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Week 5 Assignment (6052)

Week 5 Assignment (6052)

Week 5 Assignment (6052)

Your quest to purchase a new car begins with an identification of the factors important to you. As you conduct a search of cars that rate high on those factors, you collect evidence and try to understand the extent of that evidence. A report that suggests a certain make and model of automobile has high mileage is encouraging. But who produced that report? How valid is it? How was the data collected, and what was the sample size?

In this Assignment, you will delve deeper into clinical inquiry by closely examining your PICO(T) question. You also begin to analyze the evidence you have collected.

To Prepare:

  • Review the Resources and identify a clinical issue of interest that can form the basis of a clinical inquiry.
  • Develop a PICO(T) question to address the clinical issue of interest for the Assignment.
  • Use the key words from the PICO(T) question you developed and search at least four different databases in the Walden Library. Identify at least four relevant systematic reviews or other filtered high-level evidence, which includes meta-analyses, critically-appraised topics (evidence syntheses), critically-appraised individual articles (article synopses). The evidence will not necessarily address all the elements of your PICO(T) question, so select the most important concepts to search and find the best evidence available.
  • Reflect on the process of creating a PICO(T) question and searching for peer-reviewed research.

The Assignment (Evidence-Based Project)

Part 3: Advanced Levels of Clinical Inquiry and Systematic Reviews

Create a 6- to 7-slide PowerPoint presentation in which you do the following:

  • Identify and briefly describe your chosen clinical issue of interest.
  • Describe how you developed a PICO(T) question focused on your chosen clinical issue of interest.
  • Identify the four research databases that you used to conduct your search for the peer-reviewed articles you selected.
  • Provide APA citations of the four peer-reviewed articles you selected.
  • Describe the levels of evidence in each of the four peer-reviewed articles you selected, including an explanation of the strengths of using systematic reviews for clinical research. Be specific and provide examples.

    ORDER CUSTOM, PLAGIARISM-FREE PAPER

In the previous article in this series, our hypothetical nurse, Rebecca R., with the help of one of her hospital’s expert evidence-based practice (EBP) mentors, Carlos A., learned Step 1 of the EBP process—how to formulate a clinical question. The impetus behind her desire to develop her question, as you may re call in our case scenario, was that Rebecca’s nurse man- ager asked her to search for more evidence to support her idea of using a rapid response team to decrease rates of in-hospital car- diac arrests and unplanned ICU admissions—both of which were on the rise on Rebecca’s medical– surgical unit. She learned of the idea of a rapid response team from a study she read on the sub- ject in Critical Care Medicine.1

Here is the clinical question Rebecca formulated: “In hospital- ized adults (P), how does a rapid response team (I) compared with no rapid response team (C) affect the number of cardiac arrests (O) and unplanned admissions to the ICU (O) during a three-month period (T)? Her question, called a PICOT question, containsWeek 5 Assignment (6052)

the following elements: patient population (P), intervention of interest (I), comparison interven- tion of interest (C), outcome(s) of interest (O), and time it takes for the intervention to achieve the outcome(s) (T). (To review PICOT questions and how to formulate them, see “Asking the Clinical Question: A Key Step in Evidence-Based Practice,” March.)

This month Rebecca begins Step 2 of the EBP process, search­ ing for the evidence. For an over- view of this step, see How to Search for Evidence to Answer the Clinical Question.

THE BEST EVIDENCE TO ANSWER THE CLINICAL QUESTION In their next meeting, Carlos and Rebecca discuss what type of evidence will best answer her clinical question. Carlos explains that knowing the type of PICOT question you’re asking (for example, is it an intervention, etiology, diagnosis, prognosis, or meaning question?) will help you determine the best type of study design to search for. Rebecca’s PICOT question is an interven- tion question because it compares two possible interventions—a rapid response team versus no rapid response team.Week 5 Assignment (6052)

ajn@wolterskluwer.com AJN ▼ May 2010 ▼ Vol. 110, No. 5 41

Searching for the Evidence Strategies to help you conduct a successful search.

This is the fourth article in a series from the Arizona State University College of Nursing and Health Innovation’s Center for the Advancement of Evidence-Based Practice. Evidence-based practice (EBP) is a problem-solving approach to the delivery of health care that integrates the best evidence from studies and patient care data with clinician expertise and patient preferences and values. When delivered in a context of caring and in a supportive organizational culture, the highest quality of care and best patient outcomes can be achieved.

The purpose of this series is to give nurses the knowledge and skills they need to implement EBP consistently, one step at a time. Articles will appear every two months to allow you time to incorporate information as you work toward implementing EBP at your institution. Also, we’ve scheduled “Chat with the Authors” calls every few months to provide a direct line to the experts to help you resolve questions. See details below.

Need Help with Evidence-Based Practice? Chat with the Authors on May 5!

On May 5 at 1 pm EDT, join the “Chat with the Authors” call. It’s your chance to get personal consultation from the experts! Dial-in early! U.S. and Canada, dial 1-800-947-5134 (International, dial 001-574-941-6964). When prompted, enter code 121028#.

Go to www.ajnonline.com and click on “Podcasts” and then on “Conversations” to listen to our interview with Susan B. Stillwell and Ellen Fineout-Overholt.

 

 

42 AJN ▼ May 2010 ▼ Vol. 110, No. 5 ajnonline.com

Determine the level of evi- dence. Research evidence, also called external evidence, can be viewed from a hierarchical per- spective. The best external evi- dence (that which provides the most reliable information) is at the top of the list and the least reliable is at the bottom (see Hi­ erarchy of Evidence for Inter­ vention Studies2). The level and quality of the evidence are impor- tant to clinicians because they give them the confidence they need to make clinical decisions. The research methodology that provides the best evidence will differ depending on the type of clinical question asked. To answer a question that includes an in- tervention, such as Rebecca’s question, a systematic review of

randomized, controlled trials or a metaanalysis in which studies are compared using statistical analy- sis is the best study design.2-5 When well designed and executed, these studies provide the strongest evi- dence, and therefore the most confidence for clinical decision making.

“What happens when there isn’t a metaanalysis or systematic review available?” Rebecca asks. Carlos replies that the next-best evidence would be Level II evi- dence, the findings of a random- ized, controlled trial. Carlos reminds Rebecca that when de-

Cumulative Index to Nursing and Allied Health Literature

The CDSR and DARE databases contain systematic reviews and metaanalyses of randomized, controlled trials. The reviews conducted by the Cochrane Col- laboration are contained in the CDSR, and abstracts of sys- tematic reviews not conducted by Cochrane are indexed in the DARE. Cochrane reviews are considered to have the strongest level of evidence for intervention questions because they have the best study designs and are gener- ally the most rigorous.

To find other types of evidence, databases other than CDSR and DARE must be searched. Because the intervention—rapid response team—is a multidisciplinary, in- terprofessional initiative, evidence to answer Rebecca’s question may be found in medical as well as in nursing and allied health journals. Therefore, the PubMed database, which contains medical and life sciences literature, and the CINAHL database, which contains nursing and allied health literature, should be searched. Abstracts can be reviewed and accessed free of charge in the Cochrane Library and PubMed databases (although a fee may be required to obtain electronic cop- ies of reviews or articles), but a subscription is required to access CINAHL.

SEARCHING STRATEGIES Now that Rebecca and Carlos have decided what databases to search, they need to select the keywords they’ll use to begin their search.

Choose keywords from the PICOT question. Rebecca and Carlos identify the following keywords from her PICOT ques- tion: hospitalized adults, rapid response team, cardiac arrests, and ICU admissions. Lynne

ciding whether to use evidence to support a practice change, it’s important to consider both the level and quality of the evidence as well as the feasibility of imple- menting the intervention. Week 5 Assignment (6052)

WHERE TO FIND THE EVIDENCE Rebecca and Carlos set up an appointment with Lynne Z., the hospital librarian, to learn how to begin searching for the evi- dence. Lynne tells Rebecca and Carlos that no matter what type of question is being asked, it’s wise to search more than one database. Because databases index different journals, searching several data- bases will reduce the possibility of missing relevant literature.

Select relevant databases to search. To find evidence to an-

swer Rebecca’s PICOT question, Lynne recommends searching the following databases: • the Cochrane Database of

Systematic Reviews (CDSR) and the Database of Abstracts of Reviews of Effects (DARE), which are found in the Co- chrane Library and can be ac- cessed through the Cochrane Collaboration Web site (www. cochrane.org)

• PubMed, which includes MEDLINE (www.ncbi.nlm. nih.gov/pubmed)

• CINAHL (www.ebscohost. com/cinahl), an acronym for

How to Search for Evidence to Answer the Clinical Question 1. Identify the type of PICOT question. 2. Determine the level of evidence that best answers the question. 3. Select relevant databases to search (such as the CDSR, DARE, PubMed, CINAHL). 4. Use keywords from your PICOT question to search the databases. 5. Streamline your search with the following strategies: • Use database controlled vocabulary (such as “MeSH terms”). • Combine searches by using the Boolean connector “AND.” • Limit the final search by selecting defining parameters (such as “humans” or

“English”).

 

 

ajn@wolterskluwer.com AJN ▼ May 2010 ▼ Vol. 110, No. 5 43

the same search conducted at different times will likely produce different numbers of articles.)

Rebecca and Carlos want to combine their searches because they’re interested in finding articles that contain all of the keywords (hospitalized adults AND rapid response team AND cardiac arrests AND ICU admis­ sions). After they enter each key- word into the selected database and search it individually, they’ll combine all the searches using the Boolean connector “AND.” There’s a chance, however, that combining the searches may re- sult in few or even no articles. For example, the first time Rebecca searched PubMed using its con- trolled vocabulary for her PICOT keywords, and then combined

the searches, the database came up with only one article. She de- cided to refocus her search, hoping that including only the interven- tion and outcomes keywords, and not the patient population, would produce articles relevant to her clinical issue.

Place limits on the final com- bined search to further narrow the results. This strategy can eliminate articles written in lan- guages other than English or those in which animals, and not hu mans, are the subjects. Other limits—such as age or sex of subjects or type of article (such as clinical trial, editorial, or review)—are available; however, placing too many limits on a search may produce too few or even no articles.

recommends that in cases when a database has its own indexing language, or controlled vocabu- lary, the search be conducted with these index terms. In this way, the search will be the most inclusive. Week 5 Assignment (6052)