What Even is a “Progressive EMS System?” - Tom Grawey, DO

I’m fortunate enough to get out and interact with EMS providers from all over, whether it’s in person or virtually over twitter. Not uncommonly when engaging in conversations about our “shops” I hear the phrase “We have progressive protocols” or “We have a really progressive EMS system.” I’ve heard this phrase so much, I started to wonder what even IS a progressive EMS system?

A quick google search tells that Webster’s Dictionary calls progressive “characterized by progress” and “moving forward or onward.” From my experience, when people tell me they belong to a progressive EMS system, what they’re ultimately trying to say is that their guidelines, equipment, or policies allow them to do more. Progressive EMS systems have guidelines for drug facilitated airway management. Progressive EMS systems bring ED care to the field. When I was a new medical director, my goal was to lead an EMS system where my medics would be proud to say they belong to a progressive EMS system.

The problem with “progressive EMS” is that it implies that progress is always better. Describing your EMS system as “progressive” doesn’t mean that it’s a good EMS system. It implies that new ideas are favored over what really matters: ideas that improve patient centered outcomes. We should reframe the way people are proud to be from a progressive EMS system into something more meaningful: taking pride in participating in an Evidence Based EMS System.

What is an Evidence Based EMS System?

Evidence based EMS systems practice evidence based medicine (EBM). EBM is a systematic approach to clinical problem solving which allows the integration of best available research evidence with clinical expertise and patient values. This means designing patient care guidelines and EMS systems of care that consider clinical research, the knowledge gained from experience treating patients and the values of patients in the community.

For example, I was recently asked whether I wanted to add ticagrelor (Brilinta) to my ALS system for use in the care of STEMI patients. I reviewed the best available research which didn’t show a clear patient oriented benefit for patients receiving the drug from EMS. I considered my own clinical expertise as an ED physician and EMS medical director, acknowledging that as much as you’d like to debate the utility of clearly defined AHA STEMI criteria, many STEMI activations have a component of subjectivity. Finally, I considered patient values in our community: I know that EMS and ED physicians tend to over activate the cath lab (and a certain amount of over-activation is good thing). This means that a percentage of STEMI alerts in my EMS system won’t get an emergent cath and won’t be having an acute MI. This overactivation represents patients who won’t benefit from this drug and may actually suffer some harm, depending on the true etiology of his/her symptoms and abnormal EKG findings. Utilizing EBM, we ultimately passed on adding ticagrelor to our drug box.

Since part of EBM is drawing from clinical experience and considering your patient population, different clinicians are entitled to their own version of evidence based medicine based on their local practice. This is particularly true where evidence is mixed and doesn’t provide a clear route toward best practice. If you’re someone that carries ticagrelor for use in 911 STEMI patients, your guidelines may have a justification for being different. I share this example to point out that more interventions/tools/drugs isn’t always better. Considering all facets of EBM is how you ultimately land on what is best for your community.

Truly Progressive EMS is Evidence Based

The future of EMS as outlined in EMS Agenda 2050 is a system of care that supports a community through “data-driven, evidence-based and safe approaches to prevention, response and clinical care.” EMS 2050 doesn’t discuss “bringing the ED/ICU to the field” (another common phrase associated with “progressive EMS”). Instead, the future of EMS is about determining the best practices for care outside of the ED/ICU setting. Much of EMS either isn’t evidence based or is driven by research performed in non-prehospital settings. While this is probably acceptable for some aspects of what we do, we need to remember that the environment we work in is different and the patients we serve are often less differentiated and faced with different challenges than in the hospital.

Progress in EMS shouldn’t be driven by doing more for patients, but by utilizing data, research and safety to do better for patients. It’s about providing EMS clinicians with evidence based guidelines and empowering them to utilize higher order thinking to choose the best plan of care for the patient. It’s about doing drug facilitated airways in select situations where patients will see the most benefit. It’s about taking a powerful tool like ultrasound with dozens of indications and figuring out where it can truly impact patient centered outcomes.

So next time when you’re talking about the great care that you provide to the community you serve, take a pause before saying that you belong to a progressive EMS system. When what you are doing is based on EBM, take pride and brag a little about how you improve patient outcomes in your community by saying “I love my evidence based EMS system.”

References:

1. Sackett D, Richardson WS, Rosenberg W, Haynes RB. Evidence-Based Medicine How to Practice and Teach it. 2000.

2. Montalescot G, van ’t Hof AW, Lapostolle F, et al. Prehospital Ticagrelor in ST-Segment Elevation Myocardial Infarction. N Engl J Med 2014;371(11):1016–27.

3. Montalescot G, van ’t Hof AW, Bolognese L, et al. Effect of Pre-Hospital Ticagrelor During the First 24 h After Primary Percutaneous Coronary Intervention in Patients With ST-Segment Elevation Myocardial Infarction. JACC: Cardiovascular Interventions 2016;9(7):646–56.

4. Lange DC, Conte S, Pappas-Block E, et al. Cancellation of the Cardiac Catheterization Lab After Activation for ST-Segment–Elevation Myocardial Infarction: Frequency, Etiology, and Clinical Outcomes. Circ Cardiovasc Qual Outcomes [Internet] 2018 [cited 2021 Apr 18];11(8). Available from: https://www.ahajournals.org/doi/10.1161/CIRCOUTCOMES.117.004464

5. EMS Agenda 2050: A People-Centered Vision for the Future of Emergency Medical Services. :58.