Clinical case reports have a long history in medicine. The earliest known examples date back to ancient Egypt (Nissen and Wynn, 2014a), and remain important in supporting contemporary, evidence-based healthcare (Akers, 2016). A case report is defined as a detailed narrative that describes, for medical, scientific or educational purposes, a clinical problem experienced by one or more patients (Gagnier et al, 2013). Published case reports have been central to the early discovery of previously unknown significant public health concerns, including HIV/Aids (Centres for Disease Control and Prevention, 1981), and congenital abnormalities associated with thalidomide use in pregnancy (McBride, 1961).
While considered a low-level form of evidence in the evidence-based practice hierarchy, there are many advantages in the use of clinical case reports (Box 1). Although limited in their generalisability, they are a flexible, credible and relatively straightforward way to develop a body of knowledge. They make use of naturally occurring data to produce a complete picture of a care encounter. When research on a topic is limited and more robust evidence is unavailable, a clinical case report may be the best available evidence to inform clinical practice and guidelines, especially for rare or unusual presentations (Scott, 2009). A clinical case report may provide a new perspective or advance the understanding of a well established concept (Aronson, 2003).
As a vehicle for informal critical reflection by health professionals, unpublished clinical case reports (in the form of case audits or case reviews) have also been acknowledged as being an important part of continuing professional development (CPD) within the registration frameworks of many disciplines including paramedicine (Health and Care Professions Council, 2019; Paramedicine Board of Australia, 2019). Published clinical case reports can be seen as an extension to this practice, with the learning promulgated to a wider international audience for greater impact.
CARE reporting guideline
Clinical case reports should be held to the same level of quality and transparency as evidence arising from research methods that are higher in the evidence-based hierarchy. CAse REport (CARE) is a consensus-based reporting guideline for clinical case reports (Gagnier et al, 2013), developed through the Enhancing the QUAlity and Transparency Of health Research (EQUATOR) Network in accordance with an established process for developing reporting guidelines (Moher et al, 2010).
CARE is one of many reporting guidelines for health research published through the EQUATOR Network. Others include the well-known Consolidated Standards of Reporting Trials (CONSORT) reporting guideline for randomised controlled trials (Schulz et al, 2010) and Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting guideline for systematic reviews and meta-analyses (Moher et al, 2010). Adherence to these guidelines is important as they provide consistent structure, ensure completeness and promote transparency, all of which serve to strengthen procedural rigour and increase the reliability and quality of the evidence.
The CARE reporting guideline, including a 13-item checklist, was first published in late 2013 (Gagnier et al, 2013), and this was followed by an elaboration and explanation document in 2017 (Riley et al, 2017). Information and resources are available on the CARE website: www.care-statement.org.
Current practice in the publication of prehospital clinical case reports
To assess the current state of clinical case report publications in the discipline of paramedicine and adherence to the CARE guideline, the authors conducted a search using the Google Scholar ‘search within citing articles’ function for articles that cite the 2013 CARE reporting guideline paper, using the search string: ~prehospital OR ~ambulance OR ~paramedic OR ‘emergency medical service’. Google Scholar identified a total of 735 articles that cite the 2013 CARE reporting guideline paper. Of these, just three were prehospital clinical case reports (Kulla et al, 2014; Angelopoulos et al, 2016; Dahmen et al, 2018). Only two of these appear to have closely adhered to the CARE guideline (Kulla et al, 2014; Dahmen et al, 2018).
While it is acknowledged that this was not an exhaustive approach, these preliminary data may indicate that few published prehospital clinical case reports cite and/or accurately follow the CARE reporting guideline. This creates a risk to the quality of prehospital clinical case reports and may undermine the validity of the research as a source of evidence robust enough to be reliable.
With the International Committee of Medical Journal Editors (2018) recommending adherence to reporting guidelines such as those produced through the EQUATOR Network, it is unclear why so few published clinical case reports do so. A lack of awareness of the CARE guideline is a likely factor.
More established reporting guidelines relating to higher levels of research, such as CONSORT and PRISMA for randomised controlled trials and systematic reviews respectively, are heavily promoted and advocated for; it could be that reporting quality in case reports is perceived to be of lower importance.
Another factor could be a perception that CARE does not ‘fit’ prehospital clinical case reports, a concern raised previously in other disciplines leading to the creation of discipline-specific variations of the guideline (Agha et al, 2016a).
PARAMEDICS-CARE: a proposed extension to the CARE guideline
In recognition of the need to take discipline-specific nuances into account, several adaptations of the CARE reporting guideline, called ‘extensions’, have been made. Developed through the EQUATOR Network, current discipline-specific extensions include Surgical Case Report (SCARE) (Agha et al, 2016b), therapeutic massage and bodywork (TMB) (Munk and Boulanger, 2014) and homeopathic clinical case reports (HOM-CASE) (van Haselen, 2016). Each of these professions have unique aspects and require tailored reporting—paramedicine is no different. Prehospital clinicians use a discipline-specific vernacular, and have elements such as dispatch criteria, findings from ‘the scene’, emergency medical service system-specific information, clinical models, scope of practice and disposition decisions that are not present in other disciplines of medicine. Other characteristics of the prehospital environment, such as the requirement for clinicians to perform diagnostic assessments concurrently with therapeutic interventions, mean a fit-for-purpose reporting guideline is needed.
The authors propose an extension to the CARE reporting guideline, to be known as Paramedics CAse REports (PARAMEDICS-CARE), adapted to the unique characteristics of prehospital care. The PARAMEDICS-CARE working group, consisting of an international collaboration of paramedics, academics and journal editors, is being established and has registered an intent to develop this extension with the EQUATOR Network (2019). The development of the extension will use evidence-based consensus methodology consistent with published guidance for the development of reporting guidelines, including publication of a research protocol and systematic review of the literature (Moher et al, 2010). Once implemented, the PARAMEDICS-CARE reporting guideline will help improve the quality, rigour, accuracy and transparency of prehospital case reports.
Conclusion
Clinical case reports are an important source of evidence in prehospital care, but few published reports appear to follow the existing consensus-based reporting guideline. Adherence to recognised reporting guidelines increases the transparency, quality, rigour and credibility of published manuscripts.
Prehospital care clinicians and researchers are encouraged to prepare clinical case reports in accordance with the existing CARE reporting guideline (with adaptations for prehospital care as required), and to embrace the proposed prehospital extension to the CARE reporting guideline when it becomes available.
Such action will contribute to ensuring prehospital research across the spectrum of the hierarchy of evidence continues to grow in rigour and quality, which in turn may increase the likelihood of evidence-translation and positive impacts on patient outcomes and system effectiveness and efficiency.