Finding and applying evidence during clinical rounds: the "evidence cart"

Abstract

Context: Physicians need easy access to evidence for clinical decisions while they care for patients but, to our knowledge, no investigators have assessed use of evidence during rounds with house staff.

Objective: To determine if it was feasible to find and apply evidence during clinical rounds, using an "evidence cart" that contains multiple sources of evidence and the means for projecting and printing them.

Design: Descriptive feasibility study of use of evidence during 1 month (April 1997) and anonymous questionnaire (May 1997).

Setting: General medicine inpatient service.

Patients: Medical students, house staff, fellows, and attending consultant.

Intervention: Evidence cart that included 2 secondary sources developed by the department (critically appraised topics [CATs] and Redbook), Best Evidence, JAMA Rational Clinical Examination series, the Cochrane Library, MEDLINE, a physical examination textbook, a radiology anatomy textbook, and a Simulscope, which allows several people to listen simultaneously to the same signs on physical examination.

Main outcome measures: Number of times sources were used, type of sources searched and success of searches, time needed to search, and whether the search affected patient care.

Results: The evidence cart was used 98 times, but could not be taken on bedside rounds because of its bulk; hard copies of several sources were taken instead. When the evidence cart was used during team rounds and student rounds, some sources could be accessed quickly enough (10.2-25.4 seconds) to be practical on our service. Of 98 searches, 79 (81%) sought evidence that could affect diagnostic and/or treatment decisions. Seventy-one (90%) of 79 searches regarding patient management were successful, and when assessed from the perspective of the most junior team members responsible for each patient's evaluation and management, 37 (52%) of the 71 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%) corrected a previous clinical skill, diagnostic test, or treatment. When the cart was removed, the perceived need for evidence rose sharply, but a search for it was carried out only 12% of the time (5 searches performed out of the 41 times evidence was needed).

Conclusions: Making evidence quickly available to clinicians on a busy medical inpatient service using an evidence cart increased the extent to which evidence was sought and incorporated into patient care decisions.