Where Should We Start?


The Institute for Healthcare Improvement (IHI) Breakthrough Collaborative Series Model is a method used to bring organizations together to learn and collaborate to make significant improvements in a specific topic area.1 This process was used in ambulance service in Massachusetts from 2009—2013 to improve prehospital stroke care.2 A key element of the method is to begin with existing evidence that helps guide developing aims, measures and change ideas.


A core tenet of improvement, research and established professions is to start somewhere–preferably to begin with what’s known and stand on the shoulders of others. In research, we’re asked to present a review of the literature; in business it’s part of the market analysis of the business plan. This ensures your approach is based on the best-known evidence, and your local learning (if published and shared) may help further collective efforts to enhance ambulance service.


Evidence Base of Ambulance Service


In ambulance service, the evidence base is light. This is simultaneously part of the problem, a key to our challenge and a driver for change. In 2001, the National EMS Research Agenda stated it bluntly: “There is not enough high quality EMS-related research to drive improvements in patient outcome, and vast amounts of money are being spent for patient care with little rigorous evaluation of the effectiveness of that care. Methodologically sound research must be incorporated into all facets of the EMS system.”3 For many EMS leaders, the absence of definitive evidence leads them to either pick and choose procedures to implement or, worse, ignore the evidence all together. This does not move EMS forward.


Alternatively, the Institute of Medicine’s (IOM) 2006 report on EMS challenged that “EMS professionals and policy makers at all levels should work to establish a culture of science-based decision making “¦” and “”¦ scientific evidence should be used to support system level decisions “¦” including clinical and operational practices.4 In order for the EMS profession to meet the demands of the transforming healthcare environment and the constraints of local communities, we have to stretch to understand existing evidence and continually apply it to our practice.


Where Do I Find this Evidence Base?


A good place to begin your team’s journey is with free industry reports and papers that are publicly available. These include reports and projects from the National Highway Traffic Safety Administration (NHTSA), National EMS Advisory Council (NEMSAC), and the websites of associations such as the National Association of EMS Physicians (NAEMSP) and National Association of State EMS Officials (NASEMSO), which also publish papers and position statements. These documents are frequently rooted in existing evidence and compiled by committees of EMS stakeholders.


Peer-reviewed EMS research appears in a number of journals. One worthy of a subscription is Prehospital Emergency Care (PEC), which is dedicated to ambulance service and is the official journal of the NAEMSP, NASEMO, the National Association of EMS Educators (NAEMSE) and National Association of EMTs (NAEMT). A subscription provides you access to the full online archive going back to 1997.


Another way to access peer-reviewed research is by searching the database at www.pubmed.gov. Access is limited to abstracts, but that can be enough to help you find out what’s out there. Note: It’s always advisable to read the actual paper and not just an abstract, so if you find an abstract of interest, please obtain the original paper.Google remains a powerful resource as well. I often find myself researching a topic online and then following the references authors include in presentations and articles online. Trade journals such as JEMS and EMS World can also be helpful, but be aware that these articles are not held to the rigor of peer-reviewed journals when it comes to referencing ideas and presenting data.


These resources will start you at the front of the pack of EMS leaders and put you on good footing to ignite a culture of science-based decision making in your organization.


Science-Based Decision Making


Developing a culture of science-based decision making in your system is not instantaneous. If there was a known approach that worked out of the box, we’d all be doing it. Here are some thoughts for how you can start:


1. At the initiation of any effort to change, clarify with your team what you are trying to accomplish. The more specific you are, the easier it is to design and execute.


2. Begin with some prep work. This may include searching PubMed and Google for position papers, reports and peer-reviewed papers on the topic. Also, take the time to learn about what you are currently doing. What are the existing processes and policies? What is the organizational history of how you got there? What data do you track or can you pull about the current state? Compile what you’ve found and share it with your team to review and digest before meeting.


3. When you do meet, discuss what you’ve all discovered from the prep work. Is there a gap between what the evidence says and what your current practice is? Are there any missing areas in the existing evidence available to help you? What questions do you have?


4. Make a list of changes to help you close the gap between existing evidence and current practice. What changes can you make that you believe will result in improvement? How will you measure that improvement?


5. Use rapid, small-scale tests of change (e.g., the Plan, Do, Study, Act tool) that follow the scientific method and display your data over time in run charts to learn deeply and efficiently. You can even annotate the changes you are testing.


6. Regularly meet as a team to share learning, exchange ideas and plan for further improvement.


When it’s all said and done, I encourage you to share your learning and results (even failures). Peer-reviewed abstracts and papers are preferred to add to the evidence, but other avenues are helpful too.


Starting with the published evidence to date, building on and testing those ideas using the rigor of the scientific method, and sharing our results will go a long way toward meeting the aims of the National EMS Research Agenda and the IOM report. It will also help us accelerate the enhancement of ambulance service and engage our peers in the healthcare environment. Don’t feel you have to be a pro on your first try. The best way to learn and improve is through action. So, what’s your next action?




1. The Breakthrough Series: IHI’s Collaborative Model for Achieving Breakthrough Improvement [white paper]. Institute for Healthcare Improvement: Boston, 2003.


2. Daudelin D, Kulick E, D’Amore K, et. Al. The Massachusetts emergency medical service stroke quality improvement collaborative, 2009—2012. Preventing Chronic Disease. 2013;10(9).


3. National EMS Research Agenda [white paper]. National Highway Traffic Safety Administration: Washington, D.C., 2001.


4. Emergency Medical Services at the Crossroads [white paper]. Institute of Medicine: Washington, D.C., 2006.

No posts to display