By Guillermo Fuentes
The term “evidence-based practice” has been used in EMS for more than a decade. The reality is, as a profession, we fail to understand what implementing an evidence-based practice actually means.
One of the most influential thinkers on the subject, the late physician David Sackett, defined evidence-based medicine as “the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients. The practice of evidence-based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research” [1]. Using this definition, let’s take a look at the current state of the EMS profession and see how we measure up.
One of the central tenets of EMS dogma – that advanced care is better than basic care – is under assault. The scientific literature is no longer supporting the concept that more care is always better. More and more research is indicating that BLS care leads to similar or better patient outcomes as ALS care.
In 2005, two Canadian researchers performed a literature review and summarized the results of 21 studies comparing the effectiveness of BLS and ALS care in trauma, cardiac arrest, myocardial infarction and altered mental status. They concluded that in the limited available research, ALS showed little benefit [2].
Since 2005, several other studies have supported the suggestion that ALS interventions provide limited benefits, especially in time-critical settings, such as trauma and cardiac arrest. This evidence does not mean that paramedics shouldn’t respond to emergencies or that all ALS care is worthless, but it should cause us to question whether EMS has adopted the principles of evidence-based practice.
Challenging EMS tenets
So more treatments and interventions aren’t always better than fewer; but surely faster responses must be better than slower. Yet the evidence hardly supports that central tenet of EMS either, even for trauma and cardiac arrest.
In 2002, Blackwell published his first study on response time and cardiac arrest outcomes; he concluded that a faster response time improves outcomes if that time is under five minutes, when measured from onset of arrest to the arrival of help [3]. Once that time exceeded five minutes, outcomes did not appear to be impacted by response time [4,5].
Our profession did what many industries do when confronted with challenges that would be difficult to overcome – we ignored them. Many other researchers, including Pons and Weiss, found little evidence that response time impacted clinical outcomes [4,5].
No formula for success
So if faster EMS and more ALS aren’t supported by research, what is? What would evidence-based practice in EMS look like? The evidence does not support any one given model; it does not give us a formula for success.
What it does do is allow for EMS leaders to think differently about the problem. What if instead of being prescriptive in response times and levels of care, we designed systems based on clinical outcomes and truly embraced the balance between clinical capacity, research and patient desire.
One of the first attempts of this approach is the RFP for EMS services recently released by Multnomah County, Ore. The Multnomah County RFP has performance measures and requirements for response times and ALS service, but the penalties for non-compliance are tempered if the contractor meets the clinical outcomes required.
This is a step toward evidence-based practice; it may also signal a new era for EMS when the indicators of excellent service are not provider certification levels and response and transport times, but instead are patient outcomes and patient satisfaction.
References
1. Sackett DL, Rosenberg WM, Gray JM, Haynes RB, Richardson WS. Evidence based medicine. BMJ: British Medical Journal. 1996 Jul 20;313(7050):170.
2. Isenberg DL, Bissell R. Does advanced life support provide benefits to patients?: A literature review. Prehospital and disaster medicine. 2005 Aug;20(4):265-70.
3. Blackwell TH, Kaufman JS. Response time effectiveness: comparison of response time and survival in an urban emergency medical services system. Academic Emergency Medicine. 2002 Apr 1;9(4):288-95.
4. Pons PT, Markovchick VJ. Eight minutes or less: does the ambulance response time guideline impact trauma patient outcome? The Journal of emergency medicine. 2002 Jul 31;23(1):43-8.
5. Weiss S, Fullerton L, Oglesbee S, Duerden B, Froman P. Does ambulance response time influence patient condition among patients with specific medical and trauma emergencies? Southern medical journal. 2013 Mar;106(3):230-5.
About the author
Guillermo Fuentes, MBA, is a partner at Fitch & Associates. He has management oversight of two major EMS programs and also supervises statistical and operational analysis, computer modeling and the development of deployment plans as well as major technology purchases and communications center installations for clients. He previously served as the chief administrative officer of the Niagara Regional Police Agency, in Ontario, Canada, and associate director of EMS for the Niagara Region.
