• Evidence Based Practice – a primer for Paramedics

    by Alan Batt. Last modified: 23/02/14

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    Following on from Jason Merrill’s excellent two part piece on Introduction to Evidence Based EMS (Part 1 & Part 2) here we will review the topic of evidence based medicine (EBM) and evidence based practice (EBP) in general, and provide links to some readings dealing with evidence based practice and the challenges of evidence based prehospital care provision.

    ebmmugWhat is evidence based medicine?

    Sackett at al. (1997) describe evidence based medicine as “”the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients”. Broader implementations of EBM in healthcare are also known as Evidence Based Practice (EBP) and Evidence Based Healthcare.

    EBP evolved from the need to bridge academic progress with everyday clinical practice. EBP has led to more structured, objective decision making in healthcare, and provision of interventions based on scientific research rather than on practitioner opinion. Clinical practice has been completely transformed by evidence based thinking, and prehospital care provision is no exception.

    How is evidence based practice implemented?

    Broadly speaking, there are five steps, which are similar to steps in the scientific method.

    1. Definition of problem
    2. Systematic retrieval of the best evidence available
    3. Critical appraisal of evidence available
    4. Application of results in clinical practice
    5. Evaluation of performance

    How do I find the evidence?

    EBM TriadThe best source of evidence based recommendations are rigorous systematic reviews that are based on multi-site randomised, double blinded, controlled trials in humans.

    The Cochrane Collaboration is one of the best-known databases of systematic reviews. Like other databases of systematic reviews such as UpToDate, Trip and DynaMed, it requires authors to provide a detailed and repeatable plan of their literature search and evaluations of the evidence. Upon reviewing all the evidence, treatment is categorized as (1) likely to be beneficial, (2) likely to be harmful, or (3) evidence did not support either benefit or harm.

    However, the knowledge gained from clinical research does not directly answer the primary clinical question of what is best for the individual patient at hand and many authors believe that evidence-based practice should not discount the value of clinical experience.

    Indeed, Hess (2004) considers evidence based practice/evidence-based medicine to be a combination of external research evidence, clinical experience and patient values & expectations. More detailed explanations for grading of evidence levels can be found in Part 1 & Part 2 of Introduction to Evidence Based EMS.

    Why should I care about EBP?

    You should care about EBP because it has the potential to change what you do and how you do it! More importantly, it can help you to deliver better care to your patients!

    spinal

    For instance, how many of us were until recently (and some still are) routinely applying collars and longboards to extricate patients from vehicles? Come on, hands up! Did you know that this practice is largely based on two papers by JD Farrington entitled “Death in a Ditch” & “Extrication of victims–surgical principles” published in…1967 & 1968! No evidence is associated with these papers, merely observations – well, EBP is potentially about to change this archaic practice for good!

    Recent studies by Dixon et al., Engsberg et al., Shafer & Naunheim, have all indicated that in road-traffic collision settings, self-extrication results in the least amount of cervical-spine movement, and is a safer method of extrication for the majority of patients*. The use for or against application of a cervical collar is also being investigated. Dixon et al. have now received funding to further investigate the biomechanics of extrication, and this study is ongoing at the time publication.

     
    Farrington JD. Death in a Ditch. 1967. Bull Am Coll Surg. 2013 Jun;98(6):44-53; discussion 43. PMID: 23789199.
     Free full text
     
    Farrington JD. Extrication of victims--surgical principles. J Trauma. 1968 Jul;8(4):493-512. PMID: 5658633.

     
    Shafer JS1, Naunheim RS. Cervical spine motion during extrication: a pilot study. West J Emerg Med. 2009 May;10(2):74-8. PMID: 19561822.

     
    Dixon M1, O'Halloran J, Cummins NM. Biomechanical analysis of spinal immobilisation during prehospital extrication: a proof of concept study. Emerg Med J. 2013 Jun 28. PMID: 23811859.

     
    Engsberg JR1, Standeven JW, Shurtleff TL, Eggars JL, Shafer JS, Naunheim RS. Cervical spine motion during extrication. J Emerg Med. 2013 Jan;44(1):122-7. PMID: 23079144.

    So what next?

    next

    Firstly, we’ve a great article on how to read a paper. Once you can comfortably read a paper, you should begin to develop your critical analysis skills. Learn about the different levels of evidence, take a course or workshop in critical appraisal skills, and begin searching through some of the evidence-based databases listed at the end of this article.

    Systematic reviews are literature reviews focused on a research question that try to identify, appraise, select and synthesize all high quality research evidence relevant to that question. These are an essential part of evidence based practice. Good sources of systematic reviews include the Cochrane Library and Best Evidence Topics (BestBETS).

    Your institution may be able to give you access to paid databases such as Up-To-Date and DynaMed. Free resources include the Cochrane Database, the Dalhousie CPEBP Project, EvidenceSearch and the TRIP Database –  a medical search engine with emphasis on evidence based medicine (EBM) and clinical guidelines and queries, including content from Cochrane and Bandolier.

    Once you delve into the world of evidence based practice, you will find yourself beginning to continually assess the evidence upon which you base your clinical decisions. You will find yourself willing to seek out quality appraised sources of evidence from the millions of potential sources out there – and you will begin choosing those that are relevant to your practice.

    Once you have found the evidence you need to ask yourself 3 key questions:

    1. Can I trust this information?
    2. If the information is true, will the use of this information make an important difference?
    3. Can I use the information in this instance?

    Evidence Based Practice in EMS – some reading

     
    Jensen JL1, Petrie DA, Travers AH; PEP Project Team. The Canadian prehospital evidence-based protocols project: knowledge translation in emergency medical services care. Acad Emerg Med. 2009 Jul;16(7):668-73. PMID: 19691810.

     
    Lang ES1, Spaite DW, Oliver ZJ, Gotschall CS, Swor RA, Dawson DE, Hunt RC. A national model for developing, implementing, and evaluating evidence-based guidelines for prehospital care. Acad Emerg Med. 2012 Feb;19(2):201-9. PMID: 22320372.

     
    Myers JB1, Slovis CM, Eckstein M, Goodloe JM, Isaacs SM, Loflin JR, Mechem CC, Richmond NJ, Pepe PE; U.S. Metropolitan Municipalities' EMS Medical Directors. Evidence-based performance measures for emergency medical services systems: a model for expanded EMS benchmarking. Prehosp Emerg Care. 2008 Apr-Jun;12(2):141-51. PMID: 18379908.

     
    Callaham M. Quantifying the scanty science of prehospital emergency care. Ann Emerg Med. 1997 Dec;30(6):785-90. PMID: 9398774.

     
    El Sayed MJ. Measuring quality in emergency medical services: a review of clinical performance indicators. Emerg Med Int. 2012;2012:161630. PMID: 22046554.

    Where do I find the evidence?

    Evidence Based Practice Resources

    * Research findings and conclusions displayed on this site are not a recommendation to change your scope of practice or disregard your service providers guidelines. Always follow local protocols/guidelines.

    References

     
    1.

    Sackett DL, Rosenberg WM, Gray JA, Haynes RB, Richardson WS. Evidence based medicine: what it is and what it isn’t. BMJ. 1996 Jan 13;312(7023):71-2. PMID: 8555924.

     
    2.

    Hess DR. What is evidence-based medicine and why should I care? Respir Care. 2004 Jul;49(7):730-41. PMID: 15222906.

     
    3.

    Jensen JL1, Petrie DA, Travers AH; PEP Project Team. The Canadian prehospital evidence-based protocols project: knowledge translation in emergency medical services care. Acad Emerg Med. 2009 Jul;16(7):668-73. PMID: 19691810.

     
    4.

    Lang ES1, Spaite DW, Oliver ZJ, Gotschall CS, Swor RA, Dawson DE, Hunt RC. A national model for developing, implementing, and evaluating evidence-based guidelines for prehospital care. Acad Emerg Med. 2012 Feb;19(2):201-9. PMID: 22320372.

     
    5.

    Myers JB1, Slovis CM, Eckstein M, Goodloe JM, Isaacs SM, Loflin JR, Mechem CC, Richmond NJ, Pepe PE; U.S. Metropolitan Municipalities’ EMS Medical Directors. Evidence-based performance measures for emergency medical services systems: a model for expanded EMS benchmarking. Prehosp Emerg Care. 2008 Apr-Jun;12(2):141-51. PMID: 18379908.

     
    6.

    Callaham M. Quantifying the scanty science of prehospital emergency care. Ann Emerg Med. 1997 Dec;30(6):785-90. PMID: 9398774.

     
    7.

    El Sayed MJ. Measuring quality in emergency medical services: a review of clinical performance indicators. Emerg Med Int. 2012;2012:161630. PMID: 22046554.

     
    8.

    Shafer JS1, Naunheim RS. Cervical spine motion during extrication: a pilot study. West J Emerg Med. 2009 May;10(2):74-8. PMID: 19561822.

     
    9.

    Dixon M1, O’Halloran J, Cummins NM. Biomechanical analysis of spinal immobilisation during prehospital extrication: a proof of concept study. Emerg Med J. 2013 Jun 28. PMID: 23811859.

     
    10.

    Engsberg JR1, Standeven JW, Shurtleff TL, Eggars JL, Shafer JS, Naunheim RS. Cervical spine motion during extrication. J Emerg Med. 2013 Jan;44(1):122-7. PMID: 23079144.

     
    11.

    Farrington JD. Extrication of victims–surgical principles. J Trauma. 1968 Jul;8(4):493-512. PMID: 5658633.

     
    12.

    Farrington JD. Death in a Ditch. 1967. Bull Am Coll Surg. 2013 Jun;98(6):44-53; discussion 43. PMID: 23789199.

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    Alan Batt

    Alan Batt

    Paramedic, educator, researcher
    Alan is a critical care paramedic, paramedic educator and prehospital researcher, currently working around the world as an educator and researcher. He has previously worked and studied across Europe, North America and the Middle East. He holds a Graduate Certificate in Intensive Care Paramedic Studies, and an MSc in Critical Care. His main interests are in care of the elderly, end-of-life care, patient safety, professionalism (including role and identity), and paramedic education.

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