Bringing Evidence to EMS

Process for developing guidelines yields new pain protocol in Maryland


Four years into the quest to develop evidence-based guidelines for delivering prehospital emergency care, the National Highway Traffic Safety Administration has released an update on where it stands.

NHTSA’s Office of EMS and HRSA’s EMS for Children Program have been working with EMS stakeholders since 2008 to create and test a model for developing and implementing such guidelines, which would promote care based on best current scientific knowledge. Its recent timeline depicts what it’s achieved to date and outlines its next steps.

“EBGs are an important element in improving the quality of prehospital care,” NHTSA notes, “as they promote a consistent approach by prehospital providers for a given clinical scenario, and thus facilitate creation of standards for measures to evaluate the quality of prehospital emergency care.” Developing clinical guidelines based on rigorous appraisal of existing evidence is significantly different, the organization adds, from basing care decisions on consensus, convention, opinion or anecdote.

The challenge to develop standard evidence-based prehospital protocols came from the Institute of Medicine’s 2006 Future of Emergency Care series, which included the seminal Emergency Medical Services at the Crossroads report. The first evidence-based guidelines stakeholder meeting followed in 2008, convened by NHTSA and cosponsored by FICEMS (the Federal Interagency Committee on EMS) and the National EMS Advisory Council (NEMSAC).

Those who attended helped inform a draft model process to shepherd development, implementation and evaluation of EMS guidelines. That is built on what NHTSA describes as “an objective and transparent process for appraising the quality of clinical evidence.” That same year, the EMS for Children National Resource Center beta-tested the process to develop a guideline for managing pediatric seizures.

The Children’s National Medical Center (CNMC) further tested the process in drafting guidelines for prehospital pain management and when to call a helicopter for an injured patient. They offered those guidelines to the Maryland Institute for Emergency Medical Services Systems (MIEMSS), which governs EMS in that state. MIEMSS adopted the pain-management protocol for use in Maryland but passed on the HEMS guideline because it was close to its existing protocol, but didn’t require online medical direction for helicopter activation as Maryland does.

Maryland providers were trained on the new pain-management protocol and began using it in 2011, and are now collecting data to evaluate acceptance, compliance and patient outcomes.

Future Plans

Work continues. Before the end of the year, the journal Academic Emergency Medicine will publish a paper describing development of the EBG model process. A final report from the CNMC study, including its guidelines on pain management and helicopter use, will also become available. Separate manuscripts detailing all of the prehospital guidelines developed using the model process will be pitched to top journals. Project leaders will also begin examining processes for implementing EBGs at the state level, and the model process will likely be tweaked to facilitate its adoption and implementation.

For more, see http://www.ems.gov.