conflict of interest - national association of ems ... 2013 travers evidence to practice.… ·...
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Andrew Travers, MD, MSc, FRCPC [email protected]
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From Evidence to Practice
Canadian Prehospital Evidence Based Protocols
Andrew Travers MD MSc FRCPCProvincial Medical Director
Emergency Health ServicesHalifax, Nova Scotia
Conflict of Interest
• Academic– ILCOR
• Financial– None
www.gov.ns.ca/health/ehs
Andrew Travers, MD, MSc, FRCPC [email protected]
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Culture
ClinicalParamedic
AdministrativeParamedic
AcademicParamedic
Academic Centre
Regulator Contractor
Evidence-BasedPractice Culture
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Andrew Travers, MD, MSc, FRCPC [email protected]
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‘Living Document’
Academic Emergency Medicine 2009. 16(7): 668-673.
#10Cone and McManusTop 10 EMS Research Articles of 2009NAEMSP 2010
Andrew Travers, MD, MSc, FRCPC [email protected]
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Evidence Straight
Evidence Used
Take home tools
Objectives
Evidence
Definitions
Evidence Straight
Evidence Used
Take home tools
Objectives
Evidence
Definitions
Andrew Travers, MD, MSc, FRCPC [email protected]
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evidence-based medicine
the judicious and conscientious use of:
best evidence from research
combined with clinical experience,
applied to patient problemsLouis, Bichat, & Magendie 1850
the EBM cyclehow to formquestionshow to
evaluateperformance
how toapply
clinicallyhow to
criticallyappraise
how tosearch
Andrew Travers, MD, MSc, FRCPC [email protected]
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Evidence-Based Practice
Practice-Based Evidence
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’?
Andrew Travers, MD, MSc, FRCPC [email protected]
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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.
Operational
Cultural
Published Evidence
Process: In Concept
Appraisal
FormalSearch
Topic Selection
EvaluatePerformance
OperationalizationDissemination
Protocol
Operational
Cultural
Published Evidence
Process: In Concept
Appraisal
FormalSearch
Topic Selection
EvaluatePerformance
OperationalizationDissemination
Protocol
Evidence
GettingThe
EvidenceStraight
GettingThe
EvidenceUsed
Andrew Travers, MD, MSc, FRCPC [email protected]
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Getting theEvidence
Getting it Used
Getting itStraight
CPEP
Evidence Straight
Evidence Used
Take home tools
Objectives
Evidence
Definitions
Andrew Travers, MD, MSc, FRCPC [email protected]
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PCI vs TNK
PCI
Evidence Straight
Evidence Used
Take home tools
Objectives
Evidence
Definitions
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.
Andrew Travers, MD, MSc, FRCPC [email protected]
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http://emergency.medicine.dal.ca/ehsprotocols
http://www.gov.ns.ca/health/ehs
• BC Ambulance Service
• Alberta Emergency Health Services
• BC Ambulance Service
• NS Emergency Health Services
Andrew Travers, MD, MSc, FRCPC [email protected]
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• BC Ambulance Service
• Alberta Emergency Health Services
• BC Ambulance Service
• NS Emergency Health Services
Andrew Travers, MD, MSc, FRCPC [email protected]
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• BC Ambulance Service
• Alberta Emergency Health Services
• BC Ambulance Service
• NS Emergency Health Services
Andrew Travers, MD, MSc, FRCPC [email protected]
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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
Andrew Travers, MD, MSc, FRCPC [email protected]
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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
CPEP: Class of RecommendationCanadian Task Force Guidelines
Andrew Travers, MD, MSc, FRCPC [email protected]
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LOE and COR for EHS Protocols
Size of Treatment Effect
Est
imat
e of
Cer
tain
ty
• 411 Questions
• 356 Experts
• 277 Topics
• 29 Countries
• 5 Years
• 1 New Set of Guidelines!
Andrew Travers, MD, MSc, FRCPC [email protected]
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New 2012: Direction of Evidence
New 2012: 3x3 Tables replace Class of Recommendations
Andrew Travers, MD, MSc, FRCPC [email protected]
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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
%@&$? PICO.
Medic MD
Andrew Travers, MD, MSc, FRCPC [email protected]
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Paramedic: PICO Question Bank
Clinical11858%Systems
6130%
Education24
12%
N=242
Better questions toMedical Director.
Medic MD
%@&$?PICO?
Andrew Travers, MD, MSc, FRCPC [email protected]
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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.
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
Andrew Travers, MD, MSc, FRCPC [email protected]
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CPEP
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
Andrew Travers, MD, MSc, FRCPC [email protected]
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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
Andrew Travers, MD, MSc, FRCPC [email protected]
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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
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
CPEP: Other Weaknesses
• A contemporary and generalizable method of ‘grading’evidence remains elusive.
• Minimal peer review & auditing.
• Ensuring that protocols remain up to date.
• Minimal funding of infrastructure.
• Lack of publications from the CPEP initiative.
Andrew Travers, MD, MSc, FRCPC [email protected]
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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
GUIDELINES APPRAISAL PROJECT (GAP) FOR EMS
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
Andrew Travers, MD, MSc, FRCPC [email protected]
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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
GUIDELINES APPRAISAL PROJECT (GAP) FOR EMS
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
GUIDELINES APPRAISAL PROJECT (GAP) FOR EMS
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.
GUIDELINES APPRAISAL PROJECT (GAP) FOR EMS
Andrew Travers, MD, MSc, FRCPC [email protected]
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44% are ‘evidence-based’Respiratory most common
54% of protocols have no CPG
223 Included
481 CPG
Guidelines
Publications Knowledge Gapson ‘What & How’
Andrew Travers, MD, MSc, FRCPC [email protected]
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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.