Innovation but precious little evaluation: time for more IDEAL-ism in prehospital care?
Friday, October 7, 2011
Recognized uncertaintyThere are many examples in prehospital care of innovations introduced with enthusiasm, but where the supporting evidence-base is lacking. To name but a few here: non-invasive pacing (Sherbino et al, 2006), mechanical chest compression devices (Brooks et al, 2011), and oxygen administered to the patient with acute myocardial infarction (Cabello et al, 2010). Evidence that benefit exceeds harm for these interventions has yet to be established in a well conducted study (high-quality research is now underway addressing most of these issues). That is not to say these interventions do not work, but there is recognized uncertainty.Contemporary enthusiasm for mild therapeutic hypothermia (MTH) following cardiac arrest has recently been challenged (Nielsen et al, 2011) and while there is some evidence for this intervention, it is considered low-level (Walters et al, 2011); supporting this author's view that it would be premature for ambulance services to introduce MTH outside of a well-designed, ethically approved research study.Two more examples that were published as this commentary was being written include a randomized trial of 8718 patients comparing the impedance threshold device (ITD) with a sham device (Aufderheide et al, 2011). Contrary to an earlier, non-randomized UK study (Thayne et al, 2005) suggesting that the ITD improved short-term survival, the ITD did not significantly improve survival with satisfactory function in this recent high-quality study. Moreover, another prehospital study in the same edition found no difference in outcomes with either a brief period of basic life support (BLS) compared with two minutes of BLS provided by ambulance personnel prior to first analysis of cardiac rhythm (Stiell et al, 2011) differing from more optimistic assessments from lower quality, UK observational series (Fletcher et al, 2011). These should serve as yet more reminders that robust evaluation is required before widespread adoption of innovative treatments. Using treatments before we have a robust evidence-base could be described as experimenting on patients, we need to go about it the right way through well-designed, ethically approved research that gives a fair assessment of the value of a therapeutic intervention.It is not just about treatments either. There has been enthusiasm for introducing strategies for risk assessment in patients with suspected transient ischaemic attack (TIA), but modelling has suggested using ambulance services to expedite TIA care was unlikely to be cost effective (Mant et al, 2008). The ABCD2 score has not proven useful in the emergency department setting (Perry et al, 2011). Critical care paramedics are an attractive proposition (NHS Confederation, 2011) but there is no good evidence yet of their value to patients or the NHS, and the research underpinning the NHS Confederation report has been criticized for its poor quality (Hughes, 2011). It is possible to do such research well, see for example the work from Sheffield on paramedic practitioners (Mason et al, 2007).
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