Major Topic #9: Evidence

The guidelines contained in this document are based upon a combination of available objective evidence, a review of generally accepted practices, and the consensus of expert opinions in the field of IFT — in short, the best information available. In the current health care environment, however, the efficiency and efficacy of medical practice, policies, and operations are held to a higher standard of evidence than in the past. Ongoing evidence collection is the key to ensuring that IFT provides the best possible care in an optimal fashion.

The members of the IFT Workgroup concur with the authors of the EMS National Research Agenda who state, “...the lack of scientific knowledge about optimal patient care has confused clinicians and left them floundering to provide the best care without the guidance of good science.” As with any other area of emergency care, the practices and processes involved in delivering IFT need objective evaluation to determine their impact and cost-effectiveness.

Evidence assessing the status of IFT services can range from “micro” to “macro” in scope. The level of detail will be determined by the questions to be answered, and may include some or all of the following strategies:

• Tracking/Monitoring
• Quality Management
• Case Review
• Performance Indicators
• Surveillance Methods Used in Assurance Phase
• Formal Research

Data Collection for IFT Evidence

• Uniform data definitions are essential to collect evidence that can enable multisite studies, and true comparison of IFT practice and methods of delivery.
  
  
• Databases such as the National EMS Informa-tion System (NEMSIS) and the National Trauma Data Bank can be used to ensure standard data elements and the optimal utility of data.
  
  
• Because patient volume within any one IFT service may be low, collaborative research can be conducted and used to derive results that can be applied to other groups of IFT patients and other systems of IFT delivery.
  
  
• The data for IFT research may require linkage with prehospital data, ED data, hospital data, and that of the institutions pre and post IFT, to study outcomes as well as process.
  
  
• The evidence collection process and data elements to be used for assessment and assurance are optimally identified as new/updated IFT service is planned and before its implementation, so data can be gathered before and after IFT is deployed.

Outcome and Process Evaluation
Assessing the status of the current practice of IFT includes two areas of study: (1) outcomes evaluation, and (2) process evaluation. 

Outcome evaluation examines the effectiveness or efficacy of particular interventions on patient status. An outcome evaluation of IFT assesses a particular clinical aspect of patient care during IFT, and its impact on patient outcome. Examples of prime candidates for outcome evaluation include:

• Defining and ensuring adequate and effective patient care during IFT. The EMS Outcomes Project names six categories for patient outcome:¹
  • survival
  • impaired physiology
  • limit disability
  • alleviate discomfort
  • satisfaction
  • cost-effectiveness
    
    
• Evaluation of best-model practices for different levels of providers and for different geographic areas
  
  
• Timing of transfer — When is it too early or too late to transfer patients?
  
  
• What practices are most effective in preventing infection during IFT?
  
  
• Does constant availability of medical direction make a difference in outcomes?
  
  
• Does the level of provider make a difference in outcome for particular acuity levels of patients?

Process Evaluation — It would be difficult to conclude that a specific intervention caused a specific outcome, if the process of achieving it was not carried out as intended.

Process evaluation focuses on the quality of implementation — how well the intended process was carried out. It examines operational and system efficiency. Examples include:

• Where can costs be reduced in operation and equipment and still provide optimal care?
  
  
• What system QI model works best to monitor the outcomes of patients in a particular region/State?
  
  
• Regional resource assessment and management.
  
  
• Additional training — what is important and what's not?
  
  
• Response time standards.
  
  
• Were protocols adhered to? Why or why not (related to system components)?
  
  
• Dispatch issues — call-taking, triage, personnel assignment, as they relate to IFT.
  
  
• Tracking referral patterns and trends to determine future patient population.

References
1. Maio, Ronald. Emergency Medical Services Outcomes Evaluation. U.S. Department of Transportation, National Highway Traffic Safety Administration. July, 2003.