title: The development of evidence-based prehospital guidelines using a GRADE-based methodology.
abstract: BACKGROUND
  The burgeoning literature in prehospital care creates an opportunity to improve care through evidence-based guidelines (EBGs). Previously, an established process for the creation of such guidelines and adoption and implementation at the local level was lacking. This has led to great variability in the content of prehospital protocols in different jurisdictions across the globe. Recently the Federal Interagency Committee on Emergency Medical Services (FICEMS) and the National EMS Advisory Council (NEMSAC) approved a National Prehospital Evidence-based Guideline Model Process for the development, implementation, and evaluation of EBGs. The Model Process recommends the use of established guideline development tools such as Grading of Recommendations, Assessment, Development, and Evaluation (GRADE). Objective. To describe the process of development of three prehospital EBGs using the National Prehospital EBG Model Process (EBG Model Process) and the GRADE EBG development tool.
  
  
  METHODS
  We conducted three unique iterations of the EBG Model Process utilizing the GRADE EBG development tool. The process involved 6 distinct and essential steps, including 1) assembling the expert panel and providing GRADE training; 2) defining the evidence-based guideline (EBG) content area and establishing the specific clinical questions to address in patient, intervention, comparison, and outcome (PICO) format; 3) prioritizing outcomes to facilitate systematic literature searches; 4) creating GRADE tables, or evidence profiles, for each PICO question; 5) vetting and endorsing GRADE evidence tables and drafting recommendations; and 6) synthesizing recommendations into an EMS protocol and visual algorithm. Feedback and suggestions for improvement were solicited from participants and relevant stakeholders in the process.
  
  
  RESULTS
  We successfully used the process to create three separate prehospital evidence-based guidelines, formatted into decision tree algorithms with levels of evidence and graded recommendations assigned to each decision point. However, the process revealed itself to be resource intensive, and most of the suggestions for improvement would require even more resource utilization.
  
  
  CONCLUSIONS
  The National Prehospital EBG Model Process can be used to create credible, transparent, and usable prehospital evidence-based guidelines. We suggest that a centralized or regionalized approach be used to create and maintain a full set of prehospital EBGs as a means of optimizing resource use.
authors.forename: Kathleen M
authors.initials: KM
authors.lastname: Brown
authors.forename: Charles G
authors.initials: CG
authors.lastname: Macias
authors.forename: Peter S
authors.initials: PS
authors.lastname: Dayan
authors.forename: Manish I
authors.initials: MI
authors.lastname: Shah
authors.forename: Tasmeen S
authors.initials: TS
authors.lastname: Weik
authors.forename: Joseph L
authors.initials: JL
authors.lastname: Wright
authors.forename: Eddy S
authors.initials: ES
authors.lastname: Lang
mesh_terms: D032921:Consensus; D004632:Emergency Medical Services / Q000379:methods / Q000458:organization & administration / Q000592:standards*; D055416:Evidence-Based Emergency Medicine / Q000379:methods / Q000458:organization & administration / Q000592:standards*; D006801:Humans; D017410:Practice Guidelines as Topic / Q000592:standards*; D014481:United States