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Evidence based Practice in Emergency Medicine
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Transcript of Evidence based Practice in Emergency Medicine
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Evidence based practice in EMS Dr.Venugopalan.P.P
DA,DNB,MNAMS,MEM[GWU-US] Director ,Emergency Medicine -Aster DM Health Care
India
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Back ground
EMS is expected to do life saving critical interventions in the field
Critical decisions
Criticism
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Background
EMS is developing across globe
Different parts of the world
Variations in practice
Standardisation
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Background
EMS personnel should know basic approach
Protocol based practice
EMS protocol
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What we had been taught …
What evidence says ..
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Many similar areas
EMS airway manipulation
Drugs administration
Fluid Resuscitation
Collar application
Field Resuscitation
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Evidence based Practice
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Knowledge translationEmergency medicine
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Knowledge translation-KT
Knowledge translation (KT) is the umbrella term for all of the activities involved in moving research from the
laboratory, the research journal, and the academic conference into the hands of people and organizations who can put it
to practical use
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Canadian Institutes for Health Research (CIHR)
“Knowledge translation (KT) is defined as 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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Evidence Based Medicine
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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Evidence based medicine
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How to applyEvidence based practice in EMS
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Ask questions
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The caseA 65 year old male with a long history of type 2 diabetes and obesity.
Otherwise his medical history is unremarkable. He does not smoke.
He had knee surgery 10 years ago but otherwise has had no other major medical problems.
Over the years he has tried numerous diets and exercise programs to reduce his weight but has not been very successful.
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The caseHis granddaughter just started high school and he wants to see her graduate and go on to college.
He understands that his diabetes puts him at a high risk for heart disease and is frustrated that he cannot lose the necessary weight.
His neighbor told him about a colleague at work who had his stomach stapled and as a result not only lost over 100 lbs. but also "cured" his diabetes.
He wants to know if this procedure really works.
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PICO is a mnemonic that helps one remember the key components
of a well focused question
P-Patient problem
I-Intervention,Prognostic or Exposure
C-Comparison
O-Outcome
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Apply PICO to the case
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Which study ?
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As you move up the pyramid the study designs are more rigorous and allow for less bias or
Type of studies
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Clinical question in our patient
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Acquire evidencesSelect the appropriate resource(s) and conduct a search
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Evidence resources
There are literally millions of published reports, journal articles, correspondence and studies available to clinicians
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Evidence sources Primary resources: PubMed/MEDLINE will give you access to the primary literature.
Secondary resources: ACP Journal Club, Essential Evidence, FPIN Clinical Inquiries, and Clinical Evidence will provide you with an assessment of the original study.
The Cochrane Library provides access to systematic reviews which help summarize the results from a number of studies.
These are often called “pre-appraised” or EBP resources.
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EBP Resources Evidence search
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Article DatabaseEvidences cited
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E Books and Libraries Evidence search
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Cross search engines Evidence search
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HOW TO SEARCH Step 1: Use PICO to formulate the search strategy; start with the
Patient problem(s) and Intervention
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VERIFY WITH MESH TERMSStep 2. Look at Search Details to verify MeSH terms
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MeSH search
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MeSH search
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Step 3. Limit to appropriate study design
Best evidence for a therapy question is a randomized controlled clinical trial (RCT)
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Select the type of question (Therapy) and the type of search (Narrow). You may get more search
To focus more
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Step 4. Review the resultsEBP in EMS
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Evaluating the Validity of a Therapy Study
Three basic questions that need to be answered for every type of study:
Are the results of the study valid?
What are the results?
Will the results help in caring for my patient?
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Evaluating Medical Research• look for certain criteria to determine the research quality. – Know what questions to answer.
• Read every part of the research.
• Consider the type of journal
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Evaluating Medical Research
• Peer review helps ensure quality. – Subject-matter experts
review material prior to publication
• Internet sites can be valid tools.
• Studies must follow a structured process.
• There will always be limitations.
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Validity criteria.
1. Were patients randomized?
2. Was group allocation concealed?
3. Were patients in the study groups similar with respect to known prognostic variables?
Guyatt, G. Rennie, D. Meade, MO, Cook, DJ. Users' Guide to Medical Literature: A Manual for Evidence-Based Clinical Practice, 2nd Edition 2008.
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Validity criteria.4. To what extent was the study blinded?
5. Was follow-up complete?
6. Were patients analyzed in the groups to which they were first allocated?
7. Aside from the experimental intervention, were the groups treated equally?
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next step is to review the results.
How large was the treatment effect?
What was the absolute risk reduction?
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Experimental Event Rate (EER)
outcome present / total in experimental group
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Control Event Rate (CER)
outcome present / total in control group
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Absolute Benefit Increase (ABI)
The arithmetic difference between the rates of events in the experimental and control group
An Absolute Benefit Increase (ABI) refers to the increase of a good event as a result of the intervention.
An Absolute Risk Reduction (ARR) refers to the decrease of a bed event as the result of the intervention. [ARR = EER-CER]
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Relative Risk (RR)
the ratio of the risk in the experimental group compared to the risk in the control group.
Proportional reduction in risk between the rates of events in the control group and the experimental group.
[RR = EER/CER]
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Relative Benefit Increase (RBI)
the proportional increase in benefit between the rates of events in the control group and the experimental group.
[RBI = EER - CER / CER]
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Numbers Needed to Treat (NNT)
The number of patients who need to be treated to prevent one bad outcome or produce one good outcome.
It is the number of patients that a clinician would have to treat with the experimental treatment compared to the control treatment to achieve one additional patient with a favorable outcome.
[NNT = 1/ARR]
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Clinical versus Statistical Significance
EBP-EMS
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Apply the results to your patient
EBP-EMS
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Finally Self evaluation
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Evaluating the Validity of a Diagnostic Test Study
Statistical questions and concerns are slightly different
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Are the results valid?
1. Did participating patients present a diagnostic dilemma?
2. Did investigators compare the test to an appropriate, independent reference standard?
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Are the results valid?
3. Were those interpreting the test and reference standard blind to the other results?
4. Did the investigators perform the same reference standard to all patients regardless of the results of the test under investigation?
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Diagnostic studies EBP
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How to evaluate results ?EBP
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Sensitivity and SpecificityEBP
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Likelihood Ratio EBP
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LR changes
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How can I apply the results to patient care?
Will the reproducibility of the test result and its interpretation be satisfactory in your clinical setting?
Are the study results applicable to the patients in your practice?
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How can I apply the results to patient care?
Will the test results change your management strategy?
Will patients be better off as a result of the test?
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Evaluating the Validity of a Diagnostic Test Study
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Evaluating the Validity of a Prognosis Study
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Impact on EMS Evidence based Practice
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Level of EvidenceEBP EMS
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Levels evidences EBP EMS
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Class recommendations Eased on evidences
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Class recommendation EBP EMS
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Direction of Evidences 2012
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3 x3 Table Replaces Class recommendations
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EBP -ImpactProtocols /Guidelines
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Impact EBP Protocol /Guideliune
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Algorithms EBP-EMS
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EMS Manual Protocol/Guidelines
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EBP- EMS in India, 2015 November
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Practice bundles and Field guide
Protocols /Guidelines
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Change in Practice modeEMS made easy
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Prehospital ResearchEBP -EMS
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Pathway to Quality EMS Care
EBP-EMS
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Most disturbing Alarming too …
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Latest info ….
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www.drvenu.net , www.emergencymedicinemims.com
www.astermedcity.com
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www.astermedcity.comwww.drvenu.netwww.drvenu.net