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What are the highest priorities for research in emergency prehospital care?
  1. Helen Snooks1,
  2. Angela Evans1,
  3. Bridget Wells1,
  4. Julie Peconi1,
  5. Marie Thomas1,
  6. Malcolm Woollard2,
  7. Henry Guly3,
  8. Emma Jenkinson4,
  9. Janette Turner5,
  10. Chris Hartley-Sharpe6,
  11. on behalf of the 999 EMS Research Forum Board
  1. 1
    Centre for Health Information, Research and Evaluation, Institute of Life Science, School of Medicine, Swansea University, Swansea, UK
  2. 2
    Coventry University, Coventry, UK
  3. 3
    Derriford Hospital, Plymouth, UK
  4. 4
    City Hospital, Birmingham, UK
  5. 5
    Medical Care Research Unit, Sheffield University, Sheffield, UK
  6. 6
    London Ambulance Service, London, UK
  1. Professor H A Snooks, Centre for Health Information, Research and Evaluation, Institute of Life Science, School of Medicine, University of Wales, Swansea SA2 8PP, UK; h.a.snooks{at}

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The recent UK Department of Health publication “Taking Healthcare to the Patient: Transforming NHS Ambulance Services1 recommended that the Department of Health should commission a programme of work to build the evidence base for the delivery of emergency and unscheduled prehospital care. As a starting point, the Department of Health commissioned the 999 EMS Research Forum to review the evidence base for the delivery of emergency prehospital care; to identify gaps in the evidence base; and to prioritise topics for future research.

The 999 EMS Research Forum is a partnership of academics, clinicians and prehospital care practitioners and managers formed in 1999, whose aim is to encourage, promote and disseminate research and evidence-based policy and practice in 999 health care.

Prioritisation of research topics is a key part of the process of commissioning of research, although methods may differ.2 3 The desirability of including a wide range of stakeholders in a structured approach has been stressed, in order to achieve a credible result that may be more likely to produce research that informs policy and practice.46 This emergency prehospital care research prioritisation exercise included three elements (fig 1):

Figure 1

Prioritisation exercise: flow chart of processes.

  • Identification of published reviews, policy documents and ongoing research within the field of emergency prehospital care.

  • Identification of gaps by matching existing and forthcoming research evidence against policy documents.

  • Delphi consultation with key stakeholders in the field of emergency care.

Objectives, methods and results are presented in full at = 506.

Thirty policy documents were identified and classified according to source; 52 reviews of evidence published since 2000 and 43 ongoing or recently completed studies were identified and graded (systematic review, comprehensive review or expert opinion).Through the matching exercise, 96 topics were identified.

A total of 158 individuals and 10 organisations were invited to participate including members of emergency, prehospital and primary care clinical and research networks; an ambulance service trust chief executive, an operations director, medical/clinical directors and R&D leads; international experts; and patient representative groups. Forty people participated in the consultation.

The “top 10” priority topics were:

  • Development of emergency medical services (EMS) performance measures other than response times for use in performance management, audit and research.

  • Prehospital clinical management of stroke.

  • Safety, costs and benefits of alternatives to conveyance to hospital.

  • Development of patient-focused clinical outcomes measures.

  • Methods for combining information on prehospital care and patient outcomes across ambulance service and other healthcare organisations.

  • Developing interventions to appropriately manage the increase in 999 calls.

  • Evaluation of mechanical aids for cardiopulmonary resuscitation.

  • Nasal route for administration of pain relief.

  • Alternatives to ambulance response or transport to emergency departments (EDs) for stroke.

  • Clinical prehospital management of confused/aggressive patients with head injuries.


A large number of topics covering a broad range of clinical and organisational themes were included in the review. The areas identified as highest priorities for research reflect three key issues:

  • Identification of clinically relevant performance measures for use across the whole EMS system and not just the ambulance service.

  • Development of alternative methods of patient management to reduce transports to ED.

  • Need for research evidence to underpin the delivery of clinical care in the prehospital setting.

The development of more relevant and meaningful EMS performance measures was clearly identified as the most important issue that future research needs to address. For many years the achievement of response time standards has been the single measure against which the quality of ambulance services has been judged. However, research has shown that, with the exception of a very small number of patients, response time does not affect outcome7 8 and is not therefore a useful indicator of quality for the vast majority of ambulance service users. Furthermore, response times only reflect the transport element and not the care provided. The 999 workload of ambulance services encompasses a broad range of clinical conditions with varying degrees of urgency, and it is estimated that only 10% of calls are truly life-threatening.1 The use of response times as a performance measure has resulted in ambulance services being organised and managed around the needs of a few which can then result in an inappropriate service for many others (including transport to hospital for conditions that, with a different response, could be managed at home). Research to inform the development of alternative methods of patient management was also prioritised, as was the linkage of information across healthcare providers, illustrating the synergistic relationship between delivery of appropriate services and performance measurement.

The results of this study to prioritise research topics through review of evidence and consultation can be used to help build a strategy for commissioning and undertaking research in prehospital care at local, national and international levels. They provide a robust foundation on which the Department of Health and other commissioners can build a programme of future research.

The 999 EMS Research Forum Board members: Dr Frank Archer, Monash University, Australia; Tom Clarke, Newcastle City Hospital; Professor Jeremy Dale, University of Warwick; Henry Guly, Derriford Hospital; Chris Harley-Sharpe, London Ambulance Service; David Janes, University College Dublin; Fionna Moore, London Ambulance Service; Professor Jon Nicholl, University of Sheffield; Professor Helen Snooks, University of Swansea; Janette Turner, University of Sheffield; Professor Malcolm Woollard, Coventry University; Dr Rachael Donohoe, London Ambulance Service; Dr Julia Williams, University of Hertfordshire.


The named authors have written this commentary on behalf of the 999 EMS Research Forum Board members, all of whom contributed to the full report. We would like to thank all those who participated in the Delphi consultation exercise.


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  • Funding: This project was supported through a grant from the Department of Health. The interpretation of results presented represents the views of the authors and not necessarily the Department of Health.

  • Competing interests: None.

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