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

    by Marc Colbeck. Last modified: 07/03/15

    Ebben RH1, Vloet LC, Verhofstad MH, Meijer S, Mintjes-de Groot JA, van Achterberg T. Adherence to guidelines and protocols in the prehospital and emergency care setting: a systematic review. Scand J Trauma Resusc Emerg Med. 2013 Feb 19;21:9. PMID: 23422062.


    The authors attempted: “(1) to give an overview of professionals’ adherence to (inter)national guidelines and protocols in the emergency medical dispatch, prehospital and emergency department (ED) settings, and (2) to explore which factors influencing adherence were described in studies reporting on adherence.”  They found 35 articles, none of which dealt with dispatchers.  The authors excluded articles that relied on self-reported levels of adherence, and which dealt only with local guidelines.

    Unfortunately, it looks like most of the prehospital studies were European and focused on doctors.  Only 6 of the 35 studies they used actually stated that paramedics were one of the professional care groups (several said ‘not specified’).

    The lowest adherence rates were found with cardiac treatment recommendations (7.8% -27.5%) and the highest adherence was to treatment recommendations related to oxygen administration and septicaemia treatment (77.5% – 95%)

    There was no clear indication that patient characteristics (age, gender, etc.) affected adherence … “although male sex, lower age and a disease specific condition (rhythm on the electrocardiogram) seemed to positively influence adherence to cardiology guidelines.”

    The authors noted that there was a wide range of adherence both in and out of the hospital, and also that … “Suboptimal adherence has also been shown in other critical care fields, such as the intensive care unit and the recovery room, but also on more general topics as hand hygiene and medication safety.”

    They suggested that those writing guidelines should include specific key quality indicators to mark that the guideline has been followed; this has shown to be useful in monitoring adherence.

    Three of the studies they reviewed showed that adhering to guidelines improved patient outcomes, however the authors note that the studies weren’t strong enough to draw a general conclusion about the effectiveness of clinical practice guidelines in decreasing morbidity and mortality.  The studies were:

    Charpentier S1, Sagnes-Raffy C, Cournot M, Cambou JP, Ducassé JL, Lauque D, Puel J; ESTIM Midi-Pyrénées Investigators. Determinants and prognostic impact of compliance with guidelines in reperfusion therapy for ST-segment elevation myocardial infarction: results from the ESTIM Midi-Pyrénées Area. Arch Cardiovasc Dis. 2009 May;102(5):387-96. PMID: 19520324.


    Roy PM1, Meyer G, Vielle B, Le Gall C, Verschuren F, Carpentier F, Leveau P, Furber A; EMDEPU Study Group. Appropriateness of diagnostic management and outcomes of suspected pulmonary embolism. Ann Intern Med. 2006 Feb 7;144(3):157-64. PMID: 16461959.


    Scliopou J1, Mader TJ, Durkin L, Stevens M. Paramedic compliance with ACLS epinephrine guidelines in out-of-hospital cardiac arrest. Prehosp Emerg Care. 2006 Jul-Sep;10(3):394-6. PMID: 16801287.

    The authors note that the included studies were all retrospective, that there is no clear and widely used definition of the term ‘adherence’ in relation to guidelines, and that one of the studies described how serious the deviations were, pointing out that previous research has shown that 45% of guideline deviations can be categorised as serious or very serious.

    A part of their final conclusions were: “In the prehospital setting monitoring recommendations came with higher adherence percentages than treatment recommendations. For both settings, the cardiology treatment recommendations were less adhered to than recommendations for other medical conditions.”

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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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