Emergency Medical Services Research Research Articles

Should time from cardiac arrest until call to emergency medical services (EMS) be collected in EMS research?

Because of the difficulty and cost of collecting the time from collapse to placing the 911 call in instances of out-of-hospital cardiac arrest and because of the potential noise and bias that might be inherent in such data, a simulation study was conducted to quantitate the impact that such data might have on estimates of the relationship between time from collapse to defibrillation and probability of survival. In the absence of bias, an underestimate of the slope on the order of 20% to 30% might be expected. However, in the presence of bias, the impact on the slope estimate is unpredictable. The most likely bias would tend to cause an overestimate of the slope. It is suggested that unless the time from collapse to placing the 911 call can be obtained accurately and without bias, it is probably not worthwhile to do so.

Conducting Retrospective Emergency Medical Services Research

Conducting Retrospective Emergency Medical Services Research

Essential Resources for Research: Mentors, Funding, and Research Tools

Research is a multifaceted process that cannot be conducted in a vacuum. Rigorously designed investigations capable of addressing the issues inherent in emergency medical services (EMS) require many resources and a collaborative approach to research. This discussion delineates some of the resources that are useful for quality EMS research.

Priorities for Research in Emergency Medical Services for Children: Results of a Consensus Conference

Study objective: To arrive at a consensus on the priorities for future research in emergency medical services for children. Methods: A consensus group was convened using the Rand-UCLA Consensus Process. The group took part in a 3-phase process. Round 1 involved reviewing a compendium of relevant research articles and answering a mailed questionnaire. Panel members were asked to prioritize topics on the basis of the 1993 Institute of Medicine Report on Emergency Medical Services for Children. Participants were asked to rate each topic based on the significance of the research, and whether the topic would (1) improve general knowledge, (2) change behavior, (3) improve health, (4) decrease the cost of care, or (5) change public policy. A 4-point Likert scale was used. Participants were also asked if the research would require a multicenter study and if the research were feasible. Round 2 of the study involved a meeting of the panel, where the results of Round 1 were discussed and the topics were reprioritized. The topics were given a rank order and a final ranking was done in Round 3. Results: The panel considered a list of 32 topics; these were combined and reworded to give them more precise meaning. Several new topics were also added. Fifteen topics were given a rank order and placed within the 7 broad categories of the Institute of Medicine report. Clinical aspects of emergency care, systems organization, configuration, and operation and injury prevention were given high priority rankings. The first 5 topics were very close in point-rank order. Conclusion: The panel was able to develop a list of important topics for future research in emergency medical services for children that can be used by foundations, governmental agencies, and others in setting a research agenda for such services. [Seidel JS, Henderson D, Tittle S, Jaffe DM, Spaite D, Dean JM, Gausche M, Lewis RJ, Cooper A, Zaritsky A, Espisito T, Maederis D: Priorities for research in emergency medical services for children: Results of a consensus conference. Ann Emerg Med February 1999;33:206-210.]

Priorities for research in Emergency Medical Services for Children

To arrive at a consensus on the priorities for future research in emergency medical services for children. A consensus group was convened using the Rand-UCLA Consensus Process. The group took part in a 3-phase process. Round I involved reviewing a compendium of relevant research articles and answering a mailed questionnaire. Panel members were asked to prioritize topics on the basis of the 1993 Institute of Medicine Report on Emergency Medical Services for Children. Participants were asked to rate each topic based on the significance of the research, and whether the topic would (1) improve general knowledge (2), change behavior (3), improve health (4), decrease the cost of care, or (5) change public policy. A 4-point Likert scale was used. Participants were also asked if the research would require a multicenter study and if the research were feasible. Round II of the study involved a meeting of the panel, where the results of Round I were discussed and the topics were reprioritized. The topics were given a rank order and a final ranking was done in Round III. The panel considered a list of 32 topics; these were combined and reworded to give them more precise meaning. Several new topics were also added. Fifteen topics were given a rank order and placed within the 7 broad categories of the Institute of Medicine report. Clinical aspects of emergency care, systems organization, configuration, and operation and injury prevention were given high priority rankings. The first 5 topics were very close in point-rank order. The panel was able to develop a list of important topics for future research in emergency medical services for children that can be used by foundations, governmental agencies, and others in setting research agenda for such services.

Priorities for research in Emergency Medical Services for Children: Results of a consensus conference

Study Objective The study objective was to arrive at a consensus on the priorities for future research in Emergency Medical Services for Children (EMSC). Methods A consensus group was convened using the Rand-UCLA Consensus Process. The group took part in a 3-phase process. Phase I involved reviewing a compendium of relevant research articles and answering a mailed questionnaire. Panel members were asked to prioritize topics based on the 1993 Institute of Medicine Report on Emergency Medical Services for Children. Participants were asked to rate each topic based on the significance of the research and whether the topic would (1) improve general knowledge, (2) change behavior, (3) improve health, (4) decrease the cost of care, or (5) change public policy. A 4-point Likert scale was used. They were also asked in the research would require a multicenter study and if the research were feasible. Round II of the study involved a meeting of the panel, where the results of Round I were discussed and the topics reprioritized. The topics were given a rank order and a final ranking was done in Round III. Results The panel considered a list of 32 topics and these were combined and reworded to give them more precise meaning. Several new topics were also added. Fifteen topics were given a rank order and placed within the 7 broad categories of the Institute of Medicine report. Clinical aspects of emergency care systems organization, configuration and operation and injury prevention were given high priority rankings. The first 5 topics were very close in point-rank order. Conclusion The panel was able to develop a list of important topics for future research in EMSC that can be used by foundations, governmental agencies, and others in setting a research agenda for EMSC. (J Emerg Nurs 1999;25:12-6)

EMS systems: foundations for the future.

Emergency medical services (EMS) occupy a unique position in the continuum of emergency health care delivery. The role of EMS personnel is expanding beyond their traditional identity as out-of-hospital care providers, to include participation and active leadership in EMS administration, education, and research. With these roles come new challenges, as well as new responsibilities. This paper was developed by the SAEM EMS Task Force and provides a discussion of these new concepts as well as recommendations for the specialty of emergency medicine to foster the continued development of all of the potentials of EMS.

EMS Agenda for the Future: Where We Are … Where We Want to Be

During the past 30 years, emergency medical services (EMS) in the United States have experienced explosive growth. The American health care system is now transforming, providing an opportune time to examine what we have learned over the past three decades in order to create a vision for the future of EMS. Over the course of several months, a multidisciplinary steering committee collaborated with hundreds of EMS-interested individuals, organizations, and agencies to develop the “EMS Agenda for the Future.” Fourteen EMS attributes were identified as requiring continued development in order to realize the vision established within the Agenda. They are Integration of Health Services, EMS Research, Legislation and Regulation, System Finance, Human Resources, Medical Direction, Education Systems, Public Education, Prevention, Public Access, Communication Systems, Clinical Care, Information Systems, and Evaluation. Discussion of these attributes provides important guidance for achieving a vision for the future of EMS that emphasizes its critical role in American health care. [Delbridge TR, Bailey B, Chew JL Jr, Conn AKT, Krakeel JJ, Manz D, Miller DR, O'Malley PJ, Ryan SD, Spaite DW, Stewart RD, Suter RE, Wilson EM: EMS agenda for the future: Where we are … where we want to be. Ann Emerg Med February 1998;31:251-263.]

Ems agenda for the future: Where we are … where we want to be

During the past 30 years, emergency medical services (EMS) in the United States have experienced explosive growth. The American health care system is now transforming, providing an opportune time to examine what we have learned over the past three decades in order to create a vision for the future of EMS. Over the course of several months, a multidisciplinary steering committee collaborated with hundreds of EMS-interested individuals, organizations, and agencies to develop the EMS Agenda for the Future. Fourteen EMS attributes were identified as requiring continued development in order to realize the vision established within the Agenda. They are integration of health services, EMS research, legislation and regulation, system finance, human resources, medical direction, education systems, public education, prevention, public access, communication systems, clinical care, information systems, and evaluation. Discussion of these attributes provides important guidance for achieving a vision for the future of EMS that emphasizes its critical role in American health care.

Research in Emergency Medical Services for Chi

Research is the key to future improvements in emergency medical services for chi (EMS-C). Ultimately these improvements should result in better prevention of childhood emergencies and better outcomes for children who experience emergency illness or injury. Research in EMS-C can be descriptive of the system and its users or focused on specific clinical or basic scientific questions. Descriptive research is needed to describe the EMS-C system, its users, the types of problems for which it is used, and the associated outcomes and costs. To facilitate the descriptive research, a uniform data set, a taxonomy of chief complaints, and a method of linkage among databases collected by different components of the system are needed. Focused research efforts in clinical and basic sciences are also needed. The Institute of Medicine report identified seven research areas for highest priority: clinical aspects of emergencies and emergency care; indices of severity of injury and, especially, seventy of illness; patient outcomes and outcome measures; costs; system organization, configuration, and operation; and effective approaches to education and training, and prevention. Maturity of the subspecialty of emergency medicine will be indicated by the development of basic science research and epidemiology by physicians with clinical interests in emergency medicine. The most exciting discoveries are likely to come in areas that we have not yet imagined. Rapid development of meaningful research will require massively increased funding to support both the research itself and the training of future scientists to work in pediatric emergency medicine.

A retrospective analysis of institutional review board and informed consent practices in EMS research

To assess the frequency of institutional review board (IRB) review and informed consent in emergency medical services (EMS) research. Two-year, retrospective review of published EMS research. One hundred two studies were analyzed. Seventy-one (70%) were exempt from IRB review; 31 (30%) were not exempt. Seventeen nonexempt studies (55%) did not obtain IRB review. Eight of these did not specify a consent method; one used implied consent and eight used volunteers. Volunteers gave informed consent in one study. Of the 14 nonexempt studies with IRB approval, seven did not specify a consent method. Two used informed consent, one received an informed consent waiver, one used verbal consent, and three involved volunteers. Written parent permission was used once when volunteers were minors. IRB review is often omitted by EMS investigators. This raises ethical concerns about EMS research. Investigators should document their consent method or approval to use an informed consent waiver in their manuscripts. A consent method should be specified for volunteers.

Outcome analysis in EMS systems

See related article, p 1258. Enormous advances in the structure and sophistication of emergency medical services (EMS) systems have occurred during the past two decades. However, little is known about the effect of prehospital interventions on patient outcome. Despite a plethora of EMS research, only two specific interventions have been proven to impact outcome in any prehospital patient population (early CPR and early defibrillation in the setting of out-of-hospital, nontraumatic cardiac arrest). Given the expense and complexity of establishing and maintaining prehospital care systems, it has become clear that the single most important current need in EMS is the proper scientific evaluation of the impact of prehospital interventions on patient outcome. In this issue, Lindbeck and associates deal with such an issue. In their evaluation of victims of out-ofhospital, nontraumatic cardiac arrest transported by helicopter, they report a 1% survival to hospital discharge. In this survivor, successful resuscitation already had been accomplished by ground-based advanced life support (ALS) personnel before the arrival of the helicopter. This finding has led to an alteration in the use of air medical resources for this problem within their system. Under certain circumstances, it appears that the use of air medical resources will have improved efficiency with a very low risk for withholding a potentially beneficial intervention. For this, the authors are to be applauded. How this investigation ought to affect the use of air medical resources in other EMS systems, however, should not follow immediately from these data. Attempting to interpret how prehospital outcome studies in one system should impact others is an important but precarious pathway. This is highlighted by the fact that the patient population in this study had an expected probability of survival of essentially zero regardless of what interventions occurred. This is so

Barriers to EMS System Evaluation: Problems Associated with Field Data Collection

For more than two decades, emergency medical services (EMS) systems have proliferated primarily based upon governmental impetus and funding at the federal, state, and local levels. Although many of the foundations of patient care rendered in these systems have been based upon intuitive logic, the understanding of the impact on patient outcome is poor, at best. The reasons for the current status are varied, but five issues are preeminent:1) The authority for the development of these medical systems has been based primarily in political and bureaucratic institutions which have little or no medical expertise;2) Little attention has been paid to system evaluation, particularly in the area of cost-effectiveness;3) Few academic medical institutions have become involved in EMS research;4) Traditional approaches to medical research primarily are disease-specific and are not multidisciplinary. Thus these are not useful for evaluating and understanding the highly complex and uncontrolled environmental interactions that typify EMS systems; and5) The process of efficiently and reliably collecting accurate data in the prehospital setting is extremely difficult.

Pragmatic Problems in Prehospital Research

Emergency Medical Services (EMS) researchers face a variety of obstacles when conducting out-of-hospital investigations. This paper reviews some common problems and discusses practical solutions to facilitate the process and help avoid traps. This discussion focuses on prospective prehospital research.One challenge to EMS research is to find new methods of improving the quality of care delivered in the field. There has been an emphasis placed on “exciting” topics, such as cardiac arrest and trauma resuscitation. Other events dominate the daily practice of prehospital medicine, but have not been well-studied. For example, what is the best way to immobilize the spine? What should be done for a patient with a suspected C-spine injury who is wearing a motorcycle helmet? No one has a scientifically proven approach to solve these common prehospital problems. There is a need to look at problems such as immobilization, asthma, overdose, and congestive heart failure to see what can be done differently in the field.

Prehospital Research

Prehospital care experienced a “honeymoon” from the early 1970s until recently. Treatments usually were extrapolated directly from the hospital setting, even though the prehospital environment is markedly different. That honeymoon is over and emergency medical services (EMS) providers must prove what is beneficial. Additionally, academic prehospital care physicians interested in professional advancement, must show the same ability as do the more traditional medical academicians to expand the knowledge base of their chosen field.This manuscript will highlight the basic features and identify the potential benefits and pitfalls of prehospital research. This chapter is not a cookbook for EMS research, nor will it obviate the need for accessing other sources on research design. Other manuscripts within this series will focus on more specific topics; yet, it will be obvious that many of the points made here will be re-emphasized in the following papers. That simply is a reflection of the importance of these commonly overlooked perils and pitfalls.

Out-of-hospital resuscitation research: Rationale and strategies for controlled clinical trials

There is no better place to test life-saving resuscitation interventions than in the prehospital setting. Patients rarely survive cardiac arrest if resuscitation techniques have failed before leaving the scene. Also, paramedics are usually very experienced in key initial resuscitative techniques, and they routinely operate under strict paramilitary protocol, resulting in better study compliance. In addition, the large study populations that are derived from emergency medical services (EMS) systems lead to faster study completion and statistically stronger data. Most important, by reinforcing standardized care, rigidly scrutinized trials improve patient care, regardless of the effect of the study intervention. The success of productive EMS research centers requires routine communication between hospital and EMS administrators and their medical directors, designation of mutually acceptable data collectors who guarantee confidentiality, reciprocal exchange of study data provided as educational seminars to the hospitals, commitments to support the budget requests of an EMS program and appropriate system modifications, inclusion of EMS personnel in study design from the very beginning, prospective education of the medical community and media before protocol implementation, an authoritative grassroots medical director, and a paramedic supervisor system.

An optically scanned ems reporting form and analysis system for statewide use: Development and five years' experience

Analysis of emergency medical services (EMS) systems data is crucial to planning, education, research, and quality assurance programs. Currently, comparative analysis of EMS data between regions or states is virtually impossible due to wide variations in data collection and analysis methods. To devise a practical and uniform EMS reporting system, we referenced the minimum data set (MDS) established by the federal government in 1974 and surveyed 22 states known to be using uniform reporting systems. In developing our final data set, elements were added based on inclusion in the MDS, national survey results, a review of current EMS literature, and consensus of local EMS providers. This set of 48 elements then was incorporated into a reporting form using narrative and optically scanned formats, allowing automated data collection for computer analysis. After a pilot study, the system was improved to allow high-speed ink reading and large volume data storage and analysis using a microcomputer. This system has subsequently been adopted by seven states. The combined data base exceeds 250,000 cases. Error screening algorithms ensure data integrity and are also used for quality assurance. Customized output reports can be generated within minutes and have assisted in EMS quality assurance, planning, and research. We believe that the successful performance of this system supports the use of the suggested data elements as well as optical scanning and microcomputer analysis of EMS data.

Prehospital data entry compliance by paramedics after institution of a comprehensive EMS data collection tool

Objective: To determine the completeness of data entry by paramedics after an extensive modification of the prehospital first-care form in an urban emergency medical services (EMS) system. Design: Comprehensive medical information was added to the EMS data collection tool used by a metropolitan fire department. We evaluated the frequency of failure to enter data pertaining to medical assessment and/or treatment of victims of cardiac arrest after implementation of the system. Results: Failure to enter data in the first month was compared with two subsequent two-month blocks. A high rate of noncompliance existed in the first month (all medical data were missing in 24.6%). However, the subsequent two months revealed a marked decline in noncompliance (4.4%, P P Conclusion: Data entry noncompliance can be a significant problem after implementation of a new prehospital data collection system. However, compliance can be markedly improved over a relatively short period. Because EMS system evaluation is based on data collected in the field, EMS researchers and administrators must be aware of the data entry compliance rate in their system when attempting to make conclusions from such information.

Prehospital data entry compliance by paramedics after institution of a comprehensive EMS data collection tool

To determine the completeness of data entry by paramedics after an extensive modification of the prehospital first-care form in an urban emergency medical services (EMS) system. Comprehensive medical information was added to the EMS data collection tool used by a metropolitan fire department. We evaluated the frequency of failure to enter data pertaining to medical assessment and/or treatment of victims of cardiac arrest after implementation of the system. Failure to enter data in the first month was compared with two subsequent two-month blocks. A high rate of noncompliance existed in the first month (all medical data were missing in 24.6%). However, the subsequent two months revealed a marked decline in noncompliance (4.4%, P less than .001). This decline was maintained after a three-month interim (5.0%, P less than .001). Data entry noncompliance can be a significant problem after implementation of a new prehospital data collection system. However, compliance can be markedly improved over a relatively short period. Because EMS system evaluation is based on data collected in the field. EMS researchers and administrators must be aware of the data entry compliance rate in their system when attempting to make conclusions from such information.

A Policy Perspective on Research in Emergency Medical Services Systems

In 1973 the Emergency Medical Services (EMS) research program was established under Title XII of the Public Health Services Act. This program, administered by the National Center for Health Services Research (NCHSR), sponsors research to provide useful information for the design and performance of EMS service programs. NCHSR has sought to encourage applied research which identifies major issues affecting EMS, provides acceptable solutions, and recommends policy changes in a useful and timely manner. Using specific selection criteria, grants are awarded to selected investigators; projects are targeted to areas of particular concern, in particular the development of methods to measure EMS system and component performance. This paper presents a discussion of the development of the NCHSR policy for EMS research and the constraints affecting the research efforts, and offers an opinion about its future direction and goals.