The development of evidence-based prehospital guidelines using a GRADE-based methodology.

BACKGROUND: The burgeoning literature in prehospital care creates an opportunity to improve care through evidence-based guidelines (EBGs). Previously, an established process for the creation of such guidelines and adoption and implementation at the local level was lacking. This has led to great variability in the content of prehospital protocols in different jurisdictions across the globe. Recently the Federal Interagency Committee on Emergency Medical Services (FICEMS) and the National EMS Advisory Council (NEMSAC) approved a National Prehospital Evidence-based Guideline Model Process for the development, implementation, and evaluation of EBGs. The Model Process recommends the use of established guideline development tools such as Grading of Recommendations, Assessment, Development, and Evaluation (GRADE). Objective. To describe the process of development of three prehospital EBGs using the National Prehospital EBG Model Process (EBG Model Process) and the GRADE EBG development tool. METHODS: We conducted three unique iterations of the EBG Model Process utilizing the GRADE EBG development tool. The process involved 6 distinct and essential steps, including 1) assembling the expert panel and providing GRADE training; 2) defining the evidence-based guideline (EBG) content area and establishing the specific clinical questions to address in patient, intervention, comparison, and outcome (PICO) format; 3) prioritizing outcomes to facilitate systematic literature searches; 4) creating GRADE tables, or evidence profiles, for each PICO question; 5) vetting and endorsing GRADE evidence tables and drafting recommendations; and 6) synthesizing recommendations into an EMS protocol and visual algorithm. Feedback and suggestions for improvement were solicited from participants and relevant stakeholders in the process. RESULTS: We successfully used the process to create three separate prehospital evidence-based guidelines, formatted into decision tree algorithms with levels of evidence and graded recommendations assigned to each decision point. However, the process revealed itself to be resource intensive, and most of the suggestions for improvement would require even more resource utilization. CONCLUSIONS: The National Prehospital EBG Model Process can be used to create credible, transparent, and usable prehospital evidence-based guidelines. We suggest that a centralized or regionalized approach be used to create and maintain a full set of prehospital EBGs as a means of optimizing resource use.

An Evidence-based Guideline for Pediatric Prehospital Seizure Management Using GRADE Methodology.

OBJECTIVE: The objective of this guideline is to recommend evidence-based practices for timely prehospital pediatric seizure cessation while avoiding respiratory depression and seizure recurrence. METHODS: A multidisciplinary panel was chosen based on expertise in pediatric emergency medicine, prehospital medicine, and/or evidence-based guideline development. The panel followed the National Prehospital EBG Model using the GRADE methodology to formulate questions, retrieve evidence, appraise the evidence, and formulate recommendations. The panel members initially searched the literature in 2009 and updated their searches in 2012. The panel finalized a draft of a patient care algorithm in 2012 that was presented to stakeholder organizations to gather feedback for necessary revisions. RESULTS: Five strong and ten weak recommendations emerged from the process; all but one was supported by low or very low quality evidence. The panel sought to ensure that the recommendations promoted timely seizure cessation while avoiding respiratory depression and seizure recurrence. The panel recommended that all patients in an active seizure have capillary blood glucose checked and be treated with intravenous (IV) dextrose or intramuscular (IM) glucagon if <60 mg/dL (3 mmol/L). The panel also recommended that non-IV routes (buccal, IM, or intranasal) of benzodiazepines (0.2 mg/kg) be used as first-line therapy for status epilepticus, rather than the rectal route. CONCLUSIONS: Using GRADE methodology, we have developed a pediatric seizure guideline that emphasizes the role of capillary blood glucometry and the use of buccal, IM, or intranasal benzodiazepines over IV or rectal routes. Future research is needed to compare the effectiveness and safety of these medication routes.

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.

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.

Sideline emergencies: an evidence-based approach.

As participation in athletics continues to increase, so too will the occurrence of on-field injuries and medical emergencies. The field of sports medicine continues to advance and many events will have on-site medical staff present. This article reviews the most catastrophic injuries and medical emergencies that are encountered in sports and presents the highest level evidence in regards to on-field approach and management of the athlete.

Rapid Diagnostics for Blood Cultures: Supporting Decisions for Antimicrobial Therapy and Value-Based Care.

Bacteremia and sepsis are critically important syndromes with high mortality, morbidity, and associated costs. Bloodstream infections and sepsis are among the top causes of mortality in the US, with >600 deaths each day. Most septic patients can be found in emergency medicine departments or critical care units, settings in which rapid administration of targeted antibiotic therapy can reduce mortality. Unfortunately, routine blood cultures are not rapid enough to aid in the decision of therapeutic intervention at the onset of bacteremia. As a result, empiric, broad-spectrum treatment is common-a costly approach that may fail to target the correct microbe effectively, may inadvertently harm patients via antimicrobial toxicity, and may contribute to the evolution of drug-resistant microbes. To overcome these challenges, laboratorians must understand the complexity of diagnosing and treating septic patients, focus on creating algorithms that rapidly support decisions for targeted antibiotic therapy, and synergize with existing emergency department and critical care clinical practices put forth in the Surviving Sepsis Guidelines.

A Research Agenda to Advance Pediatric Emergency Care Through Enhanced Collaboration Across Emergency Departments.

In 2018, the Society for Academic Emergency Medicine and the journal Academic Emergency Medicine (AEM) convened a consensus conference entitled, "Academic Emergency Medicine Consensus Conference: Aligning the Pediatric Emergency Medicine Research Agenda to Reduce Health Outcome Gaps." This article is the product of the breakout session, "Emergency Department Collaboration-Pediatric Emergency Medicine in Non-Children's Hospital"). This subcommittee consisting of emergency medicine, pediatric emergency medicine, and quality improvement (QI) experts, as well as a patient advocate, identified main outcome gaps in the care of children in the emergency departments (EDs) in the following areas: variations in pediatric care and outcomes, pediatric readiness, and gaps in knowledge translation. The goal for this session was to create a research agenda that facilitates collaboration and partnering of diverse stakeholders to develop a system of care across all ED settings with the aim of improving quality and increasing safe medical care for children. The following recommended research strategies emerged: explore the use of technology as well as collaborative networks for education, research, and advocacy to develop and implement patient care guidelines, pediatric knowledge generation and dissemination, and pediatric QI and prepare all EDs to care for the acutely ill and injured pediatric patients. In conclusion, collaboration between general EDs and academic pediatric centers on research, dissemination, and implementation of evidence into clinical practice is a solution to improving the quality of pediatric care across the continuum.

Physician staffed helicopter emergency medical systems can provide advanced trauma life support in mountainous and remote areas.

INTRODUCTION: In remote and mountainous areas, helicopter emergency medical systems (HEMS) are used to expedite evacuation and provide pre-hospital advanced trauma life support (ATLS) in major trauma victims. Aim of the study was to investigate feasibility of ATLS in HEMS mountain rescue missions and its influence on patient condition at hospital admission. PATIENTS: 58 major trauma victims (Injury Severity Score ≥16), evacuated by physician staffed HEMS from remote and mountainous areas in the State of Tyrol, Austria between 1.1.2011 and 31.12.2013. RESULTS: Pre-hospital time exceeded 90min in 24 (44%) cases. 31 (53%) patients suffered critical impairment of at least one vital function (systolic blood pressure <90mmHg, GCS <10, or respiratory rate <10 or >30). 4 (6.9%) of 58 patients died prior to hospital admission. Volume resuscitation was restrictive: 18 (72%) of 25 hypotensive patients received ≤500ml fluids and blood pressure was increased >90mmHg at hospital admission in only 9 (36%) of these 25 patients. 8 (50%) of 16 brain trauma patients with a blood pressure <90mmHg remained hypotensive at hospital admission. Endotracheal intubation was accomplished without major complications in 15 (79%) of 19 patients with a Glasgow Coma Scale score <10. Rope operations were necessary in 40 (69%) of 58 cases and ATLS was started before hoist evacuation in 30 (75%) of them. CONCLUSIONS: The frequent combination of prolonged pre-hospital times, with critical impairment of vital functions, supports the need for early ATLS in HEMS mountain rescue missions. Pre-hospital endotracheal intubation is possible with a high success and low complication rate also in a mountain rescue scenario. Pre-hospital volume resuscitation is restrictive and hypotension is reversed at hospital admission in only one third of patients. Prolonged pre-hospital hypotension remains an unresolved problem in half of all brain trauma patients and indicates the difficulties to increase blood pressure to a desired level in a mountain rescue scenario. Despite technical considerations, on-site ATLS is feasible for an experienced emergency physician in the majority of rope rescue operations.

The relationship between the proportion of admitted high risk ACS patients and hospital delivery of evidence based care.

AIMS: Variations in the delivery of evidence based care to high risk patients with Acute Coronary Syndromes (ACS) exist between hospitals. We hypothesised that the relative proportion of admitted high risk patients contributes to variation in care and outcomes. METHODS: Receipt of evidence based therapies (EBT) according to patient risk was documented in the Australian Co-operative National Registry of Acute Coronary Care, Guideline Adherence and Clinical Events (CONCORDANCE). Hospitals were stratified into quartiles (Q) by fraction of high risk patients according to: GRACE Risk Score (GRS), chronic kidney disease (CKD), age, Killip class, and myocardial infarction (MI). For each category, EBT and mortality were compared between hospital groups. RESULTS: This study included 8390 ACS patients from 39 hospitals. Patients with GRS>130, CKD, and >80years, were less likely to receive EBT at high proportion hospitals (p<0.0001 for all). After adjustment, proportion of patients with CKD negatively predicted coronary angiography (CA) (Q4 vs Q1: OR 0.21, 95%CI 0.10-0.45). Adjusted 6month mortality was greater in CKD and trended greater in >80years in hospitals treating the highest proportions of these patients (Q4 vs Q1 OR 3.80, 95%CI 1.85-7.83, and OR 3.10, 95%CI 0.99-9.70 respectively). CONCLUSION: Elderly ACS patients and those with CKD are less likely to receive EBT at hospitals seeing high proportions of these patients. Failure to provide EBT to these high risk populations may contribute to avoidable mortality in these institutions.

Pharmacist input into statewide treatment protocols for emergency medical services.

PURPOSE: A pharmacist's role in helping Vermont health officials standardize pharmacotherapy-related protocols used by emergency medical services (EMS) personnel across the state is described. SUMMARY: Pharmacists with expertise in emergency medicine (EM) or critical care are ideally positioned to provide guidance on optimizing and standardizing medication-use aspects of state and local EMS protocols. In 2012, the medical director of the EMS division of the Vermont Department of Health requested that an EM pharmacist at a Burlington academic medical center review draft EMS protocols designed to replace the existing patchwork of local protocols with statewide standards of care; among the 92 draft protocols reviewed, 62 pertained to medication use. The pharmacist provided a wide range of suggestions on 33 protocols, including (1) evidence-based recommendations on use of vasopressor agents for septic shock, (2) recommendations to optimize medication ordering and preparation in the prehospital setting, (3) recommendations on prehospital management of pediatric shock and appropriate use of chemical restraints, and (4) recommendations to promote use of smart infusion pumps by EMS personnel. All of the pharmacist's suggestions were incorporated into the final protocols, which took effect in March 2014. The protocols have helped standardize care for patients receiving EMS services throughout Vermont while reducing the potential for medication errors. CONCLUSION: An EM pharmacist participated in the review and development of statewide EMS treatment protocols that focused on choice of medication therapy, dosage, administration, and identification and minimization of potential risks of medication errors.

Strategy to improve quality in emergency medical services: from assessment to policy.

The aim of this paper was to present the strategic approach applied for improvement of quality in emergency medical services (EMS) in the Republic of Macedonia. This approach was accomplished through three stages: (I) assessment and recommendations for policies; (II) development of innovative evidence-based programmes; and (III) policy implementation. Strategic assessment of EMS was performed by applying WHO standard methodology. A survey was conducted in 2006/2007 on the national level in fifteen general hospitals, four university hospitals, and sixteen pre-hospital EMS. The overall evaluation was based on a hospital emergency department (ED) questionnaire, information on the general characteristics of the pre-hospital dispatch centre, review of ED medical records, and the patient questionnaire. The key findings of the assessment showed that EMS required extensive changes and improvements. Pre-hospital EMS was not well-developed and utilised. Hospital EDs were not organised as separate divisions ran by a head medical doctor. The diagnostic and treatment capacities were insufficient or outdated. Most of the surveyed hospitals were capable of providing essential diagnostic tests in 24 h or less. There was no follow-up of the EMS patients or an appropriate link between the hospital EDs and primary health care facilities. The main findings of the assessment, recommendations, and proposals for action served as the basis for new policies and integrated into Macedonia's official strategy for emergency medical services 2009-2017.

Translation of evidence-based clinical standards into a new prehospital resuscitation policy in Los Angeles County.

OBJECTIVE: To translate a set of evidence-based clinical standards designed to allow paramedics to forego unnecessary and potentially harmful resuscitation attempts into a feasible new policy. DATA SOURCES/SETTING: Policy documents, meeting minutes, and personal communications between a large urban Emergency Medical Services (EMS) agency serving all of Los Angeles County (LAC) and a research group were reviewed over 12 months. STUDY DESIGN: LAC EMS and University of California, Los Angeles (UCLA) formed a partnership (the EMS-UCLA Collaborative) to develop and translate the standards into new EMS protocols. Clinical indicators considered appropriate and feasible by an expert panel were submitted to the agency for inclusion in the new policy. FINDINGS: The Collaborative submitted the results to the LAC EMS Commission and a physician advisory group for review. Of the 41 indicators approved by the expert panel, 22 would have resulted in changes to the current policy. All six involved asking family members about or honoring written and verbal Do Not Attempt Resuscitate requests, but only 4 of the 16 indicators based on clinical characteristics were included in the new policy. Ultimately, 10 of the 22 indicators that would have changed policy were approved and implemented. CONCLUSIONS: By collaboration, a large EMS agency and a research team were able to develop and implement a revised resuscitation policy within 1 year.

Consensus conference follow-up: inter-rater reliability assessment of the Best Evidence in Emergency Medicine (BEEM) rater scale, a medical literature rating tool for emergency physicians.

BACKGROUND: Studies published in general and specialty medical journals have the potential to improve emergency medicine (EM) practice, but there can be delayed awareness of this evidence because emergency physicians (EPs) are unlikely to read most of these journals. Also, not all published studies are intended for or ready for clinical practice application. The authors developed "Best Evidence in Emergency Medicine" (BEEM) to ameliorate these problems by searching for, identifying, appraising, and translating potentially practice-changing studies for EPs. An initial step in the BEEM process is the BEEM rater scale, a novel tool for EPs to collectively evaluate the relative clinical relevance of EM-related studies found in more than 120 journals. The BEEM rater process was designed to serve as a clinical relevance filter to identify those studies with the greatest potential to affect EM practice. Therefore, only those studies identified by BEEM raters as having the highest clinical relevance are selected for the subsequent critical appraisal process and, if found methodologically sound, are promoted as the best evidence in EM. OBJECTIVES: The primary objective was to measure inter-rater reliability (IRR) of the BEEM rater scale. Secondary objectives were to determine the minimum number of EP raters needed for the BEEM rater scale to achieve acceptable reliability and to compare performance of the scale against a previously published evidence rating system, the McMaster Online Rating of Evidence (MORE), in an EP population. METHODS: The authors electronically distributed the title, conclusion, and a PubMed link for 23 recently published studies related to EM to a volunteer group of 134 EPs. The volunteers answered two demographic questions and rated the articles using one of two randomly assigned seven-point Likert scales, the BEEM rater scale (n = 68) or the MORE scale (n = 66), over two separate administrations. The IRR of each scale was measured using generalizability theory. RESULTS: The IRR of the BEEM rater scale ranged between 0.90 (95% confidence interval [CI] = 0.86 to 0.93) to 0.92 (95% CI = 0.89 to 0.94) across administrations. Decision studies showed a minimum of 12 raters is required for acceptable reliability of the BEEM rater scale. The IRR of the MORE scale was 0.82 to 0.84. CONCLUSIONS: The BEEM rater scale is a highly reliable, single-question tool for a small number of EPs to collectively rate the relative clinical relevance within the specialty of EM of recently published studies from a variety of medical journals. It compares favorably with the MORE system because it achieves a high IRR despite simply requiring raters to read each article's title and conclusion.

Neonatal resuscitation for the preterm infant: evidence versus practice.

In an effort to determine the actual conduct of neonatal resuscitation and the errors that may be occurring during this process, we developed a method of video recording neonatal resuscitations as an ongoing quality assurance project. We initiated video recordings of resuscitations using simple video recorders attached to an overhead warmer and reviewed the resultant tapes during biweekly quality improvement meetings. We also added the continuous recording of analog information such as heart rate, oximeter values, fraction of inspired oxygen and airway pressure. We subsequently developed a checklist that includes a preresuscitation briefing and a postresuscitation debriefing, all of which are reviewed at the same time as the video recording. We have examined the use of oxygen in the very preterm infant, the effectiveness of bag and mask ventilation, including the detection of airway obstruction during such ventilation, intubation in the delivery area and environment. In addition, we have trained our teams and leaders using Crew Resource Management and focused on improved communication. The availability of a dedicated room for resuscitation allows an increased ambient environment and the ability to provide a user-friendly setting similar to the neonatal intensive care unit to optimize performance. There are numerous opportunities for improving team and leader performance and outcomes following neonatal resuscitation. Further prospective studies are required to evaluate specific interventions.

Implementation of evidence-based humanitarian programs in military-led missions: part I. Qualitative gap analysis of current military and international aid programs.

BACKGROUND: A recent Department of Defense instruction mandates country-specific assessments, identification of interventions, and development of guidance for Department of Defense to plan, train, and prepare for the provision of humanitarian assistance in stability operations. It also directs the use of outcome-based measures of effectiveness and the establishment of processes facilitating transparency of information. Whereas this would align military-led projects closer to the standards of the international aid community, how this process will be developed and implemented within the military has not yet been determined. METHODS: To begin developing an evidence-based program for military-led humanitarian aid, we conducted a qualitative gap analysis comparing information from a Web search of Department of Defense medical after-action reports, lessons learned, and expert interviews with the internationally accepted standards in humanitarian assistance impact assessment. RESULTS: There is a major gap in the ability of the Department of Defense to assess the impact of humanitarian assistance in stability operations compared with international development standards. Of the 1000 Department of Defense after-action reports and lessons learned reviewed, only 7 (0.7%) reports refer to, but do not discuss, impact assessment or outcome-based measures of effectiveness. CONCLUSIONS: This investigation shows that the Department of Defense humanitarian assistance operations are, historically, recorded without documentation using quantifiable health data identifying which aid activities contributed directly to desired outcomes or favorable public opinion, and rarely are analyzed for effectiveness. As humanitarian assistance operations assume an ever greater role in US military strategy, it is imperative that we investigate useful impact assessment models to meet mission directives and, more important, to maximize coordination in a necessarily integrated and cooperative development environment. These findings provide baseline knowledge for the implementation of an evidence-based impact assessment process to validate future Department of Defense humanitarian assistance operations.

Implementation of evidence-based humanitarian programs in military-led missions: part II. The impact assessment model.

The Department of Defense does not implement health-sector humanitarian assistance impact assessments to complement those of the international humanitarian aid community. This oversight fails to meet the recent Department of Defense Directive 3000.05 mandate calling for the application of measures of effectiveness. The decision by the Department of Defense to incorporate humanitarian assistance in stability operations should be supported by evidence-based impact assessments. This article proposes implementation of an impact assessment model in Department of Defense humanitarian assistance operations. The use of an impact assessment model will refocus previously identified information gaps from traditional military input-output management toward a greater emphasis on outcomes. This will help answer which humanitarian activities are successful, which are not, and why. Over time, the use of an impact assessment model will ensure that the Department of Defense and its operational units are learning as an organization while applying evidence-based lessons learned to future stability operations. Most important, the use of this model will both provide better understanding of the role that the Department of Defense has in humanitarian activities and help interpret and transfer these activities to the host nation and international aid community in a timely and efficient manner.

Benchmarking en el proceso de urgencias entre siete hospitales de diferentes comunidades autónomas / Benchmarking in the emergency unit process in 7 hospitals from different autonomous communities

Objetivo. Identificar y compartir los mejores resultados entre hospitales respecto al proceso de atención de urgencias, detectar las prácticas que expliquen las diferencias e identificar buenas prácticas. Material y método. Ámbito: 7 hospitales de diferentes comunidades autónomas. Periodo de estudio: 2005-2007. Se definieron los criterios de comparabilidad asegurando la homotecia. Se seleccionaron 11 criterios, y se establecieron 7 indicadores para comparar los hospitales, analizándose los datos de los últimos 3 años, estableciendo el benchmark (servicio con los mejores resultados) entre los centros. Se elaboró un cuestionario sobre el proceso, sobre las etapas, los resultados y los procedimientos usados en cada etapa del proceso en cada centro. Resultados. Se ha comprobado la homotecia entre los 7 hospitales, identificándose algunas diferencias entre centros. Se han analizado 7 indicadores, correspondiendo a 1.526.890 pacientes atendidos en el periodo de estudio. Se ha identificado un benchmark, con los mejores resultados en 4 de los indicadores: porcentaje de ingresos desde urgencias del 8,3%, presión de urgencias del 56,14%, tiempo de estancia en urgencias, 2h y 20min, y porcentaje de pacientes con estancia de más de 24h, 0,05%. Se han analizado las diferencias en las etapas del proceso, los recursos y procedimientos utilizados en cada etapa en el centro benchmark con el resto que puedan explicar mejores resultados. Conclusiones. Se ha establecido un conjunto de indicadores para identificar el benchmark entre los servicios de urgencias. Con dichos indicadores se ha establecido el benchmark(AU)

Objective. To identify and to share the results among hospitals regarding the process of attention at the Emergency Unit, and to detect the practices that explain the differences. Material and method. Setting: 7 hospitals of different regions in Spain. Period of study: 2005-2007. Firstly the comparability criteria were defined assuring the homotecia in the «emergency process». In order to fulfil the study objectives, 11 criteria were selected and every center sent the information of each one. 7 indicators were identified to compare hospitals processes’. Data regarding all the attentions provided during the study period was analyzed, establishing the benchmark among the centers. Finally, a questionnaire was elaborated for the process analysis, considering all the stages of the process, the resources and the procedures used in every stage, to be fulfilled in each hospital. Results. The homotecia has been verified in the 7 hospitals, with some differences between centers. 7 indicators have been analyzed in the different hospitals, corresponding to 1 526 890 patients attended in the study period. A benchmark has been identified, with the best results in four of seven indicators: % of admissions from urgencies: 8.3%, emergency pressure: 56.14%, emergency length of stay: 2 hs 20min, and % of patients with length stay > 24h: 0.05%. Differences between the stages of the process, resources and procedures used in every stage in the benchmark center have been analyzed. Conclusions. A set of indicators to compare Emergency Departments has been identified, letting us establish the benchmark(AU)