BETting on the Evidence in Emergency Medicine.ppt · gastric lavage Need for bicarbonate Complete...

Preview:

Citation preview

BETting on the Evidencein Emergency Medicine

Kevin Mackway-Jones

Manchester

Outline

• We have a problem

• We have a dream

• We have a plan

• We take a gamble

• Las Vegas!

The Problem

The Problem – How we practiced

“Faith is the substance of things hoped for,

the evidence of things not seen”

Hebrews 11:1

The fact that an opinion has been

widely held is no evidence whatever

that it is not utterly absurd; indeed

in view of the silliness of the majority

of mankind, a widespread belief is more

likely to be foolish than sensible

Bertrand Russell

Marriage and Morals (1929)

The Problem – How we practiced

“Charismatic expertise based uponsubjective self-confidence unsupportedby objective ability"

The greater the ignorance the

greater the dogmatism

William OslerMontreal Medical Journal (1902)

The Problem – How we practiced

“The triumph of hope over experience"

The Dream

The Dream

“Evidence-based medicine (EBM)is the integration of best researchevidence with clinical expertise andpatient values"

The Plan

• Establish a journal club

• Change practice

• Save more lives

POORATTENDANCE

NOCHANGE

LACK OFINTEREST

A downward

spiral

• Get help

• Reflect on failure

• Recognise the limitations of thedepartment

• Recognise the limitations of the evidence

• Set achievable goals

• Formalise critical appraisal

• Formalise journal scanning

• Formalise attendance

The Gamble

The birth of BETs

BETs

• Clinical scenario

• 3 part question

• Search strategy

• Evidence table

• Discussion

• Clinical bottom line

• For the busy clinician

• The best available evidence

(not just the best)

• Simple questions - understandable answers

CLINICALCOMMITMENT

FORMALISEDREPORTING

CLINICALCONUNDRUMS

LEARNINGFOR ALL

CHANGEEFFECTED

A virtuous

circle

“There’s a BET

In that!”

R2

= 0.9943

0

200

400

600

800

1000

1200

1400

1600

1800

Jun-97O

ct-97Feb-98Jun-98O

ct-98Feb-99Jun-99O

ct-99Feb-00Jun-00O

ct-00Feb-01Jun-01O

ct-01Feb-02Jun-02O

ct-02Feb-03Jun-03O

ct-03Feb-04Jun-04O

ct-04Feb-05Jun-05O

ct-05Feb-06Jun-06O

ct-06Feb-07Jun-07O

ct-07Feb-08Jun-08

Date

BE

Ts

pla

ced

The Engine

• Major perceived barrier was lack of time

• Most appropriate way to move towardsEBP was by using evidence based guidelinesor proposals developed by colleagues

From Access to Practice

McColl A et al 1998

• Accumulator BETs

Patient with pleuritic chestpain or possible

pulmonary embolus

D-Dimer

Interpret VQ withclinical riskassessment

Clinical RiskAssessment Low

CompleteCDU/021overleaf

AdmitAnticoagulate

CompletePDI/020overleaf

Home

Moderate/ High

Normal

Raised

No PE

No

Yes

CompleteRef/023overleaf

Abnormal CXR

VQ scanCT pulmonary angiography

Co

nsid

er

for

OP

inve

stig

atio

n

CompleteCDU/022overleaf

Other diagnosisrequiring admission

Admitfor treatment

High / High

Normal

Yes

Low / Low

No

PE Other

CompleteRef/024overleaf

Abnormal

MTSChestPain

LMWH

No

BB106

BB 271

BB 611

BB 610

BB 307

BB 490

BB 463

BB 486

BB 594

BB 421

BB 178

• Consultants

• Specialty trainees

• Medical students

TCA Guideline

Patient with known orsuspected TCA OD

Admit to ITUAdmit CDU for

psychosocial assessment

CompletePDI/320overleaf

CompleteRef/326overleaf

Adequate breathing

No

Yes

Yes

Intubate andventilate

Adequateand secure airway

CompleteCDU/322overleaf

No

MTSCollapsed

Adult

MTSOD and

Poisoning

Adequate circulationFluid infusion

Ingestion less than1 h before

No

Yes

Yes

Considergastric lavage

Need forbicarbonate

CompleteCDU/323overleaf

CompleteCDU/324overleaf

BicarbonateIV

Treatmentadvice -overleaf

Treatmentadvice -overleaf

Yes

No

Disposition risk assessment

Refer Acute Medicine

CompleteCDU/325overleaf

CompleteRef/327overleaf

CompleteRef/328overleaf

High

Moderate

Low

CompleteCDU/321overleaf

Diabetic foot

Guideline

Diabetic patientwith foot problem

Outpatient follow up Admit

CompletePDI/910overleaf

CompleteRef/914overleaf

MTSLimb

Problems

Clinical riskassessment

No

High

MTS Diabetes

Yes

CDU/911overleaf

No

Yes

No #

#

No

X-ray

CDU/912overleaf

SIRS +or ketotic

Clinicallyinfected

At risklimb

Vascularreferral

Skin broken

Debride,culture, dress

and ABs

Clinicallyinfected

Swollen orpainful

Discharge toGeneral Practitioner

Systemicinfection

Specialist centrewithin 24h

Depth

Oral antibioticsand dressing

Fracture clinic

PILDiabetic

foot

CDU/912overleaf

CompleteRef/913overleaf

CompleteRef/915overleaf

No

Yes

Yes

Low

Moderate

Yes

Yes

No

No

No

Yes

Deep

< 1 mmTopical

antibiotics anddressing

PILDiabetic

foot

Constipation

Guideline

Child with constipation

Admit underappropriate team

Faecalimpaction

CompleteCDU/652overleaf

Follow up by GeneralPractitioner

CompletePDI/650overleaf

MTSUnwellChild

CompleteRef/653overleaf

MTSAbdominal

pain inchildhood

Associatedmedical / surgical

condition

No

CompleteCDU/651overleaf

Under 2 years

Yes

Under 2 years

Regimen 1

First episode

Regimen 2 Regimen 3 Regimen 4

PILConstipated

Child

Yes

No

No

No

Yes Yes

Yes

No

Acute Porphyria

Guideline

Patient with possibleacute porphyria

Admit to Medical Ward Admit to Critical Care Area

CompletePDI/410overleaf

MTSCollapsed

Adult

Clinical Risk AssessmentNot high

Pain controlled

CompleteCDU/412overleaf

No

Yes

MTSAbdominal

Pain

MTSUnwellAdult

Reassess andtreat pain

CompleteRef/414overleaf

Discharge toGeneral Practitioner

CompleteRef/413overleaf

Critical Carereview

Analgesiaadvice -overleaf

High

CCMneeded

CompleteRef/415overleaf

Adequatebreathing

Fitting

ConsiderRSI

No

No

Yes

Yes

CompleteCDU/411overleaf

Admit CDU

Reassessat 6 h

Settling

Notsettling

Therapy advice -overleaf

Therapy advice -overleaf

Therapy advice -overleaf

Therapy advice -overleaf

Therapy advice -overleaf

Research andeducation

• CPAU

• MIOPED

• CHALICE

• ECG PRIME

• MMR

• MSHR

• MACS

Summary

• Poorpractice

• Unrealisticexpectations

• Realisticexpectations

• Change in culture andbehaviour

• Unconsciousincompetence

• Consciousincompetence

• Consciouscompetence

• Mastery

BETting on the Evidencein Emergency Medicine

Kevin Mackway-Jones

Manchester

The life so short, the craft so long to learnHippocrates Aphorisms I