Core Topics in General & Emergency Surgery: Companion to Specialist Surgical Practice by Simon Paterson-Brown MBBS MPhil MS FRCS Read Free Book Online Page B

reduce the chance of error through a locally agreed protocol.
    Implementation of evidence-based medicine
    Healthcare professionals have always sought evidence on which to base their clinical practice. Unfortunately, the evidence has not always been available, reliable or explicit, and when it was available it has not been implemented immediately. James Lancaster in 1601 showed that lemon juice was effective in the treatment of scurvy, and in 1747 James Lind repeated the experiment. The British Navy did not utilise this information until 1795 and the Merchant Navy not until 1865. When implementation of research findings is delayed, ultimately the people who suffer are the patients.
    A number of different groups of people may need to be committed to the changes before they can take place with any degree of success. These include:
    • healthcare professionals (doctors, nurses, etc.);
    • healthcare providers and purchasers;
    • researchers;
    • patients and the public;
    • government (local, regional and national).
    Each of these groups has a different set of priorities. To ensure that their own requirements are met by the proposal, negotiation is required, which takes time. There are many potential barriers to the implementation of recommendations, and clinicians may become so embroiled in tradition and dogma, that they are resistant to change. They may lack knowledge of new developments or the time and resources to keep up to date with the published literature. Lack of training in a new technology, such as laparoscopic surgery or interventional radiology, may thwart their use, even when shown to be effective. Researchers may become detached from the practicalities of clinical practice and the needs of the health service and concentrate on inappropriate questions or produce impractical guidelines. Managers are subject to changes in the political climate and can easily be driven by policies and budgets. The resources available to them may be limited and not allow for the purchase of new technology, and even potentially cost-saving developments may not be introduced because of the difficulties in releasing the savings from elsewhere in the service.
    Patients and the general public can also influence the development of the healthcare offered. They are susceptible to the persuasion of the mass media and may demand the implementation of ‘miracle cures’ or fashionable investigations or treatments. Such interventions may not be practical or of any proven benefit. They can also determine the success or failure of a particular treatment. For instance, a treatment may be physically or morally unacceptable, or there may be poor compliance, especially with preventative measures such as diets, smoking cessation or exercise. All these aspects can lead to a delay in the implementation of research findings.
    Potential ways of improving this situation include the following:
    • Provision of easy and convenient access to summaries of the best evidence, electronic databases, systematic reviews and journals in a clinical setting.
    • Development of better disease management systems through mechanisms such as clinical guidelines, ICPs and electronic reminders.
    • Implementation of computerised decision-support systems.
    • Improvement of educational programmes – practitioners must be regularly and actively apprised of new evidence rather than relying on the practitioner seeking it out; passive dissemination of evidence is ineffective.
    • More effective systems to encourage patients to adhere to treatment and general healthcare advice; the information must be clear, concise, correct and actively distributed.
    There is a gap between research and practice, and there is a need for evidence about the effectiveness of different methods of implementing changes in clinical practice. The NHS Central R&D Committee set up an advisory group to look into this problem and identified 20 priorities for evaluation, as shown in Box 1.2 .