Emergency Medical Services (EMS) 2050: A Vision for the Future of Pediatric Prehospital Care

Abstract

The National Highway Traffic Safety Administration (NHTSA) released EMS Agenda 2050 in 2019. It places into context the problems of prehospital care of children today and projects where we want to be in 2050. It does not provide a list of solutions but provides a vision for EMS as a people-centered EMS system that meets the goals of the six guiding principles. This vision for EMS in 2050 can be applied by leaders in pediatrics, emergency medicine, emergency medical services (EMS), and local, state and federal governments, and proposed actions help to frame how the emergency medicine and EMS communities can optimize the care of children in future EMS systems.     

E MERGENCY M EDICAL S ERVICES I NFORMATION S YSTEMS AND A F UTURE EMS N ATIONAL D ATABASE

Since the early 1970s, various publications and legislation have contributed to the development of emergency medical services (EMS) information systems and databases. Yet, even today, EMS systems vary in their ability to collect patient and systems data and to put these data to use. In addition, no means currently exists to easily link disparate EMS databases to allow analysis at local, state, and national levels. For this reason, the National Association of State EMS Directors is working with its federal partners at the National Highway Traffic Safety Administration (NHTSA) and the Trauma and EMS program of the Health Resources and Services Administration's (HRSA's) Maternal and Child Health Bureau to develop a national EMS database. Such a database would be useful in developing nationwide EMS training curricula, evaluating patient and EMS system outcomes, facilitating research efforts, determining national fee schedules and reimbursement rates, and providing valuable information on other issues related to EMS care.     

Advances in pediatric emergency medical service systems

Only recently has attention turned to the needs of children in the EMS system, and it has been shown that there is work to be done if these needs are to be met. The founders of EMS systems were trained in adult specialties and worked without input from the pediatric community. It is not surprising that the special needs of children within an adult-oriented EMS system were underemphasized. Children make up less than 10% of prehospital runs and less than 5% of the critically ill patients. Numerous EMS systems nationwide are undertaking this work and federal support is evident through the Maternal and Child Health EMSC program. Vital issues include the need for experts in emergency medical services to work together with experts in pediatric emergency care and for sound program evaluations to be performed to demonstrate the efficacy of these new programs.     

The Pediatric Emergency Care Applied Research Network (PECARN): Rationale,Development, and First Steps*

Since its formal recognition as a medical specialty, the field of pediatric emergency medicine has made substantial advances with respect to its scope and sophistication. These advances have occurred in clinical practice as well as in the research base to improve clinical practice. There remain, however, many areas in emergency medical services for children (EMSC), in the out‐of‐hospital as well as the emergency department (ED) and hospital settings, that suffer from a lack of data to guide practice. In an effort to expand the quality and quantity of research in pediatric emergency care, the Pediatric Emergency Care Applied Research Network (PECARN) was created in October 2001. PECARN is the first federally funded national network for research in EMSC. PECARN is the result of Cooperative Agreement grants funded through the Health Resources and Services Administration (HRSA) with the purpose of developing an infrastructure capable of overcoming inherent barriers to pediatric EMSC research. Among these recognized barriers are low incidence rates of serious pediatric emergency events, the need for large numbers of children from varied backgrounds to achieve broadly representative study samples, lack of an infrastructure to test the efficacy of pediatric emergency care, and the need for a mechanism to translate study results into clinical practice. PECARN will serve as a national platform for collaborative research involving the continuum of care within the EMSC system, including out‐of‐hospital care, patient transport, ED and in‐hospital care, and rehabilitation. This article describes the history of EMSC, the need for a national collaborative research network in EMSC, the organization and development of PECARN, and the work plan for the Network.     

National Emergency Medical Services Information System (NEMSIS)

The absence of emergency medical services (EMS) patient care data has hindered development andevaluation of EMS systems. The National Highway Traffic Safety Administration (NHTSA), in cooperation with the Health Resources andServices Administration (HRSA), has provided funding to the National Association of State EMS Directors to develop a National EMS Information System (NEMSIS). NEMSIS is being designed to provide a uniform national EMS dataset, with standard terms, definitions, andvalues, as well as a national EMS database, with aggregated data from all states on a limited number of data elements. Forty-eight of the states, the District of Columbia, andthree territories signed a memorandum of agreement documenting support for the NEMSIS project andexpressing a desire for full implementation of the NEMSIS dataset. NHTSA has agreed to house the National EMS Database at its National Center for Statistics andAnalysis. NHTSA, in cooperation with HRSA andthe Centers for Disease Control andPrevention, recently entered into a cooperative agreement with the University of Utah School of Medicine to operate a NEMSIS Technical Assistance Center that will provide related assistance to official EMS agencies andto commercial software vendors. The Technical Assistance Center will also biannually assess state andterritorial capabilities to provide data to the national EMS database. NEMSIS will provide a uniform national EMS dataset, with standard terms, definitions, andvalues, as well as a national EMS database, with aggregated data from all states on a limited number of data elements. Many of the potential benefits of implementation of NEMSIS are enumerated in this report.     

Emergency medical services information systems and a future EMS national database

Since the early 1970s, various publications and legislation have contributed to the development of emergency medical services (EMS) information systems and databases. Yet, even today, EMS systems vary in their ability to collect patient and systems data and to put these data to use. In addition, no means currently exists to easily link disparate EMS databases to allow analysis at local, state, and national levels. For this reason, the National Association of State EMS Directors is working with its federal partners at the National Highway Traffic Safety Administration (NHTSA) and the Trauma and EMS program of the Health Resources and Services Administration's (HRSA's) Maternal and Child Health Bureau to develop a national EMS database. Such a database would be useful in developing nationwide EMS training curricula, evaluating patient and EMS system outcomes, facilitating research efforts, determining national fee schedules and reimbursement rates, and providing valuable information on other issues related to EMS care. PREHOSPITAL EMERGENCY CARE 2002;6:123-130     

A Model Protocol for Emergency Medical Services Management of Asthma Exacerbations

Emergency medical services (EMS) is an important part of the continuum of asthma management. The magnitude of the EMS responsibility is very large, with millions of patients with asthma treated each year by EMS personnel. In response to inconsistencies between the 1997 National Asthma Education andPrevention Program asthma guidelines anda variety of existing EMS protocols on the management of asthma exacerbations, the Centers for Disease Control andPrevention convened a workgroup in 2004 to discuss the various opportunities andchallenges ahead. At the meeting, andover the ensuing year, the workgroup created a model protocol that was derived from the National Asthma Education andPrevention Program guidelines. The model protocol is available in both text andalgorithm format andoffers guidance for EMS systems to develop andimplement treatment protocols in their local areas. The workgroup recommendations emphasize flexibility, simplicity, andlow-risk practices. By integrating these recommendations into existing protocols, we believe that EMS systems could improve prehospital care for patients with asthma. Demonstration projects are needed to carefully examine the implementation process andthe actual impact of the model protocol on various outcomes. The workgroup also encourages more research on EMS management of asthma exacerbations. In the meantime, improved collaboration between EMS andnational asthma organizations is an immediate priority andwill continue to advance future discussions on how to improve asthma management in the prehospital setting. The workgroup hopes that state andlocal EMS systems will see the value of the model protocol andencourage its use.     

Multicenter Evaluation of Prehospital Opioid Pain Management in Injured Children

Background: The National Association of Emergency Medical Services Physicians’ (NAEMSP) Position Statement on Prehospital Pain Management and the joint National Highway Traffic Safety Administration (NHTSA) and Emergency Medical Services for Children (EMSC) Evidence-based Guideline for Prehospital Analgesia in Trauma aim to improve the recognition, assessment, and treatment of prehospital pain. The impact of implementation of these guidelines on pain management in children by emergency medical services (EMS) agencies has not been assessed. Objective: Determine the change in frequency of documented pain severity assessment and opiate administration among injured pediatric patients in three EMS agencies after adoption of best practice recommendations. Methods: This is a retrospective study of children <18 years of age with a prehospital injury-related primary impression from three EMS agencies. Each agency independently implemented pain protocol changes which included adding the use of age-appropriate pain scales, decreasing the minimum age for opiate administration, and updating fentanyl dosing. We abstracted data from prehospital electronic patient records before and after changes to the pain management protocols. The primary outcomes were the frequency of administration of opioid analgesia and documentation of pain severity assessment as recorded in the prehospital patient care record. Results: A total of 3,597 injured children were transported prior to pain protocol changes and 3,743 children after changes. Opiate administration to eligible patients across study sites regardless of documentation of pain severity was 156/3,089 (5%) before protocol changes and 175/3,509 (5%) after (p = 0.97). Prior to protocol changes, 580 (18%) children had documented pain assessments and 430 (74%) had moderate-to-severe pain. After protocol changes, 644 (18%) patients had pain severity documented with 464 (72%) in moderate-to-severe pain. For all study agencies, pain severity was documented in 13%, 19%, and 22% of patient records both before and after protocol changes. There was a difference in intranasal fentanyl administration rates before (27%) and after (17%) protocol changes (p = 0.02). Conclusion: The proportion of injured children who receive prehospital opioid analgesia remains suboptimal despite implementation of best practice recommendations. Frequency of pain severity assessment of injured children is low. Intranasal fentanyl administration may be an underutilized modality of prehospital opiate administration.     

Use of ems for seriously ill children in the office: A survey of primary care physicians

Objectives. To describe how primary care physicians (PCPs) transport seriously ill children from their offices to emergency departments (EDs). Methods. The authors conducted a mail survey of PCPs in upstate New York. Results. The response rate was 60% (119/199). Sixty-six percent (79/119) of the physicians had transferred at least one child from their office to an ED via EMS. Forty-five percent (53/119) had encountered a case of suspected epiglottitis in the office. EMS was used to send 45% (24/53) of suspected epiglottitis cases to the ED, while 40% (21/53) transferred children with possible epiglottitis via family auto. Similarly, the family's auto was used to transport 26% (6/23) of the patients with suspected foreign body aspiration, 46% (32/70) with severe asthma, 59% (30/51) with severe dehydration, and 37% (14/38) with suspected meningococcemia. In contrast, the family's auto was never used for patients with active seizures. The physicians denied that they would call EMS more often if transport time were shorter (58%) or if costs were less (64%). Sixty percent of the PCPs were not sure whether EMS personnel are skilled in pediatric emergencies. Conclusion. The PCPs often failed to call EMS for seriously ill children seen in the office and, instead, used the family's auto for emergency transportation. In this survey, transport time and cost were not barriers to use of EMS. The physicians expressed a lack of confidence in EMS providers' pediatric skills. Targeting educational programs to PCPs that highlight 1) the availability, training, and skill of EMS personnel and 2) the medicolegal risks of family transportation may result in more appropriate use of EMS for children.     

Resource Document: Coordination of Pediatric Emergency Care in EMS Systems

Background: Citing numerous pediatric-specific deficiencies within Emergency Medical Services (EMS) systems, the Institute of Medicine (IOM) recommended that EMS systems appoint a pediatric emergency care coordinator (PECC) to provide oversight of EMS activities related to care of children, to promote the integration of pediatric elements into day-to-day services as well as local and/or regional disaster planning, and to promote pediatric education across all levels of EMS providers. Methods: A systematic review of the literature was undertaken to describe the evidence for pediatric coordination across the emergency care continuum. The search strategy was developed by the investigators in consultation with a medical librarian and conducted in OVID, Medline, PubMed, Embase, Web of Science, and CINAHL databases from January 1, 1983 to January 1, 2016. All research articles that measured a patient-related or system-related outcome associated with pediatric coordination in the setting of emergency care, trauma, or disaster were included. Opinion articles, commentaries, and letters to the editors were excluded. Three investigators independently screened citations in a hierarchical manner and abstracted data. Results: Of 149 identified titles, nine were included in the systematic review. The nine articles included one interventional study, five surveys, and three consensus documents. All articles favored the presence of pediatric coordination. The interventional study demonstrated improved documentation, clinical management, and staff awareness of high priority pediatric areas. Conclusion: The current literature supports the identification of pediatric coordination to facilitate the optimal care of children within EMS systems. In order for EMS systems to provide high quality care to children, pediatric components must be integrated into all aspects of care including day-to-day operations, policies, protocols, available equipment and medications, quality improvement efforts, and disaster planning. This systematic review and resource document serves as the basis for the National Association of EMS Physicians position statement entitled “Physician Oversight of Pediatric Care in Emergency Medical Systems.”     

Prehospital Glucose Testing for Children with Seizures: A Proposed Change in Management

Objective: Many Emergency Medicine Services (EMS) protocols require point-of-care blood glucose testing (BGT) for any pediatric patient who presents with seizure or altered level of conscious. Few data describe the diagnostic yield of BGT when performed on all pediatric seizures regardless of presenting mental status. We analyzed a large single center dataset of pediatric patients presenting with prehospital seizures to determine the prevalence of hypoglycemic seizures and the utility of repeat BGT in the emergency department (ED). Methods: This was a retrospective, IRB-approved chart analysis of all pediatric patients (≤14 years) transported by EMS to the Harbor-UCLA pediatric ED over a 2-year period with a chief complaint of seizure. Cases were selected in which witnessed seizures had occurred in the field by family or EMS. Chart review included prehospital, nursing and physician records. Hypoglycemia was defined as blood glucose <60 mg/dL. Analysis included blood glucose, witnessed field seizure, initial mental status assessed by Glasgow Coma Scale (GCS), and further mental status assessments, along with age, sex, and medical history. Medical records were reviewed for subsequent BGT and patient outcome. Results: A total 770 children were transported by EMS due to seizures. Four patients (0.5%) had recorded hypoglycemia in the field, yet only two received treatment to raise blood glucose. Additionally, one child (0.1%) was normoglycemic (81 mg/dL) in the field with hypoglycemia (43 mg/dL) in the ED but required no intervention. Two were found by EMS to have an ALOC (GCS ≤ 12) and hypoglycemia. Only the patient with hypoglycemia secondary to a suspected glipizide ingestion received ED glucose administration. The most common discharge diagnosis was simple febrile seizure (38.6%). Conclusion: Hypoglycemia in the pediatric seizure patient is extremely rare, thus universal field BGT has low utility and potential downstream effects. We propose a novel algorithm for the initial evaluation and management of prehospital pediatric seizures. Although limited to a retrospective analysis of a single medical center, our findings suggest the importance of reassessing prehospital seizure protocols. A larger patient sample should be studied to validate these findings and identify unique cases where glucose testing might be useful.     

Pediatric emergency care in a metropolitan area

Regional emergency medical services (EMS) system planning requires a data base describing the population to be served. No such regional data base exists for childhood emergencies. This study was undertaken for two reasons: (1) to establish, in a metropolitan region, the demographics of the population and the type of clinical problems for which pediatric emergency care is sought, and (2) to determine if the critical care categories used for EMS planning accurately reflect the emergency care needs of pediatric patients in the region.

All pediatric visits (6,190) to 13 area hospitals during 1 month were reviewed. The most common diagnostic categories seen were trauma (48%) and infectious illness (29%).

Six hundred and six visits satisfied criteria for inclusion in one of the following critical care categories: trauma, poisonings, burns, spinal cord injuries, behavioral disorders, cardiovascular illness, and a general category designated “medical.” The last group was the largest of the categories (185 visits) and contained the greatest number of seriously or critically ill children.

Of the total visits, 9.5% were by children 1 year or under, and 19.1% were by children 13 to 16 years old. For visits of a serious or critical nature, these age groups comprised 16% and 29%, respectively, of the total for such visits.

This study documents that the emergency care needs of children differ from those of adults and deserve special attention in the planning of emergency care systems.     

Is Online Pediatric Continuing Education Effective in a Rural State?

Objective. This prospective study was designed to evaluate the effectiveness of online pediatric education for prehospital emergency medical technicians (EMTs). Methods. Online emergency medical services (EMS) continuing education modules, on various pediatric emergency topics, were developed for dissemination statewide. Pre- andposttest scores were compared by EMT level of training, rural versus urban location, andindividual module performance. Results. A total of 539 participants completed both the pre- andposttests. Of these, more than one-third (38.0%) reported Bernalillo County, the only urban county in the state, as the county in which they worked. Pretest scores ranged from 0 to 15 (mean = 8.5; 95% confidence interval [CI] = 8.2, 8.7), with a median of 8.0 anda mode of 8.0. Posttest scores were higher, ranging from 4 to 15 (mean = 11.6; 95% CI = 11.4, 11.7). For the posttest, the median score was 12.0 andthe mode was 13.0. Urban andrural EMTs improved in posttests comparably. EMT-Basic participants' scores improved (mean change in score = 3.4, 95% CI = 3.1, 3.7) more than those of EMT-Intermediates (mean = 2.9, 95% CI = 2.5, 3.2) or EMT-Paramedics (mean = 2.7, 95% CI = 2.2, 3.3). Conclusions. 1) The New Mexico EMS for Children (EMSC) online pediatric continuing education program increased EMTs' cognitive knowledge; 2) rural EMTs accessed the training more than urban EMTs; and3) although pre- andposttest results varied by EMT licensure level, improvements in scores also varied such that posttest scores were more similar than pretest scores.     

Pediatric Prehospital Medication Dosing Errors: A Mixed-Methods Study

Prehospital dosing errors affect approximately 56,000 US children yearly. To decrease these errors, barriers, enablers and solutions from the paramedic (EMT-P) and medical director (MD) standpoint need to be understood. We conducted a mixed-methods study of EMT-P and MDs in Michigan utilizing focus groups (FG). FGs were held at EMS agencies and state EMS conferences. Questions focused on the drug dose delivery process, barriers and enablers to correct dosing and possible solutions to decrease errors. Responses were coded by the research team for themes and number of response mentions. Participants completed a pre-FG survey on pediatric experience and agency characteristics. There were 35 EMT-P and 9 MD participants: 43% of EMT-Ps had been practicing > 10 years, 11% had been practicing < 1 year; and 25% reported they had not administered a drug dose to a child in the last 12 months. EMT-Ps who were “very comfortable” with their ability to administer a correct drug dose to infants, toddlers, school-aged, and adolescents were: 5%, 7%, 10%, and 54%, respectively. FGs identified themes of: difficulty obtaining weight, infrequent pediatric encounters, infrequent/inadequate pediatric training, difficulties with drug packaging, drug bags that were not “EMS friendly,” difficulty with drug calculations, and lack of dosing aids. Simplification of dose delivery, an improved length based tape for EMS, pediatric checklists, and dose cards in mL were given as solutions. This mixed-methods study identified barriers and potential solutions to reducing prehospital pediatric drug dosing errors. Solutions should be thoroughly tested prior to implementation.     

The Epidemiology of Emergency Medical Services Use by Children: An Analysis of the National Hospital Ambulatory Medical Care Survey

Objective. There is an absence of nationally representative data describing pediatric patients who use emergency medical services (EMS) andthe factors associated with EMS use by children. This study characterizes pediatric emergency department (ED) visits for which the patient arrived by EMS andidentifies factors associated with those visits using a nationally representative database. Methods. A secondary analysis of the ED component of the 1997–2000 National Hospital Ambulatory Medical Care Survey was performed. The dependent variable was the mode of arrival to the ED (EMS vs. not EMS), andindependent variables were grouped into four domains: demographic, clinical, system, andservice characteristics. Bivariate analyses andmultivariate logistic regression analyses were conducted. Results. There were 110.9 million ED visits by children aged <19 years between 1997 and2000. Pediatric patients constituted 27.3% of all ED visits during this time, and7.9 million (7.1%) of these patients arrived via EMS. Pediatric patients represented 13% of all EMS transports. The annual EMS utilization rate by children was 26 per 1,000, compared with 66 per 1,000 in the adult population (p < 0.001). Sixteen percent of children transported by EMS were admitted to the hospital. Sixty-two percent of pediatric patients arriving at the ED by EMS were transported as a result of injury or poisoning. Characteristics significantly associated with arrival by EMS in the final multivariate model included demographic (age, African American race, urban residence), clinical (need for greater immediacy of care, illnesses associated with certain diagnoses), andservice (greater number of diagnostic services) variables. Conclusions. Pediatric patients transported by EMS are more likely to have injuries andpoisoning, andhave higher-acuity illness than those arriving at the ED by other means. The epidemiology of pediatric EMS use may have important operational, training, andpublic health implications andrequires further study.     

Simulation-based Assessment of Paramedic Pediatric Resuscitation Skills

Background. Emergency medical services (EMS) providers infrequently encounter seriously ill and injured pediatric patients. Clinical simulations are useful for assessing skill level, especially for low-frequency, high-risk problems. Objective. To identify the most common performance deficiencies in paramedics' management of three simulated pediatric emergencies. Methods. Paramedics from five EMS agencies in Michigan were eligible subjects for this prospective, observational study. Three clinical assessment modules (CAMs) were designed and validated using pediatric simulators with varying technologic complexity. Scenarios included an infant cardiopulmonary arrest, sepsis/seizure, and child asthma/respiratory arrest. Each scenario required paramedics to perform an assessment and provide appropriate pediatric patient care within a 12-minute time limit. Trained instructors conducted the simulations by following strict guidelines for sequences of events and responses. Videos of CAMs were reviewed by an independent evaluator to verify scoring accuracy. Percentage of steps completed for each of the three scenarios and specific performance deficiencies were recorded. Results. Two hundred twelve paramedics completed the CAMs. The average percentages of steps completed were as follows: arrest CAM, 45.3%; asthma CAM, 51.6%; and sepsis CAM, 47.1%. Performance deficiencies included lack of airway support or protection; lack of support of ventilations or cardiac function; inappropriate use of length-based treatment tapes; and inaccurate calculation and administration of medications and fluids. Conclusion. Multiple deficiencies in paramedics' performance of pediatric resuscitation skills were objectively identified using three manikin-based simulations. EMS educators and EMS medical directors should target these specific skill deficiencies when developing continuing education in prehospital pediatric patient care.     

R EVIEW AND S ELF -A SSESSMENT TO A CCOMPANY EMERGENCY MEDICINE

Cardiac arrest in children outside the hospital is associated with high mortality rates. Recent investigations have suggested that the use of advanced life support (ALS) measures by emergency medical services (EMS) personnel may decrease survival. These studies have used the pediatric Utstein style of defining ALS and basic life support (BLS) measures. The pediatric Utstein style defines BLS as “an attempt to restore effective ventilation and circulation” using noninvasive means to open the airway but specifically excludes the use of bag-valve-mask devices. Advanced life support is defined as the “addition of invasive maneuvers to restore effective ventilation and circulation.” The authors of the study described below believe that using this definition would categorize some patients into an ALS group who would otherwise be categorized as having received BLS (i.E., “bag-valve-mask only”). Objective: To compare survival rates among children receiving BLS or ALS following out-of-hospital cardiac arrest using amended definitions of prehospital life support measures. Specifically, the definition of BLS was expanded to include the use of bag-valve-mask devices only. Methods: This was a retrospective chart review in an urban, pediatric emergency department. Patients included all children presenting to the emergency department between January 1, 1986, and December 31, 1999, following out-of-hospital cardiac arrest. The main outcome measure was survival to hospital discharge. Results: Two hundred ten children were identified. Twenty-one patients were excluded from further analysis because of absent or incomplete medical records. One hundred eighty-nine patients were studied. Five children (2.6%) survived to discharge from the hospital. Of 189 children, 39 (20.6%) were provided BLS measures by prehospital personnel; 150 (79.4%) received ALS. There was no significant difference between groups in survival to hospital discharge. Patients who survived to hospital discharge were more likely to be in sinus rhythm upon arrival in the emergency department (p < 0.001) and to have received fewer doses of standard-dose epinephrine in the emergency department (p < 0.001). Conclusion: The use of ALS by prehospital personnel for children with out-of-hospital cardiac arrest did not improve survival to discharge from the hospital when compared with the use of BLS.     

National Prehospital Evidence-Based Guidelines Strategy: A Summary for EMS Stakeholders

Multiple national organizations have recommended and supported a national investment to increase the scientific evidence available to guide patient care delivered by Emergency Medical Services (EMS) and incorporate that evidence directly into EMS systems. Ongoing efforts seek to develop, implement, and evaluate prehospital evidence-based guidelines (EBGs) using the National Model Process created by a multidisciplinary panel of experts convened by the Federal Interagency Committee on EMS (FICEMS) and the National EMS Advisory Council (NEMSAC). Yet, these and other EBG efforts have occurred in relative isolation, with limited direct collaboration between national projects, and have experienced challenges in implementation of individual guidelines. There is a need to develop sustainable relationships among stakeholders that facilitate a common vision that facilitates EBG efforts. Herein, we summarize a National Strategy on EBGs developed by the National Association of EMS Physicians (NAEMSP) with involvement of 57 stakeholder organizations, and with the financial support of the National Highway Traffic Safety Administration (NHTSA) and the EMS for Children program. The Strategy proposes seven action items that support collaborative efforts in advancing prehospital EBGs. The first proposed action is creation of a Prehospital Guidelines Consortium (PGC) representing national medical and EMS organizations that have an interest in prehospital EBGs and their benefits to patient outcomes. Other action items include promoting research that supports creation and evaluates the impact of EBGs, promoting the development of new EBGs through improved stakeholder collaboration, and improving education on evidence-based medicine for all prehospital providers. The Strategy intends to facilitate implementation of EBGs by improving guideline dissemination and incorporation into protocols, and seeks to establish standardized evaluation methods for prehospital EBGs. Finally, the Strategy proposes that key stakeholder organizations financially support the Prehospital Guidelines Consortium as a means of implementing the Strategy, while together promoting additional funding for continued EBG efforts.