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

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

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 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. Key features, unique advantages, and challenges faced over the past ten years. Provide some recommendations. Provide some recommendations. From Evidence to EMS Practice: Building the National Model

8. Nova Scotia: An Overview Total landmass is 52, 840 km2, with approximately 25,000 km of paved highways. Population 973,000 105,000 requests for ambulances 95,000 responses per year 85,000 transports per year via ground We receive, co-ordinate and flight follow 900 Aeromedical missions per year We initiate Medical First Response by Fire Departments 18,000 times per year

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

10. 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

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

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

13. EBP3O: Class of Recommendation Canadian Task Force Guidelines From Evidence to EMS Practice: Building the National Model

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

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

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

23. Culture Clinical Paramedic Administrative Paramedic Academic Paramedic Academic Centre RegulatorContractor Evidence-Based Practice Culture

24. The EBM Cycle & Paramedic Practice Jan Jensen ACP

25. Unique Aspects Regional experience in paramedic driven research & EBM. 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). National Occupational Competency Profile (NOCP). –EBM and Research Competencies From Evidence to EMS Practice: Building the National Model

26. NOCP: Competencies EBMResearch Methodology KTEthics EMR EBM definition PICO Types: QL & QKnowledge Translation Definition PCPSearchStudy Design LOE & COR MicroPatient Eligibility ACP Users Guides Clinical StatsMacroConsent Process TCP Educator EBM tools ProtocolMesoWaivers of IC IC in emerg. Researcher Prepare CAT Analytic Stats Grant, Protocol MesoEthics Applica.

27. 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

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

29. 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 Applicability Rigour of Development Clarity & Presentation Stakeholder Involvement Editorial Independence Completed

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

31. EB3PO: Other Weaknesses A contemporary and generalizable method of ‘grading’ evidence is lacking. A contemporary and generalizable method of ‘grading’ evidence is lacking. Minimal peer review & auditing. Minimal peer review & auditing. Ensuring that protocols remain up to date. Ensuring that protocols remain up to date. Minimal funding of infrastructure. Minimal funding of infrastructure. Lack of publications from the EBP3O initiative. Lack of publications from the EBP3O initiative. From Evidence to EMS Practice: Building the National Model

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

33. EBP3O: Other Future Directions Creation and linkage of ‘online’ and ‘didactic’ basic and advanced EBP course for paramedics with input into the EB3P0. Creation and linkage of ‘online’ and ‘didactic’ basic and advanced EBP course for paramedics with input into the EB3P0. ‘Evidence mapping’. ‘Evidence mapping’. Linkage of protocol compliance/performance with evidence evaluation process. Linkage of protocol compliance/performance with evidence evaluation process. Integration/adaptation into ILCOR, Cochrane, etc. Integration/adaptation into ILCOR, Cochrane, etc. –Movement of paramedics into these domains. From Evidence to EMS Practice: Building the National Model

34. Closing Remarks Include paramedics early – “content experts”. A collaborative, community based model is feasible. Address the needs of the end-user(s). Incorporate input from the end-user(s). Standardised/adaptable prehospital ‘grading’. Optimize evidence search & appraisal process. From Evidence to EMS Practice: Building the National Model