alcanter WB, Mondragon JA, Camp EA, Prater SJ, Doughty CB. Impact of High-Fidelity Pediatric Simulation on Paramedic Seizure Management. PREHOSP EMERG CARE 2016; 20:499-507. [PMID: 26953677 DOI: 10.3109/10903127.2016.1139217] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND A simulation-based course, Pediatric Simulation Training for Emergency Prehospital Providers (PediSTEPPs), was developed to optimize pediatric prehospital care. Seizures are common in Emergency Medical Services (EMS), and no studies have evaluated pediatric outcomes after EMS simulation training. OBJECTIVES The primary objective was to determine if PediSTEPPs enhances seizure protocol adherence in blood glucose measurement and midazolam administration for seizing children. The secondary objective was to describe management of seizing patients by EMS and Emergency Departments (EDs). METHODS This is a two-year retrospective cohort study of paramedics who transported 0-18 year old seizing patients to ten urban EDs. Management was compared between EMS crews with at least one paramedic who attended PediSTEPPs and crews that had none. Blood glucose measurement, medications administered, intravenous (IV) access, seizure recurrence, and respiratory failure data were collected from databases and run reports. Data were compared using Pearson's χ(2) test and odds ratios with 95% confidence intervals (categorical) and the Mann-Whitney test (continuous). RESULTS Of 2200 pediatric transports with a complaint of seizure, 250 (11%) were actively seizing at the time of transport. Of these, 65 (26%) were treated by a PediSTEPPs-trained paramedic. Blood glucose was slightly more likely to be checked by trained than untrained paramedics (OR = 1.35, 95% CI 0.72-2.51). Overall, 58% received an indicated dose of midazolam, and this was slightly more likely in the trained than untrained paramedics (OR = 1.39, 95% CI 0.77-2.49). There were no differences in secondary outcomes between groups. The prevalence of hypoglycemia was low (2%). Peripheral IVs were attempted in 80%, and midazolam was predominantly given by IV (68%) and rectal (12%) routes, with 51% receiving a correct dose. Seizures recurred in 22%, with 34% seizing on ED arrival. Respiratory failure occurred in the prehospital setting in 25 (10%) patients in the study. CONCLUSION Simulation-based training on pediatric seizure management may have utility. Data support the need to optimize the route and dose of midazolam for seizing children. Blood glucose measurement in seizure protocols may warrant reprioritization due to low hypoglycemia prevalence. KEY WORDS seizure; emergency medical services; simulation; pediatrics.
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Martin-Gill C, Gaither JB, Bigham BL, Myers J, Kupas DF, Spaite DW. National Prehospital Evidence-Based Guidelines Strategy: A Summary for EMS Stakeholders. PREHOSP EMERG CARE 2016; 20:175-83. [DOI: 10.3109/10903127.2015.1102995] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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FitzGerald GJ. Paramedics and scope of practice. Med J Aust 2015; 203:240-1e.1. [PMID: 26377283 DOI: 10.5694/mja15.00775] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2015] [Accepted: 08/04/2015] [Indexed: 11/17/2022]
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Carter H, Thompson J. Defining the paramedic process. Aust J Prim Health 2015; 21:22-6. [DOI: 10.1071/py13059] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2013] [Accepted: 08/30/2013] [Indexed: 11/23/2022]
Abstract
The use of a ‘process of care’ is well established in several health professions, most evidently within the field of nursing. Now ingrained within methods of care delivery, it offers a logical approach to problem solving and ensures an appropriate delivery of interventions that are specifically suited to the individual patient. Paramedicine is a rapidly advancing profession despite a wide acknowledgement of limited research provisions. This frequently results in the borrowing of evidence from other disciplines. While this has often been useful, there are many concerns relating to the acceptable limit of evidence transcription between professions. To date, there is no formally recognised ‘process of care’-defining activity within the pre-hospital arena. With much current focus on the professional classification of paramedic work, it is considered timely to formally define a formula that underpins other professional roles such as nursing. It is hypothesised that defined processes of care, particularly the nursing process, may have features that would readily translate to pre-hospital practice. The literature analysed was obtained through systematic searches of a range of databases, including Ovid MEDLINE, Cumulative Index to Nursing and Allied Health. The results demonstrated that the defined process of care provides nursing with more than just a structure for practice, but also has implications for education, clinical governance and professional standing. The current nursing process does not directly articulate to the complex and often unstructured role of the paramedic; however, it has many principles that offer value to the paramedic in their practice. Expanding the nursing process model to include the stages of Dispatch Considerations, Scene Assessment, First Impressions, Patient History, Physical Examination, Clinical Decision-Making, Interventions, Re-evaluation, Transport Decisions, Handover and Reflection would provide an appropriate model for pre-hospital practices.
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Steib A, Mertes PM, Marret E, Albaladejo P, Fusciardi J. Compliance with guidelines for the perioperative management of vitamin K antagonists. Thromb Res 2014; 133:1056-60. [PMID: 24746585 DOI: 10.1016/j.thromres.2014.03.053] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2013] [Revised: 03/12/2014] [Accepted: 03/31/2014] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Perioperative vitamin K antagonist management is an issue of concern in many countries. The availability of best practice guidelines meets health professionals' needs, but compliance is uncertain and should be assessed. MATERIALS AND METHODS Our aim was to assess practitioner compliance with the guidelines on perioperative VKA management issued by the French National Authority for Health through a national register set up in partnership with the French College of Anaesthetists and Intensivists. Seven sections of data entry were focused on perioperative management of VKAs for elective or emergency procedures. High-risk patients were identified. Compliance with guidelines was calculated per item RESULTS 932 charts were completed between October 2009 and December 2010. VKA therapy was interrupted in 74% (622/837) of elective procedures and bridged in 69% cases (428/622) mainly with LMWH. According to guidelines, bridging was strongly recommended in 39% high-risk patients (175/394) but 13% of these (23/175) received no bridging. Bridging was overused in 60% of low risk patients (242/406). Other compliance rates were as follows: (i) administration of therapeutic enoxaparin doses (=200IU/kg/day): only 18% of high-risk patients (18/98), (ii) INR measurement on evening prior to the procedure 65% (525/803), (iii) concomitant prothrombin complex concentrate and vitamin K administration in emergency surgery 24% (21/87), (iv) postoperative therapeutic enoxaparin doses: only 20% despite widespread prescription. The incidence rate of bleeding and thrombotic events was 7.1% and 0.96% respectively. CONCLUSIONS These poor compliance rates with guidelines suggest that the knowledge-to-action transfer plan was inadequate and that further interventions are required.
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Affiliation(s)
- Annick Steib
- Department of Anaesthesiology, University Hospital (Nouvel Hôpital Civil), Strasbourg, France.
| | - Paul-Michel Mertes
- Department of Anaesthesiology, University Hospital (Nouvel Hôpital Civil), Strasbourg, France
| | | | - Pierre Albaladejo
- Department of Anaesthesiology, University Hospital, Grenoble, France
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Bulger EM, Snyder D, Schoelles K, Gotschall C, Dawson D, Lang E, Sanddal ND, Butler FK, Fallat M, Taillac P, White L, Salomone JP, Seifarth W, Betzner MJ, Johannigman J, McSwain N. An Evidence-based Prehospital Guideline for External Hemorrhage Control: American College of Surgeons Committee on Trauma. PREHOSP EMERG CARE 2014; 18:163-73. [DOI: 10.3109/10903127.2014.896962] [Citation(s) in RCA: 143] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Pediatric Prehospital Pain Management: Impact of Advocacy and Research. CLINICAL PEDIATRIC EMERGENCY MEDICINE 2014. [DOI: 10.1016/j.cpem.2014.01.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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L Wright J. Evidence-based Guidelines for Prehospital Practice: A Process Whose Time Has Come. PREHOSP EMERG CARE 2013; 18 Suppl 1:1-2. [DOI: 10.3109/10903127.2013.844875] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Shah MI, Macias CG, Dayan PS, Weik TS, Brown KM, Fuchs SM, Fallat ME, Wright JL, Lang ES. An Evidence-based Guideline for Pediatric Prehospital Seizure Management Using GRADE Methodology. PREHOSP EMERG CARE 2013; 18 Suppl 1:15-24. [DOI: 10.3109/10903127.2013.844874] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Muecke S, Curac N, Binks D. Informing clinical policy decision-making practices in ambulance services. INT J EVID-BASED HEA 2013; 11:299-304. [DOI: 10.1111/1744-1609.12039] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Brown KM, Macias CG, Dayan PS, Shah MI, Weik TS, Wright JL, Lang ES. The Development of Evidence-based Prehospital Guidelines Using a GRADE-based Methodology. PREHOSP EMERG CARE 2013; 18 Suppl 1:3-14. [DOI: 10.3109/10903127.2013.844871] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Gausche-Hill M, Brown KM, Oliver ZJ, Sasson C, Dayan PS, Eschmann NM, Weik TS, Lawner BJ, Sahni R, Falck-Ytter Y, Wright JL, Todd K, Lang ES. An Evidence-based Guideline for prehospital analgesia in trauma. PREHOSP EMERG CARE 2013; 18 Suppl 1:25-34. [PMID: 24279813 DOI: 10.3109/10903127.2013.844873] [Citation(s) in RCA: 88] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND The management of acute traumatic pain is a crucial component of prehospital care and yet the assessment and administration of analgesia is highly variable, frequently suboptimal, and often determined by consensus-based regional protocols. OBJECTIVE To develop an evidence-based guideline (EBG) for the clinical management of acute traumatic pain in adults and children by advanced life support (ALS) providers in the prehospital setting. Methods. We recruited a multi-stakeholder panel with expertise in acute pain management, guideline development, health informatics, and emergency medical services (EMS) outcomes research. Representatives of the National Highway Traffic Safety Administration (sponsoring agency) and a major children's research center (investigative team) also contributed to the process. The panel used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology to guide the process of question formulation, evidence retrieval, appraisal/synthesis, and formulation of recommendations. The process also adhered to the National Prehospital Evidence-Based Guideline (EBG) model process approved by the Federal Interagency Council for EMS and the National EMS Advisory Council. RESULTS Four strong and three weak recommendations emerged from the process; two of the strong recommendations were linked to high- and moderate-quality evidence, respectively. The panel recommended that all patients be considered candidates for analgesia, regardless of transport interval, and that opioid medications should be considered for patients in moderate to severe pain. The panel also recommended that all patients should be reassessed at frequent intervals using a standardized pain scale and that patients should be re-dosed if pain persists. The panel suggested the use of specific age-appropriate pain scales. CONCLUSION GRADE methodology was used to develop an evidence-based guideline for prehospital analgesia in trauma. The panel issued four strong recommendations regarding patient assessment and narcotic medication dosing. Future research should define optimal approaches for implementation of the guideline as well as the impact of the protocol on safety and effectiveness metrics.
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Thomas SH, Brown KM, Oliver ZJ, Spaite DW, Lawner BJ, Sahni R, Weik TS, Falck-Ytter Y, Wright JL, Lang ES. An Evidence-based Guideline for the Air Medical Transportation of Prehospital Trauma Patients. PREHOSP EMERG CARE 2013; 18 Suppl 1:35-44. [DOI: 10.3109/10903127.2013.844872] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Macias CG. Quality improvement in pediatric emergency medicine. Acad Pediatr 2013; 13:S61-8. [PMID: 24268087 DOI: 10.1016/j.acap.2013.06.007] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2012] [Revised: 05/13/2013] [Accepted: 06/19/2013] [Indexed: 10/26/2022]
Abstract
Pediatric patients, who accounted for 17.4% of US emergency department (ED) visits in 2010, present unique challenges that can impede an ED's ability to provide optimal care. To meet the growing demand for comprehensive, high-quality care, health care systems are incorporating quality improvement (QI) methods to reduce costs and variations in care and to improve access, safety, and ultimately the outcomes of medical care. This overview of QI initiatives within the field of pediatric emergency medicine explores how proven QI strategies are being integrated into efforts that target the care of children within the broader emergency care community. These initiatives are categorized within the domains of education, infrastructures supporting QI efforts, research, and community/government collaborations. Professional societies supporting education, such as the American Academy of Pediatrics, have made several strides to cultivate new health leaders that will use QI methodology to improve outcomes in pediatric emergency care. In addition to educational pursuits, professional societies and QI organizations (eg, Children's Hospital Association) offer stable infrastructures from which QI initiatives, either disease specific or broadly targeted, can be implemented as large-scale QI initiatives (eg, quality collaboratives). This overview also provides examples of how QI methodology has been integrated into research strategies and describes how the pediatric emergency medicine community can spread innovation and best practices into the larger emergency care community.
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Affiliation(s)
- Charles G Macias
- Department of Pediatrics, Center for Clinical Effectiveness, Evidence Based Outcomes Center, Texas Children's Hospital, Baylor College of Medicine, Houston, Tex.
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Brown KM, Hirshon JM, Alcorta R, Weik TS, Lawner B, Ho S, Wright JL. The implementation and evaluation of an evidence-based statewide prehospital pain management protocol developed using the national prehospital evidence-based guideline model process for emergency medical services. PREHOSP EMERG CARE 2013; 18 Suppl 1:45-51. [PMID: 24134543 DOI: 10.3109/10903127.2013.831510] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND In 2008, the National Highway Traffic Safety Administration funded the development of a model process for the development and implementation of evidence-based guidelines (EBGs) for emergency medical services (EMS). We report on the implementation and evaluation of an evidence-based prehospital pain management protocol developed using this model process. METHODS An evidence-based protocol for prehospital management of pain resulting from injuries and burns was reviewed by the Protocol Review Committee (PRC) of the Maryland Institute for Emergency Medical Services Systems (MIEMSS). The PRC recommended revisions to the Maryland protocol that reflected recommendations in the EBG: weight-based dosing and repeat dosing of morphine. A training curriculum was developed and implemented using Maryland's online Learning Management System and successfully accessed by 3,941 paramedics and 15,969 BLS providers. Field providers submitted electronic patient care reports to the MIEMSS statewide prehospital database. Inclusion criteria were injured or burned patients transported by Maryland ambulances to Maryland hospitals whose electronic patient care records included data for level of EMS provider training during a 12-month preimplementation period and a 12-month postimplementation period from September 2010 through March 2012. We compared the percentage of patients receiving pain scale assessments and morphine, as well as the dose of morphine administered and the use of naloxone as a rescue medication for opiate use, before and after the protocol change. RESULTS No differences were seen in the percentage of patients who had a pain score documented or the percent of patients receiving morphine before and after the protocol change, but there was a significant increase in the total dose and dose in mg/kg administered per patient. During the postintervention phase, patients received an 18% higher total morphine dose and a 14.9% greater mg/kg dose. CONCLUSIONS We demonstrated that the implementation of a revised statewide prehospital pain management protocol based on an EBG developed using the National Prehospital Evidence-based Guideline Model Process was associated with an increase in dosing of narcotic pain medication consistent with that recommended by the EBG. No differences were seen in the percentage of patients receiving opiate analgesia or in the documentation of pain scores.
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Affiliation(s)
- Kathleen M Brown
- from the Department of Pediatrics and Emergency Medicine, George Washington School of Medicine , Washington, DC (KMB) ; Emergency Department, Children's National Medical Center , Washington, DC (KMB) ; Maryland Institute for Emergency Medical Services Systems , Baltimore, Maryland (RA) ; Health Resources and Services Administration/Maternal and Child Health Bureau , Rockville, Maryland (TSW) ; Department of Emergency Medicine, University of Maryland School of Medicine , Baltimore, Maryland (BL) ; Baltimore City Fire Department , Baltimore Maryland (BL) ; Shock Trauma and Anesthesiology Research-Organized Research Center, University of Maryland School of Medicine , Baltimore Maryland (SH) ; Department of Pediatrics, Emergency Medicine, and Health Policy, George Washington University School of Medicine and Public Health , Washington, DC (JLW) ; Child Health Advocacy Institute, Children's National Medical Center , Washington, DC (JLW) ; and Department of Emergency Medicine, Department of Epidemiology and Public Health, University of Maryland , Baltimore, Maryland (JMH)
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Hagiwara MA, Suserud BO, Jonsson A, Henricson M. Exclusion of context knowledge in the development of prehospital guidelines: results produced by realistic evaluation. Scand J Trauma Resusc Emerg Med 2013; 21:46. [PMID: 23799944 PMCID: PMC3699357 DOI: 10.1186/1757-7241-21-46] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2012] [Accepted: 06/16/2013] [Indexed: 11/10/2022] Open
Abstract
Background Prehospital work is accomplished using guidelines and protocols, but there is evidence suggesting that compliance with guidelines is sometimes low in the prehospital setting. The reason for the poor compliance is not known. The objective of this study was to describe how guidelines and protocols are used in the prehospital context. Methods This was a single-case study with realistic evaluation as a methodological framework. The study took place in an ambulance organization in Sweden. The data collection was divided into four phases, where phase one consisted of a literature screening and selection of a theoretical framework. In phase two, semi-structured interviews with the ambulance organization's stakeholders, responsible for the development and implementation of guidelines, were performed. The third phase, observations, comprised 30 participants from both a rural and an urban ambulance station. In the last phase, two focus group interviews were performed. A template analysis style of documents, interviews and observation protocols was used. Results The development of guidelines took place using an informal consensus approach, where no party from the end users was represented. The development process resulted in guidelines with an insufficiently adapted format for the prehospital context. At local level, there was a conscious implementation strategy with lectures and manikin simulation. The physical format of the guidelines was the main obstacle to explicit use. Due to the format, the ambulance personnel feel they have to learn the content of the guidelines by heart. Explicit use of the guidelines in the assessment of patients was uncommon. Many ambulance personnel developed homemade guidelines in both electronic and paper format. The ambulance personnel in the study generally took a positive view of working with guidelines and protocols and they regarded them as indispensable in prehospital care, but an improved format was requested by both representatives of the organization and the ambulance personnel. Conclusions The personnel take a positive view of the use of guidelines and protocols in prehospital work. The main obstacle to the use of guidelines and protocols in this organization is the format, due to the exclusion of context knowledge in the development process.
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Cone DC, Bogucki S, Brice JH, Perina D. More science for the new subspecialty. Acad Emerg Med 2012; 19:195-6. [PMID: 22320370 DOI: 10.1111/j.1553-2712.2011.01287.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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