Clinical Librarians at Barnet Primary Care NHS Trust: addressing the information requirements of clinical governance

Recently, a number of government initiatives have placed an increased emphasis on the importance of health information. These include A First-Class Service: quality in the NHS1 which calls for the everyday use of evidence-based practice, and The new NHS: modern and dependable2 which introduced the concept of clinical governance. The provision of high quality information is essential to meet these requirements. Many healthcare professionals are confused by the concept of clinical governance and its effect on their day-to day practice.3,4 However, clinical governance is simply a formalized framework for assuring the quality of patient care on an individual level as well as across organizations. ‘The essence of clinical governance is the setting and monitoring of standards in delivering clinical care.’5 Clinical governance requires that treatment should be evidence-based and that the quality is assessed. It also imposes corporate accountability with chief executives of Trusts holding ultimate responsibility. Finally, there is an emphasis on continuing professional development. Each of these tenants of clinical governance implies an increased need for high quality information. In 1998/9, a survey of the existing library services at the former Barnet Community Healthcare NHS Trust was carried out. This revealed that 35% of all searches carried out by the library staff were in response to questions that were directly related to the care of patients in the Trust. It was recognized that a new model for providing access to health information was needed in order for busy clinicians to satisfy their huge demand for clinical evidence and so provide best quality care. A bid was submitted to the North Thames Postgraduate Medical and Dental Education deanery and to the North London Education Consortium for funding for a clinical librarian service. This was granted for an initial period of 2 ½ years. The project was launched in January 2000 with 1.6 clinical librarians. The clinical librarians are attached to specific multidisciplinary teams or managerial groups from across the organization. They currently serve a total of 13 teams or groups (see Table 1). Each of the teams has its own dynamic and has chosen to use the services of the clinical librarians in different ways. In some cases the clinical librarians attend ward rounds while in others they are present at referral or team meetings. In order to assess the impact of the clinical librarian service, members of teams in receipt of the service are required to complete two different questionnaires. The first is a qualitative questionnaire to assess general satisfaction with the service. The second questionnaire is circulated on a 6-monthly basis. It is designed to map changes in information usage and asks team members to estimate how often they request information for specific purposes (such as to confirm a diagnosis, select an appropriate method of treatment or for continuing professional development) and how often they use certain information resources. ‘Control’ teams have also been asked to participate in this second survey so that any developments in information usage in study teams can be compared with teams not in contact with the clinical librarians. Clinical governance imposes a corporate responsibility to provide the best possible quality of healthcare. This affects the provision of services across a Trust. On the front line, quality is assured by requiring each clinician to engage in continuing professional development and to practise evidence-based practice. It is supporting clinicians in these activities which makes up most of the work of the clinical librarians. The heart of the clinical librarian service is the provision of patient-focused information to clinicians on the selected teams to support them in practising evidence-based health care. To promote requests for and the use of information, the clinical librarians are available in the clinical setting. Depending on the team, they attend ward rounds, referral meetings, outpatient clinics, team meetings and educational meetings. They can also be contacted by telephone, fax, e-mail and mobile phone. In line with David Sackett’s6 model of information provision in the clinical setting, the clinical librarians have their own ‘evidence cart’. This comprises a laptop loaded with The Cochrane Library, embase Psychiatry, the National Research Register and assia. As this project is not based in the acute setting the laptops can also be used in conjunction with mobile phones to connect to the Internet. This allows searching of web-based information sources such as the Ovid Biomed collection of databases, again in the clinical setting as appropriate. The clinical librarians have, since the project began, responded to a wide variety of questions from team members. These have ranged from simple requests for background information on rare disorders, through calls for patient information to highly focused clinical questions on treatment, diagnosis or prognosis. The examples below represent a few of the requests made by one multidisciplinary team. Psychiatric sequelae of head injuries A patient who had experienced a marked change behaviour was seen in the outpatient department. The patient complained of feeling anxious, panicky and dependant. The history revealed an earlier head injury and the clinician wondered if this event may have been the cause of the patient’s behavioural changes. A search of the literature suggested that this may indeed have been the case and also suggested a number of suitable treatment options. Haloperidol for a patient with butterfly dystrophy During an outpatient clinic the team saw a patient who was having psychotic experience. The patient was also under the care of an ophthalmologist for her butterfly dystrophy, a rare degenerative disorder. The community psychiatric nurse asked whether or not haloperidol, an antipsychotic, could be prescribed to a patient with this condition. A search of the literature was carried out before the patient left the clinic which showed that there was no evidence that the drug should not be prescribed. Management of attention deficit hyperactivity disorder The psychiatric social worker was seeing a client whose problems included dealing with a 2-year-old child with attention deficit hyperactivity disorder (ADHD). The client had been told by the general practitioner that no therapies for this condition were suitable for such a young child. However, the social worker was convinced that the child’s condition was putting her client at risk of a relapse and asked if the clinical librarian could provide some evidence that the client could take to the GP. Although the bulk of the work of the clinical librarians is aimed at facilitating evidence-based practice with respect to the care of individual patients, there are also other areas of their work which support clinical governance. The clinical librarians contribute to a number of groups involved in implementing policy to ensure that developments are evidence-based. One such group is the Primary Care Working Party. This is a group of stakeholders including GPs, patient representatives and mental health professionals who are working towards implementing standards 2 and 3 of the government’s National Service Framework for Mental Health. A second example is the Health Development Group for Learning Disabilities which is in the process of producing evidence-based summaries on the health needs of people with learning disabilities. The role of the clinical librarian in these groups is to search for evidence and clinical guidelines on which to base local protocols, guidelines and service recommendations. This is seen as a natural extension of the role of the clinical librarian as it again ensures that patients are in receipt of best quality health care. A second tenant of clinical governance is continuing professional development (CPD) and this too is catered for by the clinical librarians. The existing library services of the organization offer a range of current awareness services aimed at helping clinicians, as well as Trust managers and other personnel, keep up to date with developments in their fields. These include a contents page service; alerts of updates on key NHS and government websites and a limited selective dissemination of information service. Through their intense contact with individual clinicians, the clinical librarians are able to provide these services on a more detailed basis and can also be pro-active in providing relevant information when it becomes available. From the start of the clinical librarian project it was realized that many clinicians felt the need for training in the different aspects of evidence-based practice. A series of workshops was devised to address this problem. The first of these was a session on formulating well-built clinical questions which introduced clinicians to including information about the patient, intervention, comparison and outcome in their questions. Following on from this hands-on workshops were offered giving basic internet training, concentrating on using high quality health-related resources, and more advanced searching skills using the Ovid Biomed collection of databases. These sessions were all offered to the teams on a multidisciplinary basis and the feedback suggested that the experience of learning with other members of the team was enjoyable and instructive in itself. The clinical librarians are now planning to offer a workshop on basic critical appraisal skills, again aimed at the whole multidisciplinary team. The formal evaluation of the clinical librarian project is still underway, however, preliminary statistical returns do shed some light on the impact of the service (see Table 2). From this we see that the total number of searches carried out by the existing library services and the clinical librarians has more than doubled since the project began. The searches carried out by the clinical librarians have not reduced the number requested from the existing library services, suggesting that the clinical librarians are meeting a previously unmet need. It is also worth pointing out that the searches carried out by the clinical librarians represent requests for information from a limited number of clinicians, whereas those carried out by the existing library services cover the whole organization. From this we assume that there is still a large need for information that remains unmet across the organization. Over the period of the clinical librarian project, many favourable comments were made about the service by those involved. ‘It has been an eye-opener to evidence-based medicine to me. It provides an immediate source of information when one is stuck with a clinical problem for which the team has no immediate answers. Thus problems are not just ignored but passed on for evidence and information, there and then, at ward rounds. It also improves academic discussion in the team.’ ‘Your project works because it is a bottom-up approach rather than a top-down one.’ However, certain criticisms have been raised: ‘We need to be on the Internet here and the clinical librarian would assist with training and improving search techniques.’ ‘Having a clinical librarian is all well and good but the work generated in terms of reading and sifting begs questions about time at another level.’ Clinical librarians offer an effective way of combating some of the information needs of clinical governance. They can facilitate individual clinicians, multidisciplinary teams and organizations as a whole in providing evidence-based healthcare directly to patients as well as across services as a whole. They can also aid in keeping clinicians up-to-date by providing training and current awareness services. The clinical librarians have been well-received by all involved.