An Evidence-based Guideline for Prehospital Analgesia in Trauma

Abstract

Background. The management of acute traumatic pain is a crucial component of prehospital care and yet the assessment and administration of analgesia is highly variable, frequently suboptimal, and often determined by consensus-based regional protocols. Objective. To develop an evidence-based guideline (EBG) for the clinical management of acute traumatic pain in adults and children by advanced life support (ALS) providers in the prehospital setting. Methods. We recruited a multi-stakeholder panel with expertise in acute pain management, guideline development, health informatics, and emergency medical services (EMS) outcomes research. Representatives of the National Highway Traffic Safety Administration (sponsoring agency) and a major children's research center (investigative team) also contributed to the process. The panel used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology to guide the process of question formulation, evidence retrieval, appraisal/synthesis, and formulation of recommendations. The process also adhered to the National Prehospital Evidence-Based Guideline (EBG) model process approved by the Federal Interagency Council for EMS and the National EMS Advisory Council. Results. Four strong and three weak recommendations emerged from the process; two of the strong recommendations were linked to high- and moderate-quality evidence, respectively. The panel recommended that all patients be considered candidates for analgesia, regardless of transport interval, and that opioid medications should be considered for patients in moderate to severe pain. The panel also recommended that all patients should be reassessed at frequent intervals using a standardized pain scale and that patients should be re-dosed if pain persists. The panel suggested the use of specific age-appropriate pain scales. Conclusion. GRADE methodology was used to develop an evidence-based guideline for prehospital analgesia in trauma. The panel issued four strong recommendations regarding patient assessment and narcotic medication dosing. Future research should define optimal approaches for implementation of the guideline as well as the impact of the protocol on safety and effectiveness metrics.     

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.     

Community Implementation of a Prehospital Spinal Immobilization Guideline

Objective: The purpose of this study was to qualitatively describe the underpinnings of the successful implementation of a collaborative prehospital spinal immobilization guideline throughout the emergency medical services (EMS) community in two counties in Colorado. We also describe lessons learned that may be beneficial to other communities considering similar initiatives. Methods: Qualitative data were collected from key informants who were directly involved in the implementation of a new prehospital spinal immobilization guideline among four community hospitals in two different hospital systems and the associated EMS providers within the two counties. We interviewed a purposively selected sample of emergency department (ED) physicians and other ED staff, hospital decision makers, EMS educators as well as fire department and EMS medical directors. Data were collected and reviewed until saturation was achieved. We conducted qualitative analysis to summarize and synthesize themes. Results: Ten key informants were interviewed, at which point saturation was achieved and several clear themes emerged. Participants described successful community-wide guideline implementation despite a history of competition, isolation, and conflict between the various EMS organizations and hospitals on past EMS and trauma initiatives. Factors related to success included the nearly universal perception that the initiative was “cutting edge” and thus an important paradigm shift in care for the community, as a whole. Participants reported the ability of community stakeholders to jointly assure a collaborative approach, characterized by intensive education for EMS personnel and others involved, and the ability of the community to together secure the new equipment required for success. Conclusions: Key informants described a convergence of factors as leading to the successful implementation of a prehospital spinal immobilization guideline. Lessons learned regarding how to overcome a tradition of competition and isolation to allow for success may be useful to other communities considering similar initiatives.     

An Evidence-based Guideline for the Air Medical Transportation of Prehospital Trauma Patients

Abstract

Background. Decisions about the transportation of trauma patients by helicopter are often not well informed by research assessing the risks, benefits, and costs of such transport. Objective. The objective of this evidence-based guideline (EBG) is to recommend a strategy for the selection of prehospital trauma patients who would benefit most from aeromedical transportation. Methods. A multidisciplinary panel was recruited consisting of experts in trauma, EBG development, and emergency medical services (EMS) outcomes research. Representatives of the Federal Interagency Committee on Emergency Medical Services (FICEMS), the National Highway Traffic Safety Administration (NHTSA) (funding agency), and the Children's National Medical Center (investigative team) also contributed to the process. The panel used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology to guide question formulation, evidence retrieval, appraisal/synthesis, and formulate recommendations. The process followed the National Evidence-Based Guideline Model Process, which has been approved by the Federal Interagency Committee on EMS and the National EMS Advisory Council. Results. Two strong and three weak recommendations emerged from the process, all supported only by low or very low quality evidence. The panel strongly recommended that the 2011 CDC Guideline for the Field Triage of Injured Patients be used as the initial step in the triage process, and that ground emergency medical services (GEMS) be used for patients not meeting CDC anatomic, physiologic, and situational high-acuity criteria. The panel issued a weak recommendation to use helicopter emergency medical services (HEMS) for higher-acuity patients if there is a time-savings versus GEMS, or if an appropriate hospital is not accessible by GEMS due to systemic/logistical factors. The panel strongly recommended that online medical direction should not be required for activating HEMS. Special consideration was given to the potential need for local adaptation. Conclusions. Systematic and transparent methodology was used to develop an evidence-based guideline for the transportation of prehospital trauma patients. The recommendations provide specific guidance regarding the activation of GEMS and HEMS for patients of varying acuity. Future research is required to strengthen the data and recommendations, define optimal approaches for guideline implementation, and determine the impact of implementation on safety and outcomes including cost.     

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

Abstract

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.     

Barriers to and Enablers for Prehospital Analgesia for Pediatric Patients

Abstract

Objective. To identify and investigate the barriers and enablers perceived by paramedics regarding the administration of analgesia to pediatric emergency medical services (EMS) patients. Methods. This was a qualitative study in which in-depth semistructured interviews of a purposively-sampled group of 16 paramedics were performed before achieving redundancy. The interviews were structured and the data were thematically analyzed. Emerging themes were categorized into four domains, and novel themes were identified and further explored. Results. Thirteen of 16 paramedics reported success with analgesia in children at least once in their careers. Provider anxiety, unfamiliarity and discomfort with pediatrics, unfamiliarity with the protocol, insufficient didactic and clinical education, and concern for adverse effects from analgesic agents were perceived as barriers to pediatric pain management. The paramedics had differing beliefs about the importance of pain control, the role of parents in medical care for children, and the paramedic's ability to assess pediatric patients. Having a positive relationship with online medical control and using commercially available assistive guides were viewed as enablers for pediatric pain management. The response from paramedic supervisors and emergency department staff, unwanted attention from authority figures, perceived superiority of hospital care, difficulty obtaining intravenous access, and overall culture of stinginess in medication administration played important roles in an overall preference to defer pediatric analgesia. Some paramedics mentioned a specific experience or mentoring relationship with a more seasoned provider who taught them the importance of pain management. Paramedics reported various effects of transport distance on their decision to administer analgesia. Conclusions. We have identified a number of previously unrecognized barriers to and enablers for prehospital pediatric analgesia. The majority of these factors lead to an overall preference of paramedics to defer administration of analgesic agents. A number of educational and EMS system changes could be made to address these barriers and increase the frequency of appropriate pediatric prehospital analgesia.     

Research in Prehospital Care: Overcoming the Barriers to Success

Objective. The objective of this project was to determine how investigators conduct clinical trials in the prehospital setting and to suggest how emergency medical services (EMS) systems can develop the capacity to conduct prehospital clinical research. Methods. A representative sample of U.S.-based study sites was selected from all studies registered on clinicaltrials.gov since the year 2000, where prehospital care providers conducted study-related activities in the prehospital setting. The site principal investigator and the research coordinator or EMS liaison were invited to participate in a structured discussion. A single interviewer conducted each discussion following a structured guide that generically asked for barriers and enablers to the sites’ research success and then reviewed commonly identified prehospital research barriers. Notes were taken during each discussion and reviewed for common themes. Themes were reviewed by the project team and sent for comment to all participants. Results. Discussions were held with 25 principal investigators, 9 coordinators, and 7 EMS liaisons. A total of 27 communities were represented in the discussions from 22 different states. The communities had a range of research experience from one prehospital trial to multiple trials. Key barriers were funding, ethics approval, data collection, protocol training and compliance, randomizing and blinding interventions, obtaining patient outcomes, adequate study staffing, and partnering with EMS agencies. Conclusion. This project identified many challenges to EMS research, but they were not insurmountable. Not every community can conduct every prehospital study. Communities should engage in studies that align with their values and resources. Investigators need to develop honest relationships where issues can be openly discussed and the community can collaborate on prehospital research. Learning from those who have overcome challenges may be a key to expanding the quality and quantity of EMS research.     

Analysis of Prehospital Documentation of Injury-Related Pain Assessment and Analgesic Administration on the Contemporary Battlefield

In addition to life-saving interventions, the assessment of pain and subsequent administration of analgesia are primary benchmarks for quality emergency medical services care which should be documented and analyzed. Analyze US combat casualty data from the Department of Defense Trauma Registry (DoDTR) with a primary focus on prehospital pain assessment, analgesic administration and documentation. Retrospective cohort study of battlefield prehospital and hospital casualty data were abstracted by DoDTR from available records from 1 September 2007 through 30 June 2011. Data included demographics; injury mechanism; prehospital and initial combat hospital pain assessment documented by standard 0-to-10 numeric rating scale; analgesics administered; and survival outcome. Records were available for 8,913 casualties (median ISS of 5 [IQR 2 to 10]; 98.7% survived). Prehospital analgesic administration was documented for 1,313 cases (15%). Prehospital pain assessment was recorded for 581 cases (7%; median pain score 6 [IQR 3 to 8]), hospital pain assessment was recorded for 5,007 cases (56%; median pain score5 [CI95% 3 to 8]), and 409 cases (5%) had both prehospital and hospital pain assessments that could be paired. In this paired group, 49.1% (201/409) had alleviation of pain evidenced by a decrease in pain score (median 4,, IQR 2 to 5); 23.5% (96/409) had worsening of pain evidenced by an increase in pain score (median 3, CI95 2.8 to 3.7, IQR 1 to 5); 27.4% (112/409) had no change; and the overall difference was an average decrease in pain score of 1.1 (median 0, IQR 0 to 3, p < 0.01). Time-series analysis showed modest increases in prehospital and hospital pain assessment documentation and prehospital analgesic documentation. Our study demonstrates that prehospital pain assessment, management, and documentation remain primary targets for performance improvement on the battlefield. Results of paired prehospital to hospital pain scores and time-series analysis demonstrate both feasibility and benefit of prehospital analgesics. Future efforts must also include an expansion of the prehospital battlefield analgesic formulary.     

Guideline Implementation Research: Exploring the Gap between Evidence and Practice in the CRUSADE Quality Improvement Initiative

Translating research results into routine clinical practice remains difficult. Guidelines, such as the 2002 American College of Cardiology/American Heart Association Guidelines for the Management of Patients with Unstable Angina and non‐ST‐segment elevation myocardial infarction, have been developed to provide a streamlined, evidence‐based approach to patient care that is of high quality and is reproducible. The C an R apid Risk Stratification of U nstable Angina Patients S uppress AD verse Outcomes with E arly Implementation (CRUSADE) Quality Improvement Initiative was developed as a registry for non–ST‐segment elevation acute coronary syndromes to track the use of guideline‐based acute and discharge treatments for hospitalized patients, as well as outcomes associated with the use of these treatments. Care for more than 200,000 patients at more than 400 high‐volume acute care hospitals in the United States was tracked in CRUSADE, with feedback provided to participating physicians and hospitals regarding their performance over time and compared with similar institutions. Such access to data has proved important in stimulating improvements in non–ST‐segment elevation acute coronary syndromes care at participating hospitals for delivery of acute and discharge guideline‐based therapy, as well as improving outcomes for patients. Providing quality improvement methods such as protocol order sets, continuing education programs, and a CRUSADE Quality Improvement Initiative toolbox serve to actively stimulate physician providers and institutions to improve care. The CRUSADE Initiative has also proven to be a fertile source of research in translation of treatment guidelines into routine care, resulting in more than 52 published articles and 86 abstracts presented at major emergency medicine and cardiology meetings. The cycle for research of guideline implementation demonstrated by CRUSADE includes four major steps—observation, intervention, investigation, and publication—that serve as the basis for evaluating the impact of any evidence‐based guideline on patient care. Due to the success of CRUSADE, the American College of Cardiology combined the CRUSADE Initiative with the National Registry for Myocardial Infarction ST‐segment elevation myocardial infarction program to form the National Cardiovascular Data Registry—Acute Coronary Treatment & Intervention Outcomes Network Registry beginning in January 2007.     

An Open,Interoperable, and Scalable Prehospital Information Technology Network Architecture

Abstract

Some of the most intractable challenges in prehospital medicine include response time optimization, inefficiencies at the emergency medical services (EMS)–emergency department (ED) interface, and the ability to correlate field interventions with patient outcomes. Information technology (IT) can address these and other concerns by ensuring that system and patient information is received when and where it is needed, is fully integrated with prior and subsequent patient information, and is securely archived. Some EMS agencies have begun adopting information technologies, such as wireless transmission of 12-lead electrocardiograms, but few agencies have developed a comprehensive plan for management of their prehospital information and integration with other electronic medical records. This perspective article highlights the challenges and limitations of integrating IT elements without a strategic plan, and proposes an open, interoperable, and scalable prehospital information technology (PHIT) architecture. The two core components of this PHIT architecture are 1) routers with broadband network connectivity to share data between ambulance devices and EMS system information services and 2) an electronic patient care report to organize and archive all electronic prehospital data. To successfully implement this comprehensive PHIT architecture, data and technology requirements must be based on best available evidence, and the system must adhere to health data standards as well as privacy and security regulations. Recent federal legislation prioritizing health information technology may position federal agencies to help design and fund PHIT architectures.     

Implementation of a Prehospital Protocol Change For Asthmatic Children

Background: Respiratory distress due to asthma is a common reason for pediatric emergency medical services (EMS) transports. Timely initiation of asthma treatment, including glucocorticoids, improves hospital outcomes. The impact of EMS-administered glucocorticoids on hospital-based outcomes for pediatric asthma patients is unknown. Objective: The objective of this study was to evaluate the effect of an evidence-based pediatric EMS asthma protocol update, inclusive of oral glucocorticoid administration, on time to hospital discharge. Methods: This was a retrospective cohort study of children (2–18 years) with an acute asthma exacerbation transported by an urban EMS system to 10 emergency departments over 2 years. The investigators implemented an EMS protocol update one year into the study period requiring glucocorticoid administration for all patients, with the major change being inclusion of oral dexamethasone (0.6 mg/kg, max. dose = 10 mg). Protocol implementation included mandatory paramedic training. Data was abstracted from linked prehospital and hospital records. Continuous data were compared before and after the protocol change with the Mann-Whitney test, and categorical data were compared with the Pearson χ² test. Results: During the study period, 482 asthmatic children met inclusion criteria. After the protocol change, patients were more likely to receive a prehospital glucocorticoid (11% vs. 18%, p = 0.02). Median total hospital time after the protocol change decreased from 6.1 hours (95% CI: 5.4–6.8) to 4.5 hours (95% CI: 4.2–4.8), p < 0.001. Total care time, defined as time from ambulance arrival to hospital discharge, also decreased [6.6 hours (95% CI: 5.8–7.3) vs. 5.2 hours (95% CI: 4.8–5.6), p = 0.01]. Overall, patients were less likely to be admitted to the hospital (30% vs. 21%, p = 0.02) after the change. Those with more severe exacerbations were less likely to be admitted to a critical care unit (82% vs. 44%, p = 0.02) after the change, rather than an acute care floor. Conclusions: Prehospital protocol change for asthmatic children is associated with shorter total hospital and total care times. This protocol change was also associated with decreased hospitalization rates and less need for critical care in those hospitalized. Further study is necessary to determine if other factors also contributed     

The Impact of a National Guideline on the Management of Cancer Pain on the Practice of Pain Assessment and Registration

The Dutch clinical practice guideline on the diagnosis and management of pain in patients with cancer was published in 2008 and intensively promoted to healthcare professionals who see patients with cancer. One of the most important recommendations is the systematic registering of the pain and its intensity. To evaluate in which degree this part of the practice guideline is implemented, we analyzed the medical records of patients attending the outpatient oncological clinic in an academic hospital, a large teaching hospital, and 4 smaller peripheral hospitals. None of the participating hospitals assessed pain by a standardized scale. Reference to pain in the medical record happened more frequently in the academic hospital than in the other hospitals. The frequency of recording pain in the medical record in the academic hospital was much higher in this study than the one previously reported, whereas the findings in the other hospitals were comparable. There may be several reasons for the difference in reporting rate of pain in patients with cancer. Our findings indicate that the clinical practice guideline with regard to pain registration is poorly implemented in oncology outpatient clinics. More efforts should be made to generate the awareness for the need of pain registration.     

Moving Evidence Forward: Addressing the Barriers to Evidence-Based Practice in Radiotherapy

Improving the quality of care is an ongoing challenge for medical professionals in the Canadian healthcare system. One generally accepted method of improving health outcomes has been the clinical implementation of evidence-based practice. Historically, the barrier in clinical settings has been efficient access to reliable information. Point-of-care (P-O-C) tools have been proven to be effective and help promote evidence-based practice in professions outside radiation therapy. To examine the potential usefulness of a P-O-C tool for radiation therapists, a Canada-wide survey was distributed to practicing radiation therapists. Results showed a clear desire by radiation therapists for a P-O-C tool. Sixty-nine percent of surveyed practitioners stated that having a practitioner-focused evidence resource would change their daily work practice, but stipulated that the proper integration of resources into the day-to-day workplace is crucial to supporting clinical evidence-based decision-making. Study participants also highlighted several barriers to their ability to do so, including access to evidence-based data, differing organizational research philosophies and practices, lack of resources to promote discipline-specific practitioner research, and necessary integration of educational and mentoring programs into daily practices. Although they have not been found to be an all-encompassing remedy, P-O-C tools have the potential to aid front-line healthcare providers in fostering evidence-based practice.     

Prehospital Fluid Administration in Trauma Patients: A Survey of State Protocols

Objective: The optimal resuscitation approach during the initial treatment of hypotensive trauma patients remains unknown, but some clinical trials have observed a survival benefit from restricting fluid administration prior to definitive hemorrhage control. We sought to characterize emergency medical services (EMS) protocols for the administration of intravenous fluids in this setting. Methods: Publicly accessible statewide EMS protocols for the treatment of hypotensive trauma patients were included and characterized by: 1) goal of fluid administration, 2) dosing strategy, 3) maximum dose, 4) type of fluid, and 5) specific protocols for head trauma, if present. Results: Of the 27 states with a publicly available, statewide protocol, 21 have a numeric systolic blood pressure (SBP) target for resuscitation. Of these, 16 describe a goal of maintaining SBP ≥90 mmHg with or without additional goals, three specify a goal that is less than 90 mmHg, and two specify a goal ≥100 mHg. Dosing strategies also vary and include both standard bolus strategies (200 mL, 250 mL, 500 mL, and 1 L with repeat) as well as weight-based strategies (20 mL/kg). Nine states specify a maximum dose of 2 L without medical control. Fifteen protocols recommend the use of normal saline, 1 recommends the use of lactated Ringer's, and 11 recommend the use of either normal saline or lactated Ringer's. Nine states have distinct protocols for patients with head trauma, all of which indicate maintaining a higher SBP than for trauma patients without head trauma. Conclusion: State EMS protocols for fluid administration for hypotensive trauma patients vary in regard to SBP goal, fluid dose, and fluid type. Clinical trials to determine the optimal use of intravenous fluids for hypotensive trauma patients are needed to define the optimal approach.