Research in EMSResearch in EMSIntroduction to researchIntroduction to research

Steven Kanarian, MPH, EMT-PSteven Kanarian, MPH, EMT-P

ObjectivesObjectives

Understand research stepsUnderstand research steps Types of researchTypes of research Understand the need for Understand the need for

research in EMSresearch in EMS Role of provider in researchRole of provider in research

What is research?What is research?

Research is learning, seeking the Research is learning, seeking the truthtruth

We learn and gain experience every We learn and gain experience every day.day.

Research is observational or Research is observational or experienceexperience Anecdotal experienceAnecdotal experience Systematic observationSystematic observation Hypothesis testingHypothesis testing

What is evidence based What is evidence based medicine?medicine?

Aims to apply evidence gained Aims to apply evidence gained from the scientific method to from the scientific method to certain parts of medicinecertain parts of medicine Evaluates:Evaluates:

Quality of evidenceQuality of evidence Risk/benefit of treatmentRisk/benefit of treatment

Uses current best evidence to Uses current best evidence to guide careguide care

IOM recommends:IOM recommends:

Separate institute of Separate institute of emergency medicine research emergency medicine research neededneeded The Future of Emergency Care in the US: The Future of Emergency Care in the US:

The Institute of Medicine Subcommittee The Institute of Medicine Subcommittee on Prehospital Emergency Medical on Prehospital Emergency Medical Services, (Ann. Emerg. Med. 2006;48:126-Services, (Ann. Emerg. Med. 2006;48:126-130)130)Challenge for EMS is to measure outcomes.

Types of researchTypes of research

Retrospective – looking backRetrospective – looking back Prospective – designing a study Prospective – designing a study

protocol, collecting data in the protocol, collecting data in the futurefuture

BlindedBlinded RandomizedRandomized Experimental Experimental

Types of researchTypes of research

Retrospective – looking backRetrospective – looking back

Types of researchTypes of research

Prospective – designing a study Prospective – designing a study protocol, collecting data in the protocol, collecting data in the futurefuture

Types of researchTypes of research

BlindedBlinded

Types of researchTypes of research

RandomizedRandomized

Types of researchTypes of research

Experimental Experimental

Literature ReviewLiterature Review

Used to define and explore the Used to define and explore the research topicresearch topic

Literature SearchLiterature Search

Discovers existing researchDiscovers existing research Will help refine questionsWill help refine questions CINAHL, MEDLINE, Science CINAHL, MEDLINE, Science

Direct, PubMedDirect, PubMed Keywords and review articlesKeywords and review articles Note bibliographies and authorsNote bibliographies and authors Search will guide your projectSearch will guide your project

Developing a QuestionDeveloping a Question

Developing the questionDeveloping the question Narrow questionNarrow question Consider past researchConsider past research New trendsNew trends Consults expertsConsults experts

Determining the type of Determining the type of studystudy

ResourcesResources Data availabilityData availability

RegistryRegistry Call report reviewCall report review

Question being askedQuestion being asked StaffingStaffing

Developing the Research Developing the Research ProjectProject

Developing the methodsDeveloping the methods Power calculationPower calculation IRB approvalIRB approval Interacting with providersInteracting with providers Conducting a pilot studyConducting a pilot study Implementing study/analyze Implementing study/analyze

datadata

Reporting the findingsReporting the findings

CME or local conferenceCME or local conference PCRF Forum at JEMSPCRF Forum at JEMS NAEMSP, NAEMSE conferencesNAEMSP, NAEMSE conferences Article or abstract publicationArticle or abstract publication Pre-hospital Emergency Care Pre-hospital Emergency Care

(PEC)(PEC) Annals of Emergency Medicine Annals of Emergency Medicine

(AEM)(AEM)

An Introduction to EMS An Introduction to EMS Research Research

Lawrence H. Brown, Elizabeth Criss, N. Lawrence H. Brown, Elizabeth Criss, N. Heramba PrasadHeramba Prasad

Prentice Hall, Brady publicationsPrentice Hall, Brady publications

Recommended reading….

Reviewing Research Reviewing Research ArticleArticle

Journal/TitleJournal/Title Authors Authors Type of studyType of study Who is doing/paying for studyWho is doing/paying for study MethodsMethods FindingsFindings ConclusionsConclusions

Reading the LiteratureReading the Literature

Critical analysisCritical analysis do the numbers add updo the numbers add up do the numbers make sensedo the numbers make sense do the results answer the questiondo the results answer the question is the data extrapolated too faris the data extrapolated too far

Evaluating An ArticleEvaluating An Article

Evaluate demographicsEvaluate demographics similar system configurationsimilar system configuration similar patient distributionsimilar patient distribution

Evaluate numbersEvaluate numbers enough patientsenough patients right equipmentright equipment comparing apples to apples comparing apples to apples

Reading the LiteratureReading the Literature

Limitations to existing literatureLimitations to existing literature no perfect project no perfect project acknowledge strengths & acknowledge strengths &

weaknessesweaknesses Incorporating into practiceIncorporating into practice

influence current practiceinfluence current practice how much is enoughhow much is enough evidence-based practiceevidence-based practice

Participating in research is importantParticipating in research is important to current practiceto current practice to future practiceto future practice to establishing the professionalism of EMSto establishing the professionalism of EMS

Begin with reading the literatureBegin with reading the literature booksbooks journalsjournals electronic mediaelectronic media

Be critical of researchBe critical of research not all published research is good researchnot all published research is good research not all published research is valuable researchnot all published research is valuable research not all published research is reported correctlynot all published research is reported correctly

Hold people accountableHold people accountable Research is the future of EMSResearch is the future of EMS

validatesvalidates promotespromotes improvesimproves

Let’s take a closer lookLet’s take a closer lookSignificant research in EMSSignificant research in EMS

Research: General Principles and Research: General Principles and Emergency Medicine ApplicationEmergency Medicine Application

John B. McCabe, MD, FACEPJohn B. McCabe, MD, FACEP

Problems with Research in Problems with Research in Emergency MedicineEmergency Medicine

Sporadic patient Sporadic patient loadload

Pre-defined Pre-defined treatmenttreatment

Medical recordsMedical records Multi-institutional Multi-institutional

cooperation may cooperation may be difficultbe difficult

Funding ??Funding ??

What are these???What are these???

MAST PantsMAST Pants

Thought to…..Thought to….. Auto-transfuse 2 units of bloodAuto-transfuse 2 units of blood Increase PVRIncrease PVR Raise BPRaise BP Stabilize pelvic fracturesStabilize pelvic fractures Control surface bleedingControl surface bleeding

Widely used in 1980’s-1990’sWidely used in 1980’s-1990’s

“What happened???”

What happened…What happened… STUDY: Randomized trial of STUDY: Randomized trial of

pneumatic antishock garments in pneumatic antishock garments in the prehospital management of the prehospital management of penetrating abdominal injuries penetrating abdominal injuries

MDWilliam H BickellMDWilliam H Bickell, MDPaul E Pepe, MDPaul E Pepe †, , ‡, , , MDMark , MDMark L BaileyL Bailey, MDCharles H Wyatt, MDCharles H Wyatt and MDKenneth L and MDKenneth L Mattox* Mattox* *Department of Surgery, Baylor College of Medicine, Ben Taub *Department of Surgery, Baylor College of Medicine, Ben Taub General Hospital, Houston, Texas, USAGeneral Hospital, Houston, Texas, USA†Department of Medicine, Baylor College of Medicine, Ben Taub †Department of Medicine, Baylor College of Medicine, Ben Taub General Hospital, Houston, Texas, USAGeneral Hospital, Houston, Texas, USA‡City of Houston Fire Department Emergency Medical Services, ‡City of Houston Fire Department Emergency Medical Services,

Houston, Texas, USAHouston, Texas, USA

Randomized StudyRandomized Study Alternate day randomization (control, Alternate day randomization (control,

N=104, MAST, N = 97)N=104, MAST, N = 97) The results demonstrated no significant The results demonstrated no significant

difference in the survival rates of the difference in the survival rates of the control and PASG treatment groups (81 control and PASG treatment groups (81 of 104 vs 67 of 97).of 104 vs 67 of 97).

“ “ From these data we conclude that, From these data we conclude that, contrary to previous claims, the PASG contrary to previous claims, the PASG provides no significant advantage in provides no significant advantage in improving survival in the urban improving survival in the urban prehospital management of penetrating prehospital management of penetrating abdominal injuries. “abdominal injuries. “

The Ontario Prehospital The Ontario Prehospital Advanced Life Support StudyAdvanced Life Support Study

(OPALS)(OPALS)Ian G Stiell MD, MSc, FRCPC *‡§, George A Wells PhD ‡§, Ian G Stiell MD, MSc, FRCPC *‡§, George A Wells PhD ‡§,

Daniel W Spaite MD ¶IIII, Graham Nichol MD, MPH, FRCPC Daniel W Spaite MD ¶IIII, Graham Nichol MD, MPH, FRCPC #§, Bernard O’Brien PhD**, Douglas P Munkley MD, #§, Bernard O’Brien PhD**, Douglas P Munkley MD,

MCFP(EM)¶, Brian J Field EMA III II, Marion B Lyver MD, MCFP(EM)¶, Brian J Field EMA III II, Marion B Lyver MD, FRCPC, MCFP(EM)#, Lorraine G Luinstra BScN, MHA¶, FRCPC, MCFP(EM)#, Lorraine G Luinstra BScN, MHA¶,

Eugene Dagnone MD, FRCPC‡‡, Tony Campeau BSc§§, Eugene Dagnone MD, FRCPC‡‡, Tony Campeau BSc§§, Roxanne Ward RN§, Steve Anderson BSc§ and For the OPALS Roxanne Ward RN§, Steve Anderson BSc§ and For the OPALS

Study GroupStudy Group

OPALSOPALS

Largest ALS study in the WorldLargest ALS study in the World Will involve 25,000 cardiac Will involve 25,000 cardiac

arrest, trauma and respiratory arrest, trauma and respiratory patientspatients

““Before and after”studyBefore and after”study 8 years of collecting data8 years of collecting data

Outcomes measuredOutcomes measured

Disease Specific Quality of LifeDisease Specific Quality of Life Respiratory Distress and Trauma Respiratory Distress and Trauma

areasareas Process of care measures (rates Process of care measures (rates

of success failure for skills)of success failure for skills) Response timeResponse time Length of stayLength of stay

Unique StudyUnique Study

Before phaseBefore phase Rapid Defib phaseRapid Defib phase ALS phaseALS phase Able to compare the incremental Able to compare the incremental

improvementimprovement

ProvedProved

AED Defibrillation saves livesAED Defibrillation saves lives Medics treat respiratory distress Medics treat respiratory distress

and chest pain effectivelyand chest pain effectively Sets bar for other large scale Sets bar for other large scale

prospective studiesprospective studies

1st responders increase 1st responders increase survivalsurvival

January 1, 1999 to January 31, January 1, 1999 to January 31, 19951995

5,335 Cardiac Arrest Patients5,335 Cardiac Arrest Patients 46.8% witnessed by bystanders46.8% witnessed by bystanders 14.5% received bystander CPR14.5% received bystander CPR 25% received 125% received 1stst responder CPR responder CPR Increased save rate to 3.5 and 8.5% Increased save rate to 3.5 and 8.5%

for VFibfor VFib

Occupational injuries among Occupational injuries among EMS personnelEMS personnel

McGuire, Hunting, Guidotti, Smith McGuire, Hunting, Guidotti, Smith Prehospital Emergency Care 2005;9: 405-411Prehospital Emergency Care 2005;9: 405-411

ObjectiveObjective

Describe the epidemiology of Describe the epidemiology of occupational injuries among occupational injuries among EMS personnel, calculate injury EMS personnel, calculate injury rates, and compare findings with rates, and compare findings with other occupational groups.other occupational groups.

EMS Providers treat 22 million EMS Providers treat 22 million patents per year, little known patents per year, little known about our injuriesabout our injuries

MethodsMethods

Retrospective review of injury records Retrospective review of injury records kept by two urban agencieskept by two urban agencies

617 cases over 3 years617 cases over 3 years Injury rate was 34.6 per 100 employeesInjury rate was 34.6 per 100 employees Most often sprains, strains and tearsMost often sprains, strains and tears Back most frequentBack most frequent 277 cases resulted in lost days from 277 cases resulted in lost days from

workwork

ConclusionsConclusions

Injuries greater for EMS than Injuries greater for EMS than any other industry in 2000 any other industry in 2000 according to DOL statisticsaccording to DOL statistics

Recommended funding and Recommended funding and further research are critical to further research are critical to define problem and prevent define problem and prevent injuriesinjuries

What would you like to What would you like to study??study??

Emerging topicsEmerging topics

Intubation by paramedicsIntubation by paramedics Pain managementPain management EMS Skill retentionEMS Skill retention System designSystem design Clinical interventionsClinical interventions

Where to start?Where to start?

Descriptive study- what are we Descriptive study- what are we doing for our community/school?doing for our community/school?

Where are we making a Where are we making a difference?difference? Pain managementPain management Injury preventionInjury prevention Reduced response timeReduced response time Reduced health care costsReduced health care costs

Research starts with a Research starts with a question and a desire to question and a desire to

learn the truth.learn the truth.

We know EMS makes a We know EMS makes a difference, let’s prove it!!difference, let’s prove it!!

Please leave a Please leave a comment…comment…

Questions about researchQuestions about research How to review an articleHow to review an article