News, Patient Care

ACEP Policies Lead to Evidence-Based Medicine

Issue 5 and Volume 40.


The American College of Emergency Physicians (ACEP) released two new policy statements that are being viewed by experts as significant steps forward in getting evidence-based changes into the EMS field.

The policy statements, issued in January, address the management of patients with potential spinal injuries and severe hemorrhage, and are one step in an extended process of changing how EMS providers deliver patient care.

“Both of them are on hot clinical topics,” James Augustine, MD, FACEP, director of clinical operations at Emergency Medicine Physicians and a board member of the ACEP, said.

Augustine added the policy statements are in line with what other organizations have done and are a critical step in getting these policies adapted nationwide.

“I think the first thing this shows is we’re going to practice evidence-based medicine backed by a broad coalition of organizations,” Brent Myers, MD, MPH, executive vice president and chief medical officer at Evolution Health and associate chief medical officer at American Medical Response, said.

Each of the policies address issues that have been discussed widely within the EMS world, and each is a topic where there’s been considerable talk of changes necessary with the way providers treat patients.

In fact, with “EMS Management of Patients with Potential Spinal Injury,” the ACEP has the potential of upending the way out-of-hospital providers handle patients with potential spine injuries, which often includes backboards and cervical collars as a precautionary measure.

“The American College of Emergency Physicians believes that the current out-of-hospital management practices of patients with spinal injury lack evidentiary scientific support,” the board of the organization wrote. In fact, the group notes, “Evolving scientific evidence demonstrates that some of these current out-of-hospital care practices cause harm, including airway compromise, respiratory impairment, aspiration, tissue ischemia, increased intracranial pressure, and pain, and can result in increased use of diagnostic imaging and mortality.”

The ACEP suggests spinal motion restriction (SMR) should be considered for patients who meet valid indications such as the NEXUS criteria or Canadian C-spine rules. The restrictions should be used for patients with a plausible blunt mechanism of injury and any of the following: altered level of consciousness or clinical intoxication; mid-line spinal pain or tenderness; focal neurologic signs or symptoms, anatomic deformity of the spin; or a distracting injury.

The organization also noted that backboards shouldn’t be used as a “therapeutic intervention or a precautionary measure either inside or outside a hospital.”

“The point of this is in many cases, the board is just not needed,” Myers said.

The concept of immobilizing patients with potential spinal injuries emerged during the Vietnam War. However, over time research has suggested otherwise.

“We took that to the extreme by immobilizing everyone, no matter how slight their mechanism of injury would be,” Augustine said. “There’s a downside of immobilizing everyone, particularly with aging patients. Those patients don’t benefit from it.

“We’re trying to reverse that, we’re trying to figure out whether there are people that do need to have it.”

In the second policy, “Out-of-Hospital Severe Hemorrhage Control,” the ACEP believes that aggressive hemorrhage control is a critical component in out-of-hospital care. The outline of the policy, which includes the use of tourniquets when sustained direct pressure or a pressure dressing is ineffective, is based on real-world data generated from battlefield situations and in the civilian arena.

The new policy also suggests protocols should address the use of a commercially produced tourniquet with demonstrated arterial flow occlusion; that tourniquets not be released until the patient reaches definitive care; that providers consider the use of topical hemostatic gauze pads in combination with direct pressure/dressing for wounds where a tourniquet isn’t possible; that tourniquets may be the first-line treatment for extremity arterial hemorrhage; the consideration of the use of tranexamic acid (TXA); and specific training for EMS personnel include hemorrhage control techniques using tourniquets and topical hemostatic gauze agents.

“Consideration should also be given to the use of tourniquets and topical hemostatic gauze agents by other first responders such as law enforcement and firefighters as part of a system-wide out-of-hospital severe hemorrhage control program that also addresses the role civilians can play,” the board of the ACEP wrote in drafting the policy.

“We’ve learned more and more that tourniquets are an appropriate method of hemorrhage control,” Augustine said. “We’ve been back and forth for 150 years on these, particularly in wartime.”

The use of tourniquets got a major push during the wars in Iraq and Afghanistan, and, on a domestic level, there were multiple cases of lives saved following the Boston Marathon bombings when passersby used makeshift tourniquets to help those suffering from devastating injuries.

The new policies are just the latest step in a long process to get the suggestions adapted on a local level. That process starts with the policy statements from the ACEP and other similar national organizations, which are then formulated into statewide and then local protocols in each jurisdiction around the country. It’s a process that could take years.

“National bodies can’t, and shouldn’t, write protocols on the care of patients,” Augustine said. “Nonetheless, they write policy statements. Now individual organizations look at the policy statements, and ask, ‘How do we write our local protocols?'”

There’s evidence that it can take 15–17 years to implement new ways of clinical processes, Augustine explained, and this latest step marks a few years into that measure. That time frame is good, he added, because it gives everyone a chance to be certain what looks good today really is good down the road.

“I believe the hard work is still to come,” Augustine said. “Each local EMS agency and their medical protocol agency will have to take into account these policies–and others written like them– to come up what’s best for their practice.”

A change in approaching SMR is already occurring on some local levels. In April 2015, the Monmouth Ocean Hospital Service Corporation (MONOC), a nonprofit company comprised of 15 acute care hospitals throughout New Jersey that provide BLS and ALS services to local communities, discontinued the routine utilization of long spine boards during transport. Citing the ongoing research on the matter, officials noted SMR often ends up hurting the patient rather than helping them.

MONOC officials also sent a letter to area hospitals and EMS organizations urging them to follow the same policy. “We realize that SMR is a major change in the way we care for our patients, however, as advocates for our patients, we can all recognize that this change is good for patient care,” MONOC Medical Director, Mark Merlin, MD, and MONOC CEO, Jeff Behm, said in the letter.

Time notwithstanding, Myers sees these policies and the process surrounding their creation as a significant step for prehospital care providers.

“It’s a wonderful thing for us and gets us, truly, into the house of medicine,” Myers said.

JEMS Games gold medal winners, left to right, Kevin Ramdayal, EMT-P; Randy Li, EMT-P; David Cadogan, EMT-P and Joseph Hudak, EMT-P, from FDNY. Photo Glen E. Ellman

 

FDNY Wins Gold AT 12th Annual JEMS Games

The JEMS Games are held annually as a special event at the EMS Today Conference amd Exposition. Teams of three from across the country, and world, compete in patient care scenarios that test their skills as EMS professionals.

The goal of the JEMS Games is to present a fun, challenging and educational experience for emergency medical personnel that results in participants being better prepared for the challenges they encounter when treating patients in the field.

The scenario of the 2015 JEMS Games challenged teams to care for five patients of a helicopter crash occurring in a residential neighborhood. Three patients (including a baby) were directly affected by the damage caused by the crash, while two additional patients were surprises for the competing teams and presented after the nine-minute mark of the challenge. Time was called at the 17-minute mark, after which the lead paramedic had one minute to gather information from his crew and subsequently provide a hospital report over the microphone in the remaining two minutes.

A total of 23 teams participated in the JEMS Games preliminaries held on Thursday, Feb. 26. The top three teams then competed in the final round on Friday, Feb. 27.

The final competition granted show attendees continuing education based on the scenario presented and accompanying mini- lectures held between each round of participation. EMS Today provides training that’s essential to professional success, and the JEMS Games brings that training to life.

For more information on EMS Today or the JEMS Games, please visit www.emstoday.com.

The 2015 JEMS Games winning teams:

  • The 1st Place (gold medal) team: FDNY EMS (N.Y.)
  • The 2nd Place (silver medal) team: Boca Raton Fire Rescue Team B (Fla.)
  • The 3rd Place (bronze medal) team: Cumberland County EMS (N.C.)