Presentation given in International emergency medicine conference in Dubai 2016

1. Evidence based practice
in EMS
Dr.Venugopalan.P.P
DA,DNB,MNAMS,MEM[GWU-US]
Director ,Emergency Medicine -Aster DM Health Care
India

2. Back ground
EMS is expected to
do life saving
critical
interventions in the
field
Critical decisions
Criticism

3. Background
EMS is developing
across globe
Different parts of
the world
Variations in
practice
Standardisation

4. Background
EMS personnel
should know basic
approach
Protocol based
practice
EMS protocol

5. What we had been taught …
What evidence says ..

6. Many similar areas
EMS airway manipulation
Drugs administration
Fluid Resuscitation
Collar application
Field Resuscitation

7. Evidence based
Practice

12. Knowledge translation
Emergency medicine

13. 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

14. 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”

17. 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.

18. Evidence based
medicine

23. How to apply
Evidence based practice in EMS

24. Ask questions

25. The case
A 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.

26. The case
His 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.

27. PICO is a mnemonic that helps
one remember the key components
of a well focused question
P-Patient problem
I-
Intervention,Progn
ostic or Exposure
C-Comparison
O-Outcome

28. Apply PICO to the
case

29. Which study ?

30. As you move up the pyramid the study designs
are more rigorous and allow for less bias or
Type of studies

31. Clinical question
in our patient

32. Acquire evidences
Select the appropriate resource(s)
and conduct a search

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

34. 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.

35. EBP Resources
Evidence search

36. Article Database
Evidences cited

37. E Books and Libraries
Evidence search

38. Cross search engines
Evidence search

39. HOW TO SEARCH
Step 1: Use PICO to formulate the search strategy; start with the
Patient problem(s) and Intervention

40. VERIFY WITH MESH TERMS
Step 2. Look at Search Details to verify MeSH terms

41. MeSH search

42. MeSH search

43. Step 3. Limit to appropriate
study design
Best evidence for a therapy question is a randomized controlled
clinical trial (RCT)

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

45. Step 4. Review the results
EBP in EMS

46. 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?

47. 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

48. 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.

49. 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.

50. 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?

51. next step is to
review the results.
How large was the treatment effect?
What was the absolute risk
reduction?

52. Experimental Event
Rate (EER)
outcome present / total in
experimental group

53. Control Event Rate
(CER)
outcome present / total in control
group

54. 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]

55. 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]

56. 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]

57. 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]

58. Clinical versus Statistical
Significance
EBP-EMS

61. Apply the results to your patient
EBP-EMS

62. Finally
Self evaluation

63. Evaluating the Validity of
a Diagnostic Test Study
Statistical questions and concerns
are slightly different

64. Are the results
valid?
1. Did participating patients present
a diagnostic dilemma?
2. Did investigators compare the test
to an appropriate, independent
reference standard?

65. 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?

66. Diagnostic studies
EBP

67. How to evaluate results ?
EBP

68. Sensitivity and Specificity
EBP

69. Likelihood Ratio
EBP

70. LR changes

71. 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?

72. 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?

73. Evaluating the Validity of a Diagnostic
Test Study

74. Evaluating the Validity of a Prognosis
Study

75. Impact on EMS
Evidence based Practice

76. Level of Evidence
EBP EMS

77. Levels evidences
EBP EMS

78. Class recommendations
Eased on evidences

79. Class recommendation
EBP EMS

80. Direction of Evidences
2012

81. 3 x3 Table
Replaces Class recommendations

82. EBP -Impact
Protocols /Guidelines

83. Impact EBP
Protocol /Guideliune

84. Algorithms
EBP-EMS

85. EMS Manual
Protocol/Guidelines

86. EBP- EMS in India, 2015 November

87. Practice bundles and Field
guide
Protocols /Guidelines

88. Change in Practice mode
EMS made easy

89. Prehospital Research
EBP -EMS

90. Pathway to Quality EMS Care
EBP-EMS

91. Most disturbing
Alarming too …

92. Latest info ….

94. www.drvenu.net , www.emergencymedicinemims.com
www.astermedcity.com

95. www.astermedcity.com
www.drvenu.net
www.drvenu.net