Voluntary Guidelines for Out-of-Hospital Practices
This Policy Resource and Education Paper is an explication of the Policy Statement Voluntary Guidelines for Out-of-Hospital Practices.
A joint policy statement and PREP between ACEP, the National Association of EMS Physicians (NAEMSP) and the National Association of State EMS Directors (NASEMSD)
EMS systems frequently encounter new guidelines and standards established by a variety of organizations, including professional societies (such as ACEP and NAEMSP), clinical specialty societies (such as AHA, the American Heart Association), government agencies (such as OSHA, the Occupational Safety and Health Administration), industry associations (such as NFPA, the National Fire Protection Association), and other non-profit groups (such as ASTM, the American Society for Testing and Materials). In some cases, particularly those involving government agencies, true standards are being set forth, with regulatory backing and mandatory compliance. Frequently, however, voluntary guidelines are being set forth as the best opinion of the promulgating agency, group, or society. In the vast majority of cases, these guidelines are developed through a rigorous process involving a detailed review of available information on the topic, and often involving a consensus process between members of many organizations with interest in the topic.
While such guidelines may be accompanied by advice regarding implementation, this is not always the case. EMS systems face myriad standards and guidelines that potentially affect the patient care practices of the system. The systems frequently turn to medical oversight, regional or state EMS offices, or other sources of leadership for assistance in evaluating these standards and guidelines for possible implementation.
For the purpose of this position statement, only "voluntary guidelines" will be considered. This position statement is not meant to address regulatory standards and other guidelines that are mandated by legal authority, through statute or formal regulation.
The National Association of EMS Physicians, the National Association of State EMS Directors, and the American College of Emergency Physicians believe that:
The approach that a given EMS agency, system, region, or state office takes in implementing voluntary guidelines must be driven by both local needs and local resources. It must be recognized that logistical, financial, and public health needs, and regulatory realities may influence how, when, or even whether a given EMS agency, system, or region considers or adopts new guidelines. Incorporation of new guidelines into any existing EMS system must be considered in the context of the public's health as a whole, rather than a single illness or injury. The EMS physician medical director must be intimately involved in all these deliberations and decisions.
Logistical/Operational: Given the tremendous variability in EMS system size, design, capabilities, and resources, it is obvious that EMS systems must have different approaches to evaluating and implementing new guidelines. The manner in which any given system goes about evaluating and implementing guidelines will necessarily be affected by these factors as well as local EMS and public health needs. Additionally, the effect of incorporating new guidelines into pre-existing, day-to-day operations must be considered. From an operational standpoint, systems should not sacrifice baseline performance to institute new guidelines, unless the new guidelines have a higher public health priority.
Financial: It must be recognized that implementation and adherence to a new set of guidelines may have significant associated costs, such as training of personnel, purchase and maintenance of new equipment, and medical oversight expenses. The costs of attaining compliance with such guidelines must be recognized: resources expended on compliance with one set of guidelines will not be available for compliance with other guidelines, or for routine functions. From a financial standpoint, as well as an operational standpoint as outlined in A. above, it is rarely reasonable to sacrifice baseline capabilities in favor of compliance with new guidelines.
While in optimal circumstances new guidelines could be viewed as tools which EMS systems could use as leverage for additional resources, this is not always possible. In particular, EMS systems that rely principally on billing for services rendered (as opposed to local tax revenue support or other subsidization) will likely not be able to utilize this strategy. Similarly, many EMS services with public funding or subsidies are constrained by statutory or contractual limitations on the amount funds available. Accordingly, it may be necessary to evaluate guidelines in terms of the opportunity costs of compliance, cost-benefit (comparing economic costs with economic benefits), and cost-effectiveness (evaluating cost per degree of effect, either marginal or incremental).
Regulatory: Each EMS agency and its medical director must be aware of the degree of latitude granted by state legislation and regulations in modifying patient care activities and crafting protocols, policies, and other documents that involve areas for which guidelines have been promulgated. Those working in states where strict adherence to statewide standards is required may have to consider new guidelines in a different way than those working in states that allow local variation. The former will need to work with or through the appropriate state-level authorities and agencies, while the latter will need to take on the responsibility locally.
When considering the implementation of guidelines, EMS systems should consider both the strength of the science supporting the guidelines as well as its applicability to the local EMS and public health environment.
Strength of science: EMS systems evaluating a set of guidelines must consider the strength of the science supporting the guidelines to determine if the evidence is significant enough to warrant EMS system implementation, especially when its implementation may compromise other infrastructure needs of the EMS system.
Local applicability: Guidelines should also be considered in the context of a local EMS system's characteristics, operations, and environment. A given set of guidelines may not be applicable to all given EMS systems. For instance, some guidelines while appropriate for urban EMS systems may not be appropriate for EMS systems operating in rural or remote areas. Additionally, guidelines based on scientific studies of effectiveness in one community may not be applicable to all communities because of differences in the characteristics of the community and/or EMS/public safety systems.
EMS systems must provide the highest quality of service and patient care based on current resources and public health needs. Voluntary guidelines should be used to supplement and enhance the overall local system structure and function, and should be implemented in a systematic process encompassing all facets of an EMS system. Voluntary guidelines should not be considered required standards of care.