How We Incorporate Evidence Into Our Practice

I'm participating in a multisociety task force (ACCP, SCCM, ATS) to develop an approach or a guide to how to incorporate clinical evidence into clinical practice.  The task force met yesterday at the SCCM.  Part of the impetus for the group is the cantankerous point/counterpoint sort of presentations that seem to be occurring with some regularity at national meetings.  Such debates you may have seen over the use of drotrecogin alpha, the use of steroids, degree of glucose control, Hgb administration in severe sepsis, and the list goes on.  One of the things that we are addressing is our current approach to incorporating evidence, with discussion about whether, indeed, placebo-controlled, double-blind, randomized trials trump all other forms of evidence.  We approach the question of when clinical, i.e. physiologic evidence should guide a person to step outside of guidelines, or whether that is ever the case.  We talk about when retrospective evidence is adequate and when it is not.  When we should standardize and when we should not.  And I hope I have convinced others that regardless of how that choice is or was made, that outcomes must be followed, so that we can adjust our care. All of us in the collaborative face decisions every day about what evidence to follow and when and how to do so.  I hope this document and the sessions at various society meetings that will follow will make for some practical help to make those decisions.  

At the SCCM

I'm at the SCCM meeting for a few days.  Yesterday I gave a talk called "Strategies for 24-hour Coverage of Rural ICUs".  I used Kansas as a paradigm for rural states.  Did you know that approximately 51% of our population lies outside the counties of Sedgwick, Shawnee, Wyandotte, and Johnson.  That's of interest, because according to the census bureau only one in four Americans lives in a rural area.  I did a quick poll at the beginning of the talk to see how many people in the room had grown up in a town of 25,000 or smaller.  In keeping with national census data, about 25 % of the room raised their hands.  I then asked how many people (critical care specialists) live or work in towns of that size today.  Far fewer hands.  Statistics show that 10% of physicians live or work in rural areas, vs. 25% of the population liiving there.  Of the critical care physicians in our state, my count shows about 10% outside of the major metropolitan counties, though the number fluctuates over time.  One can easily see that the possibilities for 24-hour intensivist coverage are limited.  I'm planning to do this talk for our meeting on January 14, so that we can discuss our options and what we're already doing to ensure that midwesterners all receive the highest quality critical care services.