Characterization and Application of Statewide Emergency Medical Services Advanced Life Support Protocols

Introduction: Many emergency medical services (EMS) systems in the United States utilize statewide protocols, but the number, type, and role of these systems in prehospital decision-making are largely unknown. Study Objective: To characterize statewide protocols and determine their role in prehospital decision-making. Methods: All states were queried for the presence of mandatory statewide Advanced Life Support (ALS)-level EMS protocols. Protocols were categorized as diagnosis-based, symptom-based, procedural, or non-clinical by two fellowship-trained EMS physicians. A data abstraction guide with category examples was included. Discrepancies were resolved by a third blinded EMS physician. The number and type of protocols were compiled, and simple statistics and chi-squared analysis were used to evaluate state-by-state variation. Results: Nine states have mandatory statewide ALS protocols, totaling 804 individual protocols, including 672 (83.6%) clinical and 132 (16.4%) non-clinical protocols. Symptom-based protocols accounted for 59.5% of the clinical protocols, while 13.2% were diagnosis-based and 27.2% procedural. Per state, there was a median interquartile range (IQR) of 46 (14.5) symptom-based, 8 (8) diagnosis-based, and 17 (22.5) procedural protocols. There was significant variation in the type and number of protocols by state (p < 0.001). Conclusion: Significant variation exists in statewide EMS protocols. While many are symptom-based, a notable portion are diagnosis-based, challenging the notion that paramedics cannot diagnose. These findings suggest a need for higher-level clinical decision-making in EMS. Further research is warranted at other EMS training levels and to inform EMS training programs.