BETting on the Evidencein Emergency Medicine
Kevin Mackway-Jones
Manchester
Outline
• We have a problem
• We have a dream
• We have a plan
• We take a gamble
• Las Vegas!
The Problem
The Problem – How we practiced
“Faith is the substance of things hoped for,
the evidence of things not seen”
Hebrews 11:1
The fact that an opinion has been
widely held is no evidence whatever
that it is not utterly absurd; indeed
in view of the silliness of the majority
of mankind, a widespread belief is more
likely to be foolish than sensible
Bertrand Russell
Marriage and Morals (1929)
The Problem – How we practiced
“Charismatic expertise based uponsubjective self-confidence unsupportedby objective ability"
The greater the ignorance the
greater the dogmatism
William OslerMontreal Medical Journal (1902)
The Problem – How we practiced
“The triumph of hope over experience"
The Dream
The Dream
“Evidence-based medicine (EBM)is the integration of best researchevidence with clinical expertise andpatient values"
The Plan
• Establish a journal club
• Change practice
• Save more lives
POORATTENDANCE
NOCHANGE
LACK OFINTEREST
A downward
spiral
• Get help
• Reflect on failure
• Recognise the limitations of thedepartment
• Recognise the limitations of the evidence
• Set achievable goals
• Formalise critical appraisal
• Formalise journal scanning
• Formalise attendance
The Gamble
The birth of BETs
BETs
• Clinical scenario
• 3 part question
• Search strategy
• Evidence table
• Discussion
• Clinical bottom line
• For the busy clinician
• The best available evidence
(not just the best)
• Simple questions - understandable answers
CLINICALCOMMITMENT
FORMALISEDREPORTING
CLINICALCONUNDRUMS
LEARNINGFOR ALL
CHANGEEFFECTED
A virtuous
circle
“There’s a BET
In that!”
R2
= 0.9943
0
200
400
600
800
1000
1200
1400
1600
1800
Jun-97O
ct-97Feb-98Jun-98O
ct-98Feb-99Jun-99O
ct-99Feb-00Jun-00O
ct-00Feb-01Jun-01O
ct-01Feb-02Jun-02O
ct-02Feb-03Jun-03O
ct-03Feb-04Jun-04O
ct-04Feb-05Jun-05O
ct-05Feb-06Jun-06O
ct-06Feb-07Jun-07O
ct-07Feb-08Jun-08
Date
BE
Ts
pla
ced
The Engine
• Major perceived barrier was lack of time
• Most appropriate way to move towardsEBP was by using evidence based guidelinesor proposals developed by colleagues
From Access to Practice
McColl A et al 1998
• Accumulator BETs
Patient with pleuritic chestpain or possible
pulmonary embolus
D-Dimer
Interpret VQ withclinical riskassessment
Clinical RiskAssessment Low
CompleteCDU/021overleaf
AdmitAnticoagulate
CompletePDI/020overleaf
Home
Moderate/ High
Normal
Raised
No PE
No
Yes
CompleteRef/023overleaf
Abnormal CXR
VQ scanCT pulmonary angiography
Co
nsid
er
for
OP
inve
stig
atio
n
CompleteCDU/022overleaf
Other diagnosisrequiring admission
Admitfor treatment
High / High
Normal
Yes
Low / Low
No
PE Other
CompleteRef/024overleaf
Abnormal
MTSChestPain
LMWH
No
BB106
BB 271
BB 611
BB 610
BB 307
BB 490
BB 463
BB 486
BB 594
BB 421
BB 178
• Consultants
• Specialty trainees
• Medical students
TCA Guideline
Patient with known orsuspected TCA OD
Admit to ITUAdmit CDU for
psychosocial assessment
CompletePDI/320overleaf
CompleteRef/326overleaf
Adequate breathing
No
Yes
Yes
Intubate andventilate
Adequateand secure airway
CompleteCDU/322overleaf
No
MTSCollapsed
Adult
MTSOD and
Poisoning
Adequate circulationFluid infusion
Ingestion less than1 h before
No
Yes
Yes
Considergastric lavage
Need forbicarbonate
CompleteCDU/323overleaf
CompleteCDU/324overleaf
BicarbonateIV
Treatmentadvice -overleaf
Treatmentadvice -overleaf
Yes
No
Disposition risk assessment
Refer Acute Medicine
CompleteCDU/325overleaf
CompleteRef/327overleaf
CompleteRef/328overleaf
High
Moderate
Low
CompleteCDU/321overleaf
Diabetic foot
Guideline
Diabetic patientwith foot problem
Outpatient follow up Admit
CompletePDI/910overleaf
CompleteRef/914overleaf
MTSLimb
Problems
Clinical riskassessment
No
High
MTS Diabetes
Yes
CDU/911overleaf
No
Yes
No #
#
No
X-ray
CDU/912overleaf
SIRS +or ketotic
Clinicallyinfected
At risklimb
Vascularreferral
Skin broken
Debride,culture, dress
and ABs
Clinicallyinfected
Swollen orpainful
Discharge toGeneral Practitioner
Systemicinfection
Specialist centrewithin 24h
Depth
Oral antibioticsand dressing
Fracture clinic
PILDiabetic
foot
CDU/912overleaf
CompleteRef/913overleaf
CompleteRef/915overleaf
No
Yes
Yes
Low
Moderate
Yes
Yes
No
No
No
Yes
Deep
< 1 mmTopical
antibiotics anddressing
PILDiabetic
foot
Constipation
Guideline
Child with constipation
Admit underappropriate team
Faecalimpaction
CompleteCDU/652overleaf
Follow up by GeneralPractitioner
CompletePDI/650overleaf
MTSUnwellChild
CompleteRef/653overleaf
MTSAbdominal
pain inchildhood
Associatedmedical / surgical
condition
No
CompleteCDU/651overleaf
Under 2 years
Yes
Under 2 years
Regimen 1
First episode
Regimen 2 Regimen 3 Regimen 4
PILConstipated
Child
Yes
No
No
No
Yes Yes
Yes
No
Acute Porphyria
Guideline
Patient with possibleacute porphyria
Admit to Medical Ward Admit to Critical Care Area
CompletePDI/410overleaf
MTSCollapsed
Adult
Clinical Risk AssessmentNot high
Pain controlled
CompleteCDU/412overleaf
No
Yes
MTSAbdominal
Pain
MTSUnwellAdult
Reassess andtreat pain
CompleteRef/414overleaf
Discharge toGeneral Practitioner
CompleteRef/413overleaf
Critical Carereview
Analgesiaadvice -overleaf
High
CCMneeded
CompleteRef/415overleaf
Adequatebreathing
Fitting
ConsiderRSI
No
No
Yes
Yes
CompleteCDU/411overleaf
Admit CDU
Reassessat 6 h
Settling
Notsettling
Therapy advice -overleaf
Therapy advice -overleaf
Therapy advice -overleaf
Therapy advice -overleaf
Therapy advice -overleaf
Research andeducation
• CPAU
• MIOPED
• CHALICE
• ECG PRIME
• MMR
• MSHR
• MACS
Summary
• Poorpractice
• Unrealisticexpectations
• Realisticexpectations
• Change in culture andbehaviour
• Unconsciousincompetence
• Consciousincompetence
• Consciouscompetence
• Mastery
BETting on the Evidencein Emergency Medicine
Kevin Mackway-Jones
Manchester
The life so short, the craft so long to learnHippocrates Aphorisms I
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