Implementation of evidence base into clinical practice in UK intensive care units

Abstract

Inhaled nitric oxide has been used in UK clinical practice for a number of years and was widely used in the management of ARDS despite the lack of available evidence of benefit to support this practice. Current practice was surveyed in 1996 and this lead to the development of clinical practice guidelines based on best available evidence and was intended to encourage safe practice whilst awaiting evidence of benefit.1 Randomized controlled trials regarding the use of inhaled nitric oxide in ARDS followed providing an ideal opportunity to study the implementation of clinical guidelines based on evolving evidence. We surveyed the respondents to our previous survey and asked questions regarding current clinical use of inhaled nitric oxide, knowledge and views on the UK guidelines for inhaled nitric oxide treatment and knowledge and views of current evidence. We received a 60% reply rate from 50 questionnaires. Of these, 76% stated that they still used inhaled nitric oxide. Ninety-one per cent of respondents still used inhaled nitric oxide for ARDS and 54% for other indications. In terms of severity of ARDS, only 36% followed UK guidelines. Regarding dosage, monitoring and delivery, all units administered inhaled nitric oxide according to the guidelines with the exception of scavenging and methaemoglobin measurement. Many units stated that inhaled nitric oxide was only being used for severe ARDS which was non-responsive to conventional therapies. A similar number of patients had received inhaled nitric oxide this year as in 1996. The vast majority of units (86%) were aware of the UK guidelines but only 62% followed them and 71% felt that production of guidelines was appropriate. Of the units still using inhaled nitric oxide, 14% were not aware of the two major randomized trials that gave evidence on the use of inhaled nitric oxide in ARDS. Of the units that were aware of these studies, 64% of units felt that the results were either equivocal or not supportive of the use of inhaled nitric oxide in ARDS. Fifty per cent of these units continued to use inhaled nitric oxide. The majority of units (80%) felt that further evidence was required and only 28% felt that inhaled nitric oxide should no longer be used in the management of ARDS. All surveyed units also used other unproven therapies in the management of ARDS. Inhaled nitric oxide is still widely used in adult ICUs predominantly in line with UK guidelines. Encouragingly, most users were aware of UK guidelines for inhaled nitric oxide in adult ICU and claimed to follow them. Over 70% felt that clinical practice guidelines were appropriate to allow the safe use of an unlicensed therapy. This suggests that consensus guidelines could be put to use in other areas of clinical practice. Most units are aware of the major studies of inhaled nitric oxide in ARDS and the majority believe that the evidence does not support its use. Despite this, use of this therapy continues. This is not unique to the use of nitric oxide since other unproven therapies are used in the management of ARDS. This suggests that much of current clinical practice is not evidence based.