Evidence based healthcare in the UK – any signs of life? Carl Thompson RN; PhD Editor: 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” Medline: “evidence based” in TI

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 clinical questions into 64 “types” top 3 = 30% of all questions (Ely et al. BMJ 2000;321: ) 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 ): Acute: 5% of decisions acted on. Primary: 0.2% acted on Searching: the exception not the norm nurses do have questions (tripdatabase)

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? or % 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

Haynes’ 5S Typology of Research Information SUMMARIES SYNOPSES SYNTHESES STUDIES SYSTEMS eg, CDSS bring 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 sequence

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 commentaries 6000 on the “b-list”

Progress: syntheses - nursing & guidelines 78 clinical guidelines 155 technology appraisals

Progress: studies

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

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