On December 30, 2019, the first bronchoalveolar samples of a novel pneumonia-causing virus (later known as SARS-CoV-2) were extracted from a patient in Wuhan Jinyintan Hospital in China.1 Three months later, on March 11, 2020, the World Health Organization upgraded the resultant condition arising from infection with the virus, corona virus disease 2019, COVID-19, from a Public Health Emergency of International Concern to a global pandemic.2 Over the past few months, we have seen approximately 210 countries and territories face the challenge that COVID-19 presents to its health care workers and citizens. The discrepancies in the response to COVID-19, particularly in relation to personal protective equipment (PPE) use for health care workers and whether it is required in the general community as a public health measure, warrant questioning. What frameworks guide policy and practice in this context? Are the PPE needs of health care workers and the public different?
For more than 20 years, the predominant framework for health care decision making has changed from expert-informed to evidence-based. Researchers and health professionals have advocated for evidence-based health care (EBHC) in practice due to increasing demands on the health care system and limited availability of resources.3 To support these demands, an entirely new research infrastructure has developed, with global networks of systematic reviewers, guideline developers, and methodologists leading the wave of EBHC in this emphasis on the evidence over expertise. The era of evidence-based practice has also seen the development of systematic review methods, with numerous and diverse methodologies available for researchers to synthesize evidence4,5 along with methods for interpreting and presenting the findings from evidence synthesis to different audiences.6,7 Teaching of EBHC is now integrated with undergraduate programs, short courses, and postgraduate degrees. However, this has created a problem. Although operational definitions of EBHC acknowledge that EBHC requires the integration of the best available evidence and understanding of the context in which EBHC is being delivered, with clinical expertise/judgment and patient preferences, education has primarily focused on the evidence rather than its balanced application to decision making.8 The research community has focused predominantly on developing methods for improving the evidence, with the emerging field of implementation science centered on application in local contexts. We believe the current lack of balance between evidence, context, expertise, and patient preferences is particularly evident during times of international crisis, and advocate for a more nuanced, balanced perspective on EBHC.
It is during such times of crisis that we should rely on our principles for practice, fully informed by the evidence, while also drawing on the tacit forms of knowledge that expert practitioners have developed, and actively working with patients in a patient-centered model of care. Evidence related to infection prevention and control of respiratory diseases such as COVID-19 indicates that hand hygiene (hand washing and hand rubbing) is a crucial factor to prevent and control the transmissions of infection.9 For patients with known or suspected respiratory infections, health professionals should wear a surgical mask when providing direct patient care and a respirator (N95 or equivalent) should be worn during high-risk situations (such as aerosol-generating procedures).10 However, every country faces its own unique set of challenges in relation to the feasibility and appropriateness of implementing evidence into practice. In low-to-middle-income countries, access to clean running water, procurement of alcohol-based hand rubbing solution, overcrowding, and a shortage of staffing are ongoing daily challenges.11 A global shortage of PPE has affected the capacity of high-income countries to provide services while also protecting the safety and well-being of staff, leading to the highest rates of infection and death among Western health professionals since World War II.
One could argue that we have left behind the empirical world of research and its certainties. Decisions by policymakers now reflect the lack of resources and uncertain, incomplete evidence, while the wide variety of models and predicted trajectories of COVID-19 have seen countries implement diverse strategies at national and local levels. Yet, it is during these difficult and challenging circumstances that we may glimpse EBHC in its purest form. Where evidence is absent, incomplete, or inconclusive during an emergent pandemic, the attributes of the individual context in which it is being delivered, clinical judgment, and patient preference are definitional aspects of EBHC that are increasingly applied. The difficult decisions faced by health professionals and policymakers relate to prioritizing the use of PPE and the reuse or extended use of masks, and determining to what extent masks should be advocated for in the wider community. These are questions the evidence does not address with certainty.
Despite the individual challenges faced, there is a sense of connectedness among the global community that should be applauded. Scientists from around the world are working together to develop vaccines, research data are being shared, international evidence synthesis organizations are rapidly synthesizing the emerging evidence to assist policymakers in making informed decisions, and many organizations are providing free access to resources to assist health professionals in delivering the best possible care. The COVID-19 pandemic is a stark reminder that evidence alone is often not enough. Collaborative partnerships among researchers, policymakers and health professionals are needed, which affirms the important role context, clinical expertise, and patient preference play in practicing EBHC.
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