Evidence Based Practice:Two Waves for Health

Librarians

Dr Ruth M SladekMPH, PhD

Senior Lecturer in Medical Education

Head of Medical Admissions

School of Medicine

Today’s Presentation

A narrative about what EBP has meant for health librarians

Two waves– Contributing to others’ EBP, eg Informationist

– Developing own EBP (EBL), eg Search filters

Reflections about what it means now

Historical Context…

• Long recognised problem of information overload• …“before the subject [of scurvy] could be set in a clear and

proper light, it was necessary to remove a great deal of rubbish” (Lind, 1773)

• Increasing emphasis on need for published evidence mid-end 20th Century (Bastian, Glasziou & Chalmers, 2010)

• Medline references: 1600 in 1865, 10 million in 2006• Cochrane lamented need for summaries of RCTs (14 per day)• Is it any better now?

Now 75 RCTs and 11 systematic reviews per day

First Wave: EBP

Emergence of EBP •not only more primary evidence, but new sorts of evidence (SRs; EB Clinical Guidelines)

EBP underscored ongoing need/relevance of health librarians•New broad role: improving others’ EBP (multiple professions)•Jumping with ‘ignorant’ glee!

First Wave: EBP

Why jumping with “glee”?•“Finding the Evidence” core concept (necessary but not sufficient)•Traditional experts in organising, identifying, accessing, providing published knowledge•Established roles in education, research & patient care settings•Confirmed importance/relevance to ‘healthcare’•Could see an opportunity to contribute•Validation … balancing the ledger, market value

First Wave: EBPBut, why “ignorant” glee?

– Assumption that they were ready: “At last!”

– Little/no understanding of new knowledge/skills/demands

– Mirrors other professions (?)

– Evolutionary & revolutionary for health librarians

First Wave: EBPOver time

– A continuum of growing engagement with EBP

– Recognition of new knowledge required (eg, epidemiology, critical appraisal skills)

– Collaborated to provide point-of-care resources (eg, the Consortium a la SALUS)

– Contributed to/purchased/taught new specific ‘EBP’ resources (eg, Clinical Evidence)

– Integrated “finding the evidence” into University teaching programmes (eg, Flinders University)

First Wave: EBPOver time (cont.)

– Worked with own organisations to integrate best evidence, eg, committee membership

– Collaborated, eg, ACEBCP Workshops– Ran seminars/training/workshops, eg, How to…– Contributed to synthesizing evidence

• Cochrane Review Groups/Registers• Individual authors • Guidelines

First Wave: EBPOver time (cont.)

– Increased integration with healthcare team (eg, informationists (Davidoff & Florrance, 2000)

– Attending death audits, grand rounds, clinical meetings, ward rounds

• Identifying “patient-specific, relevant published evidence”

• Thin, but sharp end of EBP wedge

• Explicit roles to search, filter & provide the best evidence for clinical decisions

• USA (1970s), UK (1990s), Australia (2000s)

• Exploration of ways to make a meaningful difference

Informationist at the RepatMaking a Difference During a Ward Round •Dr A queried the evidence to support nebulised antibiotics for bronchiectasis for Patient X.

•Written summary of best evidence provided to broader team, ie, Dr A, and Dr B (not involved with Patient X).

•Later that day, Dr B discussed evidence with pharmacist for Patient Y, and dosage influenced by evidence.

•Dr B also considered evidence for Patient Z.

•One clinical question impacted 2 doctors, 3 patients in 24 hours

(Sladek, Pinnock & Phillips, 2004)

Second Wave: EBLEvidence Based Librarianship (EBL)

– As with other professions, growing acknowledgment of need for own evidence

– New discussions, new literature, new journals– Example of Search Filters

Second Wave: EBLSearch Filters

Health librarians are expert searchers•Understand databases•Understanding syntax, subject headings, Boolean logic, rules•Can liken to clinical expert opinion

But, is expert opinion enough?

When the stakes are high (eg, searching for trials for systematic reviews), is there a more evidence-based approach?

Second Wave: EBLSearch Filters•An ‘evidence-based search strategy’ for a particular topic / database•Explicit, replicable methodology•Gold Standard Test Comparison study design (used to evaluate new diagnostic tests)•Known performance parameters•Still need to be mixed with expert opinion

Second Wave: EBLFor example, searching for RCTs on PubMed

You could construct an expert search … OR you could run an RCT search filter (99% sensitivity; 70% specificity):

((clinical[Title/Abstract] AND trial[Title/Abstract]) OR clinical trials[MeSH Terms] OR clinical trial[Publication Type] OR random*[Title/Abstract] OR random allocation[MeSH Terms] OR therapeutic use[MeSH Subheading])

Haynes et al, various dates

Second Wave: EBLFor example, searching for palliative care:

You could construct an expert search strategy …OR you could run a PubMed palliative care filter:

(advance care planning[mh] OR attitude to death[mh] OR bereavement[mh] OR terminal care[mh] OR hospices[mh] OR life support care[mh] OR palliative care[mh] OR terminally ill[mh] OR death[mh:noexp] OR palliat*[tw] OR hospice*[tw] OR terminal care[tw] OR 1049-9091[is] OR 1472-684X[is] OR 1357-6321[is] OR 1536-0539[is] OR 0825-8597[is] OR 1557-7740[is] OR 1552-4264[is] OR 1478-9523[is] OR 1477-030X[is] OR 0749-1565[is] OR 0742-969X[is] OR 1544-6794[is] OR 0941-4355[is] OR 1873-6513[is] OR 0145-7624[is] OR 1091-7683[is] OR 0030-2228[is]) OR ((advance care plan*[tw] OR attitude to death[tw] OR bereavement[tw] OR terminal care[tw] OR life supportive care[tw] OR terminally ill[tw] OR palliat*[tw] OR hospice*[tw] OR 1049-9091[is] OR 1472-684X[is] OR 1357-6321[is] OR 1536-0539[is] OR 0825-8597[is] OR 1557-7740[is] OR 1552-4264[is] OR 1478-9523[is] OR 1477-030X[is] OR 0749-1565[is] OR 0742-969X[is] OR 1544-6794[is] OR 0941-4355[is] OR 1873-6513[is] OR 0145-7624[is] OR 1091-7683[is] OR 0030-2228[is]) NOT Medline[sb]) AND English[la] AND free full text[sb]Show Palliative Care eg 3 slides from website

Some Reflections

EBP and EBL, now what?•Health librarians want to make a meaningful difference•Stepping outside of the traditional boundaries (and stereotypes)•Multiple capacities/potential, but what is most meaningful for nursing/your organisation?•Involve each other at the start (KT principles)•The nature of “developmental” relationships – the need to evolve/nurture – the notion of a continuum

Final Reflections

Service provider?

Professional?

Healthcare professional?