Administration and Leadership, Columns, Patient Care, Trauma

Practice Guidelines Should be Kept Up-to-Date

Issue 1 and Volume 40.

The Research

Carhart E, Salzman JG. Prehospital oxygen administration for chest pain patients decreases significantly following implementation of the 2010 AHA guidelines. Prehosp Emerg Care. 2014;18(4):471–475.

The Science

The authors attempted to examine the change in oxygen administration to patients with chest pain in the years immediately following the publication of the 2010 American Heart Association (AHA) guidelines. They examined patient care contacts recorded in Fisdap, a national clinical skills tracking program used by the majority of nationally accredited paramedic training programs. Data was analyzed from June 2010 to December 2012.

Authors excluded patient encounters where the patient’s initial oxygen saturation (SpO2) was < 94%, was receiving positive pressure ventilation or was hemodynamically unstable. This left 10,552 patient encounters by 2,447 paramedic students from 195 programs in 49 states.

In 2010, prior to the publication of the new AHA guidelines, almost 72% of chest pain patients received supplemental oxygen. In 2011, it dropped to 64% and in 2012 it lowered further to 53%. Oxygen was delivered by nasal cannula 79% of the time with the remainder receiving oxygen via non-rebreather mask.
Interestingly, oxygen administration dropped by 4% for every 1% SpO2 increase above 94.

The conclusion: “The prehospital administration of supplemental O2 decreased significantly following release of the 2010 updated guidelines; however, our data revealed that 50% of patients not meeting criteria for administration still received supplemental O2.”

Doc Keith Wesley Comments

I would first like to thank these researchers for attempting to measure the change in prehospital delivery of medicine following the release of evidence-based guidelines. For too many years, we’ve provided care to our patients based more on tradition than science. Supplemental oxygen possesses significant adverse effects such as increasing the resistance of blood flow through the coronary arteries, the size of the heart attack and mortality.

In 2010, the AHA did more than simply update the CPR algorithm. They provided guidelines for the use of tourniquets, oxygen and bronchodilators, as well as updated treatment for shock, seizures, chest pain, and many other common illnesses and injuries. Unfortunately, it’s the cardiac arrest topic that gets the most attention.

In contrast to the authors’ conclusion, I’m quite impressed by the 18% reduction in unnecessary and often harmful oxygen administration. It frequently takes several years for practice to change following the release of evidenced-based guidelines. On average, EMS takes 2–3 years to incorporate the new AHA guidelines as a result of the two-year renewal cycle. Perhaps things would change faster if everyone were required to renew their CPR and ACLS cards no more than 12 months after the AHA release.

But as pleased as I am by this study’s result, I would suggest far more than 50% of chest pain patients continue to receive supplemental oxygen unnecessarily. BLS agencies are usually the last to learn of these new guidelines and their protocols are often conservatively written with the fear that there’s greater potential BLS providers will harm someone by withholding oxygen when it’s otherwise indicated.

BLS and emergency medical responder providers are often the first and sometimes only EMS care, so it’s imperative we improve their education beyond CPR and get with the guidelines.

Medic Karen Wesley Comments

As an EMS instructor, it isn’t surprising to see paramedic students lagged in the adoption of the new oxygen use guidelines.

Every five years or so, textbooks are updated with the new science in practice. And once they’re published, some of that science is already out of date and incorrect. Since the AHA updates don’t always parallel the text revisions, the new science is delivered in differing cycles.

Instructors themselves don’t always keep up to date with changes, or don’t implement them because the teaching institution has strict adherence to lesson plans currently used.

It’s the responsibility of EMS medical directors and those tasked with education in their agency to ensure providers have the most up-to-date knowledge to provide medical care. Unfortunately, many EMS agencies don’t have engaged medical directors who are committed to keeping their protocols current. Statewide protocols are also slow to change and then be disseminated to all providers.

Protocols can change faster when frontline providers find something interesting in the literature and take it to our medical directors for consideration. Most medical directors are open to making changes when those changes are based in sound science.

Regardless, at the end of the day, new therapies are adopted and our practice changes for the better.