Ch1

TRANSITION SERIESTRANSITION SERIES

Topics for the Advanced EMTTopics for the Advanced EMT

CHAPTERCHAPTER

Research and EMSResearch and EMS

11

Transition Series: Topics for the Advanced EMTJoseph J. Mistovich • Daniel Limmer • Howard A. Werman, MD

ObjectivesObjectives

• Explain the integration of research into EMS education and practice.

• Demonstrate that evidence-based research guides clinical decision making.

• Discuss analyzing and interpreting research, the types, and scientific theory.


Objectives (cont’d)Objectives (cont’d)

• Express the involvement of the Advanced EMT in clinical and EMS systems research.


IntroductionIntroduction

• In EMS we spend nearly 3 billion dollars each year delivering care, but little of what we do has truly been evaluated.

• How do we know we are being helpful?• How do we know that the tools we use

are effective?


Figure 1-1 Research guides the care we provide.


Evidence-Based ApproachEvidence-Based Approach

• Outcomes of therapies and interventions are carefully measured to ensure the intended results.

• When changes are made, decisions are based on clear indications and outcomes.


Evidence-Based Evidence-Based Approach (cont’d)Approach (cont’d)

• Quality research and the evidence based approach allows the EMS profession to:– Answer questions– Expand resources wisely– Avoid spending time and money on

ineffective therapies– Focus budgets on elements that mean

the most to patient care


EMS ResearchEMS Research

• Someone once said, “Not everything that is researched is true and not everything that is true has been researched.”


Scientific MethodScientific Method

• General observations are turned into an unproven theory or hypothesis.

• Predictions are made based on the hypothesis.

• Predictions are tested to either prove or disprove the theory.


BiasBias

• Occurs when research is influenced by prior inclinations, beliefs, or prejudices.

• Outcomes are manipulated to fit an expected outcome instead of being measured objectively against the hypothesis.


Prospective vs. RetrospectiveProspective vs. Retrospective

• Prospective research method– Designed to look forward and test

therapies/outcomes in the future.– Easier to control errors and prevent

bias.


Prospective vs. Retrospective Prospective vs. Retrospective (cont’d)(cont’d)

• Retrospective research method– Looks at events that have occurred in

the past, evaluating the outcome of therapies previously performed.

– Difficult to control and less valid.


RandomizationRandomization

• The research study compares one therapy against another by randomly assigning a specific therapy to patients as opposed to having predetermined groups– Bias is controlled– Improves objectivity– Utilizes blinding to improve objectivity


BlindingBlinding

• Keeps the patient from knowing which therapy they are receiving.

• Makes it very difficult to influence outcomes thus improving objectivity.– Single blind: the researcher knows who

is getting what therapy– Double blind: neither the patient nor the

researcher knows who is getting what therapy


Control GroupsControl Groups

• In medicine, a control group is commonly a known, or currently used therapy.

• Helps to better evaluate outcomes fairly.

• Comparison adds weight and value to the analysis.


Study Group SimilarityStudy Group Similarity

• When testing a new treatment, it is important that the subjects in the group have a degree of similarity.


Systematic ReviewSystematic Review

• A series of studies pertaining to a single question are evaluated

• Results are reviewed, summarized, and used to draw evidence-based conclusions.

• Made up of many different research experiments.


Randomized Controlled TrialsRandomized Controlled Trials

• The researcher randomly assigns eligible subjects into groups to receive or not receive the intervention being tested

• A placebo may be used:– Sugar pill which has no effect


Cohort/Concurrent Control/Cohort/Concurrent Control/Case-Control Studies Case-Control Studies

• Two groups of therapies or patients are compared but they are not randomized.

• Frequently retrospective in nature.• Difficult to control all aspects of

similarity and methods among the groups.

• Prone to bias.


Case Series/Case ReportsCase Series/Case Reports

• Review the treatment of a single patient or a series of patients.

• Frequently report on unusual circumstances or outcomes.

• No control group.• Always retrospective.• Not as valid as randomized studies.


Meta-AnalysisMeta-Analysis

• Compilation of different studies looking at a single topic.

• Summarizes the work of others.• Often comments on outcomes.


Level of EvidenceLevel of Evidence

• The American Heart Association qualifies the validity of research in a linear fashion.

• Assigns varying levels of importance based on the way studies are conducted.

• Useful in evaluating the importance of data.


Level of Evidence (cont’d)Level of Evidence (cont’d)

• Can be used as a framework for considering the utility of a particular study.



• Level of Evidence 1 – The most valuable set of data results from randomized control trials or meta-analyses of RCTs.

• Level of Evidence 2 – Studies using concurrent controls without true randomization.

• Level of Evidence 3 – Studies using retrospective controls.



• Level of Evidence 4 – Studies without a control group.

• Level of Evidence 5 – Studies not directly related to the specific patient or population.


Reviewing ResearchReviewing Research

• Was the study randomized?• Was the randomization blinded?• If more than one group, were the groups

similar at the start of the trial?• Were all eligible patients analyzed?• If they were excluded, why?• Were the outcomes a result of the

therapy?• Is the outcome relevant?


Figure 1-2 Read and evaluate research


You and EMS ResearchYou and EMS Research

• As an ALS provider of the future, you will be on the front line of conducting research.

• Strong documentation will help improve future studies.

• Your service, local hospital, or region may participate and enroll patients in a specifically-designed experiment.

• You may take part in designing a study.


SummarySummary

• EMS research is an important part of the future of our profession.

• It is imperative to understand the basic concepts of research as well as know how to read and evaluate research literature.

• Being involved in research development offers a rewarding pathway for enlightened providers.

Health & Medicine

Ch1