1. Evidence-based Searching
Karen Hutchens
&
Debbie O’Reilly
Efficiency is Key
Finding the right information in the most efficient manner is key to successfully practicing evidence-based decision making.
Knowing what key components to use in your search strategy will help you develop that efficiency.
These key components of interest are:
Patient/Population
Intervention/Exposure
Comparison
Outcome
Winter 2015

2. 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
To encourage high-quality patient care guided by the best evidence, many medical and nursing schools and clinical areas are teaching techniques for critically evaluating the nursing literature. While a large step forward, these skills of evidence-based nursing are necessary but not sufficient for the practice of contemporary nursing. Incorporating the best evidence into the real world of busy clinical practice requires the applied science of information management. Students must learn the techniques and skills to focus on finding, evaluating, and using information at the point of care. This information must be both relevant to themselves and their patients as well as being valid.

3. 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, Strauss, Richardson, Rosenburg, & Haynes, 2008 as cited in Neville & Horbatt, 2010)
Carnwell (2001) defines EBP as the systematic search for, and appraisal of, best evidence in order to make clinical decisions that might require changes in current practice, while taking into account the individual needs of the patient.
Neville, K & S. Horbatt. (2008). Creating a Spirit of Inquiry to solve clinical nursing problems. Orthopaedic Nursing, 27(6),
“The goal of EBP is to use the highest quality of knowledge in the provision of care to yield the greatest impact on patients’ health status and healthcare (Melynk & Fineout-Overholt, 2005). EBP involves a systematic search for the most relevant evidence, as well as a critical appraisal of this evidence to answer a clinical question (see table 1; Bennett, 2007, p.19).”

4. What areas of nursing practice might we want to ask EBP questions about?
You might ask questions about a range of categories of practice:
Assessment – how to properly gather and interpret findings?
Causes of the problem – how to identify them?
Deciding what the problem is – where the symptoms/signs indicate a range of possible problems how do you decide which is most likely?
How to select and interpret tests used to identify problems and to monitor patient progress?
How to estimate the likely clinical progression of a condition/illness and any likely complications?
How to select interventions that do more good than harm and that are worth the effort and cost of doing them?
How to reduce the chance of the problem reoccurring or how to promote health?
How to keep up to date; improve your skills; and run a more effective/efficient nursing team?
How best to understand the perceptions of individuals and groups e.g. service users and caregivers?
We might want to ask questions about nursing procedures and practices as well as about specific illnesses or conditions. We might also want to explore best practice from the perspective of our clients/patients or their caretakers or other key stakeholders (Eastern Health or NL Dept. of Health).

5. Why is best evidence and evidence based nursing important?
Ensures patient/clients receive the care that fits their needs
Facilitates sound decision making and makes it more explicit
Minimises risk to the patient/client so that benefits outweigh harm
Provides the nurse with the skills and knowledge to evaluate healthcare literature and practice
Exposes gaps in knowledge and conflicts in evidence

6. 4 Steps to Searching Design an answerable question
Determine the type of question that you are posing
Determine the type of study that will best answer your question
Search the literature

7. 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.
PICO
P – population/patient/problem (among_______)
I – intervention (does __________)
C – comparison/control (versus _________)
O – outcome (affect __________)
P – population/patient – How would you describe a group of patients similar to yours? What are the main characteristics of the patient (disease, condition, co-existing conditions, sex, age, race, etc.)?
Examples: elderly hypertensive female; infant with colic; morbidly obese adolescent
I – intervention – Which intervention or exposure are you considering? What do you want to do for the patient? What factor may influence the prognosis of the patient?
Examples of therapies: specific pharmacotherapy; diet; psychotherapy; information
C- comparison/control – What is the alternative that you are comparing with the identified intervention or exposure? Are you comparing two drug treatments or two diagnostic tests? Are you comparing exposure to no exposure?
Examples: blood vs. urine test; SSRI vs. psychotherapy; exposure to peanut products vs. no exposure; pamphlet vs. no information.
O- outcome – What do you hope to accomplish measure, improve or affect? What are you trying to do for the patient? Reduce adverse effects? Improve function or test scores?
Examples: smoking cessation; MI risk; patient satisfaction
Once you have your PICO, you can put this into question format.

8. 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) depression
I St. John’s Wort
C antidepressants
O relief of symptoms

9. Clinical Question
For adult patients with moderate depression, is St. John’s Wort more effective for symptom relief than antidepressants?
Write out your clinical question using the PICO components.

10. Type of Question Diagnosis Intervention/Therapy
Is a yearly mammogram (I) more effective in detecting breast cancer (O) compared with every 3 yrs (C) in women under 50 (P)?
Intervention/Therapy
In 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 History
Does 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 or Harm
Are women (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)?
Diagnosis: identification of a disease or condition by a scientific evaluation of physical signs, symptoms, history, lab test results and procedures. Nursing diagnosis: a statement of a health problem or of a potential problem in the client’s health status that a nurse is licensed and competent to treat.
Therapy: the treatment/intervention/prevention and control of any disease/condition
Prognosis: a prediction of the probable outcome of a disease based on the condition of the person & usual course of the disease as observed in similar situations – should I treat or not
Etiology: 1. the study of all factors that may be involved in the development of a disease, including the susceptibility of the patient, the nature of the disease agent, and the way in which the patient’s body is invaded by the agent. 2. the cause of a disease (Mosby’s Pocket Dictionary of Medicine, nursing & health professions, 5th ed.)
So let’s look at how to add these to the PICO model

11. 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 Question In 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 Question Is 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

12. Type of Study Meta – Analyses Systematic Review
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
Meta – Analysis -A meta-analysis is the combination of the results from many quantitative studies, dealing with the same topic, which are put together in a format that provides a systematic review of the studies. In 1904, Karl Pearson conducted the first meta-analysis (not called that at the time) to overcome small sample size among studies. The researcher revisits previously completed studies in order to summarize them and achieve a more comprehensive understanding of variables or phenomena. This approach results in an entirely new study that transcends the original research
Systematic reviews - use rigorous methods to locate, assess, and summarise the results of many individual studies in a way that limits bias. They outline what is known or unknown about the effectiveness of a treatment. Systematic reviews may be qualitative or quantitative. In many cases the review summarises primary studies, but does not statistically combine the results. their conclusions are usually more reliable and accurate than a narrative or literature review.
RCT - a group of subjects is randomly allocated into either an experimental group or a control group. These groups are followed up for the variables/outcomes of interest. less bias and more certainty than other study designs that the outcomes being measured are actually due to the experimental treatment condition, rather than other factors..

13. Type of Study con’t Cohort Study Case Control Studies Case Reports
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
Cohort Study - subjects who presently have a certain condition (e.g. smokers) and/or receive a particular treatment are followed over time and compared with another group who are not affected (non-smokers) by the condition under investigation., a cohort is any group of subjects who are linked in some way or who have experienced the same significant life event within a given period. There are many kinds of cohorts, including birth (for example, all those who born between 1970 and 1975) disease, education, employment, family formation, etc. Any study in which there are measures of some characteristic of one or more cohorts at two or more points in time is cohort analysis.
Case Control Study - A study that compares two groups of people: those with the disease or condition under study (cases) and a very similar group of people who do not have the disease or condition (controls). For example, one group may have been exposed to a particular substance that the other was not. Case-control studies are a relatively inexpensive and frequently-used type of epidemiological study that can be carried out by small teams or individual researchers in single facilities in a way that more structured experimental studies often cannot be. but their retrospective, non-randomized nature limits the conclusions that can be drawn from them.
The great triumph of the case-control study was the demonstration of the link between tobacco smoking and lung cancer, by Sir Richard Doll. Doll was able to show a statistically significant association between the two in a large case control study. It is now accepted that tobacco smoking is the cause of about 87% of all lung cancer mortality in the US.

14. Note that meta-analyses are placed at the highest level of evidence in this pyramid along with systematic reviews. It is widely accepted that systematic reviews provide the best evidence as they include all applicable studies on a particular topic. The studies, therefore are heterogeneous and results of each study vary. Systematic reviews provide no quantitative summary but rather provide conclusive statements regarding the validity and accuracy of the studies. Meta- analyses, on the other hand, take selected like studies, pool the results and provide a statistical synthesis. A meta-analysis, therefore, is only as good as the studies it includes.

15. Clinical Scenario #1 Clinical Scenario #1
• On morning rounds in the Oncology unit, a first year
student turns to you for consultation. She wants to
discuss options for managing moderate nausea and
vomiting that result following chemotherapy. She shares
an experience a relative had taking ginger when
prochlorperazine didn’t provide effective relief and asks
for 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 type
of clinical question?

16. 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/Treatment
Type of Study/Methodology: Double-Blind Randomized Controlled Trial; Systematic Review/Meta Analysis of RCT

17. Clinical Scenario #2 Working on the Developmental Assessment Team for
school-aged children of mothers who used cocaine
during their pregnancy, you are interested in learning the
developmental outcomes for these children as they
begin school compared to children not exposed to
cocaine 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?

18. 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

19. Sources of Evidence Original 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

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

21. PubMed Home MeSH database – medical thesaurus
-Can do searches from here

22. Search Statement PubMed Mesh terms: Depression Depression
St. John’s wort
Antidepressants
Study type?
Limits
Subheadings
Depression
Hypercium
“Depressive Agents”
Mesh St. J wort is hypericum
Limits set 5yrs, English, 19+
Article type – meta-analysis
depression AND (hypericum OR “St. John’s Wort”) AND “antidepressive agents”

23. 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 Infection
Hand Disinfection
Nurses

24. How to save results To temporarily save and print results:
Click the check box to the left of the citations you want to save.
From Send to, select Clipboard.
Click Add to Clipboard
Click Clipboard: # items to choose citations
Click Send to, select File - Format: Abstract(text) Create File
Under File select Print

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