PROCEP Teaching and Research Center Rio de Janeiro, Brazil

1. Scientifically Informed Medical Practice and LEarning (SIMPLE)The Roadmap for Evidence Based Health Care Suzana Alves da Silva, MD, PhD PROCEP Teaching and Research Center Rio de Janeiro, Brazil

2. Evidence-Based Medicine “The integration of best research evidence with clinical expertise and patient values and circumstances” David Sackett, 1992

3. EBM Skills Cycle 0. Problem Delineation 4. Apply 1. Ask 3. Appraise 2. Acquire

4. Patient’s Opinion after a Chest Pain Unit Experience Based on ESCAPE Trial, Goodacre et al. BMJ 2007. • Patients rarely knew to whom they had been talking, either by name or designation • Patients knew that something was going wrong but rarely knew what was going wrong. They only knew that it was not a heart attack • “But it is something, you know, there is something going on” Johnson et al. Patients’ opinions of acute chest pain care: a qualitative evaluation of Chest Pain Units. J Adv Nurs 2008

5. Chest Pain Unit • Low risk patient • Follow the algorithm for low risk chest pain in the ER which includes repeated cardiac markers at 3 and 6 hours after admission + echocardiogram + non-invasive test for stratification before discharge + = • Low Patient Satisfaction • Overwhelming • $$$$$$ Johnson et al. Patients’ opinions of acute chest pain care: a qualitative evaluation of Chest Pain Units. J Adv Nurs 2008

6. The SIMPLE Model Problem delineation “The process of problematization implies a critical return to action. It starts from action and returns to it” Paulo Freire, 1972 Values Priorities Preferences

7. Patient-Practitioner Relationship and Practice Circumstances Silva, Charon, Wyer. JECP 2010.

8. Patient-Practitioner Relationship and Practice Circumstances Silva, Charon, Wyer. JECP 2010.

9. Clinical Scenario ‘I woke up with palpitations and chest pressure this morning. I just want to get it checked out, that’s all.’ This is how a 31-year-old worker, who has come to the emergency department during lunch break, describes his problem. The patient has no significant past medical history but that his father died in his 50’s of a ‘massive heart attack’. The patient lives alone, has an unclear history of similar symptoms. He states that he occasionally takes benzodiazepine ‘for sleep’. However, he stresses that, for now, he just wants his chest symptoms ‘checked out. ’ EKG, vital signs and physical examination and first cardiac enzymes are normal.

10. Chest Pain Unit Priorities Patient Practitioner Will the algorithm for low risk chest pain help me out excluding ACS for this patient? Diagnosis performance Am I having a Heart Attack? Diagnosis likelihood Is it safe to perform an outpatient investigation in this low risk patient? What is the impact on outcomes? Diagnosis utility I would like to perform the tests later. Is that okay? Diagnosis utility If I come back to work what is the probability of something bad happening? Prognosis likelihood If this patient in fact has ACS what will be the probability of being sued as a result of a bad outcome? Prognosis likelihood

11. Patient-Practitioner Relationship and Practice Circumstances Silva, Charon, Wyer. JECP 2010.

12. Low Risk Chest Pain Solving the issues of probability Pre-Test Probability of ACS < 10% Diagnosis Within 1 month < 1 out of 1.000 100% of patients > 40 y/o 3% with multiple risk factors Probability of a Bad Outcome if the patient has ACS Will have a heart attack < 1% Prognosis Meyer et al. A Critical Pathway for Patients With Acute Chest Pain and Low Risk for Short-Term Adverse Cardiac Events: Role of Outpatient Stress Testing. Ann Emerg Med 2006. Goldman. PREDICTION OF THE NEED FOR INTENSIVE CARE IN PATIENTS WHO COME TO EMERGENCY DEPARTMENTS WITH ACUTE CHEST PAIN. NEJM 1996.

13. PACT Action Domains Categories of Problems

14. HARM PROGNOSIS THERAPY DIAGNOSIS Utility Utility Utility Utility Performance Performance Performance Performance Probability Probability Probability Probability PACT Action Domains

15. The Anatomy of the Question opulation ntervention omparison utcome

16. Clinical Scenario You are seeing new patients in the “major care” area of the ED. You reassess a 45 yo male who had been held in the ED overnight while being treated for renal colic, in the hope he could be discharged. Unfortunately, this patient is not doing so well; he is extremely weak, nauseous and suffering extensive rigors. He has spiked a temp to 39.9 oC and his BP is 90/50, HR 135, and RR 22. His O2 saturation is 98% on room air. You initiate a septic work-up and order aggressive hydration and broad-spectrum antibiotics. Based on tests you diagnose septic shock secondary to UTI, complicated by an obstructing stone.

17. In patients with septic shock, does Early Goal Directed Therapy affect mortality? Utility Performance Probability

19. Acquiring the Best Available Evidence

20. Utility of a Therapeutic Intervention Guidelines Systematic Reviews Randomized trials

21. The effect of a quantitative resuscitation strategy on mortality in patients with sepsis: A meta-analysis* Alan E. Jones, MD; Michael D. Brown, MD, MSc; Stephen Trzeciak, MD, MPH. Critical Care Medicine 2008

22. Likelihood of outcome if submitted to therapy Guidelines Systematic Reviews Observational Studies

23. In-Hospital mortality in SepsisPatients submitted to EGDT Lagu et al. Incorporating initial treatments improves performance of a mortality prediction model for patients with sepsis. Pharmacoepidemiology and drug safety 2012; 21(S2): 44–52

24. Clinical Research Basic Science Clinical Expertise Clinical Knowledge “Problematization” - Constructivism Scientific Knowledge Pos-Positivism - Pragmatism Information Positivism Integration of Knowledge Evidence Hierarchy JAMA 1992 Oxford Classification Guidelines Wisdom Epistemological Hierarchy Complexity Silva and Wyer, Where is the wisdom? II, JECP 2009

25. Where is the Wisdom? “Where is the wisdom we have lost in knowledge? Where is the knowledge we have lost in information?” TS Eliot. The Rock. Acknowledgement to Peter Wyer David Eddy. Evidence-Based Medicine: A Unified Approach. Health Affairs 2005. Wyer, Silva. Where is the Wisdom I. JECP 2009. Sival, Wyer. Where is the Wisdom II. JECP 2009.

26. Thank You! Gracias! Danke! Merci! Obrigada!