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Adherence to guidelines and protocols in the prehospital and emergency care setting: a systematic review

Remco HA Ebben15*, Lilian CM Vloet12, Michael HJ Verhofstad3, Sanne Meijer1, Joke AJ Mintjes-de Groot1 and Theo van Achterberg4

Author Affiliations

1 Research group for Acute Care, Faculty of Health and Social Studies, HAN University of Applied Sciences, Verlengde Groenestraat 75, 6525 EJ, Nijmegen, The Netherlands

2 Canisius Wilhelmina Hospital, Weg door Jonkerbos 100, 6532 SZ, Nijmegen, The Netherlands

3 Sint Elisabeth Hospital, Hilvarenbeekseweg 60, 5022 GC, Tilburg, The Netherlands

4 Scientific Institute for Quality of Healthcare, Radboud University Nijmegen Medical Centre, Geert Grooteplein 21, 6525 EZ, Nijmegen, The Netherlands

5 Research group for Acute Care, Faculty of Health and Social Studies, HAN University of Applied Sciences, PO Box 6960, 6503 GL, Nijmegen, The Netherlands

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Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2013, 21:9  doi:10.1186/1757-7241-21-9

Published: 19 February 2013


A gap between guidelines or protocols and clinical practice often exists, which may result in patients not receiving appropriate care. Therefore, the objectives of this systematic review were (1) to give an overview of professionals’ adherence to (inter)national guidelines and protocols in the emergency medical dispatch, prehospital and emergency department (ED) settings, and (2) to explore which factors influencing adherence were described in studies reporting on adherence. PubMed (including MEDLINE), CINAHL, EMBASE and the Cochrane database for systematic reviews were systematically searched. Reference lists of included studies were also searched for eligible studies. Identified articles were screened on title, abstract and year of publication (≥1990) and were included when reporting on adherence in the eligible settings. Following the initial selection, articles were screened full text and included if they concerned adherence to a (inter)national guideline or protocol, and if the time interval between data collection and publication date was <10 years. Finally, articles were assessed on reporting quality. Each step was undertaken by two independent researchers. Thirty-five articles met the criteria, none of these addressed the emergency medical dispatch setting or protocols. Median adherence ranged from 7.8-95% in the prehospital setting, and from 0-98% in the ED setting. In the prehospital setting, recommendations on monitoring came with higher median adherence percentages than treatment recommendations. For both settings, cardiology treatment recommendations came with relatively low median adherence percentages. Eight studies identified patient and organisational factors influencing adherence. The results showed that professionals’ adherence to (inter)national prehospital and emergency department guidelines shows a wide variation, while adherence in the emergency medical dispatch setting is not reported. As insight in influencing factors for adherence in the emergency care settings is minimal, future research should identify such factors to allow the development of strategies to improve adherence and thus improve quality of care.

Emergency medical technicians [MeSH]; Emergency medical services [MeSH]; Emergency medicine [MeSH]; Emergency nursing [MeSH]; Guideline adherence [MeSH]