Aligning training with clinical reality: linking case-mix and self-reported confidence to Entrustable Professional Activities in physician-staffed EMS - a mixed-methods study

Aligning training with clinical reality: linking case-mix and self-reported confidence to Entrustable Professional Activities in physician-staffed EMS - a mixed-methods study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Aligning training with clinical reality: linking case-mix and self-reported confidence to Entrustable Professional Activities in physician-staffed EMS - a mixed-methods study Christian Engelen, Kai Schmid, Tobias Bexten, Jens Christian Kubitz, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9232218/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 8 You are reading this latest preprint version Abstract Background Emergency Medical Services (EMS) physicians must manage a broad spectrum of high-acuity prehospital emergencies. However, current training pathways in Germany are not explicitly competency-based and provide limited structured exposure to low-frequency, high-stakes scenarios. Entrustable Professional Activities (EPAs) offer a framework to align training with real-world clinical demands. This study aimed to identify key prehospital tasks suitable for an EPA-based curriculum. Methods We conducted a mixed-methods study combining (1) a retrospective analysis of 4,078 prehospital EMS physician records (Nuremberg, 2017–2021) to assess case-mix and procedural frequencies, and (2) an online survey of 134 Bavarian EMS physicians assessing self-reported confidence across emergency domains. Tasks were categorized based on frequency and confidence levels and mapped to candidate EPAs. Results Non-traumatic emergencies were dominated by cardiovascular and neurological conditions, while traumatic cases primarily involved extremity injuries. The most frequent interventions were intravenous access, oxygen administration, and ECG acquisition; invasive procedures were rare. Physicians reported high confidence in resuscitation, airway management, and analgesia, but lower confidence in pediatric, neonatal, obstetric, and mass-casualty scenarios. Anaesthesiology background was associated with higher confidence across several domains. Tasks characterized by either high frequency with low confidence or low frequency with high clinical risk were identified as key targets for EPA development. Conclusion Current EMS physician training in Germany does not fully align with real-world clinical demands. Integrating EPAs based on case-mix and competence gaps may improve training transparency, supervision, and patient safety. Simulation-based approaches appear essential for low-frequency, high-stakes scenarios in prehospital emergency care. entrustable professional activities medical education prehospital emergency medicine Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction Entrustable Professional Activities (EPAs) are units of professional practice that can be entrusted to a trainee once sufficient competence has been demonstrated. Since their introduction by ten Cate, EPAs have become a central component of competency-based medical education (CBME), bridging the gap between abstract competencies and observable clinical tasks. Prehospital emergency medicine presents a unique challenge for training. EMS physicians must be prepared to manage a wide range of acute conditions across all age groups, often in resource-limited and time-critical environments. While some skills are performed frequently, others - such as neonatal resuscitation, pediatric emergencies, or prehospital obstetrics—are rare but critical. This variability results in inconsistent exposure during training. [1; 2] In Germany, qualification as an EMS physician requires an additional certification (“Zusatzbezeichnung Notfallmedizin”), typically obtained after at least 24 months of clinical training. However, current regulations focus primarily on less prescriptive procedural counts (e.g., 50 endotracheal intubations performed) and do not comprehensively address the breadth of competencies required for independent prehospital practice. As a result, important but infrequently encountered scenarios may be insufficiently covered. Simulation-based training programs have been developed to address these gaps, but their availability and implementation remain inconsistent. Consequently, training often relies on opportunistic exposure rather than structured competency development. [3; 4; 5; 6] EPAs provide a potential solution by defining concrete, observable tasks that integrate knowledge, skills, and clinical judgment. They enable structured assessment, progressive autonomy, and transparent entrustment decisions. [7; 8] While EPAs have been proposed in emergency medicine, their application in physician-staffed EMS systems remains limited. [9; 10] This study aimed to identify key prehospital tasks suitable for EPA-based training by linking real-world case-mix data with self-reported confidence among EMS physicians. Methods Study design We conducted a mixed-methods study integrating retrospective case-mix analysis with a cross-sectional survey assessing self-reported confidence among EMS physicians. Retrospective data analysis A total of 4,078 EMS physician records from the Nuremberg EMS system (2017–2021) were analyzed. The protocols originate from emergency services of the EMS physician ambulance car location 4 of the Nuremberg City Ambulance Services. Data were extracted from handwritten protocols and included patient demographics, suspected diagnoses, severity scores (Glasgow Coma Scale, NACA score), and performed interventions. Incomplete records were excluded. Data were analyzed descriptively. Survey An online survey (Google Forms) was distributed to EMS physicians in Bavaria via professional mailing lists. The survey included 56 items covering demographics, professional background, and self-reported confidence in managing various emergency scenarios, medications, and procedures. Confidence was assessed using a 5-point Likert scale. Data synthesis and categorization Tasks were categorized based on: Frequency: derived from case-mix data Confidence: derived from survey responses For analytical purposes, both variables were dichotomized into high vs. low based on relative distribution within the dataset. This resulted in four categories: High-frequency / high-confidence High-frequency / low-confidence Low-frequency / high-stakes Low-frequency / low-stakes Tasks in the high-frequency / low-confidence and low-frequency / high-stakes categories were prioritized for EPA development. Statistical analysis All analyses were descriptive. Data are presented as means ± standard deviation or proportions. No inferential statistical testing was performed. Ethics The study was reviewed and approved by the institutional review board of PMU – Paracelsus Medical University, Nuremberg, Germany (IRB-2023-06). Survey participants provided informed consent. Retrospective data were analyzed in anonymized form. Results Case-mix The mean patient age was 64 years, with a balanced gender distribution. The age distribution by gender is shown in the following figure 1. The working / suspected diagnoses specified in the DIVI protocols were divided into non-traumatological and traumatological clinical pictures. Non-traumatic emergencies were dominated by cardiovascular and neurological conditions. Traumatic cases mainly involved extremity injuries. Acute coronary syndrome was the most common non-traumatic diagnosis, with 366 cases (8.97%), followed by hypertensive emergencies, which were diagnosed 318 times (7.80). Neurological emergencies such as seizures were documented in 278 cases (6.82%). Apoplexia, transient ischemic attacks, and intracranial hemorrhages occurred in a combined total of 249 cases (6.11%). This was followed by syncope with 182 cases (4.46%), and exsiccosis was diagnosed 159 times (3.90%). COPD exacerbations were recorded 150 times (3.68%), followed by tachycardic cardiac arrhythmias in 145 (3.56%) and orthostatic dysregulation in 137 cases (3.36%). Cardiac arrest was confirmed in 118 cases (2.89%). Decompensated heart failure was diagnosed 103 times (2.53%), which, together with febrile infections, sepsis or septic shock (102 cases, 2.50%) and pneumonia or bronchitis (96 cases, 2.35%), highlights the importance of cardiorespiratory and infectious diseases in emergency medicine. Acute abdomen was diagnosed 89 times (2.18%) and alcohol intoxication was diagnosed in 79 cases (1.94%). Figure 2 illustrates the distribution of diagnoses as presented in the textual summary. The analysis of traumatic emergencies revealed a significant increase in lower limb trauma, which was the most frequently documented type of injury with a total of 225 cases (5.52%). Upper limb trauma was recorded 166 times (4.07%), followed by traumatic brain injury with 148 cases (3.63%). Spinal injuries were recorded in 79 cases (1.94%), pelvic trauma in 59 cases (1.45%), and chest and facial trauma in 49 cases each (1.20%). Traumatic emergencies that occurred less than 1% of the time during the period analyzed are shown in Figure 3, which depicts the distribution of all traumatic emergencies. Procedural frequencies The most common procedures were: Intravenous access (72.6%) Oxygen administration (21.6%) ECG acquisition (13.6%) Invasive procedures such as intubation and advanced airway management were infrequent. The results are displayed in Figure 4. Online survey results A total of 134 completed responses were analyzed. Physicians reported: High confidence in resuscitation and airway management Lower confidence in pediatric, neonatal, obstetric, and mass-casualty scenarios Clinical workplace experience was the primary source of knowledge across most domains. The baseline is given in Table 1. Table 1: Demographic and professional characteristics of the study population (n = 134). Gender male n=95 (71%) female n=39 (29%) Age not specified n=1 (1%) 20-30 n=5 (4%) 30-40 n=38 (28%) 40-50 n=38 (28%) 50-60 n=39 (29%) > 60 n=14 (10%) Specialty anaesthesiology n=71 (53%) internal medicine n=27 (20%) general medicine n=13 (10%) surgery n=12 (9%) Additional qualifications course “intensive care transport” n=49 (37%) ITLS/A(C)LS/(E)PALS/NLS n=4 (3%) fellowship critical care n=42 (31%) Work setting rual n=64 (47%) urban n=70 (53%) Previous EMS experience (paramedic/EMT) No n=86 (64%) Yes n=48 (36%) 2. Self-assessed competence Differences in self-assessed competence were observed across emergency types, with high confidence in cardiac arrest scenarios (94.8%) and insecurity in obstetric, neonatal, and pediatric emergencies. Details are given in Table 2. Table 2. Self-assessed competence across selected prehospital emergency scenarios and main sources of knowledge. 3. Self-assessment – Common medication groups Self-assessed competence varied across medication groups, with the highest confidence reported for analgesics (95.5%) and sedatives (93.3%), and lower confidence for antiarrhythmics and antidotes. Clinical work was the predominant source of knowledge across all medication groups. Details are given in Table 3. Table 3: Self-assessed competence by medication group and main source of knowledge. 4. Self-assessment – procedures High self-assessed competence was reported for airway management (92.5%), mechanical ventilation (91%), and analgosedation (84.4%), whereas substantially lower confidence was observed for intraosseous access. Clinical workplace experience was the main source of knowledge for most procedures. Substantial uncertainty was reported for organisational and legal domains, particularly for mass casualty incident management and legal aspects of prehospital care. Formal courses and practical experience were the main sources of knowledge in these areas. The results are displayed in table 4. Table 4: Self-assessed competence in prehospital procedures, organisational and legal topics and main source of knowledge . EPA synthesis Tasks were assigned to four categories based on frequency and confidence. Candidate EPAs were primarily derived from: High-frequency tasks with low confidence Low-frequency tasks with high clinical risk Category tasks and scenarios educational rationale EPAs HF/HQ (high frequency, high quality) ACS, seizures, routine airway management, analgesia/sedation, ventilation Primary workplace-based learning EPAs here serve primarily to ensure entrustment transparency rather than to address competence deficits. EPA 1: Provide initial assessment and management of common adult medical emergencies (ACS, seizures, dyspnoea) EPA 2: Perform routine prehospital airway management and ventilation in adults HF/LQ (high frequency, low quality / insecurity) Legal aspects, documentation, MCI principles, command roles Curriculum-driven EPA due to high frequency and persistent uncertainty, requiring structured supervision. EPA 3: Manage legal and ethical decision-making and documentation in prehospital emergency care EPA 4: Act as first-in physician and coordinate triage and command in mass-casualty incidents LF/HS (low frequency, high stakes) Paediatric emergencies, neonatal resuscitation, prehospital childbirth, paediatric airway Simulation-based EPA s mandatory, Exposure not sufficient EPA 5: Provide prehospital care for critically ill or injured children, including airway and circulatory management EPA 6: Perform neonatal resuscitation and manage prehospital childbirth LF/LS (low frequency, low stakes) Intraosseous access, rare trauma procedures Optional EPAs. Low priority Optional EPA: Perform uncommon prehospital procedures (e.g. intraosseous access) under supervision Discussion This study links real-world case-mix with self-reported confidence among EMS physicians to identify gaps in prehospital training and inform EPA development. Cardiovascular and neurological emergencies dominated the case-mix, while invasive procedures were relatively rare. Although physicians reported high confidence in core resuscitation skills, substantial uncertainty remained in pediatric, neonatal, obstetric, and organizational domains. These findings highlight a mismatch between training exposure and required competencies. Positioning the findings within EPA-based competency frameworks EPAs offer a structured approach to address this gap by defining clearly observable clinical tasks and enabling progressive entrustment. In particular, tasks characterized by either high frequency with persistent uncertainty or low frequency with high clinical risk represent key targets for EPA-based training. Our findings align with international CBME frameworks, which emphasize workplace-based assessment and simulation for low-frequency, high-stakes scenarios. Simulation-based training appears particularly important in prehospital medicine, where real-world exposure to certain critical events is limited. [1; 6; 11-15] The current German EMS physician qualification remains largely course-based and does not explicitly define thresholds for independent practice. This may contribute to a discrepancy between formal certification and perceived readiness - a phenomenon that may impact patient safety. This discrepancy reflects a common limitation of outcome-based curricula: they define learning objectives but not the entrustment threshold for independent prehospital action. The resulting “competence illusion” risks patient safety in scenarios that demand rapid, unsupervised decision-making. [3; 6] Integrating structured experiential learning through structured supervision, simulation, and longitudinal mentorship would narrow this gap. Such models have proven effective in international prehospital training (e.g., UK PHEM curriculum, Dutch and Swiss emergency medicine rotations) where exposure and feedback are systematically tracked. [3; 16] Previous publication suggest potential advantages of EPA implementation for EMS physician training [17; 18] such as: Curriculum-practice alignment: EPAs can be back-mapped from local case-mix [1]; Assessment transparency: entrustment scales formalize readiness for independent practice in critical tasks [19]; Targeted simulation: low-frequency domains can be simulated and reassessed until entrustment is achieved, with workplace-based assessment and longitudinal portfolios Portability and accountability: EPA sign-offs provide auditable evidence of competence across systems and may enhance patient safety during high-risk transitions [20]. Practical implications : in accordance with previous reports [21] and given the observed insecurity in paediatric/neonatal/obstetric emergencies and MCI/legal topics, we have proposed an EMS physicians’ EPA set prioritizing high frequency / low confidence and low-frequency / high clinical risk tasks. Despite its promise, an EPA-based reform of EMS physician education requires careful design and resource investment [22; 23]: A) Consensus development: Stakeholders must agree on a pragmatic national set (typically 15–25 EPAs) to avoid fragmentation and assessment fatigue. B) Assessor calibration: Without structured rater training, inter-observer variability threatens validity. C) Time and workload: Integrating EPA observation into clinical service adds administrative load; implementation should therefore prioritize high-impact EPAs first. Nevertheless, international experience shows that these challenges can be faced with phased roll-out, faculty development, and institutional support. Limitations: This study has several limitations. The retrospective data were derived from handwritten records and may be incomplete or subject to documentation bias. The analysis was limited to a single EMS location, reducing generalizability. The survey relied on self-reported confidence, which may not reflect actual competence and is subject to response bias. Additionally, the analysis was purely descriptive. Conclusions An EPA-based curriculum could improve alignment between training and clinical demands by: defining clear expectations for independent practice supporting structured supervision enabling targeted simulation training Future studies should evaluate the feasibility and educational impact of EPA implementation in prehospital emergency medicine. Further studies are needed in the future to investigate how EPA can be integrated into training and whether this contributes to greater expertise in prehospital emergency care. Abbreviations ACLS – Advanced Cardiac Life Support ACS – Acute Coronary Syndrome CBME – Competency-Based Medical Education COPD – Chronic Obstructive Pulmonary Disease DIVI – German Interdisciplinary Association for Intensive Care and Emergency Medicine ECG – Electrocardiogram ED – Emergency Department EMS – Emergency Medical Services EPA – Entrustable Professional Activity / Entrustable Professional Activities GCS – Glasgow Coma Scale HF/HQ – High Frequency / High Quality HF/LQ – High Frequency / Low Quality IRB – Institutional Review Board ITLS – International Trauma Life Support LF/HS – Low Frequency / High Stakes LF/LS – Low Frequency / Low Stakes MCI – Mass Casualty Incident NA course – Notarzt Course (80h Prehospital Emergency Physician Course) NACA – National Advisory Committee for Aeronautics Score PALS – Pediatric Advanced Life Support PHEM – Prehospital Emergency Medicine PMU – Paracelsus Medical University Declarations Ethics approval and consent to participate The study was conducted in accordance with the Declaration of Helsinki and approved by the institutional review board of Paracelsus Medical University, Nuremberg, Germany (IRB-2023-06). All survey participants provided informed consent. Retrospective data were analysed in anonymised form. Consent for publication Not applicable. Availability of data and materials The datasets analysed during the current study are available from the corresponding author on reasonable request. Competing interests The authors declare no competing interests. Funding No external funding was received. Authors’ contributions JK, AK and CE were the principal investigators and designed the overall study. AK and CE supervised data collection and analyses, and both AK and CE supported interpretation of data and drafting the manuscript. KS collected data and prepared data for analyses, and both KS, CE and TB analyzed data, interpreted data, searched literature and drafted the manuscript. All authors have provided comments and critical revisions to the manuscript. All authors approved the final manuscript prior to submission. 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Cite Share Download PDF Status: Under Review Version 1 posted Reviewers agreed at journal 15 May, 2026 Reviews received at journal 18 Apr, 2026 Reviewers agreed at journal 18 Apr, 2026 Reviewers invited by journal 10 Apr, 2026 Editor invited by journal 09 Apr, 2026 Editor assigned by journal 07 Apr, 2026 Submission checks completed at journal 07 Apr, 2026 First submitted to journal 26 Mar, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-9232218","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":625522801,"identity":"1f16f8b4-32dd-48fc-90a4-2ba19fcdf53f","order_by":0,"name":"Christian Engelen","email":"","orcid":"","institution":"Lauf Hospital","correspondingAuthor":false,"prefix":"","firstName":"Christian","middleName":"","lastName":"Engelen","suffix":""},{"id":625522803,"identity":"b98ca0ab-92a0-4a82-9463-5bc301130000","order_by":1,"name":"Kai Schmid","email":"","orcid":"","institution":"Paracelsus Medical University, Nuremberg General Hospital","correspondingAuthor":false,"prefix":"","firstName":"Kai","middleName":"","lastName":"Schmid","suffix":""},{"id":625522804,"identity":"d5803a71-a3c3-4c96-9513-a2918dd7a412","order_by":2,"name":"Tobias Bexten","email":"","orcid":"","institution":"Helios Dr. Horst Schmidt Kliniken Wiesbaden","correspondingAuthor":false,"prefix":"","firstName":"Tobias","middleName":"","lastName":"Bexten","suffix":""},{"id":625522806,"identity":"05d80314-ae00-4392-ac3a-23d7099f3f08","order_by":3,"name":"Jens Christian Kubitz","email":"","orcid":"","institution":"Paracelsus Medical University, Nuremberg General Hospital","correspondingAuthor":false,"prefix":"","firstName":"Jens","middleName":"Christian","lastName":"Kubitz","suffix":""},{"id":625522808,"identity":"89788755-c213-4077-a642-e9bad97014e8","order_by":4,"name":"Anne Kamphausen","email":"data:image/png;base64,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","orcid":"","institution":"Paracelsus Medical University, Nuremberg General Hospital","correspondingAuthor":true,"prefix":"","firstName":"Anne","middleName":"","lastName":"Kamphausen","suffix":""}],"badges":[],"createdAt":"2026-03-26 09:39:04","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9232218/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9232218/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":107355648,"identity":"344de914-4696-4d6b-87e2-3a2a0a32f168","added_by":"auto","created_at":"2026-04-20 16:54:50","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":264178,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eAge distribution of patients. Note: DIVI protocol available at the time of data collection, only gender female and male could be specified.\u003c/em\u003e\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-9232218/v1/5eec7892e3f727592b419551.jpeg"},{"id":107355745,"identity":"e726839e-11dd-4ac3-aa70-a3e3d5f7e17b","added_by":"auto","created_at":"2026-04-20 16:55:05","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":915797,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eOverview of most frequent internal and non-traumatological documented suspected diagnoses\u003c/em\u003e\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-9232218/v1/44553bcf889d373114f66e03.png"},{"id":107355792,"identity":"a71c6c75-c8a4-4991-959f-0a7496a22b08","added_by":"auto","created_at":"2026-04-20 16:55:05","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":376964,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eOverview of most frequent documented surgical and traumatological suspected diagnoses\u003c/em\u003e\u003c/p\u003e","description":"","filename":"floatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-9232218/v1/399f2da7c634d9cb0a9193cb.png"},{"id":107355847,"identity":"19dd1c19-57d6-4a50-af09-f51445652a0c","added_by":"auto","created_at":"2026-04-20 16:55:13","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":398599,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eOverview of most frequent documented prehospital medical procedures (due to high numbers, frequencies are shown as logarithmic scale.)\u003c/em\u003e\u003c/p\u003e","description":"","filename":"floatimage4.png","url":"https://assets-eu.researchsquare.com/files/rs-9232218/v1/8caee00622dbbefec0eb0fa4.png"},{"id":107486281,"identity":"8e80121d-7a4e-46bb-90b7-9e513c7997e8","added_by":"auto","created_at":"2026-04-22 02:37:59","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":3097120,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9232218/v1/09a89c96-a235-4fa7-83eb-caea8fb9b69c.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Aligning training with clinical reality: linking case-mix and self-reported confidence to Entrustable Professional Activities in physician-staffed EMS - a mixed-methods study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eEntrustable Professional Activities (EPAs) are units of professional practice that can be entrusted to a trainee once sufficient competence has been demonstrated. Since their introduction by ten Cate, EPAs have become a central component of competency-based medical education (CBME), bridging the gap between abstract competencies and observable clinical tasks.\u003c/p\u003e \u003cp\u003ePrehospital emergency medicine presents a unique challenge for training. EMS physicians must be prepared to manage a wide range of acute conditions across all age groups, often in resource-limited and time-critical environments. While some skills are performed frequently, others - such as neonatal resuscitation, pediatric emergencies, or prehospital obstetrics\u0026mdash;are rare but critical. This variability results in inconsistent exposure during training. [1; 2]\u003c/p\u003e \u003cp\u003eIn Germany, qualification as an EMS physician requires an additional certification (\u0026ldquo;Zusatzbezeichnung Notfallmedizin\u0026rdquo;), typically obtained after at least 24 months of clinical training. However, current regulations focus primarily on less prescriptive procedural counts (e.g., 50 endotracheal intubations performed) and do not comprehensively address the breadth of competencies required for independent prehospital practice. As a result, important but infrequently encountered scenarios may be insufficiently covered.\u003c/p\u003e \u003cp\u003eSimulation-based training programs have been developed to address these gaps, but their availability and implementation remain inconsistent. Consequently, training often relies on opportunistic exposure rather than structured competency development. [3; 4; 5; 6]\u003c/p\u003e \u003cp\u003eEPAs provide a potential solution by defining concrete, observable tasks that integrate knowledge, skills, and clinical judgment. They enable structured assessment, progressive autonomy, and transparent entrustment decisions. [7; 8] While EPAs have been proposed in emergency medicine, their application in physician-staffed EMS systems remains limited. [9; 10]\u003c/p\u003e \u003cp\u003eThis study aimed to identify key prehospital tasks suitable for EPA-based training by linking real-world case-mix data with self-reported confidence among EMS physicians.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eStudy design\u003c/p\u003e\n\u003cp\u003eWe conducted a mixed-methods study integrating retrospective case-mix analysis with a cross-sectional survey assessing self-reported confidence among EMS physicians.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eRetrospective data analysis\u003c/p\u003e\n\u003cp\u003eA total of 4,078 EMS physician records from the Nuremberg EMS system (2017\u0026ndash;2021) were analyzed. The protocols originate from emergency services of the EMS physician ambulance car location 4 of the Nuremberg City Ambulance Services.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eData were extracted from handwritten protocols and included patient demographics, suspected diagnoses, severity scores (Glasgow Coma Scale, NACA score), and performed interventions. Incomplete records were excluded. Data were analyzed descriptively.\u003c/p\u003e\n\u003cp\u003eSurvey\u003c/p\u003e\n\u003cp\u003eAn online survey (Google Forms) was distributed to EMS physicians in Bavaria via professional mailing lists. The survey included 56 items covering demographics, professional background, and self-reported confidence in managing various emergency scenarios, medications, and procedures.\u003c/p\u003e\n\u003cp\u003eConfidence was assessed using a 5-point Likert scale.\u003c/p\u003e\n\u003cp\u003eData synthesis and categorization\u003c/p\u003e\n\u003cp\u003eTasks were categorized based on:\u003c/p\u003e\n\u003cul type=\"disc\"\u003e\n \u003cli\u003e\u003cstrong\u003eFrequency:\u003c/strong\u003e derived from case-mix data\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eConfidence:\u003c/strong\u003e derived from survey responses\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eFor analytical purposes, both variables were dichotomized into high vs. low based on relative distribution within the dataset.\u003c/p\u003e\n\u003cp\u003eThis resulted in four categories:\u003c/p\u003e\n\u003cul type=\"disc\"\u003e\n \u003cli\u003eHigh-frequency / high-confidence\u003c/li\u003e\n \u003cli\u003eHigh-frequency / low-confidence\u003c/li\u003e\n \u003cli\u003eLow-frequency / high-stakes\u003c/li\u003e\n \u003cli\u003eLow-frequency / low-stakes\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eTasks in the high-frequency / low-confidence and low-frequency / high-stakes categories were prioritized for EPA development.\u003c/p\u003e\n\u003cp\u003eStatistical analysis\u003c/p\u003e\n\u003cp\u003eAll analyses were descriptive. Data are presented as means \u0026plusmn; standard deviation or proportions. No inferential statistical testing was performed.\u003c/p\u003e\n\u003cp\u003eEthics\u003c/p\u003e\n\u003cp\u003eThe study\u0026nbsp;was reviewed and approved by the institutional review board of PMU \u0026ndash; Paracelsus Medical University, Nuremberg, Germany (IRB-2023-06).\u003c/p\u003e\n\u003cp\u003eSurvey participants provided informed consent. Retrospective data were analyzed in anonymized form.\u003c/p\u003e"},{"header":"Results","content":"\u003ch2\u003eCase-mix\u003c/h2\u003e\n\u003cp\u003eThe mean patient age was 64 years, with a balanced gender distribution. The age distribution by gender is shown in the following figure 1.\u003c/p\u003e\n\u003cp\u003eThe working / suspected diagnoses specified in the DIVI protocols were divided into non-traumatological and traumatological clinical pictures. Non-traumatic emergencies were dominated by cardiovascular and neurological conditions. Traumatic cases mainly involved extremity injuries.\u003c/p\u003e\n\u003cp\u003eAcute coronary syndrome was the most common non-traumatic diagnosis, with 366 cases (8.97%), followed by hypertensive emergencies, which were diagnosed 318 times (7.80). Neurological emergencies such as seizures were documented in 278 cases (6.82%). Apoplexia, transient ischemic attacks, and intracranial hemorrhages occurred in a combined total of 249 cases (6.11%). This was followed by syncope with 182 cases (4.46%), and exsiccosis was diagnosed 159 times (3.90%). COPD exacerbations were recorded 150 times (3.68%), followed by tachycardic cardiac arrhythmias in 145 (3.56%) and orthostatic dysregulation in 137 cases (3.36%). Cardiac arrest was confirmed in 118 cases (2.89%). Decompensated heart failure was diagnosed 103 times (2.53%), which, together with febrile infections, sepsis or septic shock (102 cases, 2.50%) and pneumonia or bronchitis (96 cases, 2.35%), highlights the importance of cardiorespiratory and infectious diseases in emergency medicine. Acute abdomen was diagnosed 89 times (2.18%) and alcohol intoxication was diagnosed in 79 cases (1.94%). Figure 2 illustrates the distribution of diagnoses as presented in the textual summary.\u003c/p\u003e\n\u003cp\u003eThe analysis of traumatic emergencies revealed a significant increase in lower limb trauma, which was the most frequently documented type of injury with a total of 225 cases (5.52%). Upper limb trauma was recorded 166 times (4.07%), followed by traumatic brain injury with 148 cases (3.63%). Spinal injuries were recorded in 79 cases (1.94%), pelvic trauma in 59 cases (1.45%), and chest and facial trauma in 49 cases each (1.20%). Traumatic emergencies that occurred less than 1% of the time during the period analyzed are shown in Figure 3, which depicts the distribution of all traumatic emergencies.\u003c/p\u003e\n\u003ch2\u003eProcedural frequencies\u003c/h2\u003e\n\u003cp\u003eThe most common procedures were:\u003c/p\u003e\n\u003cul type=\"disc\"\u003e\n \u003cli\u003eIntravenous access (72.6%)\u003c/li\u003e\n \u003cli\u003eOxygen administration (21.6%)\u003c/li\u003e\n \u003cli\u003eECG acquisition (13.6%)\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eInvasive procedures such as intubation and advanced airway management were infrequent. The results are displayed in Figure 4.\u003c/p\u003e\n\u003ch2\u003eOnline survey results\u003c/h2\u003e\n\u003cp\u003eA total of 134 completed responses were analyzed.\u003c/p\u003e\n\u003cp\u003ePhysicians reported:\u003c/p\u003e\n\u003cul type=\"disc\"\u003e\n \u003cli\u003eHigh confidence in resuscitation and airway management\u003c/li\u003e\n \u003cli\u003eLower confidence in pediatric, neonatal, obstetric, and mass-casualty scenarios\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eClinical workplace experience was the primary source of knowledge across most domains.\u003c/p\u003e\n\u003cp\u003eThe baseline is given in Table 1.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eTable 1:\u003c/em\u003e\u003c/strong\u003e\u003cem\u003e\u0026nbsp;\u003cstrong\u003eDemographic and professional characteristics of the study population (n = 134).\u003c/strong\u003e\u003c/em\u003e\u003c/p\u003e\n\u003ctable style=\"border-width: medium; border-style: none; border-color: currentcolor; border-image: initial; width: 100%;\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\"\u003e\n \u003cp\u003e\u003cstrong\u003eGender\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003emale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003en=95 (71%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003efemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003en=39 (29%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"7\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003enot specified\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003en=1 (1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e20-30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003en=5 (4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e30-40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003en=38 (28%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e40-50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003en=38 (28%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e50-60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003en=39 (29%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026gt; 60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003en=14 (10%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"5\"\u003e\n \u003cp\u003e\u003cstrong\u003eSpecialty\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eanaesthesiology\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003en=71 (53%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003einternal medicine\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003en=27 (20%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003egeneral medicine\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003en=13 (10%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003esurgery\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003en=12 (9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"4\"\u003e\n \u003cp\u003e\u003cstrong\u003eAdditional qualifications\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003ecourse \u0026ldquo;intensive care transport\u0026rdquo;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003en=49 (37%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eITLS/A(C)LS/(E)PALS/NLS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003en=4 (3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003efellowship critical care\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003en=42 (31%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\"\u003e\n \u003cp\u003e\u003cstrong\u003eWork setting\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003erual\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003en=64 (47%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eurban\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003en=70 (53%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003ePrevious EMS experience (paramedic/EMT)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003en=86 (64%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003en=48 (36%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003ch3\u003e\u003cstrong\u003e2. Self-assessed competence\u0026nbsp;\u003c/strong\u003e\u003c/h3\u003e\n\u003cp\u003eDifferences in self-assessed competence were observed across emergency types, with high confidence in cardiac arrest scenarios (94.8%) and insecurity in obstetric, neonatal, and pediatric emergencies. Details are given in Table 2.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eTable 2. Self-assessed competence across selected prehospital emergency scenarios and main sources of knowledge.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026nbsp;\u003cv:shape id=\"_x0000_i1027\" type=\"#_x0000_t75\" alt=\"Ein Bild, das Text, Screenshot, Zahl, Quittung enthält. KI-generierte Inhalte können fehlerhaft sein.\"\u003e\u0026nbsp;\u003cv:imagedata src=\"file:///C%3A/Users/btr8097/AppData/Local/Packages/oice_16_974fa576_32c1d314_2222/AC/Temp/msohtmlclip1/01/clip_image005.png\" o:title=\"Ein Bild, das Text, Screenshot, Zahl, Quittung enthält. KI-generierte Inhalte können fehlerhaft sein\"\u003e\u003cimg src=\"https://myfiles.space/user_files/58895_8739fc6c57c1c19a/58895_custom_files/img1776696384.png\" width=\"839\" height=\"787\"\u003e\u003c/v:imagedata\u003e\u0026nbsp;\u003c/v:shape\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3. Self-assessment \u0026ndash; Common medication groups\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSelf-assessed competence varied across medication groups, with the highest confidence reported for analgesics (95.5%) and sedatives (93.3%), and lower confidence for antiarrhythmics and antidotes. Clinical work was the predominant source of knowledge across all medication groups. Details are given in Table 3.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eTable 3: Self-assessed competence by medication group and main source of knowledge.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026nbsp;\u003cv:shape id=\"_x0000_i1026\" type=\"#_x0000_t75\" alt=\"Ein Bild, das Text, Screenshot, Schrift, Zahl enthält. KI-generierte Inhalte können fehlerhaft sein.\"\u003e\u0026nbsp;\u003cv:imagedata src=\"file:///C%3A/Users/btr8097/AppData/Local/Packages/oice_16_974fa576_32c1d314_2222/AC/Temp/msohtmlclip1/01/clip_image006.png\" o:title=\"Ein Bild, das Text, Screenshot, Schrift, Zahl enthält. KI-generierte Inhalte können fehlerhaft sein\"\u003e\u0026nbsp;\u003cimg src=\"https://myfiles.space/user_files/58895_8739fc6c57c1c19a/58895_custom_files/img1776696406.png\" width=\"839\" height=\"253\"\u003e\u003c/v:imagedata\u003e\u0026nbsp;\u003c/v:shape\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e4. Self-assessment \u0026ndash; procedures\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eHigh self-assessed competence was reported for airway management (92.5%), mechanical ventilation (91%), and analgosedation (84.4%), whereas substantially lower confidence was observed for intraosseous access. Clinical workplace experience was the main source of knowledge for most procedures.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSubstantial uncertainty was reported for organisational and legal domains, particularly for mass casualty incident management and legal aspects of prehospital care. Formal courses and practical experience were the main sources of knowledge in these areas. The results are displayed in table 4.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eTable 4: Self-assessed competence in prehospital procedures, organisational and legal topics and main source of knowledge\u003c/em\u003e.\u003c/p\u003e\n\u003cp\u003e\u003cimg src=\"https://myfiles.space/user_files/58895_8739fc6c57c1c19a/58895_custom_files/img1776696505.png\" width=\"839\" height=\"382\"\u003e\u003c/p\u003e\n\u003ch2\u003eEPA synthesis\u003c/h2\u003e\n\u003cp\u003eTasks were assigned to four categories based on frequency and confidence.\u003cbr\u003e\u0026nbsp;Candidate EPAs were primarily derived from:\u003c/p\u003e\n\u003cul type=\"disc\"\u003e\n \u003cli\u003eHigh-frequency tasks with low confidence\u003c/li\u003e\n \u003cli\u003eLow-frequency tasks with high clinical risk\u003c/li\u003e\n\u003c/ul\u003e\n\u003ctable style=\"width: 4.7e+2pt;border: none;\" cellspacing=\"3\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eCategory\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003etasks and scenarios\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eeducational rationale\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eEPAs\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eHF/HQ\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e(high frequency, high quality)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eACS, seizures, routine airway management, analgesia/sedation, ventilation\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003ePrimary \u003cstrong\u003eworkplace-based learning\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003eEPAs here serve primarily to ensure entrustment transparency rather than to address competence deficits.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eEPA 1:\u003c/strong\u003e Provide initial assessment and management of common adult medical emergencies (ACS, seizures, dyspnoea)\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eEPA 2:\u003c/strong\u003e Perform routine prehospital airway management and ventilation in adults\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eHF/LQ\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e(high frequency, low quality / insecurity)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eLegal aspects, documentation, MCI principles, command roles\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eCurriculum-driven EPA due to high frequency and persistent uncertainty, requiring structured supervision.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eEPA 3:\u003c/strong\u003e Manage legal and ethical decision-making and documentation in prehospital emergency care\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eEPA 4:\u003c/strong\u003e Act as first-in physician and coordinate triage and command in mass-casualty incidents\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eLF/HS\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e(low frequency, high stakes)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003ePaediatric emergencies, neonatal resuscitation, prehospital childbirth, paediatric airway\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eSimulation-based EPA\u003c/strong\u003es mandatory, Exposure not sufficient\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eEPA 5:\u003c/strong\u003e Provide prehospital care for critically ill or injured children, including airway and circulatory management\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eEPA 6:\u003c/strong\u003e Perform neonatal resuscitation and manage prehospital childbirth\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eLF/LS\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e(low frequency, low stakes)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eIntraosseous access, rare trauma procedures\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eOptional EPAs. Low priority\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003eOptional EPA: Perform uncommon prehospital procedures (e.g. intraosseous access) under supervision\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study links real-world case-mix with self-reported confidence among EMS physicians to identify gaps in prehospital training and inform EPA development.\u003c/p\u003e\n\u003cp\u003eCardiovascular and neurological emergencies dominated the case-mix, while invasive procedures were relatively rare. Although physicians reported high confidence in core resuscitation skills, substantial uncertainty remained in pediatric, neonatal, obstetric, and organizational domains. These findings highlight a mismatch between training exposure and required competencies.\u003c/p\u003e\n\u003cp\u003ePositioning the findings within EPA-based competency frameworks\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eEPAs offer a structured approach to address this gap by defining clearly observable clinical tasks and enabling progressive entrustment. In particular, tasks characterized by either high frequency with persistent uncertainty or low frequency with high clinical risk represent key targets for EPA-based training.\u003c/p\u003e\n\u003cp\u003eOur findings align with international CBME frameworks, which emphasize workplace-based assessment and simulation for low-frequency, high-stakes scenarios. Simulation-based training appears particularly important in prehospital medicine, where real-world exposure to certain critical events is limited. [1; 6; 11-15]\u003c/p\u003e\n\u003cp\u003eThe current German EMS physician qualification remains largely course-based and does not explicitly define thresholds for independent practice. This may contribute to a discrepancy between formal certification and perceived readiness - a phenomenon that may impact patient safety.\u003cbr\u003e\u0026nbsp;This discrepancy reflects a common limitation of outcome-based curricula: they define learning objectives but not the entrustment threshold for independent prehospital action.\u003cbr\u003e\u0026nbsp;The resulting \u0026ldquo;competence illusion\u0026rdquo; risks patient safety in scenarios that demand rapid, unsupervised decision-making. [3; 6]\u003c/p\u003e\n\u003cp\u003eIntegrating structured\u0026nbsp;experiential learning\u0026nbsp;through structured supervision, simulation, and longitudinal mentorship would narrow this gap.\u003cbr\u003e\u0026nbsp;Such models have proven effective in international prehospital training (e.g., UK PHEM curriculum, Dutch and Swiss emergency medicine rotations) where exposure and feedback are systematically tracked. [3; 16]\u003c/p\u003e\n\u003cp\u003ePrevious publication suggest potential advantages of EPA implementation for EMS physician training [17; 18] such as:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCurriculum-practice alignment: EPAs can be back-mapped from local case-mix [1]; \u0026nbsp;Assessment transparency: entrustment scales formalize readiness for independent practice in critical tasks [19];\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTargeted simulation: low-frequency domains can be simulated and reassessed until entrustment is achieved, with workplace-based assessment and longitudinal portfolios \u0026nbsp;Portability and accountability: EPA sign-offs provide auditable evidence of competence across systems and may enhance patient safety during high-risk transitions [20].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePractical implications\u003c/strong\u003e: in accordance with previous reports [21] and given the observed insecurity in paediatric/neonatal/obstetric emergencies and MCI/legal topics, we have proposed an EMS physicians\u0026rsquo; EPA set\u0026nbsp;prioritizing high frequency / low confidence and low-frequency / high clinical risk tasks.\u003c/p\u003e\n\u003cp\u003eDespite its promise, an EPA-based reform of EMS physician education requires careful design and resource investment [22; 23]:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eA) Consensus development: Stakeholders must agree on a pragmatic national set (typically 15\u0026ndash;25 EPAs) to avoid fragmentation and assessment fatigue.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eB) Assessor calibration: Without structured rater training, inter-observer variability threatens validity.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eC) Time and workload: Integrating EPA observation into clinical service adds administrative load; implementation should therefore prioritize high-impact EPAs first. Nevertheless, international experience shows that these challenges can be faced with phased roll-out, faculty development, and institutional support.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLimitations: \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study has several limitations. The retrospective data were derived from handwritten records and may be incomplete or subject to documentation bias. The analysis was limited to a single EMS location, reducing generalizability. The survey relied on self-reported confidence, which may not reflect actual competence and is subject to response bias. Additionally, the analysis was purely descriptive.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eAn EPA-based curriculum could improve alignment between training and clinical demands by:\u003c/p\u003e\n\u003cul type=\"disc\"\u003e\n \u003cli\u003edefining clear expectations for independent practice\u003c/li\u003e\n \u003cli\u003esupporting structured supervision\u003c/li\u003e\n \u003cli\u003eenabling targeted simulation training\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eFuture studies should evaluate the feasibility and educational impact of EPA implementation in prehospital emergency medicine.\u003c/p\u003e\n\u003cp\u003eFurther studies are needed in the future to investigate how EPA can be integrated into training and whether this contributes to greater expertise in prehospital emergency care.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003e\u003cstrong\u003eACLS\u003c/strong\u003e \u0026ndash; Advanced Cardiac Life Support\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eACS\u003c/strong\u003e \u0026ndash; Acute Coronary Syndrome\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCBME\u003c/strong\u003e \u0026ndash; Competency-Based Medical Education\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCOPD\u003c/strong\u003e \u0026ndash; Chronic Obstructive Pulmonary Disease\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDIVI\u003c/strong\u003e \u0026ndash; German Interdisciplinary Association for Intensive Care and Emergency Medicine\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eECG\u003c/strong\u003e \u0026ndash; Electrocardiogram\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eED\u003c/strong\u003e \u0026ndash; Emergency Department\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEMS\u003c/strong\u003e \u0026ndash; Emergency Medical Services\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEPA\u003c/strong\u003e \u0026ndash; Entrustable Professional Activity / Entrustable Professional Activities\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eGCS\u003c/strong\u003e \u0026ndash; Glasgow Coma Scale\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHF/HQ\u003c/strong\u003e \u0026ndash; High Frequency / High Quality\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHF/LQ\u003c/strong\u003e \u0026ndash; High Frequency / Low Quality\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eIRB\u003c/strong\u003e \u0026ndash; Institutional Review Board\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eITLS\u003c/strong\u003e \u0026ndash; International Trauma Life Support\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLF/HS\u003c/strong\u003e \u0026ndash; Low Frequency / High Stakes\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eLF/LS\u003c/strong\u003e \u0026ndash; Low Frequency / Low Stakes\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMCI\u003c/strong\u003e \u0026ndash; Mass Casualty Incident\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eNA course\u003c/strong\u003e \u0026ndash; Notarzt Course (80h Prehospital Emergency Physician Course)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eNACA\u003c/strong\u003e \u0026ndash; National Advisory Committee for Aeronautics Score\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePALS\u003c/strong\u003e \u0026ndash; Pediatric Advanced Life Support\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePHEM\u003c/strong\u003e \u0026ndash; Prehospital Emergency Medicine\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePMU\u003c/strong\u003e \u0026ndash; Paracelsus Medical University\u003c/p\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch3\u003eEthics approval and consent to participate\u003c/h3\u003e\n\u003cp\u003eThe study was conducted in accordance with the Declaration of Helsinki and approved by the institutional review board of Paracelsus Medical University, Nuremberg, Germany (IRB-2023-06). All survey participants provided informed consent. Retrospective data were analysed in anonymised form.\u0026nbsp;\u003c/p\u003e\n\u003ch3\u003eConsent for publication\u003c/h3\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003ch3\u003eAvailability of data and materials\u003c/h3\u003e\n\u003cp\u003eThe datasets analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003ch3\u003eCompeting interests\u003c/h3\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003ch3\u003eFunding\u003c/h3\u003e\n\u003cp\u003eNo external funding was received.\u003c/p\u003e\n\u003ch3\u003eAuthors\u0026rsquo; contributions\u003c/h3\u003e\n\u003cp\u003eJK, AK and CE were the principal investigators and designed the overall study. AK and CE supervised data collection and analyses, and both AK and CE supported interpretation of data and drafting the manuscript. KS collected data and prepared data for analyses, and both KS, CE and TB analyzed data, interpreted data, searched literature and drafted the manuscript. All authors have provided comments and critical revisions to the manuscript. All authors approved the final manuscript prior to submission.\u003c/p\u003e\n\u003ch3\u003eAcknowledgements\u003c/h3\u003e\n\u003cp\u003eWe thank the participating emergency physicians and the Klinikum Nuremberg for supporting data access.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eten Cate O. Entrustability of professional activities and competency-based training. Med Educ. 2005 Dec;39(12):1176-7. doi: 10.1111/j.1365-2929.2005.02341.x. \u003c/li\u003e\n\u003cli\u003eFrank JR, Snell LS, Cate OT et al. Competency-based medical education: theory to practice. Med Teach. 2010;32(8):638-45. doi: 10.3109/0142159X.2010.501190. \u003c/li\u003e\n\u003cli\u003eZoller A, H\u0026ouml;lle T, Wepler M et al. Development of a novel global rating scale for objective structured assessment of technical skills in an emergency medical simulation training. BMC Med Educ. 2021 Mar 25;21(1):184. doi: 10.1186/s12909-021-02580-4. \u003c/li\u003e\n\u003cli\u003eBranditz LD, Kendle AP, Leung CG et al. Bridging the procedures skill gap from medical school to residency: a simulation-based mastery learning curriculum. Med Educ Online. 2024 Dec 31;29(1):2412399. doi: 10.1080/10872981.2024.2412399. \u003c/li\u003e\n\u003cli\u003eHolzhausen Y, Maaz A, Cianciolo AT et al. Applying occupational and organizational psychology theory to entrustment decision-making about trainees in health care: a conceptual model. Perspect Med Educ. 2017 Apr;6(2):119-126. doi: 10.1007/s40037-017-0336-2. \u003c/li\u003e\n\u003cli\u003eTen Cate O. Entrustment Decisions: bringing the patient into the assessment equation. Acad Med. 2017 Jun;92(6):736-738. doi: 10.1097/ACM.0000000000001623. \u003c/li\u003e\n\u003cli\u003eHolzhausen Y, Maaz A, Renz A et al. Development of Entrustable Professional Activities for entry into residency at the Charit\u0026eacute; Berlin. GMS J Med Educ. 2019 Feb 15;36(1):Doc5. doi: 10.3205/zma001213. \u003c/li\u003e\n\u003cli\u003eShorey S, Lau TC, Lau ST et al. Entrustable professional activities in health care education: a scoping review. Med Educ. 2019 Aug;53(8):766-777. doi: 10.1111/medu.13879. \u003c/li\u003e\n\u003cli\u003ePassoni Lopes LC, Ferrazini RVS, Costa K et al. Entrustable professional activities, emergency medicine and medical education: a systematic review. Int J Emerg Med. 2024 Sep 5;17(1):112. doi: 10.1186/s12245-024-00699-x. \u003c/li\u003e\n\u003cli\u003eCate OT. A primer on entrustable professional activities. Korean J Med Educ. 2018 Mar;30(1):1-10. doi: 10.3946/kjme.2018.76. \u003c/li\u003e\n\u003cli\u003eGanzhorn A, Schulte-Uentrop L, K\u0026uuml;llmei J et al. National consensus on entrustable professional activities for competency-based training in anaesthesiology. PLoS One. 2023 Jul 11;18(7):e0288197. doi: 10.1371/journal.pone.0288197. \u003c/li\u003e\n\u003cli\u003eRekman J, Gofton W, Dudek N et al. Entrustability Scales: Outlining Their Usefulness for Competency-Based Clinical Assessment. Acad Med. 2016 Feb;91(2):186-90. doi: 10.1097/ACM.0000000000001045. \u003c/li\u003e\n\u003cli\u003eTen Cate O, Graafmans L, Posthumus I et al. The EPA-based Utrecht undergraduate clinical curriculum: Development and implementation. Med Teach. 2018 May;40(5):506-513. doi: 10.1080/0142159X.2018.1435856. \u003c/li\u003e\n\u003cli\u003eTekian A, Ten Cate O, Holmboe E et al. Entrustment decisions: Implications for curriculum development and assessment. Med Teach. 2020 Jun;42(6):698-704. doi: 10.1080/0142159X.2020.1733506. \u003c/li\u003e\n\u003cli\u003eStumbar SE, Eliason S, Toonkel R et al. Next steps for workplace-based assessments of entrustable professional activities. Clin Teach. 2024 Aug;21(4):e13739. doi: 10.1111/tct.13739.\u003c/li\u003e\n\u003cli\u003eTen Cate O, Chen HC, Hoff RG et al. Curriculum development for the workplace using Entrustable Professional Activities (EPAs): AMEE Guide No. 99. Med Teach. 2015;37(11):983-1002. doi: 10.3109/0142159X.2015.1060308. \u003c/li\u003e\n\u003cli\u003eCaretta-Weyer HA, Sebok-Syer SS, Morris AM et al. Better together: a multistakeholder approach to developing specialty-wide entrustable professional activities in emergency medicine. AEM Educ Train. 2024 Mar 25;8(2):e10974. doi: 10.1002/aet2.10974. \u003c/li\u003e\n\u003cli\u003eWang L, Zhao Y, Wang P et al. Application of clinical thinking training system based on entrustable professional activities in emergency teaching. BMC Med Educ. 2024 Nov 13;24(1):1294. doi: 10.1186/s12909-024-06302-4.\u003c/li\u003e\n\u003cli\u003eTen Cate O, Taylor DR. The recommended description of an entrustable professional activity: AMEE Guide No. 140. Med Teach. 2021 Oct;43(10):1106-1114. doi: 10.1080/0142159X.2020.1838465. \u003c/li\u003e\n\u003cli\u003eWaldron R, Sixsmith DM. Emergency physician awareness of prehospital procedures and medications. West J Emerg Med. 2014 Jul;15(4):504-10. doi: 10.5811/westjem.2014.2.18651. \u003c/li\u003e\n\u003cli\u003eTeng D, Venkataraman A, Singer A et al. Entrustable Professional Activities for Emergency Medicine specialists. Int J Emerg Med. 2025 Nov 25;18(1):248. doi: 10.1186/s12245-025-01075-z.\u003c/li\u003e\n\u003cli\u003eTen Cate O. Nuts and bolts of entrustable professional activities. J Grad Med Educ. 2013 Mar;5(1):157-8. doi: 10.4300/JGME-D-12-00380.1. \u003c/li\u003e\n\u003cli\u003evan Loon KA, Driessen EW, Teunissen PW et al. Experiences with EPAs, potential benefits and pitfalls. Med Teach. 2014 Aug;36(8):698-702. doi: 10.3109/0142159X.2014.909588. \u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-emergency-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"emmd","sideBox":"Learn more about [BMC Emergency Medicine](http://bmcemergmed.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/emmd","title":"BMC Emergency Medicine","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"entrustable professional activities, medical education, prehospital emergency medicine","lastPublishedDoi":"10.21203/rs.3.rs-9232218/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9232218/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eEmergency Medical Services (EMS) physicians must manage a broad spectrum of high-acuity prehospital emergencies. However, current training pathways in Germany are not explicitly competency-based and provide limited structured exposure to low-frequency, high-stakes scenarios. Entrustable Professional Activities (EPAs) offer a framework to align training with real-world clinical demands. This study aimed to identify key prehospital tasks suitable for an EPA-based curriculum.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eWe conducted a mixed-methods study combining (1) a retrospective analysis of 4,078 prehospital EMS physician records (Nuremberg, 2017\u0026ndash;2021) to assess case-mix and procedural frequencies, and (2) an online survey of 134 Bavarian EMS physicians assessing self-reported confidence across emergency domains. Tasks were categorized based on frequency and confidence levels and mapped to candidate EPAs.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eNon-traumatic emergencies were dominated by cardiovascular and neurological conditions, while traumatic cases primarily involved extremity injuries. The most frequent interventions were intravenous access, oxygen administration, and ECG acquisition; invasive procedures were rare. Physicians reported high confidence in resuscitation, airway management, and analgesia, but lower confidence in pediatric, neonatal, obstetric, and mass-casualty scenarios. Anaesthesiology background was associated with higher confidence across several domains. Tasks characterized by either high frequency with low confidence or low frequency with high clinical risk were identified as key targets for EPA development.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eCurrent EMS physician training in Germany does not fully align with real-world clinical demands. Integrating EPAs based on case-mix and competence gaps may improve training transparency, supervision, and patient safety. Simulation-based approaches appear essential for low-frequency, high-stakes scenarios in prehospital emergency care.\u003c/p\u003e","manuscriptTitle":"Aligning training with clinical reality: linking case-mix and self-reported confidence to Entrustable Professional Activities in physician-staffed EMS - a mixed-methods study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-20 16:53:27","doi":"10.21203/rs.3.rs-9232218/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"155571066382902590511658449507768113895","date":"2026-05-15T17:18:02+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-18T18:40:30+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"17075610417039361332359445914445497422","date":"2026-04-18T17:55:25+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-04-10T09:32:58+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-04-09T09:26:33+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-04-07T11:16:18+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-04-07T11:15:37+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Emergency Medicine","date":"2026-03-26T09:28:33+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-emergency-medicine","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"emmd","sideBox":"Learn more about [BMC Emergency Medicine](http://bmcemergmed.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/emmd","title":"BMC Emergency Medicine","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"6b9b6675-3ccb-4376-aff5-32bd439bfb2f","owner":[],"postedDate":"April 20th, 2026","published":true,"recentEditorialEvents":[{"type":"reviewerAgreed","content":"155571066382902590511658449507768113895","date":"2026-05-15T17:18:02+00:00","index":41,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-04-20T16:53:31+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-20 16:53:27","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9232218","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9232218","identity":"rs-9232218","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}