BETting on the Evidence in Emergency Medicine.ppt · gastric lavage Need for bicarbonate Complete...

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)


“Charismatic expertise based uponsubjective self-confidence unsupportedby objective ability"

The greater the ignorance the

greater the dogmatism

William OslerMontreal Medical Journal (1902)


“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


Other diagnosisrequiring admission

Admitfor treatment

High / High

Normal

Yes

Low / Low

No

PE Other


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



Adequate breathing

No

Yes

Yes

Intubate andventilate

Adequateand secure airway


No

MTSCollapsed

Adult

MTSOD and

Poisoning

Adequate circulationFluid infusion

Ingestion less than1 h before

No

Yes

Yes

Considergastric lavage

Need forbicarbonate



BicarbonateIV

Treatmentadvice -overleaf

Treatmentadvice -overleaf

Yes

No

Disposition risk assessment

Refer Acute Medicine




High

Moderate

Low


Diabetic foot

Guideline

Diabetic patientwith foot problem

Outpatient follow up Admit



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



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


Follow up by GeneralPractitioner


MTSUnwellChild


MTSAbdominal

pain inchildhood

Associatedmedical / surgical

condition

No


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


MTSCollapsed

Adult

Clinical Risk AssessmentNot high

Pain controlled


No

Yes

MTSAbdominal

Pain

MTSUnwellAdult

Reassess andtreat pain


Discharge toGeneral Practitioner


Critical Carereview

Analgesiaadvice -overleaf

High

CCMneeded


Adequatebreathing

Fitting

ConsiderRSI

No

No

Yes

Yes


Admit CDU

Reassessat 6 h

Settling

Notsettling

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

BETting on the Evidence in Emergency Medicine.ppt · gastric lavage Need for bicarbonate Complete...

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