eight recommendations: (1) career EMS investigators should be developed and supported; (2) centers of excellence should be created to facilitate EMS research; (3) federal agencies should commit to supporting EMS research; (4) other public and private institutions should be encouraged to support EMS research; (5) results of this research should be applied by EMS professionals and others; (6) EMS providers should require that evidence be available before implementing new procedures, devices, or drugs; (7) standardized data collection methods should be established; and (8) exceptions from informed consent rules should be adopted (NHTSA, 2001a).

The above efforts have helped draw attention to the lack of a research base for EMS and spurred some development in the area. Despite these efforts, however, large gaps in information remain. Patients in the prehospital setting often receive services that have not been proven to work or for which the evidence base is very limited. In many situations, emergency diagnostic and therapeutic strategies have been adapted from patient populations and settings that differ substantially from those of the prehospital environment. Major new programs have been launched with little or no evidence for their cost-effectiveness. Consequently, many treatment strategies employed in the field are of questionable benefit and in some cases may even be harmful.

Questions related to core aspects of current clinical practice—for example, the value of field intubation, fluid resuscitation, and advanced life support (ALS) interventions for cardiac arrest—remain unresolved. Rather than being based on scientific evidence, practices are often based on tradition or convention. And because EMS is slow to adopt a current standard of care, the care that is delivered is highly variable. Nonetheless, advancing the science base to determine what constitutes effective care in the prehospital setting would allow for improvements in EMS care over time.

Not infrequently, treatments that have established effectiveness and safety profiles when used in hospital- or office-based settings are now implemented in the out-of-hospital setting without adequate examination of patient outcomes. For example, the use of endotracheal intubation to provide ventilation and oxygenation for critically ill or injured children is a well-established and highly effective technique when employed in the relatively controlled environment of the operating room, the pediatric ICU, or even the ED. This technique, however, has been widely incorporated into the practice of paramedics in the out-of-hospital setting without sufficient evidence for its efficacy or safety. Gausche-Hill and colleagues conducted a prospective controlled evaluation of this technique compared with simple bag-valve-mask ventilation to determine its effect on survival and neurological outcomes in critically ill and injured children (Gausche-Hill, 2000; Gausche et al., 2000). The study found no evidence for the benefit of endotracheal intubation in the out-of-hospital setting but did show a substantial incidence of complications. Based on these findings, the Los Angeles and



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