Establishing consensus‐based high‐acuity low‐occurrence skills for EMS physicians: A pilot survey of EMS fellowship faculty

Abstract

Background

The specialty of emergency medical services (EMS) medicine focuses on providing out‐of‐hospital patient care, including initial stabilization, treatment, and transport in specially equipped vehicles including ambulances and airframe platforms to hospitals and better‐resourced destinations. The Core Content of EMS Medicine outlines the knowledge, procedures, and psychomotor skills relevant to prehospital patient care. However, this document does not specify the high‐consequence skills that are infrequently performed and that carry high levels of complexity as well as potential morbidity. We refer to these as high‐acuity low‐occurrence (HALO) skills. Additionally, there is no consensus definition of what meets the criteria for a HALO skill. The goals of this pilot study were twofold: (1) to determine a consensus definition for a HALO skill and (2) to survey EMS fellowship faculty to identify an initial set of EMS physician trainee skills that meet the HALO definition.

Methods

Using a modified Delphi method, we established a consensus definition of a HALO skill as well as skills that met this definition for EMS physicians. Demographic information was collected from the experts.

Results

There was 100% agreement in the definition provided of a HALO skill. No additional proposed definitions were provided. Thirteen HALO skills were suggested by the panel from the originally proposed 56 skills, requiring three rounds to establish consensus. Final skill domains emphasized by the expert panel include airway management, obstetric emergencies, and shock management.

Conclusions

We present an initial consensus definition of a HALO skill and a recommended list of HALO skills for EMS physicians in training. Opportunity exists for further research to validate the definition and list of HALO skills through the sampling of a broader group of EMS physicians.

INTRODUCTION

The out‐of‐hospital environment presents unique challenges to providing care to critically ill and injured patients. Since 2010, the Accreditation Council on Graduate Medical Education (ACGME) and American Board of Medical Specialties (ABMS) have recognized the field of prehospital and emergency medical services (EMS) medicine as a unique medical subspecialty. ¹ The practice of EMS medicine focuses on providing of out‐of‐hospital patient care, including initial resuscitation and stabilization, treatment, and transport to hospitals and better‐resourced destinations. ² The ABMS Core Content of EMS Medicine provides a broad basis of knowledge necessary for the practice EMS medicine by outlining the knowledge, procedures, and psychomotor skills relevant to prehospital patient stabilization. ³ However, this document does not specify or incorporate high‐consequence clinical situations, which are infrequent but carry high levels of mortality, morbidity, and complexity. We refer to these circumstances as high‐acuity low‐occurrence (HALO) situations.

While the premise surrounding HALO situations is of increasing interest, there is no consensus definition for what meets the criteria for HALO. ⁴ , ⁵ , ⁶ It is generally understood that a HALO skill is performed in a high‐risk, life‐threatening situation with a low frequency of occurrence in the real world. Other investigators in similar fields including emergency medicine (EM) graduate medical education, EMS clinician education, and military medicine have examined several procedures that appear to fit in the HALO category. ⁵ , ⁷ , ⁸ However, determining which of these skills and procedures should be mastered by EMS physician trainees and EMS physicians has yet to be formally identified. The 1‐year ACGME‐accredited fellowship provides the ideal training opportunity to teach EMS physician trainees once the skills have been identified. Providing care in the out‐of‐hospital environment is unique given the dynamic scenes, environmental challenges, and relative paucity of resources compared with the hospital‐based setting. Further, not all EMS physicians come from an EM background. This places the onus on EMS fellowship training programs to teach these skills rather than rely on prior residency training. Expert input is an important component of educational content development. The Delphi method is a structured communication technique that uses systematic, iterative data gathering to reach consensus among experts. ⁹ This methodology has been used to develop lists of operational and clinical knowledge gaps to help prioritize future emphasis. ¹⁰ , ¹¹ , ¹² , ¹³

For this pilot study we sought the expertise of EMS fellowship faculty due to their combined knowledge of EMS medicine and EMS medicine education. The objectives were to determine a consensus‐based definition for a HALO skill and then to subsequently identify a list of HALO skills specific to the practice of EMS medicine to help prioritize the future development of educational objectives and skill maintenance.

METHODS

A modified Delphi method was used to achieve a consensus definition and recommendations among a group of EMS physician educators. Volunteer participants were recruited by email invitation through the listserv of the Council of EMS Fellowship Directors, which is the sole listserv for EMS Fellowship Directors. Consent was obtained, and prospective participants were given a brief description of the project, expected response timeline, and expected time commitment. Respondents could decline participation and exit the survey process at any time. This project was approved by the institutional review board.

All data were recorded using an online survey instrument (Qualtrics). Characteristics of the respondents related to their experience and training in EMS were obtained at the start of the survey. After completing this section, respondents were asked to agree or disagree with a definition for a HALO skill proposed by the authors: “Time critical life, limb, or vision saving interventions that have a low frequency of occurrence.” This definition was generated by the author team following a review of previous published articles. The respondents could propose an alternate definition if they disagreed. Respondents were then asked what frequency best defined a HALO skill based on five provided answer choices including once in a career, once every 6 months, once per year, once every 5 years, and once every 10 years.

An initial skill list was compiled by the study authors through a literature review of PubMed indexed articles (search terms: “high acuity low occurrence,” “HALO,” “skill,” “procedure,” “frequency,” and “emergency”) as well as textbooks on EMS, EM, and military medicine as well as the ABMS Core Content of EMS Medicine. ³ , ¹³ , ¹⁴ , ¹⁵ , ¹⁶ This was used as a starting point for the modified Delphi process. The project was coordinated by KH and guided by AM and ML.

Respondents used a 5‐point Likert‐type scale to rate the skill as exemplary of a HALO procedure for EMS Medicine with the following descriptions: 1 (strongly disagree), 2 (disagree), 3 (neither agree nor disagree), 4 (agree), or 5 (strongly agree). A predefined agreement of greater than or equal to 75% of surveyed experts was used for an item to be included in the list for the subsequent round. Respondents were blinded to the other respondent's answers but did see the result of all the skills that were retained from the previous round at the beginning of Rounds 2 and 3. Using the denominator as number of experts who responded in the round, a skill was retained and moved into the next round when greater than or equal to 75% of experts agreed that it should be considered a HALO skill. Agreement was defined as “agree” or “strongly agree.” When greater than or equal to 75% of experts disagreed, those were considered rejected and thus discarded. Disagreement was defined as “disagree” or “strongly disagree.” Skills that were neither retained nor rejected in a round based on the 75% cutoff were only allowed to carry over to subsequent rounds a single time. This process was continued for three rounds until a final number of HALO skills were determined. During each round, the respondents had the option to suggest an unlimited number of additional items that could be added to the round.

RESULTS

Twenty‐seven participants from the Council of EMS Fellowship Directors listserv responded to an initial request for participation and consented to participate in the survey. This listserv contains membership from the approximately 77 ACGME‐accredited EMS Fellowship programs. These individuals were invited by an anonymous email link to participate in Round 1 of the survey. Of 27 initial respondents to the email, 14 completed Round 1 of the Delphi method, and 10 completed all three rounds. The respondents had varying degrees of experience in EMS medicine (Table 1). There was a minimum of 2 years of experience as an EMS physician and less than 1 year as a medical director and a maximum of 20 years of experience as an EMS physician and up to 14 years as a medical director. The characteristics of the EMS systems in which these experts devote most of their effort were diverse in population size but overwhelmingly featured 9‐1‐1 ground responses at the Advanced Life Support (ALS) level (staffed with at least one paramedic and one EMT). Three of the 14 respondents provided medical direction for specialty care transport (SCT) programs (level of care beyond the scope of a paramedic, commonly a critical care nurse and a critical care paramedic).

TABLE 1.

Panel characteristics

SME	Years as EMS physician	Years as medical director	Title	EMS system characteristics
A	2	2	Medical Director	Urban, ground, 9‐1‐1, ALS
B	14	14	Associate/Deputy Medical Director	Urban, ground, 9‐1‐1, ALS
C	18	13	Medical Director	Urban, ground/rotor, 9‐1‐1, SCT
D	12	10	Operational EMS Physician	Urban, ground/rotor, 9‐1‐1, ALS
E	6	5	Medical Director	Rural, ground, 9‐1‐1, ALS
F	12	12	Medical Director	Suburban, ground/rotor, 9‐1‐1, SCT
G	7	6	Medical Director	Suburban, rotor, interfacility, SCT
H	10	8	Medical Director	Urban, ground, 9‐1‐1, ALS
I	8	7	Medical Director	Rural, ground, 9‐1‐1, SCT
J	12	10	Medical Director	Urban, ground, 9‐1‐1, ALS
K	8	5	Medical Director	Suburban, ground/rotor, interfacility, SCT
L	20	11	Medical Director	Urban, ground, 9‐1‐1, ALS
M	7	7	Medical Director	Suburban, ground, 9‐1‐1, ALS
N	2	<1 year	Medical Director	Suburban, ground/rotor, 9‐1‐1, ALS

Abbreviations: ALS, Advanced Life Support; SCT, specialty care transport; SME, subject matter expert.

The participants responded in Round 1 with their definition of a “low frequency of occurrence” for how often a HALO skill is performed (Table 2). Most experts defined a low frequency of occurrence as a performing one of these skills once every 5 years (n = 6), although once every year was chosen by the next largest cohort of experts (n = 5). There was 100% agreement in the definition provided of a HALO skill. The accepted definition was as follows: time‐critical life, limb, or vision saving interventions that have a low frequency of occurrence. No additional definitions were proposed by the respondents.

TABLE 2.

Definition of low frequency of occurrence

Interval of occurrence	N
Once every 6 months	2
Once every year	5
Once every 5 years	6
Once every 10 years	1
Once in a career	0

Fifty‐six preliminary HALO skills were presented to the participants (Table 3). At the conclusion of Round 1, the expert panel identified 23 preliminary skills. No additional procedures were proposed. In Round 2 of the survey, 10 of the 14 experts responded. The panel accepted 14 preliminary HALO skills and rejected nine. There were two additional skills suggested as potential HALO skills which were unique from the initial list of 56 provided to the panel at the start of Round 1. These were chemically facilitated extrication and cold water immersion for heat casualties. In Round 3, the same 10 participants responded as in Round 2. The panel accepted 13 preliminary HALO skills and rejected one. No additional skills were added by the expert panel. The final list of HALO skills is presented in Table 4.

TABLE 3.

Initial list of 56 HALO skills

1	Tracheotomy complications	29	Transcutaneous pacing
2	Adult endotracheal intubation	30	Use of magnet for malfunctioning PPM/ICD
3	Pediatric endotracheal intubation	31	Intra‐aortic balloon pump management
4	Nasotracheal intubation	32	Prehospital thrombolytics for STEMI
5	Suction assisted laryngoscopic decontamination	33	Prehospital thrombolytics for stroke
6	Management of foreign‐body airway obstruction	34	Cranial burr hole
7	Cricothyrotomy	35	Portable hyperbaric chamber device
8	Control of posttonsillectomy hemorrhage	36	Procedural sedation
9	Needle cricothyrotomy	37	Lateral canthotomy
10	Transtracheal jet ventilation	38	Escharotomy
11	Rapid sequence induction	39	Fasciotomy
12	Finger thoracostomy	40	Limb amputation
13	Tube thoracostomy	41	Pulseless extremity reductions
14	Needle thoracostomy	42	Traction device application
15	Thoracotomy	43	Normal delivery of a term infant
16	Wound packing	44	Breech presentation
17	Arterial tourniquet use	45	Shoulder dystocia
18	Transfusion of blood products	46	Umbilical cord prolapse
19	Junctional tourniquet application	47	Nuchal cord
20	REBOA	48	Limb presentation
21	Venous cutdown	49	Umbilical vein cannulation
22	ECMO cannulation	50	Resuscitative hysterotomy
23	Access of dialysis grafts for resuscitation	51	Care of the entrapped patient
24	Arterial line insertion	52	Mass casualty triage
25	Central venous catheter placement	53	Antidote administration for chemical agents
26	Intraosseous access	54	Management of the patient with retained unexploded ordnance
27	Pericardiocentesis	55	Management of the severely agitated patient with chemical restraint
28	Synchronized cardioversion	56	Management of the severely agitated patient with physical restraint

Abbreviation: HALO, high acuity low occurrence.

TABLE 4.

Final list of HALO skills

1	Cricothyrotomy
2	Control of posttonsillectomy hemorrhage
3	Thoracotomy
4	Junctional tourniquet application
5	Pericardiocentesis
6	Escharotomy
7	Limb amputation
8	Breech presentation
9	Shoulder dystocia
10	Umbilical cord prolapse
11	Nuchal cord
12	Limb presentation
13	Resuscitative hysterotomy

Abbreviation: HALO, high acuity low occurrence.

Although the initial list of preliminary skills was broad, we asked experts to recommend additional objectives at the end of each round. Two additional skills were proposed after Round 2 of the Delphi method, but these were not presented in the third round due to technical limitations. These were cold water immersion for heat casualties and chemically facilitated extrication for technical rescue. Two other skills were proposed after Round 3; however, these two proposed skills had already been eliminated in a previous round by the panel (lateral canthotomy and mass casualty triage). The HALO skill selection process is presented in Figure 1.

FIGURE 1.

HALO skill selection process. HALO, high acuity low occurrence

DISCUSSION

The ABMS Core Content of EMS Medicine defines the scope of knowledge, skills, and abilities (KSAs) of an EMS physician. However, it does not specify which skills are particularly essential in time‐sensitive situations. Some of the KSAs of the EMS physician are indicated in less time‐critical, though important, situations or even preventive health or public health settings. The Core Content of EMS Medicine was created as a living document with the expectation that it would continue to evolve. ³ Similar documents are revised periodically to keep current with advances, including evidence‐based practice.

We sought the expertise of the Council of EMS Fellowship Directors to serve as subject matter experts for this pilot given this group's unique dual expertise in EMS and education as they are actively involved in the development and delivery of content to future EMS physicians. The listserv we utilized to seek participants is the designated listserv for communication among EMS fellowship directors. Our goal was twofold: (1) to determine a consensus definition for a HALO skill and (2) to identify skills that meet the definition. This process is the critical first step in developing learning objectives that can be incorporated into the education of future EMS physicians and into the continuing education process for current EMS physicians to help ensure EMS physicians at all levels of training a prepared to perform these skills in the field. The prioritization of mastery of these skills can help guide EMS physician education. Since EMS fellowship trainees can enter fellowship training following completion of ACGME‐accredited residency other than EM, it is important to identify this list so that it may be included in future fellowship training rather than assume the trainee has had prior exposure to these skills. Additionally, the unique environment and paucity of resources in the out‐of‐hospital environment highlight the importance of mastery of these particular skills.

The HALO skills identified in this pilot are focused in three domains: airway management, shock management, and obstetric emergencies. The prominence of obstetric procedures was unexpected but suggests a lack of comfort and emphasizes the need for focused goals and objectives to help EMS physicians achieve familiarity and confidence with these skills that will occur during high‐stress situations. A review of HALO skills in the obstetrics literature demonstrates that resuscitative hysterotomy and shoulder dystocia were also identified, as they were in this study. ¹³ With regard to the airway domain, control of posttonsillectomy hemorrhage was not surprising and could potentially be extrapolated to any massive airway bleeding from any number of causes. Incorporating education focused on other causes of massive airway bleeding along with management of posttonsillectomy hemorrhage would help further develop proficiency in this very important skill set. The shock management domain included skills focusing on the control of hemorrhage and reversal of obstructive shock, (e.g., pericardiocentesis) but did not specifically address other shock etiologies.

The results of this study, including a consensus definition and preliminary list of HALO skills, will help serve as a starting point for continued validation and obtaining consensus from a more diverse group of EMS physicians. Drawing from a wider group will help to further inform the development of competency‐based goals and objectives for content delivery, particularly for didactic and simulation‐based education. ¹⁷ Additionally, this study will help inform future research and investigation into those skills identified as HALO. Ultimately, we believe that HALO skills should be considered for inclusion in the list of key index procedures ¹⁸ that EMS fellows must compete during fellowship and possibly even incorporated into future iterations of the ACGME EMS milestones.

LIMITATIONS

This study has several limitations. While the panel drew from a wide range of years as an EMS physician‐educator and EMS medical director, it did not identify how much of their time is spent practicing EMS medicine in the field (direct patient care), compared with administrative, academic program oversight and other nonclinical activities. This may have limited the perspectives if the panel did not have significant field practice of EMS medicine or length of time as part of the fellowship program leadership. Additionally, participants were more likely to have experience in urban and suburban EMS services and less likely to have key roles and experience in rural EMS as well as interfacility transport. This introduces the possibility of EMS system‐based variability of HALO skills and requires further investigation.

The initial list of HALO skills for the EMS physician was not meant to be all‐encompassing. Although the panel was invited to submit additional procedures with each round, very few were submitted. Unfortunately, the two added skills did not get included in the next voting round due to a technical error with survey software between Rounds 1 and 2; however, this did not affect the first or final round of the survey. Cold water immersion for heat casualties and chemically facilitated extrication for technical rescue were included within the results of this manuscript to ensure the reader was aware of these proposed skills. Future validation studies will include these skills in the initial proposed list.

There was loss of panel participants from the initial opt‐in to completion of Round 1 of voting. Since we do not know the total number of individuals who opened and read the initial request for participation, it was not possible to determine the response rate. The number of participants decreased incrementally from each round from 27 consented to 14 completing Round 1 to 10 individuals completing Rounds 2 and 3. Given the anonymous nature of how the data were collected, the study team was unable to identify if the experts that were lost from the initial opt in to Round 1 differed in terms of recorded characteristics and the potential impact. However, in Round 3, we report a large degree of agreement among participants for the final recommendations.

CONCLUSIONS

This modified Delphi study identifies a strong consensus on the definition of a high‐acuity low‐occurrence skill for emergency medical services physicians. An initial consensus list of high‐acuity low‐occurrence interventions for emergency medical services physicians was also established and included skill domains of airway management, obstetric emergencies, and shock management. Obstetric emergencies had many included skills. Future research should seek to validate this list by incorporating input for emergency medical services physicians from more diverse clinical and operational backgrounds and who demonstrate time dedicated to the practice of emergency medical services medicine in the field. Establishing consensus on high‐acuity low‐occurrence skills will ultimately inform the development of competency‐based objectives and assessment tools for emergency medical services physician trainees.

AUTHOR CONTRIBUTIONS

Study concept and design: Kaytlin E. Hack, Matthew J. Levy, Eric Garfinkel, and Asa M. Margolis. Acquisition of the data: Kaytlin E. Hack, Matthew J. Levy, Eric Garfinkel, and Asa M. Margolis. Analysis and interpretation of the data: Kaytlin E. Hack, Matthew J. Levy, Eric Garfinkel, and Asa M. Margolis. Drafting of the manuscript: Kaytlin E. Hack, Matthew J. Levy, Eric Garfinkel, and Asa M. Margolis. Critical revision of the manuscript for important intellectual content: Kaytlin E. Hack, Matthew J. Levy, Eric Garfinkel, and Asa M. Margolis. Statistical expertise: Kaytlin E. Hack, Matthew J. Levy, Eric Garfinkel, and Asa M. Margolis. Acquisition of funding: N/A.

CONFLICT OF INTEREST

The authors declare no potential conflict of interest.

Hack KE, Levy MJ, Garfinkel E, Margolis AM. Establishing consensus‐based high‐acuity low‐occurrence skills for EMS physicians: A pilot survey of EMS fellowship faculty. AEM Educ Train. 2022;6:e10828. doi: 10.1002/aet2.10828