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There is a certain irony to libraries in hospitals being closed at a time when the value and impact of evidence-based information for patient care is increasingly being recognized [1, 2]. Between 1989 and 2006, it is estimated that between 36% and 44% of hospital libraries closed . The closures may have resulted from the dilution of relevant hospital library standards by the Joint Commission for the Accreditation of Healthcare Organizations. As an example, the 1999 accreditation manual included three “Knowledge-based information” (KBI) standards . The first required that hospitals provide “systems, resources and services to meet KBI needs in patient care, education, research and management.” The intent section elaborated that this could be met by an on-site library, a qualified medical librarian, or a cooperative arrangement for their provision. By 2009, all that remained was one standard requiring access to KBI. Without the provision for a library or librarian, any “current and authoritative” website could suffice . The dilution of Joint Commission standards appears to sanction reducing the level of knowledge required in hospitals. There is not enough evidence to establish a causal relationship between the revised standards and the closure of hospital libraries, but the trends coincide. Pressures that diminish the availability of information conflict with the rising absolute need for more knowledge.
Consider this: In the course of any single day, approximately 95,616 patients are hospitalized in the United States . Insurance providers record the number of tests, surgery, and drugs administered to these patients, but no one measures the level of knowledge brought to their care. The need for information to support patient care has been documented: Research shows that 2 questions arise for every 3 patients in office practice  and an average of 5 questions arise per patient encounter in academic medical settings . These questions may go unanswered. Studies report that physicians pursue answers to only 36%–55% of questions raised about patients' care [9, 10]. Unanswered questions, or even unasked questions, may lead to poorer medical care. The Institute of Medicine estimates that as many as 98,000 Americans die each year from preventable medical errors . With 95,616 patients in the hospital any given day, an average of 5 questions per patient encounter in academic settings, and at most only 55% of these questions being pursued, that leaves at least 215,136 questions a day going unanswered. No wonder health care errors have become a national crisis and remain at an unacceptable level . In the face of rising errors and accumulating knowledge, finding time to sort through the literature to find answers to specific patient questions is crucial to quality patient care. Clinicians are hard pressed to find the time to answer these care questions. Yet the one staff person whose job it is to answer them, the librarian, is no longer a requirement.
Evidence-based medicine is not without controversy: Ill-advised advocates for “evidence-free,” also known as “logical,” medicine have surfaced. Proponents of evidence-free medicine say it allows the “incorporation of a variety of facts and warrants, reasons and reasoning, into clinical decisions. Forgoing evidence allows clinical medicine to once again be a personal and prudential undertaking, arising from and focused on the individual patient” . Evidence-free medicine may be a reaction to the evidence-challenged environment of hospitals deregulated from having access to a librarian or library. It is wise not to need what you do not have. Without the assistance of a qualified librarian and support for a collection, there is no one to call for searches and no journal subscriptions if an article is needed. The conflict between weakening information requirements on the one hand and increasing need for information resources on the other may result in diminishing availability of quality care. Who would really want to be treated at a hospital lacking an information base?
Reactions to the eroding knowledge core are mounting. The following developments illustrate the pressures for change and the opportunities they create for librarians:
Increasingly, the “science” in “library science” itself is growing. The Evidence-based Library and Information Practice journal attests to the growing amount of science supporting information practice . As librarians, we must advance and embrace the structure underlying good information retrieval and audit trails documenting a quality search. Accountability for the results only increases the value of the search and searcher.
Hopefully, someday institutions will score their “information readiness” in order to quantify the information resources available for the care of individual patients. The information readiness score might be akin to designations like the “most-wired” status for hospitals  or hierarchy levels for trauma centers . The availability of search design assistance or search performance by a qualified information professional, timeliness of article delivery, currency and depth of the literature collection, number of hours of onsite access, and number of licensed databases might factor into the level of information readiness. Hospital staff may note in the EHR the level of evidence used in decision making and the consultant who conducted the search. Institutions may come to boast about the level of knowledge available for patient care, while the time to diffusion and use of knowledge at the bedside may shorten.
Many are quick to tout the broad-based searching of Google as the answer to “searching” in medicine. Searching and finding are two different things. Science has determined that multiple databases need to be searched for adequate coverage  and that Google Scholar lags behind academic databases for timeliness . When it comes to searching versus finding, librarians have a privileged position . The librarian has the combination of time, technique, and training, plus the expertise, to find the needed information. There is a subtle shift in the literature to valuing who is the searcher, paying attention to what they are searching, and determining the level of evidence of the retrieval. An article in the journal Chest recommends that “a professional information specialist should be engaged” before claiming “the literature shows that…” . In time, hospitals may return to the notion that the librarian is an expert consultant who can provide evidence, maximizes the electronic database, and is an essential component in quality care. These hospitals' patients would not be the first people to owe their lives to a librarian .
The author thanks Peter J. Fedyshin and Carla J. Funk, CAE, for reviewing the manuscript.
*Adapted from Dickens C. A tale of two cities. New York, NY: Modern Library; 1996.