evidence-based medicine for EMS protocols Annual Meeting Handouts/2014 MD… · evidence-based...

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

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evidence-based medicinefor EMS 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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“The National Association of EMS Physicians (NAEMSP) recently entered into a cooperative agreement with the National Highway Traffic Safety Administration (NHTSA) to develop a national strategy for the promotion and implementation of prehospital evidence-based guidelines.”

Christian Martin-Gill, MD, MPH

Assistant Professor of Emergency Medicine

University of Pittsburgh School of Medicine

Evidence BasedDecision Making

Decision BasedEvidence Making

Evidence Based Medicine

2.1.1.2.1Evidence guided development of medical care protocols

3.1.Evidence-based Practice


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NAEMSP 2014: Tucson

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Culture

ClinicalParamedic

AdministrativeParamedic

AcademicParamedic

Academic Centre

Regulator Contractor

Evidence-BasedPractice Culture


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57 EMS Professionals

‘Living Document’

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


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

Evidence Straight

Evidence Used

Take home tools

Objectives

Evidence

Definitions

iPhone 10The Tallest iPhone Yet


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Evidence Straight

Evidence Used

Take home tools

Objectives

Evidence

Definitions

Evidence based medicine is the judicious and conscientious use of the best evidence from research, combined with clinical experience, and applied to patient problems.


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the EBM cyclehow to formquestionshow to

evaluateperformance

how toapply

clinicallyhow to

criticallyappraise

how tosearch

Evidence-Based Practice

Practice-Based Evidence


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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’?

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.


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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

Getting theEvidence

Getting it Used

Getting itStraight

CPEP

WhatWhat HowHowGetting theEvidence

Getting theEvidence Straight

Getting theEvidence Used

Getting theEvidence

Getting theEvidence Straight

Getting theEvidence Used

C‐O‐P PICO SPSO

EBP, PDSAPA,CQI, Res

AGREE II DECIDEGRADE


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Evidence Straight

Evidence Used

Take home tools

Objectives

Evidence

Definitions

twd


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We would like to speak to you about a research study….


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DOI: 10.1161/CIRCULATIONAHA.110.971028 2010;122;S787-S817 Circulation

Demetris Yannopoulos Egan, Chris Ghaemmaghami, Venu Menon, Brian J. O'Neil, Andrew H. Travers and Robert E. O'Connor, William Brady, Steven C. Brooks, Deborah Diercks, Jonathan

CareGuidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular

Part 10: Acute Coronary Syndromes: 2010 American Heart Association

PCI vs TNK

PCI

Evidence Straight

Evidence Used

Take home tools

Objectives

Evidence

Definitions


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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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• 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

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


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CPEP: Class of RecommendationCanadian Task Force Guidelines

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

• 411 Questions

• 356 Experts

• 277 Topics

• 29 Countries

• 5 Years

• 1 New Set of Guidelines!


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Size of Treatment Effect

Est

imat

e of

Cer

tain

ty

New 2012: Direction of Evidence


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New 2012: 3x3 Tables replace Class of Recommendations

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


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%@&$? PICO.

Medic MD

Paramedic: PICO Question Bank

Clinical11858%Systems

6130%

Education24

12%

N=242

Better questions toMedical Director.


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Medic MD

%@&$?PICO?

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.

Competencies Matrix

EBM Research

Methodology

KT Ethics

Core EBM definition

PICO

Types: QL & Q Knowledge

Translation

Definition

Basic Search Study Design

LOE & COR

Micro Patient Eligibility

Advanced Users Guides Clinical Stats Macro Consent Process

TCP

Educator EBM tools Protocol Meso Waivers of IC

IC in emerg.

Researcher Prepare CAT Analytic Stats

Grant, Protocol

Meso Ethics Applica.


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CAT: Critically Appraised Topic

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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Assessment- crackles

- increased JVP- hx CHF, MI

- acuity

Mild /Moderate- able to speak

sentences- crackles base only

- O2 sat >92%

Severe- resp. distress

- crackles throughout- O2 sat <92%

morphine2.5-5mg IV

O2 100% BVM

furosemide IV(only if currently

on a diuretic)

see advancedairway

management

protocols*

nitro S/Lrepeat q5min

prn

salbutamol**

Deteriorating(see near death)

Deteriorating(see severe)

Transport

Near Death- decreased LOC

-cyanosis- dropping sats

- ineffective resp.drive

Yes

No


prn

Yes

No

ICPACPCCP

ACPCCP

ACPCCP

ICPACPCCP

PCPICPACPCCP

PCPICPACPCCP

PCPICPACPCCP

Department of Health

Protocol: Pulmonary Edema (CHF) PDN: 6282.05 Subject: Respiratory Distress (SOB) Page 1

IV saline lockICPACPCCP

PCPICPACPCCP


prn

furosemide IV(only if currently

on a diuretic)

ACPCCP

ACPCCP

morphine2.5-5mg IV

salbutamol**

PCPICPACPCCP

ACPCCP

*ACP, CCP may give PEEP at 5-10cmH2O**only if wheezes present

Last Updated: March 26, 2004

O2 to maintainsats >92%

PCPICPACPCCP

High flow withreservoir

PCPICPACPCCP


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Out of-Hospital Universal Algorithm

EHS has made every effort to ensure that the information, tables, drawings and diagrams contained in the Clinical Practice Guidelines issued XXX is accurate at the time of publication. However, the EHS guidance is advisory and has been developed to assist healthcare professionals, together with patients, to m ake decisionincluding treatments. It is intended to support the decision making process and is not a substitute for sound clinical judgment. Guidelines cannot always contain all the information necessary for determining appropriate care and cannot address all individual situations; therefore individuals using these guidelines must ensure they have the appropriate knowledge and skil ls to enable appropriate interpretation.

INTRODUCTION CPR is a series of life-saving actions that improve the chances of survival. Although, all components of CPR are important (e.g. airway management, ventilations, defibrillation), the provision of quality chest compressions are the most important intervention. Integrating the critical components of CPR requires the prehospital clinician to pay attention to their own rescuer proficiency, the victim, and the available resources.

Travers et al. Ci rculation 2010. 122: s676-S684

How they provide CPR will depend on these three items and this is reflected in the above diagram Also important is the integration of resuscitation systems to optimize the chances of recovery from cardiac arrests. These systems need to integrate together with achievable goals to increase the chances of survival. These systems include community (goal: early access, effective chest compressions), EMS (goal: provide CPR and defibrillation), ED (Goal: therapeutic hypothermia); and hospital system (Goal: post-arrest care). SAFETY Ensure that you, your team, the patient, and that any bystanders are safe throughout all phases of care. ASSESSMENT AND MANAGEMENT Rescuers should provide immediate chest compressions upon recognizing a cardiac arrest based on the following assessment. Recognition

Adult Children Infant Unresponsive (for all ages)

No Breathing Not breathing

normally (gasping)

Not breathing or only gasping

No pulse palpated within 10 seconds

CPR Sequence C-A-B for adults, children & infants

Chest Compressions

Best hands first on patient Delegate team appropriately -DEPTH-RECOIL-PAUSES Focus on High Quality CPR

o Rate at least 100/min. o Depth at least 5 cm. o Allow complete recoil. o Minimise pauses in compressions.

Less than 10 seconds Change compressors every two minutes

Airway Management

Defer invasive airway until end of six

minutes, unless multiple rescuers/resources allow coordinated care.

Initial airway of OPA and NRM Focus on effective oxygenation rather than

method ETI / EGD / BMV all considered acceptable

methods

Ventilation

2 rescuers o Defer 30:2 until 4+ minutes in which

other goals (defib and meds established)

Multirescuers o 30:2 immediately upon setup

Avoid excessive ventilation. Ventilate 1 second per breath. No Advanced Airway

o 30:2 for all when single rescuer o 30:2 ratio for adults & multirescuer o 15:2 child/infant & multirescuer

Advanced Airway (adult, child, infant) o Asynchronous with compressions o 1 breath every 6-8 seconds o 8-10 breaths min o Visible chest rise o

Defibrillation

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EHS has made every effort to ensure that the information, tables, drawings and diagrams contained in the Clinical Practice Guidel ines i ssued XXX is accurate at the time of publication. However, the EHS guidance is advisory and has been developed to assist healthcare professionals, together with patients, to m ake decisionincluding treatments. It is intended to support the decision making process and is not a substitute for sound clinical judgment. Guidelines cannot always contain all the information necessary for determining appropriate care and cannot address all individual situations; therefore individuals using these guidelines must ensure they have the appropriate knowledge and skills to enable appropriate interpretation.

Attach and use defibrillator ASAP Minimize interruptions in chest

compressions before and after shock, resume CPR beginning with compressions immediately after each shock

Adult o Non escalating 200J

Infants/Children o 2J/kg 1st then 4J/kg 2nd o NTE: 10J/kg or adult dose

Immediate resumption of compressions with no pulse check

Shock-break < 2 seconds Check rhythm after conclusion of 2 minute

compression cycle Minimize delays in rhythm analysis

IV Access & Drug Administration

Access obtained when feasible without interrupting chest compressions IV Access when feasible

Epinephrine 1 mg IV q4min Lidocaine XXX

Prehospital Post Arrest Care

Employ passive cooling methods o Remove clothing o Cool environment o Ice packs groin/axillary

to adults, children and infants TRANSFER OF CARE For patients with ROSC it is important to provide all relevant details to the receiving facility in terms of the resuscitation up to that time. It is expected that

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hypothermia, neurological, cardiovascular, and metabolic support, as well as potential transfer to the PCI lab. For patients without ROSC despite ongoing resuscitation it is critical to ensure quality chest compressions during the transfer of care and to provide support as needed to the hospital team. CHARTING In addition to the mandatory fields it is important to document the following in the ePCR text fields:

Bystander CPR(bCPR) in progress Form of bCPR (30:2 vs compression only) XXX

TIPS Pre-Arrival Tips

[1] Determine the down time if possible. [2] Plan team configuration. Team leader=highest trained CPR Rotation q5cycles or 2 min

On Scene Tips [1] Access/Egress Plan exit strategy Anticipate delays Anticipate patient size factors [2] Arrest Type Witnessed vs Unwitnessed Shockable vs non-schockable Bystander CPR vs None [3] Positioning Move to adequate space Provide hard surface [4] Ensuring CPR Quality Throughout Transport Tips

[1] Secure patients & equipment [3] Ensure CPR quality [4] Expose pt and use A/C cooling [5] Communicate with ED early

Resource Utilisation Tips

[1] Early recognition of additional needs [3] Use OLMC readily [4] Expose pt and use A/C cooling

Patient Termination Tips Tissue Donation

[1] Age < 80 yrs [2] Ho HIV, HBV, HCV [3] No leukemia or lymphoma

[5] No fulminate sepsis

Key Points - Resuscitation

Quality chest compressions is critical.

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EHS has made every effort to ensure that the information, tables, drawings and diagrams contained in the Clinical Practice Guidelines issued XXX is accurate at the time of publication. However, the EHS guidance is advisory and has been developed to assist healthcare professionals, together with patients, to make decisionincluding treatments. It is intended to support the decision making process and is not a substitute for sound cl inical judgment. Guidelines cannot always contain all the information necessary for determining appropriate care and cannot address all individual situations; therefore individuals using these guidelines must ensure they have the appropriate knowledge and skills to enable appropriate interpretation.

Adequate rate, recoil and minimal pauses are critical

Depth of CPR will be improved with CPR

feedback devices

C-A-B sequencing for all

CPR choreography of care is critical

Teamwork, Teamwork, Teamwork KNOWLEDGE GAPS Published evidence on the universal approach to cardiac arrests does not necessarily reflect the phases of prehospital care. For example, the scene survey/management, assessment, extrication, and transport are not reflected in the 2010 Resuscitation Guidelines. Practitioners need to translate this published knowledge into practice. RESEARCH OPPORTUNITIES XXX EDUCATION IMPLICATIONS Importance to maintain practice and certification in CPR and the provision of chest compressions. Recommendations include: XXX QUALITY IMPROVEMENT IMPLICATIONS Importance to maintain [1] appropriate performance, [2] measurement, [3] benchmarking, and [4] feedback change. Key Challenges to Improving CPR Quality

Travers et al. Circulation 2010. 122: s676-S684

REFERENCES http://www.ilcor.org (description) http://www.hsfc.ca (description) http://emergency.medicine.dal.ca/ehsprotocols/protocols/toc.cfm (description) METHODOLOGY Provide tools on searching and evaluating the literature.

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EHS has made every effort to ensure that the information, tables, drawings and diagrams contained in the Clinical Practice Guidelines issued XXX is accurate at the time o f publication. However, the EHS guidance is advisory and has been developed to assist healthcare professionals, together with patients, to m ake decisionincluding treatments. It is intended to support the decision making process and is not a substitute for sound clinical judgment. Guidelines cannot always contain all the information necessary for determining appropriate care and cannot address all individual situations; therefore individuals using these guidelines must ensure they have the appropriate knowledge and skills to enable appropriate interpretation.

Timeline Reference Chart

Disposition Reference Chart

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Tips • Address CV triad for reversible causes for ischemic and dysrhythima etiology for CHF

• If patient deteriorating depsite maximal therapy reconsider DDX

• The accurate diagnosis of CHF is difficlut in the out-of-hospital setting. Therapies can worsen non-CHF etiolgoies of symptoms.

Goals of Rx • Improve oxygenation

• Address the full CV triad

• CHF • Ischemia • Dysrhythmia

• Decrease SNS tone • Consider anxiolysis

• Keep patient sitting upright.

• Minimize exertion on extrication.

• Killip Classification

Oxygen for sats > 92%

Electrocardiogram

Consider BMV

Salbutamol 5 mg neb

Nitro 0.4 mg S/L q 5 min prn

Furosemide 20 mg IV with OLMC

Consider CPAP

Consider Advanced Airway: ETI

Consider PEEP post ETI

‘Practice Bundle’

‘Fieldguide’

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Tips • Address CV triad for reversible causes for ischemic and dysrhythima etiology for CHF

• If patient deteriorating depsite maximal therapy reconsider DDX

• The accurate diagnosis of CHF is difficlut in the out-of-hospital setting. Therapies can worsen non-CHF etiolgoies of symptoms.


• Address the full CV triad

• CHF • Ischemia • Dysrhythmia

• Decrease SNS tone • Consider anxiolysis

• Keep patient sitting upright.

• Minimize exertion on extrication.



Electrocardiogram

Consider BMV

Salbutamol 5 mg neb



Consider CPAP



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Tips • Address CV triad for

reversible causes for

ischemic and

dysrhythima etiology for

CHF

• If patient deteriorating

depsite maximal

therapy reconsider

DDX

• The accurate

diagnosis of CHF is

difficlut in the out-of-

hospital setting.

Therapies can worsen

non-CHF etiolgoies of

symptoms.


• Address the full CV

triad • CHF

• Ischemia

• Dysrhythmia

• Decrease SNS tone

• Consider

anxiolysis

• Keep patient sitting

upright.

• Minimize exertion on

extrication.



Electrocardiogram

Consider BMV

Salbutamol 5 mg neb



Consider CPAP




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Tips

• Address CV triad for

reversible causes for

ischemic and

dysrhythima etiology for

CHF • If patient deter iorating

depsite maxim

al

therapy reconsider

DDX • The accurate

diagnosis of CHF is

difficlut in the out-of-

hospital setting.

Therapies can worsen

non-CHF etiolgoies of

symptom

s.

Goals of Rx

• Improve oxygenation

• Address the full CV

triad • CHF

• Ischemia

• Dysrhythmia

• Decrease SNS tone

• Consider

anxiolysis

• Keep patient sitting

upright.

• Minim

ize exertion on

extrication.

• Kill ip Classi fication Oxygen for sats > 92%

Electrocardiogram

Consider BMV

Salbutamol 5 mg neb



Consider CPAP



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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

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


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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

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


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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

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



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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.


44% are ‘evidence-based’Respiratory most common

54% of protocols have no CPG

223 Included

481 CPG


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Policy Makers

Clinicians‘DECIDE Framework’


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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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evidence-based medicine for EMS protocols Annual Meeting Handouts/2014 MD… · evidence-based...

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