INTRODUCTION
The terms, evidence-based medicine (EBM), evidence-based practice (EBP), and knowledge translation (KT), are familiar to most emergency medicine (EM) and emergency medical services (EMS) clinicians and leaders. There have been calls for meaningful incorporation of these principles into EM and EMS. Several EMS research agendas from around the world have made clear recommendations about the importance of prioritizing and adequately resourcing to enable evidence-based decision-making,Reference Cone 1 - Reference O’Meara 8 with similar calls having been made in EM.Reference Lang and Johnson 9 The notion of EBM/EBP/KT is easily appreciated and agreed to; however, meaningful incorporation into clinical and administrative practice in Canadian EMS remains a challenge nationally and at the local EMS system level. This article will propose a vision for Canadian EMS EBP that we can collectively strive to achieve. This vision can be implemented with the use of the structure, process, system, and outcome (SPSO) taxonomy (Figure 1) to identify current barriers and strengths, with corresponding recommended strategies for local EMS agencies and at the national level (Table 1).Reference Kronick, Kurz and Lin 10
Figure 1 SPSO Strategies to Achieve the Canadian EMS EBP Vision.
Table 1 Identified barriers and opportunities for incorporating EBP into EMS clinical and policy decision-making
EBP = evidence-based practice; EMS = emergency medical services; GRADE = Grading of Recommendations, Assessment, Development and Evaluation; ILCOR = International Liaison Committee on Resuscitation; NOCPs = National Occupational Competency Profiles; PEP = Prehospital Evidence-based Practice Project; STEMI = ST-elevation myocardial infarction.
THE VISION OF EMS EBP
Vision statements are used by organizations to describe their long-term objectives; specifically what it is they are aiming for. They describe the future and are stable.Reference Kantaburta and Avery 11 Such an exercise is important for EBP in EMS to increase understanding and engagement among all stakeholders. We propose that the vision is: Canadian EMS clinicians and leaders will understand and use the best available evidence for clinical and administrative decision-making, to improve patient health outcomes, the capability and quality of EMS systems of care, and safety of patients and EMS professionals. With this vision set, barriers to achieving it can be identified, current strengths that will propel the vision forward, recognized and effective strategies established (Table 1).Reference Williams, Perillo and Brown 12
EMS EBP STRUCTURE
Structure: barriers
Structural elements include, but are not limited to, people, equipment, and education. Several structural barriers to the effective incorporation of EBP into EMS practices and clinical care have been identified. The predominant barriers are 1) lack of EBP and research expertise within EMS systems, 2) little or inconsistent training in EBP for clinicians and leaders, and 3) few effective clinical decision support tools that are evidence-based.
To foster the development of EBP expertise among those who work in EMS, foundational training programs for paramedics, physicians, and EMS administration and leadership must include EBP. As in EM, instilling these principles in new graduates enables effective KT. In a recent survey of the Royal College of Physicians and Surgeons of Canada residency directors, key areas of improvement were found to be increasing the number of EBM experts available at sites, incorporating EBM principles into regular learner journal clubs, and nationalization of EBM resources.Reference Bednarczyk, Pauls and Fridfinnson 13 Correspondingly, paramedic training needs to incorporate the same principles of EBP throughout the continuum of each program. EMS clinicians (paramedics, physicians, and others) should graduate prepared to locate and use reliable EBP resources. Further work is required to effectively integrate EBP at the EMS point of care with patients. During EMS calls, paramedics and online medical oversight physicians (where applicable) require reliable resources that are simple to navigate and apply. There has been little published on how best to include EBP within clinical decision support tools, and whether they improve clinical care, particularly in the EMS setting.Reference Hagiwara 14 EMS administrative leaders require EBP skills to incorporate evidence into policy decision-making, an area that requires further specific training and resources.Reference Jensen, Bigham and Blanchard 15
Structure: strengths and implementation strategies
Several strengths exist in Canada to improve structures to enable EBP. Some Canadian EMS systems have dedicated research positions, which often provide local EBP expertise. The EBP function can also be embedded into other key positions, such as clinical quality positions, particularly if these staff members receive specific training in this area. Staff members in these positions develop expertise through experience, if their system requires a structured EBP process for updates to protocols, policies, procedures, and practices (PPPP) to be updated. Research has become a requirement for training at all levels in the Paramedic Association of Canada’s National Occupational Competency Profile (NOCP), which helps drive this standard forward 16 (http://www.paramedic.ca/site/nocp?nav=02). Significant variation in the amount of time and resources invested in EBM likely exists across training programs, but this may continue to improve with national discussions and growing expectations for emphasis to be placed on EBP. Clinical decision support tools are promising. These have the potential to provide evidence-based resources and tools in a concise, easily accessible format. Some Canadian EMS systems have disseminated their local PPPP to staff via smartphone apps. The success of these is a platform to build upon to get EBP tools into the hands of those who need them at the right time. EMS stakeholders must be proactive to make incremental improvements in EBP structure, including expertise, training, and tools. Resources must be allocated in these areas to build a sustainable structure in which EBPs can thrive.
PROCESSES FOR EMS EBP
Process: barriers
Process elements include, but are not limited to, PPPP. The leading process barrier is that, in many systems, EMS PPPP are not based on research evidence. This is likely for three main reasons. First, the tendency has been to extrapolate EM knowledge into the EMS realm of practice.Reference Bigham and Welsford 17 Recently, the evidence flow has been in the inverse direction: high-quality EMS research data have been generalized to the in-hospital setting.Reference Mausz and Cheskes 18 Adapting research findings from the EMS to the EM setting (or vice versa) may work well for some clinical constructs (e.g., stroke, STEMI care in urban locations), and opportunities to do this are limited for others (e.g., rural management of abdominal pain). This is because of a lack of research evidence in some conditions, and also clinical presentation and care differ enough between the settings that generalizing must be done carefully. EMS must continue to work with EM stakeholders in identifying common areas in which EBP/KT efforts can be optimized. Likewise, EM stakeholders must continue to appreciate the nuances of EMS practices.
The second process barrier is the relative lack of research evidence available for EMS care, like the EM body of research that is in relative youth compared to hospital-based practices.Reference Wright, Trott and Lindsell 19 This concern is continuously decreasing as the quality and quantity of the EMS evidence base expands rapidly. Of note, much EMS knowledge resides in quality improvement and program evaluation programs. The information derived from these processes should be incorporated into the evidence-based decision-making processes, rather than in separate silos (Figure 2).
Figure 2 Evidence Evaluation Process in EMS. Adapted from <1>.
The third process barrier is the effort required to identify the evidence and incorporate it into practice. This has been previously well described in the EMS landmark article by Cone; we must first “get the evidence straight” and then “get the evidence used” (see Figure 2). Both parts of this equation can be perplexing to implement and maintain in a meaningful way within Canadian EMS systems.Reference Cone 1 Translation of evidence from EM to EMS must be done carefully,Reference Bigham and Welsford 17 because loosely generalized research findings can lead to practices that are no longer evidence-based. The effort required to conduct literature searches, select relevant studies (consciously excluding those that are not), analyse, synthesize, and apply to the breadth of EMS care is immense.
Process: strengths and implementation strategies
There are a few well established Canadian EMS-specific evidence resources available, including the Canadian Prehospital Evidence-based Practice (PEP) project (https://emspep.cdha.nshealth.ca/Default.aspx).Reference Jensen, Petrie and Travers 20 Similar programs exist or are in development in AustraliaReference Smith and Kenneally 21 and Ireland 22 (http://www.ul.ie/cpr/node/661). Perhaps the most well-known example of an EBP activity is the resuscitation recommendations that stem from the evidence reviews of the International Liaison Committee on Resuscitation.Reference Neumar, Shuster and Callaway 23 Incorporating these resources into EMS guideline development and updating processes is efficient – saving the steps of literature searching, selection, and appraisal. In the United States, a large national project to develop national EMS evidence-based guidelines is underway,Reference Brown, Macias and Dayan 24 , Reference Lang, Spaite and Oliver 25 and, similarly, the U.S. PEGASUS project is establishing evidence-based guidelines for pediatric EMS. 26 On a smaller scale, this was explored several years ago in Canada through a small pilot EMS evidence-based guidelines project.Reference Jensen and Dobson 27
Methodology for conducting evidence reviews is continuously becoming more streamlined and timely. One of the leading approaches for the development of evidence-based guidelines is the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology, which has been used in several projects, including the U.S. National Evidence-Based Guidelines Project,Reference Brown, Macias and Dayan 24 the ILCOR evidence review process,Reference Morrison, Gent and Lang 28 and the development of the Surviving Sepsis International Guidelines.Reference Dellinger, Levy and Rhodes 29 The AGREE II tool is a robust methodological approach for developing evidence-based guidelines.Reference Brouwers, Kho and Browman 30 Efficiently targeting the evidence for specific questions is improving with rapid evidence reviews.Reference Harker and Kleijnen 31 , Reference Ganann, Ciliska and Thomas 32 Some institutions even offer rapid reviews as a service, such as the Ottawa Hospital Research Institute 33 and McMaster University Health Forum. 34 Rapid reviews are often helpful for specific policy and system-level decisions, which may not be addressed through the evidence reviews completed for clinical guidelines. For example, recently, the Nova Scotia provincial government funded a rapid evidence review on collaborative emergency centres to inform decision-making for this program.Reference Hayden, Killian and Zygmunt 35
EMS stakeholders can use existing EBP processes established within Canada, as well as International EMS systems to advance their local systems. EM and EMS physicians who are in the position of developing and overseeing local practice guidelines need not feel they are alone in their venture. There are several EM and EMS leaders in the country who have gained significant expertise and experience in guideline development using these methods. Using a common and shared framework at the national level for “getting the evidence” and “getting the evidence straight” propels potentially limited local resources for “getting the evidence used.” It is essential to incorporate local evidence generated from quality improvement and program evaluation data into EBP. Methods used to generate these findings can be evaluated, and this evidence should be translated to practice and readily available for the end user to consider and use. Finally, EMS systems are grounded in a protocol-driven culture. Traditionally, EMS care and processes have been directive and specific. Although there is a movement towards more open guidelines, the benefit of protocols must not be dismissed. Protocols provide a structured vehicle for many people to perform in the same way, which can enable consistent application of EBPs. EMS must strike a healthy balance between the use of guidelines and protocols. This should be guided through national discussion and identification of best practices.
SYSTEMS FOR EMS EBP
System: barriers
System barriers include programs, resources, and the current EMS culture. A recent literature review identified seven publications describing evidence-based approaches and frameworks for EMS clinical policy decision-making.Reference Muecke, Curac and Binks 36 The summary from this scant literature found that EBP for decision-making is challenging and unlikely to be successful if the efforts were not adequately resourced, which includes funding, expertise, time, and high-level support. A culture that promotes (even demands) EBP and sufficient funding are required to build sustainable programs within EMS systems. This can be challenging because of the asynchronous timing of research (notoriously long), guideline release dates (e.g., resuscitation guidelines released every 5 years in the fall), and operational budget cycles (e.g., usually beginning in the spring). Purposeful inclusion of research, EBP, and anticipated changes to guidelines in business planning strategies would ensure that funding decisions for this are considered. Investment in resources, including developing local EBP expertise and time for EBP activities, can minimize the “knowledge to action” (K2A) gap.Reference Graham and Tetroe 37 Once evidence is translated or codified into EMS PPPP, efforts must be focused on factors that will enable evidence to be usedReference Gaddis, Greenwald and Huckson 38 and evaluated in an ongoing culture and system of quality (Figure 3).
Figure 3 Focus for Action with Availability of Various CPGs.
System: opportunities and implementation strategies
Effective EMS (and EM) EBP systems are developed and maintained by integrating EBP structure elements (e.g., people trained in EBP with appropriate resources) with EBP process elements (e.g., evidence review of PPPP). Because resources available to EMS for EBP may be limited, it is important for local EMS systems not to “re-invent the wheel” (see Figure 3). If a published high-quality EMS guideline informs the user on “what to do” and “how to do it,” which includes the provision of high quality, effective KT tools (e.g., slide sets, pocket guides), the focus should be the development and execution of an effective implementation strategy. If a quality published guideline informs the user on “what to do” but lacks any “how-to” tools, then the priority is to determine how to effectively operationalize the information in the local system in the most meaningful way. There is opportunity here for sharing best practices across EMS systems. If no guideline exists, or the guideline is of low quality, then the focus should be on conducting in-depth evidence appraisal. An effective Canadian EMS EBP system would clearly catalogue the various bodies of knowledge (i.e., clear what/how clinical practice guidelines [CPG] v. what only CPG, etc.), increasing efficiency for end users when searching for CPG and KT tools.
It is challenging to measure the effect of specific EBP initiatives. Does integrating evidence with clinical and policy decision-making make a difference to important outcomes? Importantly, previous work from the United States proposed EMS performance measures that were grounded in research evidence,Reference Myers, Slovis and Eckstein 39 which has been expanded in the recent COMPASS project. 40 This shifts reliance from traditional performance indicators, such as response times, to indicators that reflect important outcomes, including clinical patient care and safety outcomes. Further research is needed to demonstrate the value of EBP. One study from the United States demonstrated an increase in protocol compliance for appropriate analgesia dosing with the introduction of an evidence-based EMS guideline.Reference Hirshon, Warner and Irvin 41 Similar work is needed to demonstrate the effect on other important structure, process, system, and outcomes (SPSOs).Reference Kronick, Kurz and Lin 10 , 26 As in the process strategies, sharing limited resources at a national/international level to establish the evidence and get it straight with acceptable evidence evaluation tools enables local EMS agencies to optimize resources for “getting it used.”Reference Wright 42
CONCLUSION
The vision for EBP in Canadian EMS is to use the best available evidence to improve outcomes, including clinical, system, safety, and quality. Achieving meaningful, sustainable practices that incorporate evidence into clinical and policy decision-making can be challenging. Identification of barriers at the structure, process, and system levels enables current opportunities to become clear and targeted implementation strategies to be developed. This approach to improving EBP may be effective at the local EMS level, and the model is also applicable to EM departments and systems. Framing national discussions with this approach will be useful for developing a cohesive and collaborative Canadian strategy.
Acknowledgements: The authors would like to recognize Dr. Alix Carter for her advice in the design and writing of this article. Jan Jensen receives salary support from Emergency Health Services Operations Management, and Dr. Andrew Travers is supported by Emergency Health Services Nova Scotia. The authors would also like to thank the following, for their feedback on Canadian examples of EMS EBP initiatives: Ian Blanchard, Alberta Health Services EMS; Charlene Vacon, Alberta Health; Aaron DeRosa, Emergency Health Service Nova Scotia; and Dr. Gina Agarwal, McMaster University.
Competing interests: Academic conflicts include Senior Editor roles for the Dalhousie Canadian Prehospital Evidence-based Practice Project (JLJ) and International Liaison Committee on Resuscitations Committee Basic Life Support co-chair (AHT) and committee member (JLJ).
