From Evidence to Practice Building the National Model Andrew Travers MD MSc FRCPC Staff Physician,...

From Evidence to Practice

Building the National Model

Andrew Travers MD MSc FRCPCStaff Physician, QE-II Emergency

Provincial Medical DirectorEmergency Health Services

Halifax, Nova Scotia

[email protected]

From Evidence to EMS Practice: Building the National Model

Conflict of Interest

• No reported financial conflicts of interests to No reported financial conflicts of interests to declare.declare.

• Contributing AuthorContributing Author– Cochrane CollaborationCochrane Collaboration

Airway Review GroupAirway Review Group

– International Liaison Committee on ResuscitationInternational Liaison Committee on Resuscitation


Acknowledgements

• Dave Petrie MDDave Petrie MD• Ed Cain MDEd Cain MD• Jan Jensen ACPJan Jensen ACP

• Dave Urquhart Dave Urquhart • Corinne BurkeCorinne Burke


Dalhousie Division of EMSDalhousie University

Out-of-Hospital MedicinePrehospital Medicine

Paramedicine

Evidence-Based MedicineEBP, EBID, EBG, etc.

Objectives

• Systems and processes used in Nova Scotia to Systems and processes used in Nova Scotia to develop the develop the Evidence Prehospital Protocol Project Online (EBP3O).

• Key features, unique advantages, and challenges Key features, unique advantages, and challenges faced over the past ten years.faced over the past ten years.

• Provide some recommendations.Provide some recommendations.


Community Paramedicine

Prehospital Fibrinolysis

PrehospitalResearch Network

ProvincialTrauma Registry

MedicalCommunications

Centre

Medical First

Responders

PCP, 495

ICP, 234

ACP, 153CCP, 10

Air MedicalProgram

Simulation

Evidence-Based Prehospital Protocol Project OnlineEBP3O

EBP Objectives: 1996 - 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.


Operational

Cultural

Published Evidence

Process: In Concept

Appraisal

FormalSearch

Topic Selection

EvaluatePerformance

OperationalizationDissemination

Protocol

Evidence

GettingThe

EvidenceStraight

GettingThe

EvidenceUsed

Cone Acad Emerg Med 2007 14 11 1052

EBP3O: Levels of EvidenceSimplified Version of Canadian Task Force Guidelines and Oxford Levels of Evidence


EBP3O: Class of RecommendationCanadian Task Force Guidelines


Operational

Cultural

Published Evidence

Process: In Practice

Appraisal

FormalSearch

Topic Selection

EvaluatePerformance

OperationalizationDissemination

Protocol

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

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

LOE and COR for EHS Protocols

A B C D I

12

30

100

200

300

400

500

600

700

800

900

Frequency of Class of Recommendation

Frequency of LOE

EHS Protocols LOE & Recommendations

1 2 3


Culture

ClinicalParamedic

AdministrativeParamedic

AcademicParamedic

Academic Centre

Regulator Contractor

Evidence-BasedPractice Culture

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

Unique Aspects

• Regional experience in paramedic driven research & EBM. Regional experience in paramedic driven research & EBM. – Annual Research/EBM Conferences and CMEAnnual Research/EBM Conferences and CME– Question BankingQuestion Banking

250 ‘Paramedic Driven’ Questions250 ‘Paramedic Driven’ Questions

– Multidisciplinary Working GroupsMultidisciplinary Working Groups Students, residents, paramedics, EMS PhysiciansStudents, residents, paramedics, EMS Physicians

• National Occupational Competency Profile (NOCP).National Occupational Competency Profile (NOCP).– EBM and Research CompetenciesEBM and Research Competencies


NOCP: Competencies

EBM Research

Methodology

KT Ethics

EMR EBM definitionEBM definition

PICOPICO

Types: QL & Q Knowledge

Translation

Definition

PCP SearchSearch Study Design

LOE & COR

Micro Patient Eligibility

ACP Users GuidesUsers Guides Clinical Stats Macro Consent Process

TCP

Educator EBM toolsEBM tools Protocol Meso Waivers of IC

IC in emerg.

Researcher Prepare CATPrepare CAT Analytic Stats

Grant, Protocol

Meso Ethics Applica.

EBP3O Paramedic Nomenclature

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

and puts into EBP3O 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 Class of Recommendation/Level of

Evidence ‘Dashboard’ on the Evidence-Based Protocols.


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

Applicability Rigour of

Development

Clarity&

Presentation

Stakeholder

Involvement

EditorialIndependence

Completed

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


Development

Clarity&

Presentation

Stakeholder

Involvement


Weaknesses

Key review criteria formonitoring and auditing.

EB3PO: Other Weaknesses

• A contemporary and generalizable method of ‘grading’ A contemporary and generalizable method of ‘grading’ evidence is lacking.evidence is lacking.

• Minimal peer review & auditing.Minimal peer review & auditing.• Ensuring that protocols remain up to date.Ensuring that protocols remain up to date.• Minimal funding of infrastructure.Minimal funding of infrastructure.• Lack of publications from the EBP3O initiative.Lack of publications from the EBP3O initiative.


Patient preferences andviews sought.

Discussion oforganisational barriers.

Application costs considered.

Consideration of sideeffects, benefits, risks.

Scope&

Purpose


Development

Clarity&

Presentation

Stakeholder

Involvement


Future Development


EBP3O: Other Future Directions

• Creation and linkage of ‘online’ and ‘didactic’ basic Creation and linkage of ‘online’ and ‘didactic’ basic and advanced EBP course for paramedics with input and advanced EBP course for paramedics with input into the EB3P0.into the EB3P0.

• ‘‘Evidence mapping’.Evidence mapping’.

• Linkage of protocol compliance/performance with Linkage of protocol compliance/performance with evidence evaluation process.evidence evaluation process.

• Integration/adaptation into ILCOR, Cochrane, etc.Integration/adaptation into ILCOR, Cochrane, etc.– Movement of paramedics into these domains.Movement of paramedics into these domains.


Closing Remarks

• Include paramedics early – “content experts”. • A collaborative, community based model is feasible.

• Address the needs of the end-user(s). • Incorporate input from the end-user(s).

• Standardised/adaptable prehospital ‘grading’.

• Optimize evidence search & appraisal process.


From Evidence to Practice Building the National Model Andrew Travers MD MSc FRCPC Staff Physician,...

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