Evidence‐based emergency medicine at the ‘coal face’

Abstract

While evidence-based medicine may be trumpeted by zealots, managers and politicians, incorporating it into clinical practice is easier said than done. The present article aims to show that it can be achieved and gives some clinical examples to illustrate this. An appendix contains a summary of useful databases and websites for accessing good medical information and evidence, quickly and reliably near the bedside.

Evidence‐based practice: Where next? What, now?

“…But it is important: the Cochrane Collaboration, which has dedicated itself for its first 10 years of existence to addressing intervention questions, resolved a couple of years ago to take on diagnostic questions too, although methods of meta‐analysing the studies have yet to be refined. Finally, a series of case examples show how EBP can add another dimension of interest to our clinical practice, providing a way even of challenging the most supercilious physician accepting our patient! 4 …”

“…It should be cheap, informative and educational. For example, the series of four illustrative cases come from at least two continents, over at least 4 years, and from someone who worked at one of the EBM worldwide Meccas (Oxford, England) 4 . In an ideal world we should each of us have a series of such anecdotes every day!…”

Do we realize when we do not know? Recognizing uncertainty in clinical medicine

“…Acolytes were persuaded to take up the cause, followed by the creation of evidence‐based journals and computerized EBM databases, including one of the best‐known the Cochrane Collaboration, with systematic reviews and concise summaries of the effects of health care 3 . The introduction into the clinical workplace of online computers connected to the Internet via broadband portals has allowed real‐time searches of clinical questions to be answered at the bedside, even within the busy milieu of the ED 4 . Clinicians have meanwhile familiarized themselves with a wide range of new terms from positive and negative predictive values, odds ratios, likelihood ratios, numbers needed to treat/harm, pre‐ and post‐test probabilities and relative and absolute risk, to the fundamental evaluative scale of ‘levels of evidence’ 5 .…”

“…Even when a clinician has accessed the purest sources of EBM, such as clinically relevant papers conveniently collated and ordered on an EBM site like the TRIP database, 16 the clinician still has to correlate this information against a careful assessment of that particular patient's values. This is a fundamental underlying tenet of the appropriate practice of EBM; that is, the integration of best research evidence with an individual patient's values and preference judgements 2,4 . Conveying complex information that includes appreciable uncertainty, at the same time as clearly identifying decisions where there is a trade‐off between benefit and risk, and all the while remaining sensitive to the patient's values and preferences, is a challenge.…”

“…This is a fundamental underlying tenet of the appropriate practice of EBM; that is, the integration of best research evidence with an individual patient's values and preference judgements. 2,4 Conveying complex information that includes appreciable uncertainty, at the same time as clearly identifying decisions where there is a trade-off between benefit and risk, and all the while remaining sensitive to the patient's values and preferences, is a challenge. In addition, the clinician must be satisfied that the patient really understands the evidence.…”