From Evidence to Practice Canadian Prehospital Evidence Based Protocols Andrew Travers MD MSc FRCPC Provincial Medical Director Emergency Health Services Halifax, Nova Scotia Conflict of Interest Academic None Financial Pharma 1999-2007 1
Objectives Systems and processes used in Canada Nov to develop the Canadian Prehospital Evidence-Based Protocols. Key features, unique advantages, and challenges faced over the past ten years. Provide some recommendations on knowledge sharing. Evidence-Based Practice Practice-Based Evidence The EBM Cycle & Paramedic Practice Re-evaluate Practice/ Protocol Current Practice/ Paramedic Protocols Evidence Appraisal Question Practice/ Develop Research Question Design & Conduct Study = Results Jan Jensen ACP 2
Translating knowledge Into Practice Published Evidence Evidence Cultural Operational Topic Selection Getting Formal The Evidence Search Straight Appraisal Protocol Getting Operationalization The Dissemination Evidence Used Evaluate Performance Question Clinical Practice Guideline X X X Implementation Focus Operational Focus Recommendation Focus Evidence Appraisal Focus The Canadian Prehospital Evidence-Based Project Structure, Process, Outcomes 3
Unique Aspects Regional experience in paramedic driven research & EBM. Annual Research/EBM Conferences and CME Question Banking l 250 Paramedic Driven Questions Multidisciplinary Working Groups l Students, residents, paramedics, EMS Physicians National Occupational Competency Profile (NOCP). EBM and Research Competencies 25 12 NOCP: Competencies EMR EBM EBM definition PICO Research Methodology Types: QL & Q PCP Search Study Design LOE & COR KT Knowledge Translation Micro Ethics Definition Patient Eligibility ACP 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. 4
CPEP 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. http://emergency.medicine.dal.ca/ehsprotocols http://www.gov.ns.ca/health/ehs 5
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CPEP: Levels of Evidence Simplified Version of Canadian Task Force Guidelines and Oxford Levels of Evidence CPEP: Class of Recommendation Canadian Task Force Guidelines 7
LOE and COR for EHS Protocols The Guidelines Appraisal Project Jensen JL, Carter A, Travers AH, Dewar Z, Sibley D, Cain E Grading of Recommendations Assessment, Development and Evaluation 8
Completed Objectives described. Clinical questions described. Application to patients described. Scope & Purpose Target users defined. Piloted among users. Clarity & Presentation Specific & unambiguous. Different Mx options considered. Systematic searches. Clear selection criteria. Clear procedure for Updating. Weaknesses Editorial independent from funding. Conflicts of interest recorded. Scope & Purpose Includes individuals from relevant groups. Key review criteria for monitoring and auditing. Clarity & Presentation Key recommendations easily identifiable. Application support tools. Formulation methods clearly described. Explicit link between evidence & recommendation. Expert external review. CPEP: Other Weaknesses A contemporary and generalizable method of grading evidence is lacking. Minimal peer review & auditing. Ensuring that protocols remain up to date. Minimal funding of infrastructure. Lack of publications from the EBP3O initiative. 9
Future Development Scope & Purpose Patient preferences and views sought. Discussion of organisational barriers. Application costs considered. Clarity & Presentation Consideration of side effects, benefits, risks. GAP: Objectives To systematically review published CPGs for quality and relevance to prehospital practice To identify knowledge gaps (eg lacking CPGs) in prehospital areas of care 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 10
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 Quality Evaluation 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 Methods Included CPGs were further reviewed for evidence-basedness *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 EB-CPG was randomly assigned to 2 reviewers 11
Non-EB CPG Remain in database under nonevidence-based Still answers How Relevant to EMS Care? question (the last question on the appraisal form) Two appraisers ranked with blinded 3 rd party Results to Date Literature SEARCH for guidelines n = 481 REVIEW FOR INCLUSION (RELEVANT TO EMS)? kappa = 0.27 n = 237 REVIEW FOR INCLUSION (EVIDENCE-BASED vs. NON-EB)? kappa = 0.71 NON-EVIDENCE BASED GUIDELINES Evaluate for Relevance to EMS care EVIDENCE BASED GUIDELINES Evaluate for Quality (AGREE II) and Relevance to EMS Care n = 124 n = 113 N-EBG Results to date Not relevant Somewha t relevant 50 (40.3%) 61 (49.2%) EBG Highly relevant 13 (10.5%) Sent (%) Complete (%) N=226 93 (41.15%) 25 (11.06%) 12
Discussion Goal: update local protocol Access the PEP database: find primary research articles categorized by intervention and ranked for quality, also find CPGs and AGREE score Hierarchy of evidence based practice: do the research, search for it, find it on PEP, find the guideline already written in GAP Discussion GAP will expose gaps in existing high quality CPGs PEP and GAP will reduce knowledge to action gap by making a bottom line available to end-users CPEP: Other Future Directions Creation and linkage of online and didactic basic and advanced EBP course for paramedics with input into the EB3P0. Evidence mapping. Linkage of protocol compliance/performance with evidence evaluation process. Integration/adaptation into ILCOR, Cochrane, etc. Movement of paramedics into these domains. 13
Closing Remarks Include paramedics early content experts. A collaborative, community based model is feasible. Standardised/adaptable prehospital grading. Optimize evidence search & appraisal process. Address the needs of the end-user(s). Incorporate input from the end-user(s). 14