This article discusses the importance of evidence-based paramedic prescribing. It considers the sources of evidence that should be used to underpin prescribing decision-making, alongside how prescribing paramedics can apply critical appraisal skills to their practice.
The use of critical appraisal checklists and research reporting tools to guide critical appraisal of the research underpinning prescribing practice is discussed.
In addition, how the evidence underpinning practice is graded by the National Institute for Health and Care Excellence (NICE) is also considered.
Evidenced-based prescribing
Both the College of Paramedics (CoP) (2018) and the Royal Pharmaceutical Society (RPS) (2016) are clear that, as non-medical prescribers, advanced paramedics are required to review and critically appraise the evidence base underpinning their prescribing practice.
The CoP outlines how every medicine that can be prescribed will have an evidence base recommending its use. Therefore, advanced paramedics should be aware of the current evidence supporting the use of a given medicine (CoP, 2018).
Health Education England (HEE) outlines how advanced clinical practitioners need to use expertise and decision-making skills to inform clinical reasoning approaches, synthesising information from multiple sources to make appropriate, evidence-based judgments and diagnoses (HEE, 2017).
Straus and Sacket (1998) describe how evidence-based medicine involves: finding the best evidence to use to answer clinical questions; and critically appraising the evidence for its validity (closeness to the truth) and usefulness (clinical applicability). These findings then need to be integrated with clinical expertise and the results applied to clinical practice.
Evidence-based prescribing therefore involves applying the best available evidence when making prescribing decisions. Reference to the evidence base can minimise the risk of adverse drug reactions and interactions while ensuring the most appropriate medication is chosen for the patient's needs (CoP, 2018).
The RPS Competency Framework for All Prescribers outlines how evidence-based practice is an essential skill and a professional prescriber applies the principles of evidence-based practice, including clinical and cost effectiveness (RPS, 2016). A further consideration is that sufficient knowledge of the evidence base is important in the context of patient-centred care. This is in particular with regards to patient adherence to their prescription regimen (Nuttall and Rutt-Howard, 2020).
Evidence suggests that patients educate themselves using online resources before seeking advice from health professionals; it is not always the case that information gathered by patients is accurate, and this serves to strengthen the case for evidence-based prescribing (Nuttall and Rutt-Howard, 2020).
Clinicians must therefore use their clinical skills and experience to rapidly identify each patient's unique clinical situation, applying evidence tailored to support the patient by contextualising the evidence with their preferences, concerns and expectations. This results in a process of shared decision-making, in which the patient's values, circumstances and setting dictate the best care (Pattani and Straus, 2020).
The knowledgeable prescriber who thinks critically is therefore key to ensuring that the patient remains central to the decision-making process, but that this shared decision-making is influenced by the prescriber's accurate and up-to-date knowledge of the evidence. Consequently, prescribing practitioners have a duty to familiarise themselves with valid and reliable sources of evidence to support their practice (Nuttall and Rutt-Howard, 2020).
Sources of evidence
The CoP notes that advanced paramedics should use national sources of evidence to underpin their evidence-based prescribing. Primarily, these are those published by NICE, the British Thoracic Society (BTS) and the Scottish Intercollegiate Guidelines Network (SIGN). Where these are not available, locally agreed, evidence-based protocols should be followed (CoP, 2018).
Tidy and Jackson (2014) reflect this approach and advise that prescribers should begin by searching for evidence-based guidelines as the primary source of evidence.
If none are available, systematic reviews and Cochrane reviews should be sought. If these are not available, primary research should be searched for using databases such as PubMed.
Finally, if no other evidence is available, a general internet search or discussion with a specialist should be sought. However, caution is advised regarding the potential for both low-quality evidence from internet searching and the possibility of bias from expert opinion.
Critical appraisal in practice
HEE outlines how advanced practitioners need to critically appraise and synthesise the outcomes of research, using the results to underpin their practice. A critical approach is required to identify gaps in the evidence base and its application to practice (HEE, 2017). Therefore, as advanced practitioners, prescribing paramedics need to not only develop an in-depth knowledge of clinical guidance but also critically analyse the underpinning evidence base and apply this to their practice.
A wide range of literature and textbooks can assist clinicians and researchers in developing proficiency in critical appraisal.
Tidy and Jackson (2014) say it is useful to start when critically appraising research by considering:
Types of evidence
The widely cited hierarchy of evidence describes how the highest quality data are generated from systematic reviews of randomised controlled trials (RCTs), followed by individual RCTs, controlled observational studies (cohort and case control studies) and, finally, uncontrolled observational studies and case reports (Tidy and Jackson, 2014).
However, this hierarchy depends on the subject being researched. For example, Ho et al (2008) explain that while RCTs may be suitable for the evaluation of efficacy, they may not be appropriate for many other health outcomes-based research questions. Consequently, an RCT is not always the most suitable method of addressing a particular research question.
The choice of research methods used in a study should be considered in the context of its stated aims and objectives. The Oxford Centre for Evidence-Based Medicine (2011) has published a useful table to assist with this process, which identifies the different levels of evidence for different types of research questions.
Critical appraisal tools and reporting checklists
Alongside developing an understanding of which methodologies are best suited to answering a particular research question, it is necessary to undertake a structured critical appraisal of the available evidence in order to critically synthesise research findings and apply them to prescribing decision-making.
A range of validated and widely used critical appraisal tools guide clinicians and researchers to systematically appraise research.
Hilton (2017) provides a useful overview of these tools, alongside how they can be applied by non-medical prescribers in the context of evidenced-based prescribing. These include the range of critical appraisal checklists published by the Critical Appraisal Skills Programme (CASP). The CASP checklists are based on a three-step approach to appraisal: Is the study valid? What are the results? Are the results useful?
CASP has produced eight critical appraisal checklists designed to be used when reading research. These include tools for systematic reviews, randomised controlled trials, cohort studies, case control studies, economic evaluations, diagnostic studies, qualitative studies and clinical prediction rules (CASP, 2020).
Hilton (2017) also outlines how, alongside these appraisal tools, there are standards for reporting primary research. When reviewing published literature, it is useful to refer to the checklist specified in an article to guide critical appraisal of the findings. This includes checking whether all the criteria have been met by the research. Such reporting checklists include the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklists (Moher et al, 2009), the Consolidation Standards of Reporting Trials (CONSORT) for randomised controlled trials (Schulz et al, 2010) and the STROBE checklist for observational studies (Strengthening the Reporting of Observational studies in Epidemiology, 2009). A comprehensive library of these reporting checklists is available from the Enhancing the Quality and Transparency of Health Research (EQUATOR) Network (2020).
In light of the fact that prescribing paramedics will predominantly base their practice on NICE guidance, it is useful to also consider how NICE scrutinises evidence when developing clinical guidance. NICE guideline recommendations are based on the best available evidence (NICE, 2020). A wide range of types of evidence and other information, from scientific research using a variety of methods to testimony from practitioners and people using services, informs the guidance published (NICE, 2020).
NICE uses a framework known as GRADE (Grading of Recommendations, Assessment, Development and Evaluations). This is a transparent framework for developing and presenting summaries of evidence and provides a systematic approach for making clinical practice recommendations (Siemieniuk and Guyatt, 2020).
In GRADE, recommendations can be strong or weak, and in favour of or against an intervention. Strong recommendations suggest that all or almost all people would choose that intervention. Weak recommendations imply that there is likely to be an important variation in the decisions that informed people are likely to make. Recommendations are more likely to be weak rather than strong when the certainty in evidence is low and there is a close balance between desirable and undesirable consequences (Siemieniuk and Guyatt, 2020).
However, GRADE cannot be implemented mechanically; by necessity, there is a considerable amount of subjectivity in each decision. Two people evaluating the same body of evidence might reasonably come to different conclusions about its certainty. What GRADE does provide is a reproducible and transparent framework for grading certainty in evidence (Siemieniuk and Guyatt, 2020).
NICE outlines how health and social care practitioners should use published guidance in conjunction with their own judgment (NICE, 2018).
Therefore, prescribing paramedics are encouraged to review the underpinning evidence of published clinical guidance and also search and appraise newly published research that might also inform their clinical judgment and decision-making.
Conclusion
This article considers how the development and application of critical appraisal skills are essential and required components of non-medical prescribing. Advanced paramedics therefore need to develop proficiency in these areas.
Advanced paramedics are encouraged to review the range of resources discussed, alongside developing and applying critical appraisal skills to their practice in order to demonstrate evidenced-based prescribing.