1. Research in EMS Introduction to research Steven Kanarian, MPH, EMT-P

2. Objectives Understand research steps Understand research steps Types of research Types of research Understand the need for research in EMS Understand the need for research in EMS Role of provider in research Role of provider in research

3. What is research? Research is learning, seeking the truth Research is learning, seeking the truth We learn and gain experience every day. We learn and gain experience every day. Research is observational or experience Research is observational or experience Anecdotal experience Anecdotal experience Systematic observation Systematic observation Hypothesis testing Hypothesis testing

4. What is evidence based medicine? Aims to apply evidence gained from the scientific method to certain parts of medicine Aims to apply evidence gained from the scientific method to certain parts of medicine Evaluates: Evaluates: Quality of evidence Quality of evidence Risk/benefit of treatment Risk/benefit of treatment Uses current best evidence to guide care Uses current best evidence to guide care

5. IOM recommends: Separate institute of emergency medicine research needed Separate institute of emergency medicine research needed The Future of Emergency Care in the US: The Institute of Medicine Subcommittee on Prehospital Emergency Medical Services, (Ann. Emerg. Med. 2006;48:126-130) The Future of Emergency Care in the US: The Institute of Medicine Subcommittee on Prehospital Emergency Medical Services, (Ann. Emerg. Med. 2006;48:126-130) Challenge for EMS is to measure outcomes.

6. Types of research Retrospective – looking back Retrospective – looking back Prospective – designing a study protocol, collecting data in the future Prospective – designing a study protocol, collecting data in the future Blinded Blinded Randomized Randomized Experimental Experimental

7. Types of research Retrospective – looking back Retrospective – looking back

8. Types of research Prospective – designing a study protocol, collecting data in the future Prospective – designing a study protocol, collecting data in the future

9. Types of research Blinded Blinded

10. Types of research Randomized Randomized

11. Types of research Experimental Experimental

12. Literature Review Used to define and explore the research topic Used to define and explore the research topic

13. Literature Search Discovers existing research Discovers existing research Will help refine questions Will help refine questions CINAHL, MEDLINE, Science Direct, PubMed CINAHL, MEDLINE, Science Direct, PubMed Keywords and review articles Keywords and review articles Note bibliographies and authors Note bibliographies and authors Search will guide your project Search will guide your project

14. Developing a Question Developing the question Developing the question Narrow question Narrow question Consider past research Consider past research New trends New trends Consults experts Consults experts

15. Determining the type of study Resources Resources Data availability Data availability Registry Registry Call report review Call report review Question being asked Question being asked Staffing Staffing

16. Developing the Research Project Developing the methods Developing the methods Power calculation Power calculation IRB approval IRB approval Interacting with providers Interacting with providers Conducting a pilot study Conducting a pilot study Implementing study/analyze data Implementing study/analyze data

19. Reporting the findings CME or local conference CME or local conference PCRF Forum at JEMS PCRF Forum at JEMS NAEMSP, NAEMSE conferences NAEMSP, NAEMSE conferences Article or abstract publication Article or abstract publication Pre-hospital Emergency Care (PEC) Pre-hospital Emergency Care (PEC) Annals of Emergency Medicine (AEM) Annals of Emergency Medicine (AEM)

20. An Introduction to EMS Research Lawrence H. Brown, Elizabeth Criss, N. Heramba Prasad Prentice Hall, Brady publications Recommended reading….

21. Reviewing Research Article Journal/Title Authors Type of study Who is doing/paying for study Methods Findings Conclusions

22. Reading the Literature Critical analysis Critical analysis do the numbers add up do the numbers add up do the numbers make sense do the numbers make sense do the results answer the question do the results answer the question is the data extrapolated too far is the data extrapolated too far

23. Evaluating An Article Evaluate demographics Evaluate demographics similar system configuration similar system configuration similar patient distribution similar patient distribution Evaluate numbers Evaluate numbers enough patients enough patients right equipment right equipment comparing apples to apples comparing apples to apples

24. Reading the Literature Reading the Literature Limitations to existing literature Limitations to existing literature no perfect project no perfect project acknowledge strengths & weaknesses acknowledge strengths & weaknesses Incorporating into practice Incorporating into practice influence current practice influence current practice how much is enough how much is enough evidence-based practice evidence-based practice

25. Participating in research is important Participating in research is important to current practice to current practice to future practice to future practice to establishing the professionalism of EMS to establishing the professionalism of EMS Begin with reading the literature Begin with reading the literature books books journals journals electronic media electronic media

26. Be critical of research Be critical of research not all published research is good research not all published research is good research not all published research is valuable research not all published research is valuable research not all published research is reported correctly not all published research is reported correctly Hold people accountable Hold people accountable Research is the future of EMS Research is the future of EMS validates validates promotes promotes improves improves

27. Let’s take a closer look Significant research in EMS

28. Research: General Principles and Emergency Medicine Application John B. McCabe, MD, FACEP

29. Problems with Research in Emergency Medicine Sporadic patient load Sporadic patient load Pre-defined treatment Pre-defined treatment Medical records Medical records Multi-institutional cooperation may be difficult Multi-institutional cooperation may be difficult Funding ?? Funding ??

30. What are these???

31. MAST Pants Thought to….. Thought to….. Auto-transfuse 2 units of blood Auto-transfuse 2 units of blood Increase PVR Increase PVR Raise BP Raise BP Stabilize pelvic fractures Stabilize pelvic fractures Control surface bleeding Control surface bleeding Widely used in 1980’s-1990’s Widely used in 1980’s-1990’s “What happened???”

32. What happened… STUDY: Randomized trial of pneumatic antishock garments in the prehospital management of penetrating abdominal injuries STUDY: Randomized trial of pneumatic antishock garments in the prehospital management of penetrating abdominal injuries MDWilliam H Bickell*, MDPaul E Pepe †, ‡,, MDMark L Bailey*, MDCharles H Wyatt* and MDKenneth L Mattox* *Department of Surgery, Baylor College of Medicine, Ben Taub General Hospital, Houston, Texas, USA †Department of Medicine, Baylor College of Medicine, Ben Taub General Hospital, Houston, Texas, USA ‡City of Houston Fire Department Emergency Medical Services, Houston, Texas, USA MDWilliam H Bickell*, MDPaul E Pepe †, ‡,, MDMark L Bailey*, MDCharles H Wyatt* and MDKenneth L Mattox* *Department of Surgery, Baylor College of Medicine, Ben Taub General Hospital, Houston, Texas, USA †Department of Medicine, Baylor College of Medicine, Ben Taub General Hospital, Houston, Texas, USA ‡City of Houston Fire Department Emergency Medical Services, Houston, Texas, USA* †‡ * †‡ *

33. Randomized Study Alternate day randomization (control, N=104, MAST, N = 97) Alternate day randomization (control, N=104, MAST, N = 97) The results demonstrated no significant difference in the survival rates of the control and PASG treatment groups (81 of 104 vs 67 of 97). The results demonstrated no significant difference in the survival rates of the control and PASG treatment groups (81 of 104 vs 67 of 97). “ From these data we conclude that, contrary to previous claims, the PASG provides no significant advantage in improving survival in the urban prehospital management of penetrating abdominal injuries. “ “ From these data we conclude that, contrary to previous claims, the PASG provides no significant advantage in improving survival in the urban prehospital management of penetrating abdominal injuries. “

34. The Ontario Prehospital Advanced Life Support Study (OPALS) Ian G Stiell MD, MSc, FRCPC *‡§, George A Wells PhD ‡§, Daniel W Spaite MD ¶IIII, Graham Nichol MD, MPH, FRCPC #§, Bernard O’Brien PhD**, Douglas P Munkley MD, MCFP(EM)¶, Brian J Field EMA III II, Marion B Lyver MD, FRCPC, MCFP(EM)#, Lorraine G Luinstra BScN, MHA¶, Eugene Dagnone MD, FRCPC‡‡, Tony Campeau BSc§§, Roxanne Ward RN§, Steve Anderson BSc§ and For the OPALS Study Group

35. OPALS Largest ALS study in the World Largest ALS study in the World Will involve 25,000 cardiac arrest, trauma and respiratory patients Will involve 25,000 cardiac arrest, trauma and respiratory patients “Before and after”study “Before and after”study 8 years of collecting data 8 years of collecting data

36. Outcomes measured Disease Specific Quality of Life Disease Specific Quality of Life Respiratory Distress and Trauma areas Respiratory Distress and Trauma areas Process of care measures (rates of success failure for skills) Process of care measures (rates of success failure for skills) Response time Response time Length of stay Length of stay

37. Unique Study Before phase Before phase Rapid Defib phase Rapid Defib phase ALS phase ALS phase Able to compare the incremental improvement Able to compare the incremental improvement

38. Proved AED Defibrillation saves lives AED Defibrillation saves lives Medics treat respiratory distress and chest pain effectively Medics treat respiratory distress and chest pain effectively Sets bar for other large scale prospective studies Sets bar for other large scale prospective studies

39. 1st responders increase survival January 1, 1999 to January 31, 1995 January 1, 1999 to January 31, 1995 5,335 Cardiac Arrest Patients 5,335 Cardiac Arrest Patients 46.8% witnessed by bystanders 46.8% witnessed by bystanders 14.5% received bystander CPR 14.5% received bystander CPR 25% received 1 st responder CPR 25% received 1 st responder CPR Increased save rate to 3.5 and 8.5% for VFib Increased save rate to 3.5 and 8.5% for VFib

40. Occupational injuries among EMS personnel McGuire, Hunting, Guidotti, Smith Prehospital Emergency Care 2005;9: 405-411

41. Objective Describe the epidemiology of occupational injuries among EMS personnel, calculate injury rates, and compare findings with other occupational groups. Describe the epidemiology of occupational injuries among EMS personnel, calculate injury rates, and compare findings with other occupational groups. EMS Providers treat 22 million patents per year, little known about our injuries EMS Providers treat 22 million patents per year, little known about our injuries

42. Methods Retrospective review of injury records kept by two urban agencies Retrospective review of injury records kept by two urban agencies 617 cases over 3 years 617 cases over 3 years Injury rate was 34.6 per 100 employees Injury rate was 34.6 per 100 employees Most often sprains, strains and tears Most often sprains, strains and tears Back most frequent Back most frequent 277 cases resulted in lost days from work 277 cases resulted in lost days from work

43. Conclusions Injuries greater for EMS than any other industry in 2000 according to DOL statistics Injuries greater for EMS than any other industry in 2000 according to DOL statistics Recommended funding and further research are critical to define problem and prevent injuries Recommended funding and further research are critical to define problem and prevent injuries

44. What would you like to study??

45. Emerging topics Intubation by paramedics Intubation by paramedics Pain management Pain management EMS Skill retention EMS Skill retention System design System design Clinical interventions Clinical interventions

46. Where to start? Descriptive study- what are we doing for our community/school? Descriptive study- what are we doing for our community/school? Where are we making a difference? Where are we making a difference? Pain management Pain management Injury prevention Injury prevention Reduced response time Reduced response time Reduced health care costs Reduced health care costs

47. Research starts with a question and a desire to learn the truth.

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

49. Please leave a comment… Questions about research Questions about research How to review an article How to review an article