Applying Hospital Evidence to Paramedicine: Issues of Indirectness, Validity and Knowledge Translation

Abstract

The practice of emergency medicine (EM) has been intertwined with emergency medical services (EMS) for more than 40 years. In this commentary, we explore the practice of translating hospital based evidence into the prehospital setting. We will challenge both EMS and EM dogmabringing hospital care to patients in the field is not always better. In providing examples of therapies championed in hospitals that have failed to translate into the field, we will discuss the unique prehospital environment, and why evidence from the hospital setting cannot necessarily be translated to the prehospital field. Paramedicine is maturing so that the capability now exists to conduct practice-specific research that can inform best practices. Before translation from the hospital environment is implemented, evidence must be evaluated by people with expertise in three domains: critical appraisal, EM, and EMS. Scientific evidence should be assessed for: quality and bias; directness, generalizability, and validity to the EMS population; effect size and anticipated benefit from prehospital application; feasibility (including economic evaluation, human resource availability in the mobile environment); and patient and provider safety. RÉSUMÉLa pratique de la médecine d'urgence (MU) est étroitement liée aux services médicaux d'urgence (SMU) depuis plus d'une quarantaine d'années. Aussi les auteurs traitent-ils, dans le présent article, du transfert des données probantes, du milieu hospitalier au milieu préhospitalier. Sera remis en question un dogme admis tant par la MU que par les SMU; en effet, le transfert, sur le terrain, des pratiques en milieu hospitalier n'est pas toujours la meilleure solution. Il sera question, à l'aide d'exemples de traitements préconisés dans les hôpitaux qui se sont soldés par des échecs sur le terrain, du caractère propre du milieu préhospitalier et des raisons pour lesquelles l'application directe des données probantes, recueillies en milieu hospitalier ne convient pas nécessairement au milieu préhospitalier. Les secours paramédicaux sont une discipline en évolution, si bien que la capacité de recherche sur la pratique est suffisamment importante pour jeter une lumière nouvelle sur les pratiques exemplaires. Avant d'envisager l'application des connaissances recueillies en milieu hospitalier, il faut que les données probantes à l'appui soient évaluées par des experts dans trois domaines: l'évaluation critique, la MU et les SMU. Les données probantes de scientifiques devrait faire l'objet d'examen à l'égard: de la qualité et des biais; de l'application directe des données dans la population visée par les SMU ainsi que de leur généralisabilité et de leur validité; de l'ampleur de l'effet et des avantages prévisibles de l'application préhospitalière de ces pratiques; de la faisabilité (y compris l'évaluation économique et la suffisance des ressources humaines dans un environnement mobile); et finalement de la sécurité tant des patients que des fournisseurs de soins.

Paramedic Judgement, Decision-Making and Cognitive Processing: A Review of the Literature

“…As such, paramedics are required to assess and treat patients presenting with health and social-related emergencies of any nature and acuity (medical, traumatic, behavioural, psychological), and are routinely called on to make multiple time-sensitive clinical and nonclinical decisions. These are often performed in stressful and unpredictable situations within variable environments where lack of resources is an inherent factor (4,5). Moreover, these challenging operational circumstances yield conditions that are intrinsically uncertain and high risk (6), and are therefore prone to errors in judgement (7).…”

Collaboration, not stagnation, defines Ontario EMS

“…Before implementing new research, studies are assessed for directness, precision, consistency, bias and effect magnitude. 3 Available technology, provider training, patient safety, economics, operations, and the field environment are considered. Careful and intricate analysis of evidence, coupled with transparent expert discussion, takes time and patience.…”

Contemporary evidence-based practice in Canadian emergency medical services: a vision for integrating evidence into clinical and policy decision-making

“…First, the tendency has been to extrapolate EM knowledge into the EMS realm of practice. 17 Recently, the evidence flow has been in the inverse direction: high-quality EMS research data have been generalized to the in-hospital setting. 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).…”

“…Both parts of this equation can be perplexing to implement and maintain in a meaningful way within Canadian EMS systems. 1 Translation of evidence from EM to EMS must be done carefully, 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.…”