• Adherence to guidelines and protocols in the prehospital and emergency care setting: a systematic review

    by Marc Colbeck. Last modified: 05/01/15

    Kimura Y. Phospholipase C and the physical states of polar head groups of lipids. J Membr Biol. 1987;96(2):187-91. PMID: 3599067.

    This is a recent (2013) Scandinavian study which attempted to summarise studies looking at how well international guidelines were followed in paramedic dispatch, paramedic practice and in the emergency department.

    They couldn’t find any studies that evaluated dispatch compliance with international guidelines.

    They winnowed 367 studies down to 35 – only 10 of which covered paramedics.  Of those 10 the only topics that were actually discovered to have been studied were:

    • cardiac arrest,
    • myocardial infarction,
    • sedation,
    • TBI,
    • oxygen administration
    • septicaemia.

    Of the recommendations evaluated for compliance only 4 (10%) were monitoring recommendations and the remaining 36 (90%) were treatment recommendations.  Seven of the 10 studies were conducted in Europe and the remaining three were in North America. Multiple professionals worked in the prehospital setting in these studies, including several types of doctors and nurses, as well as EMTs and paramedics.

    So, to say this is a comprehensive representation of how PARAMEDICS do in ALL (or even many) areas of guideline compliance INTERNATIONALLY would be inaccurate.  It reviews a few areas of practice in the prehospital setting, performed by a variety of clinicians, mostly in Europe.  Still, that’s more information than we had before, so I’m not knocking it.

    What did they find?  Compliance with the guidelines ranged from 7.8% to 95%, depending on which guideline you were looking at.

    The three lowest median adherence percentages (7.8%, 22%, 27.5%) came with cardiology treatment recommendations related to myocardial infarction and cardiac arrest,  whereas the three highest median adherence percentages (77.5%, 79.8%, 95%) came with treatment recommendations related to oxygen administration  and septicaemia, and to one monitoring recommendation related to oxygen administration.

    So, these mostly European prehospital clinicians (of various types) were not so great at treating cardiac emergencies, but were somewhat-to-fairly compliant with treating and monitoring oxygen levels and treating septicaemia.

    How does that compare to in-hospital treatment? The doctors and nurses in hospital actually did a little worse.  Their compliance ranged from 0% to 98%.  Pretty sucky all around.  In fact the authors state “our results probably also imply that many patients in the prehospital and ED setting do not receive appropriate care”.  At least for the patients covered in this study.

    The authors note that other studies have shown similarly poor compliance with international guidelines in ICU and the recovery room as well as with more general topics such as hand hygiene and medication safety.  Interestingly, they also note that one of the reasons for poor compliance in the ED could be that they guidelines were prepared by specialties outside the ED, as ED guidelines are lacking.  However, they don’t offer the same caveat for poor prehospital compliance.  That seems like an oversight to me.

    The authors found only four studies that evaluated the relationship between guideline compliance and patient outcomes and state that there is insufficient evidence to draw a conclusion and that further research is required to establish this relationship.  Wow. That’s pretty important considering the generally accepted (and intuitively reasonable) belief that compliance with well-constructed, evidence-based CPGs will improve patient outcomes!  I haven’t read enough to know enough, but I wonder if we DO have good evidence that following appropriately crafted CPGs actually does improve patient outcome.  That’s an important question for us to answer before we get all agitated about whether we’re following them or not.

    There were some important limitations to the study including this whopper: “Literature shows no clear and widely used definition of adherence…”.  Yikes! How can we measure it if we can’t define it?  The studies were retrospective, and relied on charting (which has a bias) and:

    “… none of the included studies addressed the seriousness of the deviations, which may have been useful as previous research indicated that 45% of guideline deviations can be categorised as serious or very serious.”

    So if we can broadly categorise we can say that the studies reviewed in this paper suggest we’re better at adhering to monitoring guidelines than to treatment guidelines, and we’re actually worse at complying with cardiac treatment guidelines than other medical condition guidelines (which surprised me).

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    Marc Colbeck

    Marc Colbeck

    Senior Lecturer at Australian Catholic University
    Marc is a Canadian Critical Care Paramedic with 14 years of clinical experience who has been working as a professional educator since the early 2000's. He has taught at the College and University level in the Middle East and Australia, and worked as the General Manager of Clinical Governance for an Australian State Ambulance Service. He is currently a Senior Lecturer at Australian Catholic University in Queensland, Australia. His undergraduate degree is in PreHospital Care and his MA is in Counseling Psychology. He is currently working on a PhD in Translational Health Sciences with the Joanna Briggs Institute at the University of Adelaide, with a special interest in the development and maintenance of paramedic CPGs. His website is www.marccolbeck.info.

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