title: Evidence-Based Guidelines for Fatigue Risk Management in EMS: Formulating Research Questions and Selecting Outcomes.
abstract: Greater than half of Emergency Medical Services (EMS) personnel report work-related fatigue, yet there are no guidelines for the management of fatigue in EMS. A novel process has been established for evidence-based guideline (EBG) development germane to clinical EMS questions. This process has not yet been applied to operational EMS questions like fatigue risk management. The objective of this study was to develop content valid research questions in the Population, Intervention, Comparison, and Outcome (PICO) framework, and select outcomes to guide systematic reviews and development of EBGs for EMS fatigue risk management.
  
  
  
  We adopted the National Prehospital EBG Model Process and Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework for developing, implementing, and evaluating EBGs in the prehospital care setting. In accordance with steps one and two of the Model Process, we searched for existing EBGs, developed a multi-disciplinary expert panel and received external input. Panelists completed an iterative process to formulate research questions. We used the Content Validity Index (CVI) to score relevance and clarity of candidate PICO questions. The panel completed multiple rounds of question editing and used a CVI benchmark of ≥0.78 to indicate acceptable levels of clarity and relevance. Outcomes for each PICO question were rated from 1 = less important to 9 = critical.
  
  
  
  Panelists formulated 13 candidate PICO questions, of which 6 were eliminated or merged with other questions. Panelists reached consensus on seven PICO questions (n = 1 diagnosis and n = 6 intervention). Final CVI scores of relevance ranged from 0.81 to 1.00. Final CVI scores of clarity ranged from 0.88 to 1.00. The mean number of outcomes rated as critical, important, and less important by PICO question was 0.7 (SD 0.7), 5.4 (SD 1.4), and 3.6 (SD 1.9), respectively. Patient and personnel safety were rated as critical for most PICO questions. PICO questions and outcomes were registered with PROSPERO, an international database of prospectively registered systematic reviews.
  
  
  
  We describe formulating and refining research questions and selection of outcomes to guide systematic reviews germane to EMS fatigue risk management. We outline a protocol for applying the Model Process and GRADE framework to create evidence-based guidelines.
authors.forename: P Daniel
authors.initials: PD
authors.lastname: Patterson
authors.forename: J Stephen
authors.initials: JS
authors.lastname: Higgins
authors.forename: Eddy S
authors.initials: ES
authors.lastname: Lang
authors.forename: Michael S
authors.initials: MS
authors.lastname: Runyon
authors.forename: Laura K
authors.initials: LK
authors.lastname: Barger
authors.forename: Jonathan R
authors.initials: JR
authors.lastname: Studnek
authors.forename: Charity G
authors.initials: CG
authors.lastname: Moore
authors.forename: Kathy
authors.initials: K
authors.lastname: Robinson
authors.forename: Dia
authors.initials: D
authors.lastname: Gainor
authors.forename: Allison
authors.initials: A
authors.lastname: Infinger
authors.forename: Patricia M
authors.initials: PM
authors.lastname: Weiss
authors.forename: Denisse J
authors.initials: DJ
authors.lastname: Sequeira
authors.forename: Christian
authors.initials: C
authors.lastname: Martin-Gill
mesh_terms: D000465:Algorithms; D004632:Emergency Medical Services / Q000458:organization & administration*; D004634:Emergency Medical Technicians / Q000458:organization & administration / Q000523:psychology*; D055416:Evidence-Based Emergency Medicine; D005221:Fatigue / Q000517:prevention & control*; D006801:Humans; D017410:Practice Guidelines as Topic; D012308:Risk Management; D011795:Surveys and Questionnaires; D000078329:Workforce
keywords: PICO questions; evidence-based guidelines; fatigue