Evidence-based practice: DipIMC practice questions

Answer: E

Project 1 is clinical audit; Project 2 is research

HQIP defines clinical audit as a quality improvement cycle that measures the effectiveness of healthcare against agreed and proven standards and takes action to bring practice in line with them. Clinical audit tells us whether we are doing what we should be doing and how well; research is about obtaining new knowledge and finding out which treatments are the most effective. Project 1 has an explicit standard (tranexamic acid within three hours, as the trust guideline requires), measures compliance and feeds back to change practice — the audit cycle. Project 2 randomises patients between two regimens to find out which works better — research by definition, however routine the setting. Neither is service evaluation. Using routinely collected data, or intending to present the results, does not change the classification; the purpose of the project does. The distinction has consequences: HQIP notes that, unlike research, clinical audit does not need research ethics committee approval, and the ABC points out that consent for clinical trials is governed by legislation, with provision in emergencies for assent and later full consent.

Answer: A

It rests directly on level IV evidence (expert opinion) or is extrapolated from I–III

The FPHC penetrating neck injury statement grades its recommendations on a conventional hierarchy (Shekelle et al.): level I is randomised trial evidence (Ia systematic reviews or meta-analyses of randomised controlled trials (RCTs); Ib at least one RCT); level II controlled studies without randomisation or other quasi-experimental designs; level III non-experimental descriptive studies such as comparative, correlation and case-control studies; level IV expert committee reports, opinions or the clinical experience of respected authorities. Grade A is based on level I evidence; B on level II or extrapolated from level I; C on level III or extrapolated from levels I or II; and D is directly based on level IV evidence or extrapolated from levels I, II or III. So the RCT, quasi-experimental and descriptive-study options describe grades A, B and C respectively. Grade D describes the kind of evidence available, not that the advice is unsupported or optional. For penetrating neck injury, where trials do not exist, the Faculty used a three-round e-Delphi; consensus was set at 70% and all proposed statements achieved it, so no recommendation was included on a minority vote. A clinician who departs from a Grade D consensus needs a reason; one who ignores it because it is Grade D has misunderstood the grade.