From Evidence to Practice Building the National Model

1. From Evidence to Practice Building the National Model Andrew Travers MD MSc FRCPC Staff Physician, QE-II Emergency Provincial Medical Director Emergency Health Services Halifax, Nova Scotia

2. traverah@gov.ns.ca From Evidence to EMS Practice: Building the National Model

3. Conflict of Interest • No reported financial conflicts of interests to declare. • Contributing Author • Cochrane Collaboration • Airway Review Group • International Liaison Committee on Resuscitation From Evidence to EMS Practice: Building the National Model

4. Acknowledgements Dalhousie Division of EMS Dalhousie University • Dave Petrie MD • Ed Cain MD • Jan Jensen ACP • Dave Urquhart • Corinne Burke From Evidence to EMS Practice: Building the National Model

5. Out-of-Hospital Medicine Prehospital Medicine Paramedicine Evidence-Based Medicine EBP, EBID, EBG, etc.

6. Objectives • Systems and processes used in Nova Scotia to develop the Evidence Prehospital Protocol Project Online (EBP3O). • Key features, unique advantages, and challenges faced over the past ten years. • Provide some recommendations. From Evidence to EMS Practice: Building the National Model

7. From Evidence to EMS Practice: Building the National Model

8. Prehospital Fibrinolysis Simulation Air Medical Program Medical First Responders Evidence-Based Prehospital Protocol Project Online EBP3O Medical Communications Centre Provincial Trauma Registry Prehospital Research Network Community Paramedicine

9. EBP Objectives: 1996 - 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. From Evidence to EMS Practice: Building the National Model

10. Topic Selection Cone Acad Emerg Med 2007 14 11 1052 Formal Search Appraisal Protocol Operationalization Dissemination Evaluate Performance Process: In Concept Published Evidence Evidence Cultural Getting The Evidence Straight Operational Getting The Evidence Used

11. EBP3O: Levels of EvidenceSimplified Version of Canadian Task Force Guidelines and Oxford Levels of Evidence From Evidence to EMS Practice: Building the National Model

12. EBP3O: Class of RecommendationCanadian Task Force Guidelines From Evidence to EMS Practice: Building the National Model

13. Process: In Practice Published Evidence Cultural Topic Selection Operational Formal Search Appraisal Protocol Operationalization Dissemination Evaluate Performance

15. http://emergency.medicine.dal.ca/ehsprotocols http://www.gov.ns.ca/health/ehs

21. LOE and COR for EHS Protocols From Evidence to EMS Practice: Building the National Model

22. Clinical Paramedic Administrative Paramedic Academic Paramedic Evidence-Based Practice Culture Culture Regulator Contractor Academic Centre

23. The EBM Cycle & Paramedic Practice Jan Jensen ACP

24. Unique Aspects • Regional experience in paramedic driven research & EBM. • Annual Research/EBM Conferences and CME • Question Banking • 250 ‘Paramedic Driven’ Questions • Multidisciplinary Working Groups • Students, residents, paramedics, EMS Physicians • National Occupational Competency Profile (NOCP). • EBM and Research Competencies From Evidence to EMS Practice: Building the National Model

25. NOCP: Competencies

26. EBP3O 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. From Evidence to EMS Practice: Building the National Model

27. Objectives described. Clinical questions described. Application to patients described. Scope & Purpose Completed Target users defined. Piloted among users. Editorial Independence Stakeholder Involvement Rigour of Development Applicability Systematic searches. Clear selection criteria. Clear procedure for Updating. Clarity & Presentation Specific & unambiguous. Different Mx options considered.

28. Scope & Purpose Weaknesses Includes individuals from relevant groups. Editorial independent from funding. Conflicts of interest recorded. Editorial Independence Stakeholder Involvement Rigour of Development Applicability Formulation methods clearly described. Explicit link between evidence & recommendation. Expert external review. Key review criteria for monitoring and auditing. Clarity & Presentation Key recommendations easily identifiable. Application support tools.

29. EB3PO: 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. From Evidence to EMS Practice: Building the National Model

30. Scope & Purpose Future Development Patient preferences and views sought. Editorial Independence Stakeholder Involvement Rigour of Development Applicability Consideration of side effects, benefits, risks. Discussion of organisational barriers. Application costs considered. Clarity & Presentation From Evidence to EMS Practice: Building the National Model

31. EBP3O: 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. From Evidence to EMS Practice: Building the National Model

32. 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). Closing Remarks From Evidence to EMS Practice: Building the National Model