Defining the standards and establishing the protocols for the audit

One of the best starting points for EBVM is in designing practice-wide protocols rather than trying to ensure that every vet is practicing EBVM in every instance. Protocols covering subjects such as antibiotic use, or routine parasite control and prevention, are generally straightforward to design and implement. A protocol may also be part of a diagnostic plan (e.g. the clinical question could be ‘Does implementation of routine testing for this disease in this animal presenting with certain signs reduce complications or recurrence following diagnosis?’).

Ideally, there would be an evidence base available that could inform the protocols you are assessing, and that evidence base would include practice-specific factors (e.g. local resistance patterns, demographics of the client/patient population). However, in many areas, protocols may lack high level evidence for some or all parts. A number of examples exist for this: use of Tissue Plasminogen Activator in pleuropneumonia in horses, use of nutraceuticals in a number of species, incorporation of physiotherapy into patient management and even anthelmintic protocols in small animals!

These knowledge gaps do not, however, preclude you from setting up protocols based on the best evidence available, but they should prompt you to enter into assessment/audit cycles fully aware that you might not have all the measures by which to evaluate your protocols.  This approach might make you more considerate of ensuring your specific protocol is achieving what you hoped it would.

Example Scenario 1: Dry cow therapy

Rachel has just returned from a conference where a drug company stand offering a constant supply of amazing chocolates, as well as freebie merchandise, has convinced her of the merits of a new dry cow therapy. Furthermore, she has gone to the effort of using EBVM in asking whether this therapy will work in prevention of mastitis on her farms, and at a recent clinical rounds has presented the veterinary team at her clinic with an appraisal of the literature which looks supportive of this new therapy. Rachel has been approved by the partners at her clinic to go ahead with trialling this new therapy on interested farms where she thinks it will be most effective, as long as she audits the results.

In order to spread the word about this new therapy, Rachel establishes a new protocol for dry cow therapy, using the new product, which includes the types of farms where the new therapy is likely to be most effective. She then circulates her protocol to the other practice veterinarians so that they are aware of the new therapy and the evidence behind its use. Rachel also develops a data collection sheet that she and other vets can use to audit the use of this new therapy and compare new dry period infection rates on farms using the new therapy, with historical dry period infection rates when other therapies have been used.

Rachel defines a standard and sets a protocol: Farms with a certain known pathogen profile causing dry period infections are recommended to use the new dry cow therapy on selected cows in accordance with a set protocol.

Example Scenario 2: Small animal dental imaging

Tom has just recently performed a Knowledge Summary for his practice that has demonstrated that high definition computed radiography in dogs and cats has diagnostic capability for periodontal disease that is superior to visual examination.

On the basis of this evidence, and because of the potential to improve animal welfare by reducing additional visits or prolonged morbidity associated with undiagnosed disease, the partners have just invested in dental radiography. Tom now wants to establish and demonstrate to the partners that this has been a good investment and that it has improved animal welfare.

Tom defines a standard and sets a protocol: All dogs and cats presented for dental treatment will have survey radiographs of the mouth and, where appropriate, diseased teeth will be removed.