Exploring the Evolving Landscape of Ambulance Research: Insights into Ongoing Studies and Challenges for EMS Professionals

Ambulance studies have become increasingly important in the research field. It’s a critical area of study that focuses on the early stages of patient care before they arrive at a hospital.?

It's an area that requires a unique set of skills, expertise, and resources. We're excited to learn more about the process of this type of study and about the special part ambulance staff play in this field.

In this interview, we speak with Risco van Vliet , Master-of-Science Nurse practitioner at Dutch EMS RAV Brabant-Midden-West-Noord. Six months ago he started as Project manager at Diagram Research managing pre-hospital trials.?

From Pre-Hospital Care to Clinical Research

Risco started his career in health care 36 years ago as registered nurse. After working on the intensive care unit, he joined the ambulance services in 2008. He completed the Master Advanced Nursing Practise in 2015 after which he became involved in medical management, improving the quality of ambulance care. Today he staffs the Rapid Responder (RR) as Nurse practitioner.

Risco shares: “Within EMS RAV Brabant MWN we’re working towards more function differentiation on the street.” Nurse practitioners are qualified and allowed to independently indicate and perform certain medical procedures, such as prescribing medication, preform chirurgical interventions, endoscopies, cardioversion, injecting and puncturing, thus combining nursing care with medical care.?

This new role suits Risco perfectly: “I can use my skills and expertise to the fullest, while improving patient care. Because the ultimate goal is to provide more personalised care at home and avoid unnecessary hospital visits.”

In addition, Risco is combining his current position with a part-time role in the clinical research field. As Project Manager at Diagram Research, he’s responsible for coordinating pre-hospital phase studies. His main task is to put the trial into practice. “This involves tackling issues such as: How do I get more EMS to participate? And How do I reach higher levels of patient enrolment?," he shares.

Ambulance Care in the Netherlands

But before diving deeper into Risco’s work as Project Manager, we’re eager to understand more about the structure of the Dutch EMS.?

Risco?gives us an overview, sharing that in the Netherlands different types of ambulances are assigned to different levels of emergency care:

• The Low/Mid/Complex (LMC) Ambulance: These vehicles are staffed by a nurse with a driver and are sent out for non-urgent medical care. The LMC ambulance isn’t used for emergency transport.?
• The Advanced Life Support (ALS) Ambulance: The traditional, fully-equipped ambulance staffed by an ambulance nurse and ambulance driver and/or a BMA (Bachelor's in Medical Assistance). It’s a mobile first aid and is used for situations where urgent medical attention is required, staff works on an advanced life support level supported by a nationwide protocol.
• The Rapid Responder (RR) or Solo Ambulance: An emergency car, staffed by one single ambulance nurse without the possibility transporting a patient.
• The Masters Rapid Responder:?In some regions, the RR is staffed by a Physician Assistant or Nurse Practitioner (like Risco himself at EMS RAV Brabant MWN). Since they are trained and authorized to autonomously diagnose, treat and perform certain medical procedures, this RR can provide exactly the same assistance as a regular ambulance plus provide care beyond the nationwide protocol. The only thing this RR can't do is transport a patient.

Although the exact structure might differ per region with varying levels of function differentiation, the above split gives a good indication.

The Evolving Landscape of Ambulance Research

Ambulance research is a rapidly evolving field, and Risco shares a few examples of the many types of studies being conducted in this unique environment:

1. Chest pain is a common reason for ambulance calls, and it's an area of active research. One focus is on measuring troponin levels in patients' homes, which could provide important information about heart health.
2. Cardiopulmonary resuscitation (CPR) is another area of ongoing investigation, with ambulance services playing a key role in testing new techniques and devices.
3. Neurological studies are also being conducted in the ambulance setting, exploring ways to improve outcomes for patients with conditions like stroke or traumatic brain injury.

But with all those studies being conducted in the ambulance, doesn’t it get too complicated for ambulance professionals, we wonder. Do they have to remember a lot of information when responding to a call?

Risco clarifies: “Actually no. Typically only one study is being conducted at a time within a given ambulance service, so it's not like an EMS professional would have to remember 20 different studies when responding to a call. And when the EMS is participating in more than one study, they will be focused on completely different areas.”

But getting the buy-in from ambulance staff can be challenging, since participation in clinical research asks for a considerable investment of time and effort.?

Risco elaborates: “The ambulance professional has to be schooled in the working of a medical device or investigational product. They need to study the protocol, learning the inclusion and exclusion criteria. And especially post-COVID, colleagues are exhausted due to the increased workload caused by the pandemic, staff shortages and the need to catch up on education. Understandably, this results in limited willingness to invest free time for education on new studies.”?

The main goal is to make participation as effortless as possible.

According to Risco, the key to success is close collaboration. He clarifies: “It’s crucial to have a good understanding of what’s happening in the field; to understand challenges and wishes and to provide support where necessary. I’m actively seeking feedback and translating that feedback into practical work agreements. The main goal is to make participation as effortless as possible.”

Translating Research Into Practice: Navigating Challenges

Apart from encouraging ambulance staff to participate in clinical research, there are other challenges to navigate when conducting research in the pre-hospital phase.?

We discuss the main ones that differ from hospital-based research, such as the limited number of eligible patients encountered by EMS, time constraint and ethical considerations.

1.??????Finding enough eligible patients

The chance that an ambulance professional encounters an eligible patient for a specific study, is relatively small.

In the pre-hospital phase, it can be challenging to find enough eligible patients to participate in a study. This is due to the nature of the ambulance service, where EMS professionals?encounter a diverse patient population with a wide range of conditions and injuries, many of which may not meet the specific criteria for a given study.?

Risco explains: “Let me give you an example for a cardiovascular study that enrols patients with a myocardial infarction.?

• Our ambulance service conducts 170.000 trips a year, out of which 25% are related to cardiovascular complaints
• Only 0.4% of those patients are suffering a myocardial infarction
• From that small group, only 20% might meet the inclusion criteria.

So, even when an ambulance professional is enthusiastic to participate and willing to invest time and effort, the chance that this professional encounters an eligible patient for a specific study, is relatively small.”?

One solution to tackle this challenge, is to get more EMS to participate in the study, locally but also internationally. Diagram Research is experienced in running multi-centre and multi-country trials.?

Risco shares: “Expanding your reach to other countries, hopefully results into more inclusions per month. And the faster you reach the necessary enrolment number, the faster you can start drawing conclusions and conclude your study.”?

2.??????Time constraint

There’s always a sense of urgency to transport the patient to the hospital. Taking a moment to include the patient into a trial, might feel like a waste of time.

According to Risco, time constraint remains another key challenge. While hospital-based research can be conducted at a more leisurely pace, pre-hospital research has time constraints due to the need for rapid patient care and transport.?

Traditionally, ambulance services were only responsible for transporting patients to the hospital. “We’ve been always taught to to transport the patient to the hospital as quickly as possible,” Risco explains. He continues: “For example, in the case of a heart attack, the only effective treatment is thrombolysis, so you don’t hesitate, you go straight to the hospital.”

Today, EMS often administer medicines and treatments at home creating a shift from transport to treatment on site. “When a patient has trouble breathing, you can already administer medicine to open the lungs at home,” Risco illustrates.?

Despite this shift towards providing more treatments at home, the mentality of quickly transporting patients to the hospital is deeply ingrained in the ambulance service and will remain a key issue to tackle. Risco: “There’s always a sense of urgency to transport the patient. And then taking a moment to include the patient into a trial, might feel like a waste of time. Yes, time is still a tough one.”

3.?????Ethical Considerations

It can be a complex task in a high-stress environment.

Lastly, Risco touches upon ethical considerations surrounding informed consent. Risco shares that ambulance professionals often find it difficult to ask patients if they want to participate in research.?

"You’re with a patient who is in need, in pain, who is sick and uncomfortable, who is having a heart attack," he explains. "And then you have to ask: do you want to participate in a clinical trial? And explain the details of the study and the potential risks and benefits. It can be a complex task in a high-stress environment,” Risco says.?

Improving Patient Outcomes through Smarter Allocation of Resources

The current healthcare system is no longer sustainable. We have to rethink the way health care is delivered.

Ambulance utilisation has increased in the Western world over the past 20 years. With the impending rise in demand for health services, an effective utilisation of the workforce is paramount to ensure high-quality yet cost-effective health service delivery.?

Risco: “The current system is no longer sustainable. The population is aging, the demand for healthcare is rising and everybody is coping with labour shortages, soon we won’t have enough personnel available to staff the ambulances. We have to rethink the way health care is delivered, we have to work smarter and use our available resources better.”??

To illustrate, Risco shares an A and B scenario for an 80-year-old lady who has tripped at home and broken her hip:

Scenario A is the typical scenario how this situation is handled. Risco: “The emergency ambulance arrives, administers a general anaesthetic, straightens the leg and transports the patient to the hospital, where she undergoes surgery for a new hip.?

Meanwhile, the drugs continue to work. And because she's elderly, she's prone to delirium, vomiting and other after-effects of those drugs, meaning that there is a chance she will die from the consequences of her fall.”

Now let’s look at scenario B:

“In scenario B, you allocate your resources in a smarter way. Instead of sending an expensive ALS ambulance, you send out a Nurse Practitioner, who administers a local anaesthetic in the leg. There’s no need for morphine. The patient is transported in a LMC ambulance, which is cheaper. She arrives at the hospital, they repeat the injection and she receives a new hip in the operating room.” Risco explains.

He continues: “In this case, when you use your available resources in another way, the emergency ambulance remains available?and?you provide the patient with good quality care. People can stay in their own environment and don’t have to be transported back and forth to the hospital. Customised care - that's where we need to go.”?

And to get to more customised care at home, we need more clinical research to demonstrate its added value. As a research organisation, we want to play a role in this; we want to facilitate studies to demonstrate this added value and to further optimise the entire process.

Future Plans: Advancing Pre-hospital Treatment of Cardiac Arrhythmias

When asked about his future plans, Risco shares: "Thanks to my new role, I came into contact with prof. Arnoud van 't Hof , Head of the department of Interventional Cardiology at Maastricht UMC+.?Together with him and my EMS, I’ll want to develop a line of research for pre-hospital treatment of cardiac arrhythmias.”

Risco mentions that this process will probably take three to four years, and in the meantime he hopes to expand his role at the ambulance service. It's clear that Risco is passionate about his work and has ambitious goals for his future in the field.

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