The policy statements, issued in January, address the management of patients with potential spinal injuries and severe hemorrhage control, and are one step in an extended process of changing the way EMS providers deliver care to patients.
James Augustine, MD, FACEP, director of clinical operations at Emergency Medicine Physicians and a board member of the ACEP, says 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 are going to practice evidence-based medicine backed by a broad coalition of organizations,” says Brent Myers, MD MPH, executive vice president and chief medical officer at Evolution Health, and associate chief medical officer at American Medical Response.
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 wrote. In fact, the group notes that “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 restrictions should be considered for patients who meet validated indications such as the NEXUS criteria or Canadian C-Spine rules. The restrictions should be used for patients with 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 noted that backboards should not be used as a “therapeutic intervention or a precautionary measure either inside or outside a hospital.”
“There is a downside of immobilizing everyone, particularly with aging patients,” Augustine says. “We’re trying to reverse that, we’re trying to figure out whether there are people who 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 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 is not 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 wrote.
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 cannot, and should not, write protocols on the care of patients,” says Augustine. “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 to 17 years to implement new ways of clinical processes, Augustine explains, and this latest step marks a few years into that measure. That time frame is good, he adds, 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 says. “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.”
Time notwithstanding, Myers sees these policies and the process surrounding their creation as a significant step for pre-hospital care providers. “It’s a wonderful thing for us and gets us, truly, into the house of medicine,” says Myers.