Informing clinical policy decision-making practices in ambulance services

E V I D E N C E T R A N S F E R

Informing clinical policy decision-making practices inambulance services

Sandy Muecke PhD,1 Nada Curac MPH1 and Darryn Binks BHSc (Prehospital)2

1Research, and 2Clinical Professional Development, Ambulance Service of New South Wales, Sydney, New South Wales, Australia

AbstractAim This study aims to identify the processes and frameworks that support an evidence-based approach to clinicalpolicy decision-making practices in ambulance services.

Methods This literature review focused on: (i) the setting (pre-hospital); and (ii) the process of evidence transla-tion, for studies published after the year 2000. Searches of Medline, CINAHL and Google were undertaken. Referencelists of eligible publications were searched for relevant articles.

Results A total of 954 articles were identified. Of these, 20 full text articles were assessed for eligibility and sevenfull text articles met the inclusion criteria. Three provided detailed descriptions of the evidence-based practiceprocesses used to inform ambulance service protocol or guideline development or review.

Conclusions There is little published literature that describes the processes involved, and frameworks required, toinform clinical policy decision making within ambulance services. This review found that processes were iterative andinvolved collaborations across many internal and external stakeholders. In several jurisdictions, these were coordi-nated by a dedicated team. Success appears dependent on committed leadership and purposive human andstructural resources. Although time consuming, structured processes have been developed in some jurisdictions toassist decision-making processes. Further insight is likely to be obtained from literature published by those from otherdisciplines.

Key words: clinical protocols, emergency medical services, evidence-based practice, guideline, health policy.

Background

Prior to the delivery of an episode of care, two importantprocesses need to have occurred to optimise quality ofcare.1–3 The first is the generation of fundamental clinical orscientific knowledge that has the potential to improve health.The second, dependent upon the first, is the application orimplementation of this knowledge in a way that activelyimproves health. Knowledge translation describes these pro-cesses; the passage of research evidence into practice.2

Before the early 1990s, medical practice was based on thenotion that clinical experience, an understanding of humanphysiology and disease, and ‘traditional medical training andcommon sense’ were sufficient skills to underpin effectiveclinical decision making.4 Capacity for change towards theincorporation of research evidence into healthcare decisionmaking occurred after the 1960s, as the value of the

randomised controlled trial, meta-analyses and other well-conducted methodologies became apparent.4

Sackett et al.5 described evidence-based practice as the‘conscientious, explicit, and judicious use of current bestevidence in making decisions about the care of individuals’but noted that ‘external clinical evidence can inform, butnever replace, individual clinical expertise’. A literature reviewby Lomas et al.6 outlined three types of evidence that may allplay an important role in decision-making processes: (i)medical effectiveness research evidence, or context-free guid-ance about what could occur in an ideal situation; (ii) socialscience research evidence that provides context-sensitiveguidance to determine what is actually possible; and (iii)colloquial evidence that provides local relevance. In practicalterms, evidence-based judgements need to consider a com-bination of these types of evidence to ‘increase the likelihoodof making solid decisions’.6 This may be particularly so in thepre-hospital context, where there may be a paucity of high-quality medical effectiveness research evidence7,8 to informdecision making. Indeed, as evidence comes in many forms

Correspondence: Dr Sandy Muecke, Research, Ambulance Serviceof New South Wales, Church Street, Locked Bag 105, Rozelle,NSW 2039, Australia. Email: [email protected]

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doi:10.1111/1744-1609.12039 Int J Evid Based Healthc 2013; 11: 299–304

© 2013 The AuthorsInternational Journal of Evidence-Based Healthcare © 2013 The Joanna Briggs Institute

and ‘always informs expert opinions’,9 the term evidence-informed practice may better reflect the actual process.

In 2004, the World Health Organization, together with theGovernment of Mexico, convened the Ministerial Summit onHealth Research, in Mexico City, attended by 52 ministers andother delegates, from 58 countries. The summit aimed toimprove the translation of population health knowledge intopractice. The Mexico Statement summarised the meeting’sresolutions and declared that ‘health policy, public health,and health service delivery should be based upon reliableevidence derived from high quality research’ and that ‘ignor-ing research evidence is harmful to individuals and popula-tions and wastes resources’.10 In particular, embedding theprinciples of evidence-based medicine into clinical policydecision making assists in: the provision of optimal patientcare by preventing the introduction of harmful, non-beneficial or wasteful interventions;1 the premature introduc-tion of new interventions; the reduction of undesirablevariations in the quality of clinical practice; and addressinghealth equity issues.11 However, despite medical advances,patients do not always receive the care that has been shownthrough research to be the most efficacious.1,2,9 Where evi-dence exists, this reflects a failure to achieve the second of theknowledge translation processes – the conversion of researchfindings into clinical policy and practice.

Aims

Oxman et al.9 have identified common problems encoun-tered by organisations when attempts are made to utiliseevidence in policy decision-making practices. These includea ‘lack of organizational arrangements to support the use ofresearch evidence’. Indeed, while the principles of evidence-based medicine have been adopted in many areas ofhealthcare, a ‘systematic and transparent’9 process of trans-lating evidence from research studies into clinical or opera-tional practices within ambulance services is not wellunderstood.1,12 As such, this paper aims to identify evidence-based processes and frameworks that inform clinical policydecision-making practices within ambulance services.

Methods

A review of the academic pre-hospital literature was under-taken to identify the processes and frameworks that havebeen adopted by ambulance services to support the appli-cation of best-available evidence in policy decision-makingpractices. Studies eligible for inclusion in the review werethose that examined the processes involved in pre-hospitalprotocol or guideline development or review. Those studiesnot based in a pre-hospital setting were excluded. Thereview included any type of study. To ensure the contempo-rary nature of the information gathered, studies publishedbefore 2000 were excluded.

Studies were identified through systematic searches ofMedline and CINAHL. The search focussed on (i) the setting(pre-hospital) and (ii) the process of evidence translation.Key search terms are provided in Table 1. These terms were

mapped to appropriate subject headings and searched as akeyword in each database. All articles were imported into anEndNote (EndNote X5, Thomson Reuters, New York, NY,USA) library, and duplicates were removed. An initial screenof titles and abstracts was conducted by one author (NC) toidentify articles meeting the study inclusion criteria. Discus-sion articles relating to the topic of pre-hospital researchbut not fulfilling the inclusion criteria were categorised assupplementary articles. The reference list of publicationsdeemed eligible was searched for relevant articles. A Googlesearch using the terms and variations of ‘protocol develop-ment’ and the ‘prehospital setting’ was also conducted.

Results

A total of 953 articles were identified through the Medlineand CINAHL search processes. An additional article was iden-tified from the Google search. Of the 954 manuscriptsscreened on the basis of title and abstract, 20 full text articleswere assessed for eligibility and a total of seven articles metthe inclusion criteria (Fig. 1).

Most articles were published by North American (USA andCanada) authors. Some emanated from Europe and theUnited Kingdom (UK). One paper was a collaborative projectof researchers from Qatar and the USA. To varying degrees,all articles described the processes involved in developing

Table 1 Electronic search strategy (Medline). Key search terms,mapped to appropriate subject headings in each database andsearched as a key word in title and abstract. MeSH: Medical subjectheading (Medline medical index term); Dollar sign ($) = any char-acter(s); Question mark (?) = to substitute for one or no characters

MESH term (Medline) Key word (phrase searching)

Set 1: Pre-hospital setting1. Emergency medical

services‘emergency medical service$’;

‘emergency service$’, ems;‘pre?hospital’; ‘paramed$’;‘out-of-hospital’

2. Emergency treatment EMT; ‘emergency practitioner’;3. Emergency medicine4. Ambulances ‘first responder$’; ‘emergency rescue’5. Air ambulance1 OR 2 OR 3 OR 4 OR 5

Set 2: Process of evidence translation1. Translational medical

research‘translation$ medical research’;

‘translation$ research’; ‘translation$practice’; knowledge translation’;‘diffusion of innovations’;‘knowledge broker’; ‘knowledgesynthesis’; ‘knowledge transfer’;‘knowledge exchange’

2. Evidence basedmedicine

‘evidence based’; ‘evidenceinformed’; ‘protocol development’;‘develop$ protocol$’

1 OR 2Set 3: FinalSet 1 AND Set 2 Limited to availability of abstracts,

English language and humans.

300 S Muecke et al.


protocols or guidelines for use in the pre-hospital setting(Table 2). Six articles were expert committee reports ordescriptive reviews, and one was an opinion piece (Table 3).

A UK paper published in 2000 described the benefits ofestablishing guidelines for pre-hospital practice.13 Whilenoting the ‘scarcity of research evidence’, the authorobserved that guideline construction was a lengthy, ‘pains-taking’ process requiring the cooperation of a multidiscipli-nary team who possess skills in literature searching and criticalappraisal. Furthermore, to ensure ongoing success, the co-operation of ‘managers at the highest level’ was advocated.13

To assist emergency medical services providers care forchildren with special healthcare needs, the Center forPrehospital Pediatrics at the Children’s National MedicalCenter (CPP-CNMC) in Washington, DC, constructed a pre-hospital protocol.14 In their 2003 publication, the CPP-CNMC protocol group very briefly outlined the ‘consensusand information gathering’ process used to inform theprotocol. A literature review was undertaken, and interviewswere conducted with emergency medical services (EMSs)medical directors and pre-hospital care providers. Initial draftprotocols were formulated by those with expertise in thearea and distributed widely ‘twice over an eight monthperiod’14 to appropriate professional organisations, instruc-tors, medical directors and care providers.

In 2007, the National Pre-hospital Guidelines Group in theUK outlined the processes they used to inform their strokeguidelines.15 They began by clearly stating their objectivesand the specific clinical issues to be addressed. Contributionsfrom a ‘wide representation of all disciplines’ includingpatients and their families were sought. Consensus meetingswere held with the Intercollegiate Working Party for Stroke.Two members from the Rapid Emergency Stroke PathwaysWorking Group assessed the quality of publications identi-fied in literature reviews according to a modified Scottish

Intercollegiate Guidelines Network (SIGN) checklist. Evidencefrom meta-analyses and randomised controlled trials wasutilised preferentially, followed by observational or smallgroup studies. Other stroke guidelines were also reviewed.Although expert committee reports or opinions, or singlecase study evidence were not used, where there was noevidence, the clinical experience of the group was har-nessed. A plan to update the guidelines was established.

A report outlining an evaluation of the impact of the in-troduction of a medical director to the national EMS system inQatar – a process that had developed rapidly and ‘organically’since 1980 – was published in 2009.16 The paper stated thatevidence-based protocols were developed within 3 monthsbut did not describe the processes used to achieve that goal.

The Canadian Prehospital Evidence-Based ProtocolsProject (PEP) is an initiative that aims to address both knowl-edge translation processes (knowledge generation andapplication).17 The PEP grew from an initiative by the NovaScotia EMS and the Dalhousie University. The Project housesa repository of appraised evidence relating to pre-hospitalinterventions and is openly available online. A project coor-dinator manages literature reviews and sets-up automatedalerts. ‘Section editors’ undertake similar steps within their‘assigned protocol area’. Papers identified in literaturereviews or ad hoc searches are entered into the databasefor future review. The 46 section editors (two internationalmembers, 24 from seven Canadian provinces, and 13 para-medics with experience in critical appraisal) then rate studyquality using a modified ‘Level of Evidence’ (LOE) scale. Level1 evidence is that derived from ‘at least one properlyrandomized controlled trial’, with Level 3 evidence compris-ing less robust opinions, descriptive studies and reports.Based on the LOE scores for all studies within the topic area,a class of recommendation (COR) is awarded. Recommen-dations range from ‘A: good evidence to support interven-tion’ to ‘D: good evidence to support that the procedure ortreatment should not be used’. Section editors use a stand-ardised appraisal sheet to collate LOE and COR. Completedforms are returned to the project coordinator who reviewsthe appraisals and updates the website accordingly. Theonline evidence repository is organised according to para-medic protocols and interventions, making it simple forparamedics and decision makers to adapt it to the charac-teristics of their specific jurisdiction.

To address the occurrence of adverse outcomes resultingfrom unnecessary or prolonged cardiopulmonary resuscita-tion attempts, a Collaborative was formed between university-based researchers (University of California, Los Angeles)and leaders within the Los Angeles County EmergencyMedical Services (LAC EMS).18 Using the ‘principles of partici-patory research’, the group aimed to ‘translate a set ofevidence-based clinical standards’ into a policy to enableparamedics to cease resuscitative attempts for patients ‘inwhom the harm would probably exceed the benefit’. Policieswere iteratively developed over 1 year as a result of input froman expert panel, the EMS Commission (set up to advise theLAC EMS), the researchers and the LAC EMS. The expert panelidentified clinical indicators to be considered by the EMS

Database searchesMedline (n = 947), CINHAL (n = 591):

human subjects, English language, abstracts availableSearch results combined (n = 1538)

585 duplicates removed

934 records excluded

Full text articles excluded(n = 13)

Reasons:- Not in pre-hospital setting(n = 4)- Not about protocol development (n = 9)

Articles screened on basis of titleand abstract (n = 954)

Additional records identified through

Google search(n = 1)

Full text articles assessed for eligibility (n = 20)

Articles included in the review (n = 7)

Figure 1 Summary of search strategy and identification of articlesincluded in the review.

Policy decision-making in ambulance services 301


Commission in the revised policy. Panel membership con-sisted of resuscitation or end-of-life care experts, academicand community emergency physicians, a palliative carephysician/ethicist, nurse, paramedic and a chaplain. Theseauthors, however, did not describe any reviews or appraisalsof the wider literature. In California, EMS policies are reviewedcyclically, every 3 years, with changes considered in theinterim. New or amended policies are allocated by the EMSCommission chairperson to subcommittees or advisorygroups for review, approved by the EMS Commission,endorsed by the Director and then implemented by the EMScare providers.

In response to a report by the Institute of Medicine, Langet al.19 published an informative description of an eight-stepmodel to support the construction of evidence-based pre-hospital guidelines that were designed to be adapted intoprotocols locally to maximise their applicability. The firststep involves searching for existing systematic reviews fromestablished evidence-based practice centres. Guidelinesdeveloped by other pre-hospital organisations or relevantnon-EMS groups are also reviewed at the outset. The gen-eration of topics for guidelines is the subject of the secondstep, whereby a ‘thoughtfully composed’ core project teamevaluates submissions from stakeholders or considers topicalissues distilled from the literature. In the third step, therigour of the literature is evaluated. The authors promote theuse of ‘validated quality evaluation tools’ such as Appraisal ofGuidelines for Research and Evaluation II (AGREE). Step fourentails the development of the guideline from contributionsof paramedic organisations, universities and/or physicians.Use of the Grading of Recommendations, Assessment, Devel-opment and Evaluation (GRADE) system was advocated bythe authors to provide the foundation for constructingguidelines. GRADE is a system to assess the level of evidencefor a specific clinical question that is weighted towardspatient values,19 enabling clear recommendations to beissued. Agreed guidelines are adapted at the regional or locallevel into applicable protocols in step five. In step six, theseprotocols are disseminated and incorporated into educationprogrammes, followed by measures to ensure their imple-mentation (step seven). Measures of the impact of the proto-cols on the quality of care and patient outcomes constitutethe final, eighth step of the process.

Discussion

Seven pre-hospital studies fulfilled the inclusion criteria. Thepapers of Lang et al.,19 Grudzen et al.18 and Jensen et al.17

were notably informative in terms of describing the pro-cesses involved in clinical protocol or guideline develop-ment. While the latter two groups presented detailedinformation about their processes,17,18 the former19 provideda model of what could be done. All three, however, sharedmany similarities. The remaining authors addressed the issueless comprehensively.

This review indicated that success is likely to be evasivewhere there are unfunded, unstructured ‘grassroots’efforts’.19 Articles noted that the knowledge translationprocess could ‘be of immense benefit to patients and to theEMS professionals who care for them’19 but was not easy toachieve. Brown13 described protocol development as ‘timeconsuming and painstaking’ and requiring considerableresources and the support of ‘managers at the highest level’.

The more informative articles advocated for the searchof already published systematic reviews, followed by areview of other academic literature, as the first steps in thepolicy development process. Guidelines and grey literaturewere also promoted as important information sources. Toaugment and contextualise the information gatheredthrough the literature search, several papers described theincorporation of input from a carefully constructed multidis-ciplinary group/s comprised of those considered experts inthe field of pre-hospital care, research and/or the subjectmatter. Patient and community group contributions to theprocess were advocated by some, as well as consensusmeetings to provide a forum to synthesise information con-tributed by all groups and identify points of agreement(and disagreement).

Jensen et al.17 described how their knowledge translationfunctions are centralised through a project coordinator. Langet al. utilised a core evidence-based practice team to overseetheir processes.19 These staff need skills that include theability to define a problem, interrogate and critically appraisethe literature and assess the options and the applicabilityof the evidence for the context in which it is to be applied.9,20

The Canadian model,19 where guidelines are developed atthe national level and later adapted into protocols that are

Table 2 Processes involved in pre-hospital protocol development as described in the seven included articles

Process used Brown13 Singh et al.14 Jones et al.15 Munk et al.16 Jensen et al.17 Grudzen et al.18 Lang et al.19

Expert panel/group ✓ ✓ ✓ ✓ ✓ ✓ ✓

Critical literature appraisal ✓ ✓ ✓ ✗ ✓ ✗ ✓

Review of existing guidelines ✓ ✓ ✓ ✓ ✓ ✓ ✓

Collaboration with outside agencies ✓ ✓ ✓ ? ✓ ✓ ✓

Advice only from outside agencies ✓ ? ✗ ? ✗ ✗ ✗

Uses validated tool to assist inassessment of the evidence

? ? ✓ ? ✗ ✓ ✓

Process in place to evaluate/updateprotocol or guideline

✓ ? ✓ ? ✓ ? ✓

Online database ✗ ✗ ✗ ✗ ✓ ✗ ✗

✓Process specifically mentioned in article. ✗Process was not involved. ?Unclear whether process was involved.

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Table 3 Details of the seven included studies

Author,Year,Country

Study type Study aim Results Commentary on processesused to inform clinicalpolicy development in

pre-hospital setting

Brown(2000)13 UK

Opinion Discussion on thepotential benefits ofnationally createdguidelines forpre-hospital care andways in which they canbe introduced widelyinto UK ambulanceservices.

Advocacy forevidence-basedguidelines to improvecare.

At time of print, UK ambulance servicesreceived varied information to constructprotocols, including advice from localdoctors and ‘selective use of evidence’leading to inconsistencies. Importantto include expert opinions andmultidisciplinary teams. Protocoldevelopment requires high levelambulance management support. Needregular reviews.

Singh et al.(2003)14

USA

ExpertCommitteeReport

Detailed the pre-hospitalprotocol developmentprocess for childrenwith special healthcareneeds (CSHCN).

Protocols on pre-hospitalcare of CSHCN.

Review of regional practices. Use of experts:key informant interviews (EMS medicaldirectors); and pre-hospital provider focusgroups. Comprehensive literature andtransferable protocol reviews.Simultaneous education programme.Draft protocols distributed widely forreview across wide range of specialties.

Jones et al.(2007)15 UK

ExpertCommitteeReport

Develop stroke/transientischemic attackguidelines for carers andhealthcare staff workingin emergency careincluding thepre-hospital setting.

Protocol for pre-hospitalcare of stroke patients.

Consensus meetings between themultidisciplinary groups. Formal literaturereview conducted. Guidelines developedin accordance with AGREE framework.Higher levels of evidence usedpreferentially. SIGN appraisal checklistsused. Incorporated ‘views’ from patients,carers and the general public. Ongoingreviews and updates.

Munk et al.(2009)16

USA, Qatar

Non-experimentaldescriptive

Description of experienceof the EMS in Qatarwhen it employed itsfirst medical director.Briefly outlined protocoldevelopment process.

Provided comparisonsof key performanceindicators before andafter employment of amedical director.

Brief description of protocol development.Also included commentary on medicalcommand system, chart audits, educationand training.

Jensen et al.(2009)17

Canada

Expertcommitteereport

Described the formationof the Pre-hospitalEvidence-basedProtocols Project.

Construction of adatabase of pre-hospitalemergency care studiesthat have undergone aquality review process.

Described the organisational processesrequired to support the development andmaintenance of the database set up forongoing protocol/guideline developmentand review. Also outlined processes torate the quality of the evidence and theconstruction of recommendations.

Grudzen et al.(2012)18

USA


Development of clinicalstandard/policy to assistparamedic resuscitationdecision-making (whereharm may exceed thebenefit).

Appropriate protocoldeveloped within 1year.

A collaborative of experts (using modifiedDelphi technique) developedevidence-based clinical standards intoprotocols and submitted them for review.Included mention of stakeholder reviewprocess. Described issues relating toimplementation of protocol/policy.Success attributed in part to partnerships.

Lang et al.(2012)19

USA


Report of a model forpre-hospitalevidence-basedguideline development.

An eight-step model frominitial evidence reviewto implementation andevaluation.

Detailed model of how evidence-basedguidelines should be developed includingcentral management of literature reviews,evidence appraisal using validated tools,expert and community involvement andselection of strong evidence.

Policy decision-making in ambulance services 303


applicable at the local level, appears to offer the advantageof minimising replication of time and skill intensive processesand may assist in avoiding variations in practice betweenjurisdictions. The PEP database17 also reduces replication ofeffort as it facilitates the open sharing of information.

Others have also developed online databases of studiesthat can be easily accessed by many to inform the knowl-edge translation process. McMaster University in Canada hasdeveloped an impressive and extensive online warehouse of‘syntheses of research evidence about governance, financialand delivery arrangements within health systems, and aboutimplementation strategies that can support change in healthsystems’.21 This repository contains links to evidence briefsand a wide variety of systematic reviews that have beenimported from institutions such as the Cochrane Library,Centre for Reviews and Dissemination, Database of Reviews ofEffects and Health-evidence.ca.

A number of articles described the utilisation of varioustools that were designed to assist decision makers’ confi-dence in final recommendations. Tools included the AGREEinstrument19 for guideline development, Assessment of Multi-ple Systematic Reviews (AMSTAR),19 GRADE and SIGN.15

Another used their own systems to rank the level of evidenceand assign a COR.17

Seven studies fulfilled the search criteria, and of these, onlythree provided detailed descriptions of the knowledge trans-lation processes used within their organisations. The paucityof articles may or may not reflect the actual extent of utili-sation of evidence-informed policy clinical decision-makingpractices by ambulance services. The captured articles mayonly provide examples of those ambulance services thathave adopted a more structured approach. This reviewaimed to identify knowledge translation practices usedwithin ambulance services and, while the results provideuseful information, an interrogation of the wider healthcareliterature is likely to provide additional useful insights.

Conclusion

There is little published literature that describes the pro-cesses involved, and frameworks required, to inform clinicalpolicy decision-making practices within ambulance services.However, the currently implemented systems described byJensen et al.17 and Grudzen et al.,18 and the model proposedby Lang et al.19 provide notably informative guides and con-structive foundations for consideration by others. This reviewfound that pre-hospital policy-informing processes wereiterative and involved collaborations across many stakehold-ers including a range of clinicians, academics, researchersand community representatives. In several jurisdictions,these processes were coordinated by a dedicated team.Success appears dependent on committed leadership andpurposive human and structural resources. Although time-consuming, structured processes have been developed insome jurisdictions to assist decision-making processes.Shared online repositories of pre-hospital literature are anoption that could be further explored by ambulance ser-vices. While little has been published in the pre-hospital

literature, further insight is likely to be obtained from litera-ture published by those from other disciplines.

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Informing clinical policy decision-making practices in ambulance services

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