Definition and relevance of evidence based medicine

Question 17 from the first paper of 2012 (and to a lesser extent Question 2b from the first paper of 2001) ask the candidate to define "evidence-based medicine". David Sackett, a great pioneer of EBM, came up with a definition which seems to be frequently quoted, and therefore probably meets with the approval of the CICM examiners (in fact they essentially repeated it in Question 2b):

"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."

LITFL identifies five steps in the application of evidence-based medicine:

1. Ask an answerable question

• The PICO format is offered as a question structure:
  • Patient group
  • Intervention
  • Comparison
  • Outcome

2. Systematically retrieve the best evidence
3. Critically appraise the evidence for validity, clinical relevance, and applicability
4. Make a clinical decision on the basis of the evidence
5. Audit the performance of the decisions thus made

Advantages of EBM

• Improves critical appraisal skills
• Leads to the abandonment of unhelpful practices
• Makes the process of decisionmaking transparent to patiens and colleagues
• Leads to a better appreciation of uncertainty in clinical practice

Disadvantages of EBM

• Sometimes, impossible
• Time consuming and expensive
• Excessively rigorous criteria may lead to useful papers being disregarded
• Evidence can be misapplied
• Evidence is frequently out of date
• RCTs are treated as a gold standard, whereas in some settings other study designs may be more appropriate

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