Evidence-based – Searching

Karen Hutchens&

Debbie O’Reilly

Winter 2016

- Nursing- Practice- Medicine

Objectives

To understand that there is a process to systematically search the literature to find the best available evidence

To learn how to develop an answerable question using the PICO approach

To identify evidence-based practice resources and learn how to use them efficiently and effectively

What is Evidence based practice?

Evidence-based practice is the integration of the best research evidence with clinical expertise and patient values to facilitate clinical decision making.(Sackett et al., 2008 as cited in Neville & Horbatt, 2010)

Clinical Expertise

Patient Values

Best Research Evidence

EBN

What areas of nursing practice might we want to ask EBP questions about?You might ask questions about a range of categories of practice:1. Assessment – how to properly gather and interpret findings?2. Causes of the problem – how to identify them?3. Deciding what the problem is – where the symptoms/signs indicate a

range of possible problems how do you decide which is most likely? 4. How to select and interpret tests used to identify problems and to

monitor patient progress?5. How to estimate the likely clinical progression of a condition/illness and

any likely complications?6. How to select interventions that do more good than harm and that are

worth the effort and cost of doing them?7. How to reduce the chance of the problem reoccurring or how to promote

health?8. How to keep up to date; improve your skills; and run a more

effective/efficient nursing team?

What is Research in Nursing Practice?

Nursing research is research that provides evidence used to support nursing practice. Nursing, as an evidence-based area of practice, has been developing since the time of Florence Nightingale to the present day, where many nurses now work as researchers based in universities as well as in the health care setting.

4 Steps to Searching

1. Design an answerable question2. Determine the type of question that you are

posing3. Determine the type of study that will best

answer your question4. Search the literature

Designing an Answerable Question

A well-built clinical question should have 4 components. The PICO model is a helpful tool that assists you in organizing and focusing your question into a searchable query. Dividing into the PICO elements helps identify search terms/concepts to use in your search of the literature.

PICOP – population/patient/problem (among_______)I – intervention (does __________)C – comparison/control (versus _________)O – outcome (affect __________)

PICO Model P = Patient/Population

Who/age group/gender/health concernExample: for persons entering a health care facility…

I = Intervention or Exposure therapeutic./diagnostic/preventive/health care

management strategiesExample: for persons entering a health care facility, is hand

rubbing with a waterless, alcohol-based solution, …

PICO Model cont’ C = Comparison of Interest

Comparison against intervention?/more than on or no intervention

Example: for persons entering a health care facility, is hand rubbing with a waterless, alcohol-based solution, as effective as standard hand washing with antiseptic soap…

O = Outcome of Interest Desired outcome/patient affected or not affected by

interventionExample: for persons entering a health care facility, is hand

rubbing with a waterless, alcohol-based solution, as effective as standard hand washing with antiseptic soap for reducing hand contamination?

Designing an Answerable Question

Clinical scenario:Our patient is a 45-year old female who is experiencing

moderate depression. After surfing the web, she believes St. John’s Wort will cure her symptoms with less risk than conventional antidepressant medications.

P adults experiencing (moderate) depressionI St. John’s WortC antidepressantsO relief of symptoms

Clinical Question

For adult patients with moderate depression, is St. John’s Wort more effective for symptom relief than antidepressants?

PICO (TT) Model for Clinical Questions

P Patient, Population, or Problem How would I describe a group of patients similar to mine?

I Intervention, Prognostic Factor, Which main intervention, prognostic factor, or exposure am I considering?

C Comparison to intervention What is the mail alternative to compare with the intervention?

O Outcome to measure or achieve What can I hope to accomplish, measure, improve, or affect?

T What type of question asking? Therapy/Treatment, Diagnosis, Prognosis, Harm/Etiology (or “domains” in PubMed)

T Type of study you want to find What would be the best study design/methodology?

Type of Question

DiagnosisEvidence supports how to select and interpret diagnostic test, in order to confirm or exclude a diagnosis, based on their precision, accuracy safety, expense, etc.

Intervention/TherapyEvidence supports how to select treatments to offer your patients that do more good than harm and that are worth the efforts and costs of using them.

Prognosis/Predictions/Natural HistoryEvidence supports how to estimate your patient’s likely clinical course over time and anticipate likely complications of the disorder.

Etiology/HarmEvidence supports how to identify causes for disease (including its iatrogenic forms).

Type of Question

DiagnosisIs a yearly mammogram (I) more effective in detecting breast cancer (O) compared with every 3 yrs (C) in women under 50 (P)?

Intervention/TherapyIn school age children (P), what is the effect of a school-based physical activity program (I) on a reduction in the incidence of childhood obesity (O) compared with no intervention within a 1 year period (T)?

Prognosis/Predictions/Natural HistoryDoes monitoring blood glucose 4 times a day (I) improve blood glucose control (O) in people with Type 1 diabetes (P) during the first 6 months after being diagnosed with the condition (T)?

Etiology/HarmAre women 25-40 (P) who take oral contraceptives (I) at greater risk for developing blood clots (O) compared to women of the same age (P) who use IUD (C)?

Types of Questions – Examples

Are kids (P) who have obese adoptive parents (I) at increased risk for obesity (O) compared with kids (P) without obese adoptive parents (C) during the ages of five and 18 (T)?Etiology PICO QuestionIn adult patients with total hip replacements (P) how effective is PCA pain med (I) compared to prn IM pan med © in contolling post operative pain (O)?Intervention PICO QuestionIs a PKU test (I) done on two week old infants (P) more accurate in diagnosing errors in metabolism (O) compared with PKU tests done at 24 hours of age (C)?Diagnostic PICO Question

Type of Study

Type of Question/Domain Type of Study/MethodologyTherapy/Treatment Double-Blind Randomized

Controlled Trial; Systematic Review/Meta Analysis of RCT

Diagnosis Controlled Trial; Systematic Review/Meta Analysis of CT

Prognosis Cohort Studies, Case Control, Case Series

Harm/Etiology Cohort StudiesPrevention Randomized Controlled Trial,

Cohort StudiesQuality Improvement Randomized Controlled Trials

Type of Study

Meta – Analyses Systematic, objective combining many studies – increases

sample size and allows for analyses not otherwise possible Systematic Review

Comprehensive survey of a topic and finds all relevant studies of highest level of evidence – reduce bias – follows formal process

Randomised Controlled Trial/Studies One group receives treatment – Control group no treatment

(placebo) or standard treatment – patients randomly assigned – Double Blind Method

Type of Study con’t

Cohort Study Prospective or historical/retrospective – pop has a

certain exposure or particular treatment Case Control Studies

Patients with certain condition compared with people who do not – odds of developing condition

Case Reports Collections of reports on treatment of individual

patients with same condition or a single patient

www.biomed.lib.umn.edu

Find the highest strength of

evidence available to answer your

clinical question.

Clinical Scenario #1

Clinical Scenario #1• On morning rounds in the Oncology unit, a first yearstudent turns to you for consultation. She wants todiscuss options for managing moderate nausea andvomiting that result following chemotherapy. She sharesan experience a relative had taking ginger whenprochlorperazine didn’t provide effective relief and asksfor your input.What is your clinical question in PICO format?What type of clinical question is this?What is the best study design to answer this typeof clinical question?

Answer Clinical Question #1

PICO:• P – In patients receiving chemotherapy who are experiencing moderate nausea and vomiting• I – is the use of ginger• C – as effective as prochlorperazine• O – in reducing nausea and vomiting?Type of Question: Therapy/TreatmentType of Study/Methodology: Double-Blind Randomized

Controlled Trial; Systematic Review/Meta Analysis of RCT

Clinical Scenario #2

Working on the Developmental Assessment Team forschool-aged children of mothers who used cocaineduring their pregnancy, you are interested in learning thedevelopmental outcomes for these children as theybegin school compared to children not exposed tococaine during pregnancy. What is your clinical question in PICO format? What type of clinical question is this? What is the best study design to answer this type

of clinical question?

Answer Clinical Question #2

PICO:• P – (controlling for confounding factors) Do

school-aged children• I – exposed in utero to cocaine,• C – compared to children not exposed to cocaine• O – have increased incidence of learning

disabilities at age six years? Type of Question: Harm/Etiology Type of Study/Methodology: Cohort Studies

Limits of PICO

This model works best for Therapy/Treatment & Diagnosis questions.

Remember, PICO is a model, not a rigid structure.

Sources of EvidenceOriginal research and reviews published in journals

The Cochrane Library Intl organization makes available systematic reviews

of effects of healthcare interventions Up-to-date

PubMed/CINAHL Free provided by NLM MUN access

UpTODate Evidence based clinical info Quick and easy/point of care

Using PubMed

Go to: www.mun.ca Click Libraries link Under Research Tools choose Articles Under Search by Subject choose Nursing Click on PubMed

PubMed Home

MeSH database – medical thesaurus-Can do searches from here

Search Statement

PubMed Mesh terms: Depression St. John’s wort Antidepressants

Study type? Limits

Subheadings

depression AND (hypericum OR “St. John’s Wort”) AND “antidepressive agents”

DepressionHypercium

“Depressive Agents”

Search Statement

Does hand washing among healthcare workers reduce hospital acquired infections?PubMed Mesh terms:Hospital acquired infection – Hand washing – Nurses -

"cross infection" AND "hand disinfection" AND nurses

Cross InfectionHand Disinfection

Nurses

How to save results

To temporarily save and print results:1. Click the check box to the left of the citations

you want to save.2. From Send to, select Clipboard.3. Click Add to Clipboard4. Click Clipboard: # items to choose citations5. Click Send to, select File - Format:

Abstract(text) Create File6. Under File select Print

Remember

Pick out PICO Determine question type Determine type of study Select appropriate databases & do search