Presentation on theme: "Evidence-based Searching"— Presentation transcript:
1Evidence-based Searching Karen Hutchens&Debbie O’ReillyEfficiency is KeyFinding 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/PopulationIntervention/ExposureComparisonOutcomeWinter 2015
2ObjectivesTo understand that there is a process to systematically search the literature to find the best available evidenceTo learn how to develop an answerable question using the PICO approachTo identify evidence-based practice resources and learn how to use them efficiently and effectivelyTo 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.
3What 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).”
4What 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).
5Why is best evidence and evidence based nursing important? Ensures patient/clients receive the care that fits their needsFacilitates sound decision making and makes it more explicitMinimises risk to the patient/client so that benefits outweigh harmProvides the nurse with the skills and knowledge to evaluate healthcare literature and practiceExposes gaps in knowledge and conflicts in evidence
64 Steps to Searching Design an answerable question Determine the type of question that you are posingDetermine the type of study that will best answer your questionSearch the literature
7Designing 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 __________)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 adolescentI – 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; informationC- 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 satisfactionOnce you have your PICO, you can put this into question format.
8Designing 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
9Clinical QuestionFor 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.
10Type 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/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 or HarmAre 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/conditionPrognosis: 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 notEtiology: 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
12Type of Study Meta – Analyses Systematic Review Systematic, objective combining many studies – increases sample size and allows for analyses not otherwise possibleSystematic ReviewComprehensive survey of a topic and finds all relevant studies of highest level of evidence – reduce bias – follows formal processRandomised Controlled Trial/StudiesOne group receives treatment – Control group no treatment (placebo) or standard treatment – patients randomly assigned – Double Blind MethodMeta – 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 researchSystematic 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..
13Type of Study con’t Cohort Study Case Control Studies Case Reports Prospective or historical/retrospective – pop has a certain exposure or particular treatmentCase Control StudiesPatients with certain condition compared with people who do not – odds of developing conditionCase ReportsCollections of reports on treatment of individual patients with same condition or a single patientCohort 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.
14Note 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.
15Clinical 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?
16Answer Clinical Question #1 PICO:• P – In patients receiving chemotherapy who areexperiencing 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
17Clinical Scenario #2 Working on the Developmental Assessment Team for school-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 typeof clinical question?
18Answer 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/EtiologyType of Study/Methodology: Cohort Studies
19Sources of Evidence Original research and reviews published in journals The Cochrane LibraryIntl organization makes available systematic reviews of effects of healthcare interventionsUp-to-datePubMed/CINAHLFree provided by NLMMUN accessUpTODateEvidence based clinical infoQuick and easy/point of care
20Using PubMed Go to: www.mun.ca Click Libraries link Under Research Tools choose ArticlesUnder Search by Subject choose NursingClick on PubMed
21PubMed Home MeSH database – medical thesaurus -Can do searches from here
22Search Statement PubMed Mesh terms: Depression Depression St. John’s wortAntidepressantsStudy type?LimitsSubheadingsDepressionHypercium“Depressive Agents”Mesh St. J wort is hypericumLimits set 5yrs, English, 19+Article type – meta-analysisdepression AND (hypericum OR “St. John’s Wort”) AND “antidepressive agents”
23Search StatementDoes hand washing among healthcare workers reduce hospital acquired infections?PubMed Mesh terms:Hospital acquired infection –Hand washing –Nurses -"cross infection" AND "hand disinfection" AND nursesCross InfectionHand DisinfectionNurses
24How 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 ClipboardClick Clipboard: # items to choose citationsClick Send to, select File - Format: Abstract(text) Create FileUnder File select Print