Library Support for Clinical Audit.

Stephen Ayre Clinical Librarian [email protected]

‘Our Future is in Our Hands’

George Eliot Hospital

• • • • Small acute trust, District General Hospital (1728 WTE) Small Library Service (3.5 WTE) 1 Clinical Librarian (also Deputy Librarian) How to make most impact with minimum resource?

Clinical Audit

• • • • Mechanism for quality improvement in health care.

Establishing performance of clinical service against a benchmark.

Library support for clinical audit.

Library participation in clinical audit.

Audit Support Procedure

• • All audits must be registered with Trust Clinical Audit Officer.

By arrangement, new audit registration forms are passed to Clinical Librarian.

Telephone v. email

• • Chance to sell service.

Need for evidence may not have been thought of.

• Nearly all who are telephoned accept offer.

• More information derived for search.

Results

• • 227 clinical audits in 2008/10 109 audit-related searches since April 2008 (= 4 per month).

• • This represents 48%.

Excluded audits include national and documentation audits.

• Mainly (86%) doctors, but also others.

Problems

• • • Most nursing and AHP audits not registered. (less impact on career) Unaware of similar service to benchmark against.

Need to evaluate use of information provided.

Examples

• • • • • • • • Management of sepsis and septic shock Patient attitude to undergraduate medical education Scrub technique Rehabilitation and patient satisfaction after plating for clavicular fracture When to use CT scan in stroke Documentation of laparoscopy Warfarin and TRUS Use of information by hospital doctors. • • • • • • • • CT head scans at night Colonography indications and compared with colonoscopy Patient satisfaction surveys for outpatients Management of miscarriage Sacrospinous fixation Biofeedback training for faecal incontinence Length of stay of urology patients Anaesthesia and theatre annual safety checks

Spin-offs from involvement

• • • • Repeat requests.

Further marketing for Athens and ILLs.

Involvement in Clinical Audit training.

Audit into evidence-base for therapies applied to inpatients in one week in September 2008.

Wider applications

• Find existing knowledge based processes and get yourself embedded.

• Do not underestimate the power of direct telephone marketing when there is an established need.

• Business generates business.

Library Participation in Audit

• • • • • Registrar approached Clinical Librarian Wanted to know how evidence-based doctors were.

Ethnographic study too time intensive.

Questionnaires: risk of recall bias Instead empirical audit of actual practice.

Methods

• • • • Prospective medical admissions for 5 days in September 2008 (19 th -24 th ) Convenience sample of 102 patients Data collected on diagnosis and therapies 150 diagnosis/therapy pairs (2 patients no diagnosis)

Literature Search

• • • • • Clinical Knowledge Summaries Cochrane Library Medline Embase All available from NHS Evidence www.evidence.nhs.uk

Outcomes

1.

2.

3.

4.

Systematic Review of more than one randomised controlled trial Single randomised controlled trial Non-experimental evidence No or opposing evidence (not just v. placebo)

Results

1.

2.

3.

4.

Systematic Reviews: 61 (41%) Single RCT: 17 (11%) Non-experimental evidence: 48 (32%) No or opposing evidence: 24 (16%)

48, 32%

Figure 1: Evidence Base for Interventions

24, 16% 61, 41% Systematic Review RCT Non-experimental None or contrary 17, 11%

Previous audits

Study

Ellis Michaud

Country

UK Canada Nordin Johansson Hardern This audit Sweden UK UK

Date

1995 1994 1995 1996

SR

n/a n/a n/a

RCT Non experimental

53% 57% 50% 29% 27% 34% <2003 n/a 2008 41% 59% 11% 31% 32%

Contrary or no evidence

18% 16% 16% 10% 16%

Examples of no evidence 1

• • • • Antibiotics for non-infective severe acute asthma Not combining aspirin and clopidogrel for acute coronary syndrome Paracetamol for benign calf pain or headache Early blood transfusion for GI bleed haemoglobin >8 leads to more bleeding

Examples of no evidence 2

• • • Sodium valproate better than 2nd Line IV Phenytoin in status epilepticus No evidence of significant effect for chest physio for COPD exacerbation Aminophylline no better than other bronchodilator drugs, and has more adverse effects for non-infective asthma exacerbation

Discussion

• • • • • General medicine at GEH is evidence based.

Results very similar to earlier studies.

8 million articles published since 1995 have not improved situation.

Methodology to audit evidence base of clinical practice.

Library support available for other specialties.

• • • • •

References

Ellis J, Mulligan I, Rowe J, Sackett D. Inpatient general medicine is evidence based.

Lancet

1995;346:407-410 Michaud G, McGowan JL, van der Jagt R, Wells G, Tugwell P. Are therapeutic decisions supported by evidence from health care research?

Arch Intern Med

1998;158:1665-1668 Nordin-Johansson A, Asplund K. Randomised controlled trials and consensus as a basis for interventions in internal medicine.

J Intern Med

2000;247:94-104 Hardern RD, Leong FT, Page A-V, Shepherd M, Teoh RCM. How evidence based are therapeutic decisions taken on a medical admissions unit?

Emerg Med J

2003;20:447-448 Ayre S, Walters, G. Are therapeutic decisions made on the medical admissions unit any more evidence-based than they used to be?

J Eval Clin Pract

2009;15:1180-1186