cat4@york.ac.uk

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

cita

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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