[email protected] evidence based healthcare in the uk – any signs of life? carl thompson rn; phd...
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Evidence based healthcare in the UK – any signs of life?
Carl Thompson RN; PhDEditor: Evidence Based Nursing
ebn.bmj.com
Where?
York
When should I pay attention?
the need for clarity policy context “raw materials”: studies syntheses and synopses synapses and increasing capacity structures achievements
Definitions
Policy context : growth of “EBEv”
evidence based anything
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1990 1995 2000 2005 2006
year
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(n)
Medline: “evidence based” in TI 1990-2006
Context: progress by accident
EU working time directive (Junior Docs) Unlimited to 58 hours to 48 hours in
2009 New roles
Doctors Assistants; Medical Assistants; Clinical Assistants; Clinical Support Technicians; Night Nurse Practitioners; Emergency Nurse Practitioners; Specialist Nurse Practitioners; Nurse Consultants; Physician Assistants
Context: the results
At least as good as docs but at what cost?
Nurse led “intermediate” care vs. usual care
Griffiths et al. Effectiveness of intermediate care in nursing-led in-patient units. Cochrane Database of Systematic Reviews 2007, Issue 2.
context: progress by design
Raw materials: EBP & decisions
The (re)recognition of “uncertainty” Medicine. 1396 clinical questions into 64
“types” top 3 = 30% of all questions (Ely et al. BMJ 2000;321:429-432)
Nursing. Once every 30 seconds in critical care (Bucknall, AJAdvN, 2000)
Circa 50 decisions every 8 hour shift in Medical Admissions (Thompson et al. J.AdvN 2001 –2005)
EBP: “pull” AND “push” technology
Medicine: Ely et al. (1999) 64% of clinical questions not acted on – but of those that are 80% had answers.
Nursing (Thompson et al. 2001-5): Acute: 5% of decisions acted on. Primary: 0.2% acted on
Searching: the exception not the norm nurses do have questions (tripdatabase)
www.tripdatabase.com
Raw materials: baseline
Adverse events: 1:8 to 1:11 inpatients 300,000 – 1.4 million adverse events each year in
hospital sector alone (NAO data)
HAIs: 9% in-patients (n=100,000)/year Medication errors:
2.5%-5.5% for oral, 10.3 for IV (Sheldon et al. NPSA 2005)
* likely underestimate (Akbari Sari & Sheldon, BMJ 2007)
50% (half) due to planning or execution errors (Reason, 1999)
Synapses: Professional innumeracy?
0.064 or 0.01
6.4% or 1%
45% correct
80% correct
N = 454
Which is bigger?
Docs?
Doctors: 87% comfortable with communicating risk qualitatively;
only 36% quantitatively
95% residents think its important
(Fam Med 2008;40(5):354-8.)
Progress: infrastructure
Progress: infrastructure
Haynes’ 5S Typology of Research Information
SUMMARIES
SYNOPSES
SYNTHESES
STUDIES
SYSTEMS eg, CDSSbring research directly into clinical decision making
Evidence based journal Abstracts; précis and appraisal
Systematic reviews
Primary research (Medline, CINAHL etc)
Evidence based textbooks eg, Clinical Evidence, PIER
Search
sequ
ence
Progress: systems
National electronic library for health (NELH.NHS.NET)
Free access (at work and home) via NHS pass for ALL NHS staff
Cochrane, MEDLINE, tripdatabase, Centre for Reviews and Dissemination at York, distance learning appraisal materials.
CDSS: prodigy and isobel and a myriad of “home-grown” CDSS
Progress: synopses
227 Lancet or 118 New England Journal of Medicine = information in 1 Evidence-Based article (Haynes et al 2004.)
1057 abstracts and commentaries6000 on the “b-list”
Progress: syntheses - nursing & guidelines
78 clinical guidelines
155 technology appraisals
Progress: studies
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QualRCTSys rev
Progress: practice (leg ulcers)
1980s Mainly venous in origin –
compression bandaging is first line treatment
>80% of leg ulcer patients managed in community by nurses (responsible for treatment decisions)
<25% of those requiring compression bandaging received it
2000s Screening for arterial
disease using Doppler ankle brachial pressure index (ABPI) increased from 71.9% to 88.8%
Assessment of patients’ pain increased from 65.8% to 83.4%
Use of compression bandaging increased from 76.4% to 90.5%
Time to healing reduced significantly
www.rcn.org.uk/publications/pdf/guidelines/leg_ulcer_sentinel_audit1.pdf
So…
Policy context Ingredients
Synopses & Guidelines Syntheses Studies
Structures Support
Fitness for purpose (p useful | professionals) Fitness for purpose (p useful |questions)
Final thoughts
“Progress might have been all right once, but it has gone on too long.”
Ogden Nash
"Restlessness and discontent are the first necessities of progress."
Thomas Edison