Issue
20
Evidence on the ward
round
A recent Bandolier suggested a means of bringing evidence based data to
the bedside in an acute medical unit. An "evidence-cart" was constructed that
would both contain the evidence thought to be helpful, and provide the means for
projecting and printing it. The cart had a computer and projector, had available
computerised information on previously assessed evidence of relevance to a busy medical
team, as well as Best Evidence, Cochrane Library, MEDLINE, and a pile of other useful
information.
It was taken on rounds for a month, during which a log was kept of the
ways it was used, and each team member (medical students to consultants) was asked to
complete an unannounced questionnaires about their use of evidence sources during and
after that month.
It was used 98 times during the care of 166 inpatients and 30 more
patients who were not admitted. Some evidence sources could be called up quickly enough
(10-25 seconds) to be practical on the service. Sixteen clinical questions could be
answered using the cart on the ward in the time taken for a visit to the library to answer
only one of them.
Most searches were for evidence that could affect diagnostic or treatment decisions;
the remainder concerned demonstrations of specific ausculatory findings (using a device
that allowed several team members to listen to the same stethoscope simultaneously) or
concerned issues in biology or prognosis that would affect management decisions.
Over 90% of searches were successful. Those that were not formed the
basis for "educational prescriptions" to search and appraise the evidence, and
to add it to the previously assessed in-house evidence resource.
When assessed from the perspective of the most junior team member
responsible for each patient’s evaluation and management, 37 (52%) of the successful
searches confirmed their current or tentative diagnostic or treatment plans, 18 (25%) led
to a new diagnostic skill, an additional test or a new management decision, and 16 (23%)
led to a change in a previous clinical skill, diagnostic test or treatment decision.
When the cart was removed, the perceived need for searching rose
sharply. A criticism of evidence-based medicine is that of time. We are busy, we
don’t have time to mess about with searching, or appraising, or calculating NNTs or
odds ratio.
Judiciously combining electronic evidence from a variety of sources with summaries,
reviewed and appraised, of commonly occurring problems (see CATmaker
at Oxford) can be done and
can be so useful, especially to younger doctors still collecting their experiences to add
to their education.
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MMR vaccine risks
In the last few years there have been suggestions of a link between MMR
or MR (Measles and Rubella) vaccination and the development of autism and Crohn’s
disease (an inflammatory condition of the intestine). These claims naturally worried the
parents of children who were due to have MMR vaccination.
Two important new scientific studies have found no connection between MMR or MR
vaccines and autism or Crohn’s disease. These studies represent objective scientific
work undertaken into theories about the safety of MMR and MR vaccines. Both studies
support the conclusions of earlier safety reviews carried out in 1997/1998 by independent
expert committees; the Committee on Safety of Medicines (CSM) and the Joint committee on
Vaccination and Immunisation, and the Medical Research Council.
The CSM set up a Working Party on MMR vaccine in 1998 to examine reports of children
whose parents believed that MMR or MR vaccination had caused their illness. The records of
92 children with suspected autism and 15 with suspected Crohn’s disease were examined
in detail. Parents were asked to complete a questionnaire about their child’s
condition and medical details were obtained from the GP and from at least one specialist
attending each child.
These studies represent objective scientific work undertaken into
theories about the safety of MMR and MR vaccines. Both studies support the conclusions of
earlier safety reviews carried out in 1997/1998 by independent expert committees; the
Committee on Safety of Medicines (CSM) and the Joint committee on Vaccination and
Immunisation, and the Medical Research Council.
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Advances against smoking
The British government’s action plan to reduce cigarette smoking
contains 20 initiatives, but apart from a statutory ban on advertising these rely on
persuasion rather than coercion. There are no new restrictions or bans on smoking, but an
emphasis on cessation. The main innovation announced in the white paper, Smoking Kills, is
an £60m scheme to help adults stop smoking, with one week’s free supply of nicotine
patches for people on low incomes.
Other antismoking measures target teenagers and pregnant women, against
a background of what the white paper sees as the beginning of a new upward trend in
smoking that causes 120 000 premature deaths a year and costs the NHS £1.7bn ($2.9bn).
There will be an end to advertising in the media and on billboards. Most sports
sponsorship will end by 2003, with an exemption for Formula 1 motor racing until 2006. The
government will also put £50m into a publicity campaign.
Meanwhile, the British Medical Association at their Annual
Representatives Meeting in Belfast gave an overwhelming majority vote for the banning of
smoking ‘in public places’ and a tightening up of the law against selling
cigarettes to minors. Certainly that law is widely flouted. Only 3% of 15-year-olds are
refused cigarettes and children spend £135m. on cigarettes in a year.
All EU countries that have some legislation. Advertising bans exist in
France, Portugal, Finland, Italy, and Sweden. Smoking in public places is also restricted
by law, including on public transportation and in premises used by minors and in most
enclosed and covered places open to the public. France has banned smoking on all domestic
flights of less than two hours operated by national air carriers.
Belgium, Greece, Ireland, Luxembourg, and Austria regulate tobacco
advertising, although it is still allowed. The laws have set out terms and conditions for
the advertising of tobacco products, such as the inclusion of health warnings (except in
Luxembourg) or specifications regarding the design of the ads. All five countries have
introduced laws prohibiting smoking on public transportation and in places that are
accessible to the public, such as museums, hospitals, sports centres, and cinemas. Greece
has also banned smoking on all domestic flights.
In Europe only The Netherlands has introduced a law that bans smoking
in all public areas. This ban may, however, be suspended in canteens and leisure and
waiting rooms, where permission may be given to smoke either on a third of the surface
area or for a period limited to one third of the opening hours, provided this does not
bother nonsmokers.
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