How EMS Providers Can Contribute to Research

This article is excerpted from Why Research Is Important in EMS.

Conducting a research project in EMS can seem intimidating, but it doesn’t have to be. Many published studies first start as small, internal quality improvement efforts, often to help internally validate the results of outside research.¹ While these internal efforts may not yield publishable results, they can still promote improvements within a system. Additionally, they can be shared locally with other agencies or at regional and national conferences. Finally, they can serve as the first step toward a more robust research project that can be published in a peer-reviewed journal.

The elimination of Lasix from the medical protocols of our own EMS agency is one example of how a small-scale study can inform EMS practice. In 2013 many EMS systems across the country were already in the process of eliminating Lasix from their medication formularies. In addition to its questionable efficacy in the prehospital setting, there was also concern regarding the ability of EMS providers to accurately discern the underlying cause of a patient’s pulmonary edema, or even distinguish between CHF and other respiratory presentations (such as asthma, COPD or pneumonia).²

Instead of immediately changing our protocols or ignoring the outside research, we decided to conduct an internal study to see if the results of the published studies held true in our agency. This would not only help us to determine how to interpret the research, but also allow us to translate the research in a way that EMS practitioners in our agency could relate to and accept—overcoming the inertia that often compels EMS providers to continue past practices despite mounting evidence against them.

First we reviewed every patient care report from the previous year that documented the administration of Lasix. Next we tasked our medical director (who works in the emergency department of our primary receiving hospital) to match each of those PCRs with a hospital patient record for the same episode of care. Finally we looked at whether each patient’s hospital record included a diagnosis of CHF. What we found was that about half the patients to whom our providers administered Lasix over the year were not ultimately diagnosed with CHF. On the basis of that finding, and the potential harm from administering Lasix to patients not in fluid overload, we decided to remove Lasix from our ambulances.

For this small study, we did not perform any formal statistical analysis or submit to an institutional review board process. Moreover, our results were neither publishable nor generalizable to other EMS systems. Nevertheless, the results allowed our agency to make an informed decision regarding a change to our treatment protocol for CHF patients. In addition, the ability to present concrete data to our providers helped convince many who had initially resisted the proposed change.

Conducting a research study for the purpose of publishing results can be a bit more challenging, but there are plenty of opportunities. One barrier is often financial: Most EMS agencies do not prioritize (or even contemplate) research when setting budgets or hiring staff. While large research grants are often limited to major research institutions and universities, funding opportunities for smaller studies exist. In 2013, for example, the Alliance for Emergency Medical Education and Research (AEMER) in Virginia awarded approximately $20,000 in research grants to fund two different EMS-related research projects in the state.

One of the projects funded by AEMER is a study by our agency on the feasibility and safety of a protocol that would permit EMS to transport patients who do not require emergency care to alternative destinations such as medical clinics and urgent care centers. The AEMER grant has allowed our agency to defray the costs of developing an alternative destination protocol, training our providers and analyzing the results. The results of our study are forthcoming, and we plan to present our findings at this year’s Virginia EMS Symposium.

Taking on a true research project was a novel endeavor for our EMS agency, but we made it more feasible by turning to local partners for assistance. The CEO of our local receiving hospital wrote a letter of support during the grant application phase. We also enlisted the help of local emergency and primary care physicians to evaluate the results. In addition, part of our grant funding consists of a small stipend for a graduate student to assist with statistical analysis, often the most intimidating and challenging part of a research study.

There are plenty of resources for EMS researchers who require assistance with statistical analysis. Local health departments often employ epidemiologists or other public health workers who have experience with statistics. Colleges and universities, especially those with medical schools and public health programs, usually also have students looking for research projects to work on.

More generally, healthcare researchers are often willing to help less experienced colleagues at each stage of the research process. Even if a major research institution is not accessible, doctors in the local emergency department often have research experience, or at least an interest in pursuing research. Partnering with other EMS agencies on research projects is also an option.

References
1. Erich J. Conducting Research, Getting Published. EMS World, www.emsworld.com/10364695.
2. Jaronik J, et al. Evaluation of prehospital use of furosemide in patients with respiratory distress. Preh Emerg Care, 2006; 10(2): 194–7.

Mario J. Weber, JD, MPA, NRP, is a paramedic and field training officer at the Alexandria (VA) Fire Department, where he focuses on quality management, advanced training and evidence-based protocol development. He also reviews quality assurance cases and advises on the ALS training program for the Montgomery County (MD) Fire and Rescue Service. Reach him at mario.weber@m10.solutions.

Michael Gerber, MPH, NRP, is an instructor, author and consultant in Washington, DC. He is also a paramedic with the Bethesda-Chevy Chase Rescue Squad and previously worked as an EMS supervisor for the Alexandria (VA) Fire Department. Gerber has experience as an EMS educator and quality management coordinator and has presented original research at state and national EMS conferences. Reach him at mgerber@redflashgroup.com.