Evidence-Based Guideline for Prehospital Airway Management.

Airway management is a cornerstone of emergency medical care. This project aimed to create evidence-based guidelines based on the systematic review recently conducted by the Agency for Healthcare Research and Quality (AHRQ). A technical expert panel was assembled to review the evidence using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology. The panel made specific recommendations on the different PICO (population, intervention, comparison, outcome) questions reviewed in the AHRQ review and created good practice statements that summarize and operationalize these recommendations. The recommendations address the use of ventilation with bag-valve mask ventilation alone vs. supraglottic airways vs. endotracheal intubation for adults and children with cardiac arrest, medical emergencies, and trauma. Additional recommendations address the use of video laryngoscopy and drug-assisted airway management. These recommendations, and the associated good practice statements, offer EMS agencies and clinicians an opportunity to review the available evidence and incorporate it into their airway management strategies.

Evidence-Based Guidelines for Prehospital Pain Management: Recommendations.

This project sought to develop evidence-based guidelines for the administration of analgesics for moderate to severe pain by Emergency Medical Services (EMS) clinicians based on a separate, previously published, systematic review of the comparative effectiveness of analgesics in the prehospital setting prepared by the University of Connecticut Evidence-Based Practice Center for the Agency for Healthcare Research and Quality (AHRQ). A technical expert panel (TEP) was assembled consisting of subject matter experts in prehospital and emergency care, and the development of evidence-based guidelines and patient care guidelines. A series of nine "patient/population-intervention-comparison-outcome" (PICO) questions were developed based on the Key Questions identified in the AHRQ systematic review, and an additional PICO question was developed to specifically address analgesia in pediatric patients. The panel made a strong recommendation for the use of intranasal fentanyl over intravenous (IV) opioids for pediatric patients without intravenous access given the supporting evidence, its effectiveness, ease of administration, and acceptance by patients and providers. The panel made a conditional recommendation for the use of IV non-steroidal anti-inflammatory drugs (NSAIDs) over IV acetaminophen (APAP). The panel made conditional recommendations for the use of either IV ketamine or IV opioids; for either IV NSAIDs or IV opioids; for either IV fentanyl or IV morphine; and for either IV ketamine or IV NSAIDs. A conditional recommendation was made for IV APAP over IV opioids. The panel made a conditional recommendation against the use of weight-based IV ketamine in combination with weight-based IV opioids versus weight-based IV opioids alone. The panel considered the use of oral analgesics and a conditional recommendation was made for either oral APAP or oral NSAIDs when the oral route of administration was preferred. Given the lack of a supporting evidence base, the panel was unable to make recommendations for the use of nitrous oxide versus IV opioids, or for IV ketamine in combination with IV opioids versus IV ketamine alone. Taken together, the recommendations emphasize that EMS medical directors and EMS clinicians have a variety of effective options for the management of moderate to severe pain in addition to opioids when designing patient care guidelines and caring for patients suffering from acute pain.

Evidence-Based Guidelines for Prehospital Pain Management: Literature and Methods.

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.

Proposed Performance Measures and Strategies for Implementation of the Fatigue Risk Management Guidelines for Emergency Medical Services.

BACKGROUND: Performance measures are a key component of implementation, dissemination, and evaluation of evidence-based guidelines (EBGs). We developed performance measures for Emergency Medical Services (EMS) stakeholders to enable the implementation of guidelines for fatigue risk management in the EMS setting. METHODS: Panelists associated with the Fatigue in EMS Project, which was supported by the National Highway Traffic Safety Administration (NHTSA), used an iterative process to develop a draft set of performance measures linked to 5 recommendations for fatigue risk management in EMS. We used a cross-sectional survey design and the Content Validity Index (CVI) to quantify agreement among panelists on the wording and content of draft measures. An anonymous web-based tool was used to solicit the panelists' perceptions of clarity and relevance of draft measures. Panelists rated the clarity and relevance separately for each draft measure on a 4-point scale. CVI scores ≥0.78 for clarity and relevance were specified a priori to signify agreement and completion of measurement development. RESULTS: Panelists judged 5 performance measures for fatigue risk management as clear and relevant. These measures address use of fatigue and/or sleepiness survey instruments, optimal duration of shifts, access to caffeine as a fatigue countermeasure, use of napping during shift work, and the delivery of education and training on fatigue risk management for EMS personnel. Panelists complemented performance measures with suggestions for implementation by EMS agencies. CONCLUSIONS: Performance measures for fatigue risk management in the EMS setting will facilitate the implementation and evaluation of the EBG for Fatigue in EMS.

Evidence-Based Guidelines for Fatigue Risk Management in Emergency Medical Services.

BACKGROUND: Administrators of Emergency Medical Services (EMS) operations lack guidance on how to mitigate workplace fatigue, which affects greater than half of all EMS personnel. The primary objective of the Fatigue in EMS Project was to create an evidence-based guideline for fatigue risk management tailored to EMS operations. METHODS: Systematic searches were conducted from 1980 to September 2016 and guided by seven research questions framed in the Population, Intervention, Comparison, Outcome (PICO) framework. Teams of investigators applied inclusion criteria, which included limiting the retained literature to EMS personnel or similar shift worker groups. The expert panel reviewed summaries of the evidence based on the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) methodology. The panel evaluated the quality of evidence for each PICO question separately, considered the balance between benefits and harms, considered the values and preferences of the targeted population, and evaluated the resource requirements/needs. The GRADE Evidence-to-Decision (EtD) Framework was used to prepare draft recommendations based on the evidence, and the Content Validity Index (CVI) was used to quantify the panel's agreement on the relevance and clarity of each recommendation. CVI scores for relevance and clarity were measured separately on a 1-4 scale to indicate consensus/agreement among panel members and conclusion of recommendation development. RESULTS: The EtD framework was applied to all 7 PICO questions, and the panel created 5 recommendations. PICO1: The panel recommends using fatigue/sleepiness survey instruments to measure and monitor fatigue in EMS personnel. PICO2: The panel recommends that EMS personnel work shifts shorter than 24 hours in duration. PICO3: The panel recommends that EMS personnel have access to caffeine as a fatigue countermeasure. PICO4: The panel recommends that, EMS personnel have the opportunity to nap while on duty to mitigate fatigue. PICO5: The panel recommends that EMS personnel receive education and training to mitigate fatigue and fatigue-related risks. The panel referenced insufficient evidence as the reason for making no recommendation linked to 2 PICO questions. CONCLUSIONS: Based on a review of the evidence, the panel developed a guideline with 5 recommendations for fatigue risk management in EMS operations.

Altered mental status: evaluation and etiology in the ED.

The purpose of this study was to determine the etiologies responsible for altered mental status (AMS) in an emergency department (ED) population, to gauge the diagnostic (DX) value of the various features of the clinical evaluation, and to examine patient outcomes. Prospective identification of patients with AMS followed by a retrospective review of the medical record was performed in a university hospital E among ED patients with AMS. Three hundred seventeen patients (5% of the ED patient volume) were identified with a mean age of 49 years (57% men). Descriptions of the AMS included 24% unresponsive, 46% lethargic/difficult to arouse, 12% agitated, and 18% unusual behavior. The most common discharge diagnoses accounting for AMS were neurologic (28%) and toxicologic (21%) followed by trauma (14%), psychiatric (14%), infectious (10%), endocrine/metabolic (5%), pulmonary (3%), oncologic (3%), cardiovascular (1%), gastrointestinal (1%), and renal (1%). The specific features of the clinical evaluation of greatest DX value followed by rates of positive DX finding included history of present event (51%), past medical history (43%), and physical examination (41%); features of little DX value included radiographs (16%), 12-lead electrocardiogram (7%), and various laboratory studies (chemistry panel [5%], complete blood count [1%], coagulation panel [0], urinalysis [11%]). Sixty-four percent of the patients were admitted with a mean hospital stay of 7.6 days and 9% deaths. Common causes of AMS included neurologic, toxicologic, traumatic, and psychiatric syndromes. The patient history and physical examination were most useful in DX terms; ancillary investigations were less often DX. This group represented a minority of the ED population yet rates of ED resource use, hospital admission, and death were high.