National research guideline for prehospital emergency medical care

Objectives: To identify the most important research topics to establish a national research agenda and protocol for prehospital research in Saudi Arabia (KSA). Methods: A 3-round modified Delphi consensus methods were used to determine high-priority research topics. Round I included an open-ended question to list all high-priority research topics in a prehospital setting in Riyadh, KSA. Rounds II and III included ranking evaluation and consensus agreement. The included topics were listed based on the agreement of ≥70% of the experts participating in the study. The study was carried out between November 2021 and February 2022. Results: In total, 100 prehospital experts in KSA were invited to participate in all 3 rounds. Of these, 47 responded in round I, 34 in round II, and 39 in round III. In round I, participants submitted 278 research topics. After deduplication and sorting, 78 topics were assessed in the other 2 rounds. Conclusion: In this modified Delphi study, an expert panel identified the top prehospital emergency medical services (EMS) care research priorities. The leading research priorities included clinical and operational ideas. The proposed 32 high-priority topics can be used to guide researchers, research networks, policymakers, and funding organizations involved in EMS.

T he quality of prehospital emergency care for populations can be improved by using emergency medical services (EMS).][3][4] To efficiently target research that has the highest potential public health value, the process of establishing research priorities is crucial for researchers in the medical sector. 5,6While there are many ways to prioritize health research, there is no consensus on what constitutes the best approach.Setting health research priorities is essential to efforts to create national health research systems. 7Many researchers in different healthcare fields have adapted and utilized this approach.
Several worldwide studies have prioritized prehospital emergency care research.A research agenda is a significant part of research. 80][11] Therefore, the main objective of this study was to develop and establish a prehospital emergency setting research guideline with the help of experts in the prehospital care settings in KSA.This will lead to an improvement in research quality in KSA, which, in turn, will enhance health care in the prehospital setting.
Methods.A 3-round modified Delphi survey technique was used to identify research topic consensus among experts in prehospital care settings in Riyadh, KSA.Prehospital care experts were identified based on their involvement in prehospital policy, practice, and research.The modified Delphi methodology is an iterative process of multiple rounds of expert voting to reach a consensus in situations where there is minimal or no evidence and expert opinion is significant. 12The study was carried out between November 2021 and February 2022.
In the first round, research topics were generated.In the second round, the topics submitted from the first round were evaluated, and the presence or absence of consensus was determined.In the third round, we verified and validated if consensus existed or not.A predefined consensus threshold was set at ≥70% in both the second and third rounds for either inclusion or exclusion.
The study team made use of their prior expertise to approach possible policymakers, specialists, and researchers in prehospital emergency care.The team agreed to nominate participants from different specialties working in various Saudi Arabian organizations.The eligibility criteria were as follows: I) academicians or emergency clinicians with expertise in emergency medicine or prehospital emergency care; II) researchers and experts with work experience of at least 3 years.Participants who did not meet the inclusion criteria were excluded from the study.
Prior to the study, an Institutional Review Board approval was obtained from King Abdullah International Medical Research Center, Riyadh, KSA (IRBC/1971/21).
The study team identified and invited 100 participants for the 3 rounds.The identified experts were: I) emergency medicine physicians; II) academicians or researchers in prehospital emergency care; III) paramedics; and IV) emergency nurses.Additionally, all experts involved in this study had at least 3 years of experience in either prehospital emergency research or care.Thus, we expected a variation in opinions among the participants based on their clinical experience, research experience, interest, education level, and career level.Finally, no sample size calculation was carried out as Delphi studies rely on reaching a consensus rather than a sample size. 13In addition, all 100 participants were contacted in all 3 rounds.

Statistical analysis.
After collating all responses from round I, 2 investigators merged the suggestions that noticeably indicated the same research topic and excluded the responses that were undoubtedly irrelevant to the prehospital setting.In rounds II and III, for each research topic, 3-point Likert scale responses were presented using frequencies and percentages.
The threshold for inclusion consensus was identified as ≥70% of participants agreeing on a research topic, while the threshold for exclusion consensus was identified as ≥70% of participants disagreeing on a topic.Microsoft 365 Excel for Mac, version 16.65 (Microsoft, Redmond, WA., USA) was carried out for data analysis.Results.In round I, 47 (47%) of 100 participants invited through email completed the online survey.Most round I respondents (n=22, 46.8%) were paramedics.Furthermore, most participants (n=15, 31.9%) had 3-5 and 11-15 years of experience (Table 1).In round II, 34 Disclosure.Authors have no conflict of interests, and the work was not supported or funded by any drug company.
In round I, participants were requested to list all the research topics they felt required investigation.A total of 47 participants provided 287 statements.After deduplication, sorting, and removing irrelevant statements, 78 research topics were eligible for inclusion in round II.
In round II, the participants were requested to categorize the 78 topics on a 3-point Likert scale.The results were sorted into high, low, and uncertain priority categories, in which 51 topics were included as they met the inclusion threshold, and none met the threshold for exclusion.The remaining 26 topics met the nonconsensus threshold.Moreover, round III included high and uncertain priority (non-consensus) topics for further assessment.Therefore, all 78 topics were included in the final round (round III).In round III, participants were again given the 78 topics from round II (Figure 1).
In round III, the participants were requested to categorize all 78 topics using a 3-point Likert scale.This resulted in 32 topics meeting the inclusion threshold (Table 2).Additionally, the experts changed their opinion regarding 20 topics that had met the inclusion consensus in round II to non-consensus in this round (Table 3).
Discussion.This study carried out a gap analysis for prehospital research by inviting clinicians, researchers, and experts interested in prehospital emergency care to initiate and determine the top research priorities for prehospital emergency care.A total of 32 research topics met the inclusion threshold (≥70% agreement) and were considered important.
Several studies have reported the importance of repeating rounds for consensus studies, allowing participants to reflect on alternate views they may have missed and reconsider their initial responses. 14,15n our study, the significance of repeating the ranking evaluation in round III for all topics that reached the inclusion consensus increased its validity.By doing so, the experts re-ranked all 51 included topics from round II.Only 32 out of 51 topics reached the inclusion consensus.As a result, only high-priority topics were agreed upon by the experts.
The ideas developed and prioritized in this study represent a comprehensive list generated by prehospital emergency care stakeholders and experts from various backgrounds and experiences using the Delphi methodology.The results of this study are intended to serve as a guideline for future prehospital research and related funding.Patient care and outcomes were essential components of the high-priority topics in our study.Both were mentioned in the context of observational and interventional research (namely, the effectiveness of prehospital critical care, survival rate following out-of-hospital cardiac arrest, and prehospital pain management).In addition, experts provided several ideas related to system-level research and system benchmarks.Despite the importance of system benchmarks in the process, time, and efficiency of care, the main emphasis of experts' view was based on ideas related to improving patient's care and reducing mortality.This reflects the significant effort the study participants placed on designing prehospital research studies to impact patient's outcomes and save lives.][3][4] Study limitations.The response rate in round II was relatively low (32%).However, the Delphi study aims to have a good representation of research ideas from the participants rather than getting a high response rate, which was achieved.Despite the extensive list of research topics, the study focus was to determine prehospital research priorities in KSA, so the results of this Delphi study may not apply to other counties.
In conclusion, in this modified Delphi study, an expert panel identified the top prehospital EMS care research priorities.The leading research priorities included clinical and operational ideas.The proposed 32 high-priority ideas can be used to guide researchers, research networks, policymakers, and funding organizations involved in EMS.The study's implication is to determine research priorities which will be provided to the Saudi Research, Development and Innovation Authority, Ministry of Health, Saudi Red Crescent Authority, and research centers to disseminate our results, apprise future prehospital research plans, and prioritize funding.Overall, the results of this study can significantly improve the care and quality of EMS.

Figure 1 -
Figure 1 -Flow chart of the study process.

Table 2 -
Research priorities met, including criteria from round II and III.

Table 3 -
Research priorities excluded after round III.