Conflict of Interest - National Association of EMS ... 2013 Travers Evidence to Practice.… ·...

Andrew Travers, MD, MSc, FRCPC [email protected]

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From Evidence to Practice

Canadian Prehospital Evidence Based Protocols

Andrew Travers MD MSc FRCPCProvincial Medical Director

Emergency Health ServicesHalifax, Nova Scotia

Conflict of Interest

• Academic– ILCOR

• Financial– None

[email protected]

www.gov.ns.ca/health/ehs


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Culture

ClinicalParamedic

AdministrativeParamedic

AcademicParamedic

Academic Centre

Regulator Contractor

Evidence-BasedPractice Culture

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‘Living Document’

Academic Emergency Medicine 2009. 16(7): 668-673.

#10Cone and McManusTop 10 EMS Research Articles of 2009NAEMSP 2010


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Evidence Straight

Evidence Used

Take home tools

Objectives

Evidence

Definitions

Evidence Straight

Evidence Used

Take home tools

Objectives

Evidence

Definitions


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evidence-based medicine

the judicious and conscientious use of:

best evidence from research

combined with clinical experience,

applied to patient problemsLouis, Bichat, & Magendie 1850

the EBM cyclehow to formquestionshow to

evaluateperformance

how toapply

clinicallyhow to

criticallyappraise

how tosearch


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Evidence-Based Practice

Practice-Based Evidence

Evidence-Based MedicineCriticisms

Some people use EBM the way a drunk uses a lamppost – for support rather than illumination.

What on *&^%$# earth is ‘knowledge translation’?


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http://www.cihr-irsc.gc.ca/e/29418.html

Knowledge translation is a dynamic and iterative process that includes synthesis, dissemination, exchange and ethically sound application of knowledge to improve the health of Canadians, provide more effective health services and products and strengthen the health care system.

Operational

Cultural

Published Evidence

Process: In Concept

Appraisal

FormalSearch

Topic Selection

EvaluatePerformance

OperationalizationDissemination

Protocol

Operational

Cultural

Published Evidence

Process: In Concept

Appraisal

FormalSearch

Topic Selection

EvaluatePerformance

OperationalizationDissemination

Protocol

Evidence

GettingThe

EvidenceStraight

GettingThe

EvidenceUsed


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Getting theEvidence

Getting it Used

Getting itStraight

CPEP

Evidence Straight

Evidence Used

Take home tools

Objectives

Evidence

Definitions


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PCI vs TNK

PCI

Evidence Straight

Evidence Used

Take home tools

Objectives

Evidence

Definitions

CPEP Objectives: 1998 - present

To appraise EMS body of knowledge.

To stimulate debate and growth towards evidence-based EMS protocols.

To be a resource for the development of local EMS protocols; perhaps with a movement towards "best practice" paramedic protocols.

To be a guide to help recognize opportunities for prehospital research.

To develop a process of using evidence to evaluate practice change suggestions made by paramedics.


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http://emergency.medicine.dal.ca/ehsprotocols

http://www.gov.ns.ca/health/ehs

• BC Ambulance Service

• Alberta Emergency Health Services


• NS Emergency Health Services


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CPEP: Levels of EvidenceSimplified Version of Canadian Task Force Guidelines and Oxford Levels of Evidence

LEVEL DEFINITION

I Evidence from at least one properly randomized controlled trial or systematic reviews or meta-analyses that contain RCTs

II Evidence from non-randomized studies with a comparison group or systematic reviews of non-randomized studies with a comparison group. Registry-type studies with comparisons made are included here.

III Evidence from studies with no comparison group or simulation studies


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Easy to useEasy to teachPracticalDeveloped from other scales

Each level not specific to designTherapy Articles OnlyDifferent from LOE1-5

Level of Evidence

LOE I Prospective Randomised Control Group

LOE 2 Prospective Non-Randomised Control Group

LOE 3 Retrospective Control Group

LOE 4 No Control Group

LOE 5 Educational, mathematical, animal model

CPEP: Class of RecommendationCanadian Task Force Guidelines


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LOE and COR for EHS Protocols

Size of Treatment Effect

Est

imat

e of

Cer

tain

ty

• 411 Questions

• 356 Experts

• 277 Topics

• 29 Countries

• 5 Years

• 1 New Set of Guidelines!


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New 2012: Direction of Evidence

New 2012: 3x3 Tables replace Class of Recommendations


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Best signs to identify

Number of initial breaths?

CV ratio, rate?Signs of life?

Energy levels & waveforms?

Duration of CPR?Which airway?RR and Vt?Vasopressors? Timing!!Which signs?Alter management?

Antiarrhythmics?

Etc, etc?

Ensure not omit Qs:major/contentious

%@&$? PICO.

Medic MD


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Paramedic: PICO Question Bank

Clinical11858%Systems

6130%

Education24

12%

N=242

Better questions toMedical Director.

Medic MD

%@&$?PICO?


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CPEP Paramedic Nomenclature

• EBP ‘Surveillance’ Medics– Any medic who finds relevant information (online, journal, news article etc)

and puts into CPEP library.

• EBP ‘Review’ Medics– Any EBM trained medic who formally screens the validity of the information.

• EBP ‘Decision Editor’ Medics– Any medic involved in changing the Level of Recommendation/Level of

Evidence ‘Dashboard’ on the Evidence-Based Protocols.

The EBM Cycle & Paramedic Practice

Current Practice/Paramedic Protocols

EvidenceAppraisal

Re-evaluate Practice/Protocol

Question Practice/Develop Research

Question

Design & ConductStudy = Results

Jan Jensen ACP

Evidence Straight

Evidence Used

Take home tools

Objectives

Evidence

Definitions


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‘Practice Bundle’

‘Fieldguide’


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Single Master PDF

Individual PDF


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CPEP

Grading of Recommendations Assessment, Development and Evaluation

Grading the quality of evidence and strength of recommendations.

HIGH Quality

Moderate Quality

Low Quality

Very Low quality


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Knowledge

ImplementationFocus

OperationalFocus

CPG

cpg

citationsRecommendation

Focus

WHAT

HOW

WHAT

HOW

WHAT

HOW

EvidenceAppraisal Focus

ResearchFocus

Quality Evaluation:AGREE II

Consists of 23 items in six domains:

1. Scope and purpose

2. Stakeholder involvement

3. Rigour of development

4. Clarity and presentation

5. Applicability

6. Editorial independence

GUIDELINES APPRAISAL PROJECT (GAP) FOR EMS


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Objectives described.Clinical questions described.Application to patients described.

Target users defined.

Piloted among users.

Specific & unambiguous.

Different Mx options considered.

Systematic searches.

Clear selection criteria.

Clear procedure for Updating.

Scope&

Purpose

Clarity&

Presentation

Completed

Protocols

Includes individuals fromrelevant groups.

Editorial independentfrom funding.

Conflicts of interestrecorded.

Key recommendationseasily identifiable.

Application support tools.

Formulation methodsclearly described.

Explicit link between evidence & recommendation.

Expert external review.

Scope&

Purpose

Clarity&

Presentation

Weaknesses

Key review criteria formonitoring and auditing.

Protocols

CPEP: Other Weaknesses

• A contemporary and generalizable method of ‘grading’evidence remains elusive.

• Minimal peer review & auditing.

• Ensuring that protocols remain up to date.

• Minimal funding of infrastructure.

• Lack of publications from the CPEP initiative.


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Patient preferences andviews sought.

Discussion oforganisational barriers.

Application costs considered.

Consideration of sideeffects, benefits, risks.

Scope&

Purpose

Clarity&

Presentation

Future Development

Protocols

guideline appraisal project

Jensen JL, Carter A, Travers A, Dewar Z, Cain E


GAP: objectives• To systematically review published clinical

practice guidelines (CPGs) for quality and relevance to prehospital practice

• To identify knowledge gaps in prehospitalareas of care– Paramedic protocol areas without relevant, high

quality published CPGs


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Methods: Search• Systematic review of the English literature for

published CPGs

• Structured search strategy in 19 databases

• Review for Inclusion by two independent reviewers, third party adjudication


Methods: Quality and Relevance

• Medical directors and paramedics from across Canada were recruited to serve as appraisers

• Every appraiser completed on on-line tutorial on AGREE II, a validated CPG quality evaluation tool

• www.agreetrust.org


Methods

• Included CPGs were categorized as EB or non-EB• *Systematic search (systematic = search terms stated) of

>= 1 database

• *Reference list included with CPG

• +/- Formal question or clearly stated objectives

• Only those which were evidence-based moved on for full AGREE appraisal

• Each CPG was randomly assigned to 2 reviewers

• All guidelines appraised for relevance to EMS and posted on PEP website.



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44% are ‘evidence-based’Respiratory most common

54% of protocols have no CPG

223 Included

481 CPG

Guidelines

Publications Knowledge Gapson ‘What & How’


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Towards National Evidence-Informed Practice Guidelines for Canadian EMS

Evidence Straight

Evidence Used

Take home tools

Objectives

Evidence

Definitions

Closing Remarks: CPEP

• Inventory of CPGs: EMS, implementation, operation

• NOT meant to reproduce CPGs

• Platform for enabling evidence mapping.

• Knowledge sharing network for EBP culture

• Dashboard of EMS evidence: appraisal & gaps

• Examples of EMS protocols in current practice.


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Conflict of Interest - National Association of EMS ... 2013 Travers Evidence to Practice.… ·...

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