Evidence based practice in EMS Dr.Venugopalan.P.P

DA,DNB,MNAMS,MEM[GWU-US] Director ,Emergency Medicine -Aster DM Health Care

India

Back ground

EMS is expected to do life saving critical interventions in the field

Critical decisions

Criticism

Background

EMS is developing across globe

Different parts of the world

Variations in practice

Standardisation

Background

EMS personnel should know basic approach

Protocol based practice

EMS protocol

What we had been taught …

What evidence says ..

Many similar areas

EMS airway manipulation

Drugs administration

Fluid Resuscitation

Collar application

Field Resuscitation

Evidence based Practice

Knowledge translationEmergency medicine

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

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”

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.

Evidence based medicine

How to applyEvidence based practice in EMS

Ask questions

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.

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.

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

Apply PICO to the case

Which study ?

As you move up the pyramid the study designs are more rigorous and allow for less bias or

Type of studies

Clinical question in our patient

Acquire evidencesSelect the appropriate resource(s) and conduct a search

Evidence resources

There are literally millions of published reports, journal articles, correspondence and studies available to clinicians

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.

EBP Resources Evidence search

Article DatabaseEvidences cited

E Books and Libraries Evidence search

Cross search engines Evidence search

HOW TO SEARCH Step 1: Use PICO to formulate the search strategy; start with the

Patient problem(s) and Intervention

VERIFY WITH MESH TERMSStep 2. Look at Search Details to verify MeSH terms

MeSH search

MeSH search

Step 3. Limit to appropriate study design

Best evidence for a therapy question is a randomized controlled clinical trial (RCT)

Select the type of question (Therapy) and the type of search (Narrow). You may get more search

To focus more

Step 4. Review the resultsEBP in EMS

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?

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

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.

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.

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?

next step is to review the results.

How large was the treatment effect?

What was the absolute risk reduction?

Experimental Event Rate (EER)

outcome present / total in experimental group

Control Event Rate (CER)

outcome present / total in control group

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]

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]

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]

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]

Clinical versus Statistical Significance

EBP-EMS

Apply the results to your patient

EBP-EMS

Finally Self evaluation

Evaluating the Validity of a Diagnostic Test Study

Statistical questions and concerns are slightly different

Are the results valid?

1. Did participating patients present a diagnostic dilemma?

2. Did investigators compare the test to an appropriate, independent reference standard?

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?

Diagnostic studies EBP

How to evaluate results ?EBP

Sensitivity and SpecificityEBP

Likelihood Ratio EBP

LR changes

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?

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?

Evaluating the Validity of a Diagnostic Test Study

Evaluating the Validity of a Prognosis Study

Impact on EMS Evidence based Practice

Level of EvidenceEBP EMS

Levels evidences EBP EMS

Class recommendations Eased on evidences

Class recommendation EBP EMS

Direction of Evidences 2012

3 x3 Table Replaces Class recommendations

EBP -ImpactProtocols /Guidelines

Impact EBP Protocol /Guideliune

Algorithms EBP-EMS

EMS Manual Protocol/Guidelines

EBP- EMS in India, 2015 November

Practice bundles and Field guide

Protocols /Guidelines

Change in Practice modeEMS made easy

Prehospital ResearchEBP -EMS

Pathway to Quality EMS Care

EBP-EMS

Most disturbing Alarming too …

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