Bringing Evidence to the Bedside in Critical Care

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Bringing Evidence to the Bedside in Critical Care

• Allan S. Detsky
• Physician-in-Chief
• Mount Sinai Hospital

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We need information

• If asked
• We need it twice a week
• We get it from textbooks, journals and our
  colleagues

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We really need information

• If shadowed
• We need it twice for every 3 outpatients and 5
  times for every patient
• But we rarely get what we need from the resources
  that we use
• Colleagues
• Textbooks
• Journals
• Ann Intern Med 1991114576-81

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Evidence of Care Gaps

• Beta blockers in post MI patients
• Statins in post MI patients
• ACE-I in patients with CHF
• Antithrombotic therapy in patients with
  nonvalvular atrial fibrillation

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HOW CAN WE BRIDGE THIS GAP?
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• Bringing evidence to the point of care
• Need it within seconds if it is to be
  incorporated into busy clinical rounds
• Focus on users needs and important clinical
  outcomes
• Our initial attempts to bring the best evidence
  to a busy clinical team caring for over 200
  patients per month
• JAMA 19982801336-8.

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• Kinds of Questions
• 1. Therapeutic Effectiveness
• 2. Diagnostic Accuracy
• 3. Prognostic Information

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Therapeutic Effectiveness

• For patients with health state X,
• does Rx A do more good than
• harm (compared to Rx B)?

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Diagnostic Accuracy

• Does test A help us separate those with disease
  from those without for patients that look like X?

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Prognostic Information

• For patients with health state X, was the risk of
  an adverse outcome over a specified period of
  time?

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What do clinicians want on PDAs?

• Clinical bottom line from preappraised resources
• Management algorithms
• Drug dosages and interactions
• Numerical summaries of risks and benefits
• They dont want traditional clinical practice
  guidelines

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Examples
Computerized decision support systems (CDSS)
Systems
Synopsis
Clinical Evidence
Cochrane Reviews
Syntheses
Original published articles in journals
Studies
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• Internet Available Resources
• www.cebm.utoronto.ca
• www.eboncall.co.uk

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• How To design
• 1. Learn how to recognize questions.
• 2. Learn how to quantify answers.

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• Therapeutic Effectiveness
• Pc event rate in control group
• Pt event rate in experimental group

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Pc - Pt ARD (Pc - Pt)/Pc PRD Pt/Pc RR
1 NNT Pc - Pt
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• 10 - 5 5 ARD
• (10 - 5)/10 50 RRD
• 5/10 .5 RR
• 1
• 10 - 5

20 NNT
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DIAGNOSTIC TESTS

• Sensitivity
• Specificity
• Likelihood ratios

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• LR gt 1
• LR 1
• LR lt 1

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• Read and appraise individual studies, systematic
  reviews

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• Then go to websites to see how results are
  presented.

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• Next - start a simple research project.

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Medical Consults

• What is the validity of a
• cardiac risk index in
• our patients?

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• Start slowly
• Progress will take time
• Its harder than you think