You have taken over the directorship of a district hospital ICU.  Part of your mandate is to establish a Quality Assurance program.

(b)  What is the relevance of Evidence Based Medicine to your patients and how will you apply this?

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College Answer

Evidence Based Medicine has been defined as the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual  patients. It is not new let alone revolutionary. Its relevance to the candidate’s practice is its ability to add to clinical experience, basic science and physiological principle.

Unfortunately an individual would be unable to review and critically assess all the literature available in all languages. Practitioners are dependent on reviews, meta-analyses and expert opinions. Many questions have yet to be answered effectively or in many cases are yet to be addressed at all. Other questions are beyond scientific assessment eg the use of no antibiotic in pneumonia. A complete appreciation  of  EBM  requires  review  of  the  literature,  audit  of  local  practice  ie techniques/management in one’s own ICU, implementation of EBM based practice and follow-up audit of results. Although not itself assessed by trials, EBM, by scientific appraisal and review, formalises an aspect of quality improvement which should be relevant to ICU practice.

Discussion

Evidence based medicine is the system of critical evaluation of published data for applicability to the management of individual patients, or something.
The college regale us with the the Sackett definition of EBM:

"Evidence based medicine is the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients. The practice of evidence based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research."

Again, one could digress extensively here, scoring virtually no marks.

Were such an essay-style question ever to return to CICM fellowship papers, one would rant creatively, using the following points as a skeleton:

Relevance of EBM to ICU practice

  • Adds to clinical experience and physiological science
  • Informs non-abstract bedside decisionmaking as well as broader department policy
  • Forms an aspect of quality improvement

"How will you apply this?"

  • Framing a question or series of questions, which are focused and answerable
  • Literature review
  • Critical appraisal of the literature
  • Audit of local practice
  • Integration into local practice
  • Audit of outcomes and refinement of implementation strategy

References

Cook, D. J., and M. K. Giacomini. "The integration of evidence based medicine and health services research in the ICU." Evaluating Critical Care. Springer Berlin Heidelberg, 2002. 185-197.

 

Kotur, P. F. "Evidence-Based Medicine in Critical Care." Intensive and Critical Care Medicine. Springer Milan, 2009. 47-57.