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Evidence-based Medicine

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Researchers identify practices to prevent problems arising from health care

As one element of a multifaceted response to concerns about patient safety and the risks inherent in medical care, the Agency for Healthcare Research and Quality commissioned the University of California, San Francisco-Stanford University Evidence-based Practice Center (EPC) to develop a compendium of evidence-based patient safety practices. The EPC researchers produced an evidence report that identifies 83 health care safety practices supported by 70 systematic research reviews and 293 additional primary studies.

The EPC defined patient safety practice as a type of process or structure to reduce the probability of adverse events resulting from health care rather than to reduce "medical errors" per se. Safety practices such as computerized physician order entry and strategies to prevent falls among hospitalized elderly patients were based on demonstrated evidence of effectiveness and safety.

Two recent journal articles focus on the EPC's work in this area. The first article describes the methodology used by the EPC in developing the report and discusses some of the pros and cons of applying the principles of evidence-based medicine to patient safety practices. The second article discusses measures that can be taken to reduce the incidence of catheter-related infections in intensive care unit (ICU) patients.

The journal articles are briefly summarized here. Select to access the evidence report, Making Health Care Safe: A Critical Analysis of Patient Safety Practices.

The AHRQ Evidence Report/Technology Assessment No. 43 (AHRQ Publication No. 01-E058) and a summary (AHRQ Publication No. 01-E057b) are also available from the AHRQ Publications Clearinghouse.

Shojania, K.G., Duncan, B.W., McDonald, K., and Wachter, R.M. (2002, July 24). "Safe but sound: Patient safety meets evidence-based medicine." (AHRQ contract 290-97-0013). Journal of the American Medical Association 288(4), pp. 508-513.

The patient safety evidence report, which contains concise summaries of the evidence supporting more than 80 safety practices and a description of the methods employed in developing the report, has generated a substantial amount of attention. More than 500,000 copies have been ordered or downloaded from AHRQ's Web site.

In this article, researchers from the UCSF-Stanford EPC respond to some of the questions and controversies that have emerged following publication of the report. They discuss the definition of patient safety used in developing the report, identify the patient safety practices included in the review, explain how the principles of evidence-based medicine were applied to the patient safety literature, and respond to some of the concerns raised by several experts in the fields of patient safety and quality improvement.

Saint, S., Savel, R.H., and Matthay, M.A. (2002). "Enhancing the safety of critically ill patients by reducing urinary and central venous catheter-related infections." (Based in part on work performed for AHRQ under contract 290-97-0013). American Journal of Respiratory and Critical Care Medicine 165, pp. 1475-1479.

Indwelling urinary and central venous catheters (CVCs), commonly used in critically ill patients, are a major source of hospital-induced (nosocomial) infections in ICUs. These infections jeopardize patient safety and lead to unnecessary health care costs.

The EPC researchers identified several proven methods to reduce the incidence of catheter-related infections. For example, use of silver alloy urinary catheters may reduce nosocomial urinary tract infection among critically ill patients. Catheters coated with antibacterial substances other than silver also have been evaluated but to a much lesser extent. Urinary catheters of any type should be discontinued as soon as catheterization is no longer required, aseptic techniques should be used to insert and manage the catheter, and the drainage system should be manipulated as infrequently as possible.

Controlled trials of CVC infections suggest that routine changes of central venous and systemic arterial catheters do not reduce bloodstream infections and appear unnecessary. Also, use of maximum sterile barriers during CVC insertion, including sterile gloves, long-sleeved gowns, and full-size drape, as well as a nonsterile mask and often a nonsterile cap, dramatically reduce CVC infections compared with the usual practice of using only sterile gloves and a sterile small drape. The studies also recommend use of CVCs coated with antimicrobial agents in high-risk patients requiring short-term (2-20 days) catheterization; use of chlorhexidine gluconate (CHG) as the antiseptic to be applied to the skin at the CVC insertion site; and avoidance of unnecessarily prolonged catheterization and catheterization of the femoral vein.

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