圖書館結合實證醫學 EBM integrated Library 台北醫學大學．市立萬芳醫院 圖書館結合實證醫學 EBM integrated Library  第三十屆醫學圖書館工作人員研討會 時間： 2008 9/19 1:30-2:30 地點：Section A 會議廳 陳杰峰 Chiehfeng Chen 台灣實證醫學會秘書長 台北醫學大學市立萬芳醫院 實證醫學中心 整形外科  clifchen@tmu.edu.tw http://www.wanfang.gov.tw/ebm  

圖書館結合實證醫學 圖書館是學術機構的核心組織，肩負了管理知識的重任。 而實證醫學可以說是醫學知識管理的B2B(bench to bed)流程，也就是從臨床研究報告(bench)，經由整理的過程而應用於臨床病患照顧上(bed)，其最終目的就是造成健康快樂的病人。 這個過程可以描繪成一個實證醫學的知識轉譯地圖。

知識轉譯 Knowledge Translation Knowledge Translation (or KT) can be used as a noun or a verb: it describes either a structured process or the activity that results in scientifically researched evidence being used to improve the outcomes of professional practice. http://en.wikipedia.org/wiki/Knowledge_translation

實證醫學之知識轉譯地圖 --from bench to bed (“B2B” : “5S” , “7A”) 7A 5S Modify from “Straus et al.: Evidence-based medicine, Elsevier Ltd., 2005” Systems Summaries Synopses Syntheses Studies 注意到>接受>可行>有能力做>開始做>認同>養成習慣 Aware Accepted Applicable Able Acted on Agreed Adhered to Unsound Research Sound Research 7A 5S

Evolving role of librarian Hospital library Clinical librarian Academic library Librarian in university

Clinical librarian Sargeant SJ, Harrison J. Clinical librarianship in the UK: temporary trend or permanent profession? Part I: a review of the role of the clinical librarian.Health Info Libr J. 2004 Sep;21(3):173-81.

Seven main core duties attendance at ward rounds; attendance at case conferences; attendance at other clinical meetings (eg. informal discussions, case conferences; clinical guideline development; information searching; information evaluation; service promotion. Sargeant SJ, Harrison J. Clinical librarianship in the UK: temporary trend or permanent profession? Part I: a review of the role of the clinical librarian.Health Info Libr J. 2004 Sep;21(3):173-81.

Sargeant SJ, Harrison J. Clinical librarianship in the UK: temporary trend or permanent profession? Part I: a review of the role of the clinical librarian.Health Info Libr J. 2004 Sep;21(3):173-81.

Sargeant SJ, Harrison J. Clinical librarianship in the UK: temporary trend or permanent profession? Part I: a review of the role of the clinical librarian.Health Info Libr J. 2004 Sep;21(3):173-81.

willingness to ask questions; What professional and personal qualities are required to become a Clinical Librarian? the ability to build and maintain good professional relationships with the clinicians; willingness to ask questions; the ability to learn, understand and take pleasure in learning; a natural interest in clinical and scientific issues. Harrison J, Sargeant SJ.Clinical librarianship in the UK: temporary trend or permanent profession? Part II: present challenges and future opportunities.Health Info Libr J. 2004 Dec;21(4):220-6.

Knowledge required for the role of Clinical Librarians was considered to be: Some (unspecified) knowledge of anatomy and physiology; origins and meanings of medical terms; project management; literature-searching experience; knowledge of evidence-based practice; research methods (both quantitative and qualitative); epidemiology.. Harrison J, Sargeant SJ.Clinical librarianship in the UK: temporary trend or permanent profession? Part II: present challenges and future opportunities.Health Info Libr J. 2004 Dec;21(4):220-6.

Working in the clinical setting? all of the CLs reported working in ways that could be readily identified as traditional Librarians undertaking all of the following tasks: to assist in the development of clinical guidelines; researching previous and existing clinical guidelines; conducting intensive literature searches; creating a database of clinical questions to include examples of clinical questions for which high-grade evidence had been found; to answer enquiries promptly within an appropriate time frame for the user; user education and training. Harrison J, Sargeant SJ.Clinical librarianship in the UK: temporary trend or permanent profession? Part II: present challenges and future opportunities.Health Info Libr J. 2004 Dec;21(4):220-6.

Linda Ward, A survey of UK clinical librarianship: February 2004, Health Information and Libraries Journal, 22, pp.26–34, 2005

Linda Ward, A survey of UK clinical librarianship: February 2004, Health Information and Libraries Journal, 22, pp.26–34, 2005

Linda Ward, A survey of UK clinical librarianship: February 2004, Health Information and Libraries Journal, 22, pp.26–34, 2005

Linda Ward, A survey of UK clinical librarianship: February 2004, Health Information and Libraries Journal, 22, pp.26–34, 2005

marketing initiatives Some generalized statements can be derived from data about marketing initiatives: personal contacts work well, putting a name to a face; being in the clinical setting, CLs can begin to understand the jargon used; time is important, both in recognizing that health professionals have limited time (e.g. for drop-in sessions) and also managing the timing of marketing approaches. Linda Ward, A survey of UK clinical librarianship: February 2004, Health Information and Libraries Journal, 22, pp.26–34, 2005

Seven main core duties attendance at ward rounds; attendance at case conferences; attendance at other clinical meetings (eg. informal discussions, case conferences; clinical guideline development; information searching; information evaluation; service promotion. Sargeant SJ, Harrison J. Clinical librarianship in the UK: temporary trend or permanent profession? Part I: a review of the role of the clinical librarian.Health Info Libr J. 2004 Sep;21(3):173-81.

大衛的證據車 Evidence Cart Dave Sackett -CEBM - Centre for Evidence Based Medicine Dave Sackett

Mobile CDSS 行動資訊車

Seven main core duties attendance at ward rounds; attendance at case conferences; attendance at other clinical meetings (eg. informal discussions, case conferences; clinical guideline development; information searching; information evaluation; service promotion. Sargeant SJ, Harrison J. Clinical librarianship in the UK: temporary trend or permanent profession? Part I: a review of the role of the clinical librarian.Health Info Libr J. 2004 Sep;21(3):173-81.

實證醫學活動 全院學術活動 e-learning課程 文獻導讀 專家演講 研討會

seven main core duties attendance at ward rounds; attendance at case conferences; attendance at other clinical meetings (eg. informal discussions, case conferences; clinical guideline development; information searching; information evaluation; service promotion. Sargeant SJ, Harrison J. Clinical librarianship in the UK: temporary trend or permanent profession? Part I: a review of the role of the clinical librarian.Health Info Libr J. 2004 Sep;21(3):173-81.

實施實證醫學五大步驟 1. 整理出一個可以回答的問題 (Asking an answerable question) 2.尋找文獻證據 (Tracking down the best evidence) 3.嚴格評讀文獻 (Critical appraisal ) 4.應用於病人身上 (Integrating the appraisal with clinical expertise & patients’ preference) 5.對過程進行稽核 (Auditing performance in step 1-4) Gap 1 Gap 2

品質鴻溝 2 Quality Gaps 不知 知 行 EBM Step 1,2,3 EBM Step 4,5 Gap 2: Knowing-doing gap Gap 1: Knowledge gap

臨床診療指引 （clinical practice guideline） 「一種系統化製作的陳述，用來幫助臨床工作者或是病患，在面臨特定的臨床狀況時，能做出合適的健康照護決策」 Systemically defined statements to assist practitioner and patient decisions about appropriate health care of specific circumstances. -------Institutes of Medicine, 1990

"practice guideline"[Publication Type] OR "practice guidelines as topic"[MeSH Terms] OR "practice guideline"[Text Word]

臨床指引的好處Benefits of guidelines 增進品質並降低醫療錯誤 Improve quality and reduce rates of medical error 組織大量的資料Organize massive amounts of data 減少照護時的變數Reduce variations in care 排除浪費Eliminate waste 改善對慢性病的處理 Improve management of chronic disease * What about “patient outcome”? IOM, 1990

臨床診療指引—知識轉譯的橋樑 CPG – the bridge between bench and bed 知識轉譯：一種將”科學研究證據”用以改善”專業執行成果”的活動或固定流程 Knowledge Translation (or KT)(知識轉譯) describes either a structured process or the activity that results in scientifically researched evidence being used to improve the outcomes of professional practice. http://en.wikipedia.org/wiki/Knowledge_translation

The "5S" levels of organisation of evidence from healthcare research 精要: 結合於臨床系統 結論 摘要 綜述 研究文獻 Brian Haynes, R Evid Based Med 2006;11:162-164 Haynes RB. Of studies, syntheses, synopses, summaries, and systems: the "5S" evolution of information services for evidence-based healthcare decisions. Evid Based Med. 2006 Dec;11(6):162-4. Copyright ©2006 BMJ Publishing Group Ltd.

http://www.nhi.gov.tw/webdata/AttachFiles/Attach_613_1_CPG.pdf

「實證臨床指引平台」http://ebpg.nhri.org.tw --國家衛生研究院

92-93年醫療資源耗用排序 排名 各系統下之細分類 金額(千元) 佔率 % 1 呼吸系統疾病 259,434,177 31.8% 2 腎炎、腎徵候群及慢性腎衰竭 121,481,447 14.9% 3 泌尿系統疾病 80,633,465 9.9% 4 消化系統疾病 74,410,557 9.1% 5 心臟疾病 38,271,902 4.7% 6 腦中風 37,317,266 4.6% 7 骨骼系統疾病 28,063,852 3.4% 8 高血壓 21,195,323 2.6% 9 糖尿病 13,420,121 1.6% 10 外傷 8,053,462 1.0% 資料來源:92-93年全民健保資料庫

國內臨床照顧指南 各醫院有對各疾病編製之臨床照顧指南或流程 國內尚有其他臨床治療指引如： 高血壓防治手冊 高血脂防治手冊 全民健保降血脂藥物給付規定(高血脂) 癌症共識手冊(子宮頸癌、口腔癌、肺癌、大腸直腸癌、胃癌、攝護腺前列腺癌、鼻咽癌等 )

Bench Marks from our neighbourhood －example of CPG development Keeping up with the Joneses! Bench Marks from our neighbourhood －example of CPG development

日本發展經驗_以CPG為例 由日本醫療機能評價機構(JCQHC)主導,並於2002年4月建置”Minds醫療資訊交換平台”

35 CPGs on Minds

Guidelines International Network (G-I-N) 成立於2002年，著重於推廣實證臨床指引之發展與應用。 現有32個國家、76個指引發展相關組織加入GIN。 我國國家衛生研究院衛生政策研發中心於95年底以台灣代表申請加入，繼香港、日本、馬來西亞後，為亞洲地區第四個加入之國家。                                               

G-I-N 2007 70 organizations from 36 countries 400+ participants 6 plenary sessions Parallel session up to 7 tracks progressing at the same time.

實證指引公司

Seven main core duties attendance at ward rounds; attendance at case conferences; attendance at other clinical meetings (eg. informal discussions, case conferences; clinical guideline development; information searching; information evaluation; service promotion. Sargeant SJ, Harrison J. Clinical librarianship in the UK: temporary trend or permanent profession? Part I: a review of the role of the clinical librarian.Health Info Libr J. 2004 Sep;21(3):173-81.

2nd step After the discussion Homework: Cubby Review the case on the website Review previous established flow charts Discuss with the clinician

考古題 王先生，一80歲男性，因右足踝有4公分直徑的傷口，家人陪伴下，步行到門診求診。病人呼吸急促，傷口周圍紅腫，被安排住院進一步治療。 王先生已有30年的糖尿病史，主要以飲食控制。他有高血壓病史，固定服藥中。此外，還有有眩暈(vertigo, dizziness)的問題，已經一年多了。 這次的傷口，剛開始是因為4個月前一次跌倒造成的，傷口一直到這次住院都沒有好，平常是在診所定期換藥。 4個月前跌倒是因為在家中昏迷，30分鐘後自己醒來。之後，有到神經內科檢查，頸動脈超音波顯示頸動脈有輕微粥狀硬化。 這次住院後即開始呼吸急促，胸部X光檢查顯示有肺積水的問題，即掛上氧氣面罩治療。血液檢驗數據顯示白血球　WBC 19400 (x10^3/ul ) 偏高，血糖值為　572 (mg/dl )，糖化血色素(Glycated hemoglobin, HbA1c)11%　。立即用靜脈注射抗生素控制感染，抗生素是Augmentin (amoxicillin and clavulanate potassium) 每６個小時打一支。 每天四次，餐前及睡前施打胰島素HRI 　8U，以降低血糖。住院當日，病人於半夜起床上廁所時，自己跌倒，膝蓋瘀青。 隔天上午，檢驗數據顯示白血球　WBC　22100(x10^3/ul ) 仍然偏高，　血糖值　270(mg/dl )　。經感染科建議後，將抗生素改為TIENAM (imipenem and cilastatin sodium)每６個小時打一支。 當天晚餐前，打胰島素HRI 8U後，尚未進食，家人發現病人昏迷，插管急救後使用呼吸器，並轉入加護病房。

為何要搜尋? 完整研究臨床問題。(doer) 快速回答臨床問題。(user) 既完整，又快速？ To answer a specific question •Systematic investigation into and study of materials and sources in order to establish facts and reach new conclusions.

實證醫學—問題日誌 編譯: 萬芳醫院 EBM Center 2007

問題日誌案例 CVP放置7天一定要換嗎?

使用MeSH標題比對查詢 可以協助找出精確符合主題的資料 無須煩惱因縮寫、別名而遺漏相關文獻 使用同義詞也可準確查詢出相關文獻資料 使用MeSH Tree 可以依需求擴展或縮小查詢範圍 了解各醫學標題的橫向與縱向關聯 MeSH Tree可顯示標題間分類的層級關係。最上層顯示者，表示該標題詞所代表的主題意涵較廣（generic），而愈下層顯示者，則表示所代表的主題意涵愈為特異（specific）。 57 57

Clinical bottom line Pulmonary and peripheral artery catheters need not be routinely replaced more often than every 5–7 days Other short-term CVCs and arterial catheters need not be routinely replaced Safdar N, Kluger DM, Maki DG. A review of risk factors for catheter-related bloodstream infection caused by percutaneously inserted, noncuffed central venous catheters: implications for preventive strategies. Medicine (Baltimore). 2002 Nov;81(6):466-79.

reference Safdar N, Kluger DM, Maki DG. A review of risk factors for catheter-related bloodstream infection caused by percutaneously inserted, noncuffed central venous catheters: implications for preventive strategies. Medicine (Baltimore). 2002 Nov;81(6):466-79. Single citation matcher (PubMed)

appraisal Level Ib

action Action的空白頁留給大家填…

誰搜尋? To answer a specific question •Systematic investigation into and study of materials and sources in order to establish facts and reach new conclusions.

“Doer” or “User” Doer ?% of us are “Users” only. Clinical trial (重工業) Systematic review (輕工業) Guideline development ?% of us are “Users” only. U D

When systematic reviews are not availability clinicians need efficient strategies for identifying relevant research Systematic Review Steps ． Answerable Question ．Search ++++ ．Appraise × 2 ．Synthesize Apply Time ：6 months EBM Steps ．Answerable Question ．Search ．Appraise Apply Time ：6 minutes 摘錄自Paul Glasziou ‘s lecture, 2006

知識更新之分類

文獻搜尋 一級文獻(primary literature ) 二級文獻(secondary literature) 先找二級文獻再找原著 原始研究(original research ) 臨床發現(clinical findings) 二級文獻(secondary literature) 系統性回顧(systematic reviews) 統合分析(meta-analyses) 文獻回顧(reviews of individual articles) 先找二級文獻再找原著

搜尋 關鍵字 key words 搜尋策略 top down RCT Case-Control Case Reports Opinions 隨機對照試驗

尋找資料: 操作策略 Usefulness 效益 = relevance 關聯 x validity 效力 work 工作 Slawson, 1994

How EBM Helps CME? 「灌輸」(push) :「以防萬一(備用)」學習法(“just in case” learning) Who push? 半推半就 「汲取」(pull): 「恰如其時(即時)」學習法(“just in time” learning) Who pull? 弱水三千

Seven main core duties attendance at ward rounds; attendance at case conferences; attendance at other clinical meetings (eg. informal discussions, case conferences; clinical guideline development; information searching; information evaluation; service promotion. Sargeant SJ, Harrison J. Clinical librarianship in the UK: temporary trend or permanent profession? Part I: a review of the role of the clinical librarian.Health Info Libr J. 2004 Sep;21(3):173-81.

進行實證醫學的授課時，我們更感受到講授式的教學方式成效有限，根據「學習金字塔」理論(圖一)[2]得知，對成人而言，從講授式教學所獲得的長期成效，可能只剩下5%；相反地若以實際操作的方式學習，則成效可高達75%-90%，因此本研究設計一以實際操作為主的教學模式，對講求理論和實務並重的臨床醫學而言，實有其必要性。 [2] Wood EJ: Problem-based learning: exploiting knowledge of how people learning to promote effective learning. BEE-j 2002.3:3-5.

Learning pyramid 學習金字塔 （NTL, 1960’s）

實證醫學環境-電子教室 人體工學下沉式顯示器 螢幕切換器

Clinical Epidemiology - 臨床流行病學 Dave Sackett

實證醫學:臨床實踐與教學指引(Evidence-Based Medicine: How to Practice and Teach EBM with CD-ROM 3/e) 出版者 : 合記 出版年代 : 2007

Six factors influence the uptake of innovations 在設計「基於實證醫學的專業執行」之學習環境時，創新的擴散六要項： （1）相對優勢（relative benefit） （2）複雜性（complexity） （3）可試驗性（trial ability） （4）可觀察性（observability） （5）相容性（compatibility） （6）再發明（reinvention） Rogers EM. Diffusion of Innovations. 5th ed. New York: Free Press; 2003.

創新的擴散六要項 （1）相對優勢（relative benefit）、（2）複雜性（complexity）、（3）可試驗性（trial ability）、（4）可觀察性（observability）、（5）相容性（compatibility）、（6）再發明（reinvention）。 Cochrane review已進入SCI，並且自2008.6起，將有Impact Factor （1）。讓實證醫學的工具可以在網路上容易取得，並且在有趣的環境中試用（3），不要讓使用者覺得太複雜（2）；讓中文的環境中，有豐富的實證醫學應用文獻，隨時可觀察（4）；例如早期實證醫學將專家意見放在證據等級的最底層level 5，容易讓人誤解為專家意見是不具參考價值的，這種說法，和華人敬老尊賢的文化有出入（5），有可能阻礙了原本實證醫學要傳達的訊息。因此，若要讓EBM這項創新，能在我們的社會中擴散，應該經由醫界充分討論，融入醫療環境考量，產生本土的EBM論述，這也是一種再發明（6）。 Rogers EM. Diffusion of Innovations. 5th ed. New York: Free Press; 2003.

Seven main core duties attendance at ward rounds; attendance at case conferences; attendance at other clinical meetings (eg. informal discussions, case conferences; clinical guideline development; information searching; information evaluation; service promotion. Sargeant SJ, Harrison J. Clinical librarianship in the UK: temporary trend or permanent profession? Part I: a review of the role of the clinical librarian.Health Info Libr J. 2004 Sep;21(3):173-81.

Where are we? 注意到>接收到>可行>有能力做>開始做>認同>養成習慣 精要 摘要 文獻 --Sharon S, EBM: How to teach and practice EBM?, p.9, 2005

延伸學習– www.cebm.net

陳杰峰醫師@ 萬芳醫院 clifchen@ms1.hinet.net 謝謝聆聽 Thank You !!! 歡迎加入台灣實證醫學學會! 陳杰峰醫師@ 萬芳醫院 clifchen@ms1.hinet.net