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Literature Review to Improve Infusion Practice

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Literature Review to Improve Infusion Practice Regina Nailon RN, PhD Clinical Nurse Researcher Nursing Research & Quality Outcomes The Nebraska Medical Center – PowerPoint PPT presentation

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Title: Literature Review to Improve Infusion Practice


1
Literature Review to Improve Infusion Practice
  • Regina Nailon RN, PhD
  • Clinical Nurse Researcher
  • Nursing Research Quality Outcomes
  • The Nebraska Medical Center

2
Objectives
  • Describe how to define topics for exploration and
    retrieve comprehensive literature.
  • Describe the components of analyzing and
    synthesizing a literature review.

3
Why Review the Literature?
  • Promote lifelong learning and professional
    growth.
  • Identify best practices.
  • Conduct evidence based practice projects.
  • Prepare research proposals and grant
    applications.
  • Write state of the science journal articles.

4
Steps in Literature Review
  • Identify a relevant clinical topic.
  • Search literature databases.
  • Select relevant literature
  • research/other sources of evidence.
  • Critique the quality of the literature.
  • Summarize and synthesize the literature.

5
Identifying a Clinical Topic
  • Think about your practice, often!
  • Clinical issues that make you question your
    practice arise frequently.
  • Are we doing the right thing, the right way, the
    right time, with every patient?
  • Are there gaps in our practice and/or gaps in
    achieving optimal outcomes?

6
Clinical Topic for a Research Grant Application
  • Many patients leave the hospital with a central
    venous catheter in place.
  • Care is provided in a variety of settings by a
    variety of providers.
  • The need exists to standardize central venous
    catheter care given to patients in
    out-of-hospital settings to avoid adverse events
    and optimize outcomes.

7
Clinical Topic Leads to a Clinical Question
  • What is known about central venous catheter care
    provided in out-of-hospital settings?

8
and another
  • What is known about the outcomes of central
    venous catheter care provided to patients in
    out-of-hospital settings?

9
and another
  • How is central venous catheter care monitored and
    how are outcomes measured in patients receiving
    care in out-of-hospital settings?

10
More Questions
  • Are we talking about care provided by patients
    themselves?
  • Familyother caregivershealthcare providers?
  • ALL aspects of central line care?
  • Accessing, flushing,
  • dressing changes

11
Candy Store Phenomenon I want it all!
12
Dont Give UpWe Just Got Started! (EGBO)
13
Everythings Gonna Be Okay
The journey of 1,000 miles begins with a single
step - Lao Tse
The review of literature begins with a
single journal article - Regina Nailon
14
Narrowing the Question
  • Narrowing your question
  • Population of interest
  • Setting of interest
  • Intervention of interest
  • Outcome of interest
  • Ask one question at a time!

15
Asking a Searchable Question
  • PICO format
  • Population, Intervention, Comparison
    Intervention (if any), Outcome

  • Sackett et. al,
    1997

16
What I really want to know is
  • What is known about central venous
    catheter-associated adverse events that occur in
    patients receiving care in out-of-hospital
    settings?
  • Understanding current state of care outcomes
    should reveal aspects of care in need of
    standardization.

(Population, Intervention, Comparison
Intervention (if any), Outcome)
17
Narrow enough?
  • What are central venous catheter-associated
    adverse events?
  • What is care?
  • What are out of hospital settings?

18
CVC-associated Adverse Events
  • Bloodstream infection (CLABSI)
  • Occlusion
  • Thrombosis

19
CVC Care
  • Medication Administration
  • Infusion, chemotherapy, antibiotics
  • Hyperalimentation
  • Total parenteral nutrition
  • Hydration

20
CVC Care
  • Infection prevention
  • Accessing
  • Flushing
  • Dressing change
  • Troubleshooting complications

21
Out of Hospital Settings
  • Outpatient infusion center
  • Ambulatory care clinic
  • Home health
  • Skilled nursing facility
  • Community based care settings

22
Search Terms from PICO Question
  • Central venous catheter
  • Outpatient / ambulatory / home health
    care/skilled nursing/community settings
  • Infusion
  • Hyperalimenation /parenteral nutrition
  • Blood stream infection
  • Occlusion
  • Others..quality, outcomes, adverse event

23
Finding Relevant Literature
  • Reference librarians
  • Electronic Databases
  • Free
  • Medline www.medline.gov
  • Google Scholar www.scholar.google.com
  • Subscription access
  • Cumulative Index of Nursing and Allied Health
    Literature (CINAHL)
  • Cochrane Library
  • SCOPUS

24
Electronic Databases
  • MEDLINE (PubMed)
  • National Library of Medicines database of
    citations and abstracts.
  • Medicine, nursing, dentistry, veterinary
    medicine, health care systems.
  • Over 5,000 journals indexed including 190
    nursing journals.
  • Coverage generally from 1950.
  • Less than 25 of articles are written in a
    foreign language.

25
Electronic Databases
  • Google Scholar
  • Searches global catalog of library collections.
  • Covers many disciplines and sources
  • Articles, theses, books, abstracts
  • Academic publishers, professional societies,
    online repositories, universities and other web
    sites.
  • Customize to libraries of your choice. 

26
Electronic Databases
  • CINAHL
  • Database containing nursing and allied health
    article citations and abstracts, dissertations
    and other materials in the subject areas.
  • Indexing for more than 5,000 journals.
  • Full text for more than 770 journals.
  • Full text for more than 275 books/monographs.

27
Electronic Databases
  • SCOPUS
  • The worlds largest abstract and citation
    database of peer-reviewed literature.
  • Contains 47 million records, 70 with abstracts.
  • Over 19,500 titles from 5,000 publishers
    worldwide.
  • Includes over 4.6 million conference papers.
  • Provides 100 MEDLINE coverage.

28
Search Strategy
  • Index term search to identify appropriate
    terminology
  • home parenteral nutrition AND infection
  • home care AND central venous catheter AND
    occlusion
  • catheterization, central venous AND infection
    OR occlusion AND community OR skilled nursing
    facility OR clinic OR home care

29
Record your Searches
  • Record key words/databases searched.
  • Years/dates parameters searched.
  • Efficient use of time.
  • Did you find what you were looking for?
  • Re-examine/refine search terms.

30
Selecting Relevant Literature How much is enough?
  • Exhaustive search ? comprehensive body of
    literature on clinical topic.
  • Examine references for additional sources.
  • Search citations.
  • Level of evidence
  • Retrieve higher levels of evidence,
    when possible.

31
Selecting Relevant Literature (not all evidence
is created equally)
Strong
  1. Meta analyses / Systematic reviews
  2. Randomized controlled trial
  3. Quasi-experimental
  4. Correlational (Case-control, Cohort)
  5. Descriptive, Qualitative
  6. Expert opinion, textbooks

Weak
32
Systematic Reviews and Meta Analyses
  • Systematic reviews select, critically appraise,
    and synthesize research evidence.
  • Saves you the work of appraising and assimilating
    these numerous studies.
  • Meta analysis is similar to a systematic review.
    Appraises multiple studies focused on a clinical
    issue.
  • Uses statistical methods to summarize results of
    multiple studies focusing on same issue.
  • Overall summary statistic that represents the
    effects of the intervention across all the
    studies reviewed.

33
Critiquing Literature
  • Build a table of evidence, one article at a time.
  • Enables a systematic approach to organizing
    literature.
  • Requires engaged, critical review of every source
    of evidence retrieved from literature search.
  • Publication does not mean it was conducted with
    rigor.
  • Level I done poorly is not as strong as Level V
    done rigorously.

34
Critiquing Literature
  • Critique each source of evidence.
  • Level of evidence / research design.
  • Rigor - was it a high quality study?
  • Bias - are findings trustworthy?
  • Is the evidence applicable to your patient
    situation? (PICO)
  • Use framework for critiquing.
  • AGREE II Instrument to critically appraise
    evidence based guidelines. http//www.agreetrust.o
    rg/

35
Critiquing a Quantitative Design Research Study
Citation (author(s), year, title, volume, issue, pages ____________________________ _________________________________________________________________________ Purpose of Study _________________________________________________________ _________________________________________________________________________ Research Question / Hypothesis _____________________________________________ _________________________________________________________________________ Setting __________________________________________________________________ _________________________________________________________________________ Sample __________________________________________________________________ _________________________________________________________________________ How were subjects recruited? ________________________________________________ __________________________________________________________________________ Sample size ______________________________________ Was power analysis done? _______Level of Power___________________ Bias Describe any bias that may have been introduced into sample selection ___________ _________________________________________________________________________ __________________________________________________ Describe if/how investigator controlled for this bias _____________________________ _________________________________________________________________________ _________________________________________________________________________ Describe how subjects were randomized into the study or into the treatment(experimental) group(s) ____________________________________________ __________________________________________________________________________ Describe any bias that may have been introduced into subject assignment to treatment group(s) _________________________________________________________________ __________________________________________________________________________ Describe if/how investigator controlled for this bias _____________________________ __________________________________________________________________________ Study Variables Describe the Independent Variable (what is being manipulated?)_______________________________________________________________ Describe the Dependent Variable(s) _________________________________________ Describe any Extraneous Variables _________________________________________ How did the investigator control for these? ___________________________________ ________________________________________________________________________ Data Collection What data were collected? _________________________________________________ Instrument(s) used _______________________________________________________ Validity/Reliability of data collection instruments ______________________________ ________________________________________________________________________ Bias Describe any bias that may have been introduced into data collection___________________________________________________________ ________________________________________________________________________ Describe if/how investigator controlled for this bias _________________________________________________________________________ _________________________________________________________________________ Results. Describe the findings of the study ____________________________________ __________________________________________________________________________ __________________________________________________________________________ Describe Implications Study Findings have for Practice or Policy __________________________________________________________________________ __________________________________________________________________________ How likely is it that a Type I or Type II error occurred? Explain. __________________________________________________________________________ __________________________________________________________________________ Describe Study Limitations __________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ Would you recommend findings to support practice in your facility? Yes___ No ___ Explain rationale ____________________________________________________________ ____________________________________________________________________________
Nailon, R. (2009). Referenes Craig, J.,
Smyth, R. (2007). The evidence-based practice
manual for nurses (2nd ed). Edinburgh Churchill
Livingstone. Polit, D., Beck, C. (2008).Nursing
research Generating and assessing evidence for
nursing practice (8th ed.). Philadelphia
Lippincott. Rosswurm, M.A. Larrabee, J.H.
(1999). A model for change to evidence-based
practice. Image Jnl of Nursing Scholarship
31(4), 317-22.
36
Putting it all Together
  • Make notes as you read.
  • Use diagrams or outlines to list the main points.
  • Develop grid/table of evidence.
  • Categorize sources of evidence by
  • Similarities / contradictions across
    studies/sources of evidence.
  • Organize themes.
  • Chronologically, conceptually.

37
CVC-related infections in home health patients CVC-related infections in home health patients CVC-related infections in home health patients
Citation Shah et al. (2002). Central venous catheter-associated bloodstream infections in pediatric oncology home care. Infection Control and Hospital Epidemiology 23(2), 99-101. Tokars et al. (1999). Prospective evaluation of risk factors for bloodstream infection in patients receiving home infusion therapy. Annals of Internal Medicine, 131(5), 340-347.
Study Design / Level of Evidence I - Meta analysis II RCT III Quasi-experimental IV Correlational, case control or cohort V - Qualitative, or Descriptive VI Expert opinion, Textbook, IV retrospective, case control study. IV prospective, observational cohort study.
Research question/ Purpose/Aims To describe the epidemiology of and risk factors for CVC-associated BSI and to characterize the pediatric population with high use of CVCs. To determine rates of and risk factors for BSI in patients receiving home infusion therapy.
Sample and Setting 26 pediatric oncology patients with CVCs receiving services from dept of home care of the Childrens Hospital of Philadelphia and 26 pediatric oncology patients with CVCs cared for in the hospital, who had a CVC-related BSI during study period January 1, 1998 through June 30, 1998. 354 oncology and home TPN patients receiving infusion through a central or a midline catheter from 1 of 5 home agencies in Ontario, Canada and 473 patients from 4 hospitals who received infusion therapy from the home care agency affiliated with the Cleveland clinic Foundation in Cleveland, Ohio.
Data collection (Include description of instruments used if applicable) Data collected from chart review. Case patients identified as those who presented with CVC-BSI more than 48 hours after admission to home care. Control Prospective collection of data from infusion agency records and patient interviews. Infection form completed when BSI was suspected. BSI 1 or more blood cultures, antimicrobial tx or catheter removal, and no infection at another site that could have caused the bacteremia.
Findings No statistically significant difference in primary CVC management between groups (96 each, done by parents). No statistically significant differences between diagnoses, age, other pt characteristics. Home care (case) patients had higher rate than controls of CVC BSI/1000 device days (5.8versus 4.3). Not significant. Higher proportion of home care BSI attributed to gram-negative rods versus gram-positive organisms found in majority of control BSIs. Case patients more likely than controls to require blood product transfusions. 69 BSIs occurred in 59 patients. Risk factors for BSI included bone marrow transplant, TPN, receipt of infusion therapy in clinic or physician office, multi-lumen catheters. BSI rate increased with risk factors a patient had. BSI rates for patients with no risk factors 0.16/1,000 device days with 1 risk factor .46 with 2 risk factors 2.22 with 3 or more risk factors 6.77
Limitations Small sample size, short time of study period did not enable examination of catheter type or of clinical practice and the effect these may have on BSIs. Did not analyze/report BSI rates by central catheter vs midline. Midline catheters comprised 155 (16) of sample. Subsequent BSIs not counted if pt had gt1 BSI with same central line and/or same pathogen as 1st BSI
38
CVC-related occlusions in home health patients CVC-related occlusions in home health patients CVC-related occlusions in home health patients
Citation
Study Design and Level of Evidence I - Meta analysis II Randomized Controlled Trial III Quasi-experimental IV Correlational study (case control or cohort), Qualitative, or Descriptive V Expert opinion, Textbook, Non-research article
Research question/ Purpose/Aims
Sample and Setting
Data collection (Include description of instruments used if applicable)
Findings
Implications for practice
Limitations
39
CVC-related infections out pt settings NOT home CVC-related infections out pt settings NOT home CVC-related infections out pt settings NOT home
Citation Tokars et al. (1999). Prospective evaluation of risk factors for bloodstream infection in patients receiving home infusion therapy. Annals of Internal Medicine, 131(5), 340-347.
Study Design and Level of Evidence I - Meta analysis II Randomized Controlled Trial III Quasi-experimental IV Correlational study (case control or cohort), Qualitative, or Descriptive V Expert opinion, Textbook, Non-research article IV prospective, observational cohort study.
Research question/ Purpose/Aims To determine rates of and risk factors for BSI in patients receiving home infusion therapy.
Sample and Setting 354 oncology and home TPN patients receiving infusion through a central or a midline catheter from 1 of 5 home agencies in Ontario, Canada and 473 patients from 4 hospitals who received infusion therapy from the home care agency affiliated with the Cleveland clinic Foundation in Cleveland, Ohio.
Data collection (Include description of instruments used if applicable) Prospective collection of data from infusion agency records and patient interviews. Infection form completed when BSI was suspected. BSI 1 or more blood cultures, antimicrobial tx or catheter removal, and no infection at another site that could have caused the bacteremia.
Findings 69 BSIs occurred in 59 patients. Risk factors for BSI included bone marrow transplant, TPN, receipt of infusion therapy in clinic or physician office, multi-lumen catheters. BSI rate increased with risk factors a patient had. BSI rates for patients with no risk factors 0.16/1,000 device days with 1 risk factor .46 with 2 risk factors 2.22 with 3 or more risk factors 6.77
Limitations Did not analyze/report BSI rates by central catheter vs midline. Midline catheters comprised 155 (16) of sample. Subsequent BSIs not counted if pt had gt1 BSI with same central line and/or same pathogen as 1st BSI
40
Summary of Literature
  • Re-iterates what literature tells us.
  • Broad, general overview/summary of each article.
  • Highlights authors key points/findings.
  • Summarizes one article or source of evidence at a
    time.
  • No synthesis or attempt at weaving together
    multiple sources into own interpretation.
  • Often reads as choppy or disjointed.

41
Literature Summary
  • Shah et al. (2002) conducted a case control study
    to describe the epidemiology
  • of and potential risk factors for CVC-associated
    BSI and characteristics of the
  • pediatric population with high use of CVCs. 26
    pediatric oncology patients (case
  • patients) with CVCs receiving home infusion
    therapy who experienced a BSI were
  • compared with 26 hospitalized pediatric oncology
    patients (control patients) with
  • CVCs receiving infusion therapy who did not
    experience a BSI. Data were collected
  • over a 6-month period. No statistically
    significant difference in primary CVC
  • management was found between the groups (care
    provided by parents in 96 of
  • patients in each group). No statistically
    significant differences were found between
  • diagnoses, age, or type of CVC. Home care (case)
    patients had higher rate than
  • controls of CVC BSI/1,000 device days (5.8 versus
    4.3), but this was not statistically
  • significant. A higher proportion of home care
    BSIs were attributed to gram-negative
  • rods versus gram-positive organisms found in
    majority of control BSIs. Case patients
  • were more likely than controls to require blood
    product transfusions but the study
  • design was not intended to examine causation. The
    study was limited by the small
  • sample size. The short study period did not
    enable examination of catheter type or of
  • clinical practices and the effect these may have
    on BSIs.

42
Literature Summary
  • Tokars et al., (1999) conducted a prospective,
    observational cohort study to
  • determine rates of and risk factors for BSI in
    patients receiving home
  • infusion therapy through a central or a midline
    catheter. Data were collected
  • from a total of 827 patients over a 13-month time
    period. The investigators
  • found that 69 BSIs occurred in 59 patients. Five
    risk factors found to be
  • independently significant included previous BSI,
    bone marrow transplantation,
  • receipt of TPN, receipt of infusion therapy in
    clinic or physician office, multi-
  • lumen catheters. BSI rate per 1,000 central line
    days increased with number
  • of risk factors a patient had ranging from 0.16
    in patients with no risk factors
  • to 6.77 in patients with 3 or more risk factors.
    The investigators did not report
  • BSI rates by catheter type, nor did they count
    patients subsequent BSIs if the
  • patient had the same catheter and/or same
    pathogen as in their first BSI.

43
Literature Synthesis
  • Integrates literature into a narrative which
    illustrates own understanding of the key
    concepts. Bloom et
    al., 1956
  • Points out similarities and contrasting
    information.
  • Highlights key points with own conclusions woven
    throughout.
  • Emphasizes insights gained and knowledge gaps
    that remain.
  • Your voice is heard along with the presentation
    of what the literature tells us.

44
Literature Synthesis
  • Multiple studies have examined CVC-associated
    BSIs in patients
  • receiving home infusion therapy. Receipt of CVC
    infusion therapy
  • in the home setting has been associated with
    higher BSI rates than
  • those found in hospitalized patients, (Shah et
    al., 2002), but lower
  • BSI rates than those found in patients receiving
    infusion therapy in
  • a physician office or infusion clinic (Tokars et
    al., 1999). There is a
  • lack of research examining the influence that
    clinical practices and
  • type of CVC may have on the incidence of BSIs in
    patients with
  • CVCs receiving infusions in out of hospital
    settings.

45
Synthesizing Literature
  • Putting it all together, one sentence at a time
  • One paragraph at a time
  • One section at a time
  • One manuscript(masterpiece) at a time!
  • Organization of content is key!

46
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47
Why go to all this work?
  • Uncovering and implementing best practices is
    critical to optimizing patient outcomes.
  • What the literature doesnt contain is just as
    important as what the literature reveals about
    the clinical topic.
  • Uncovering gaps in knowledge is critical to
    determining research needs.

48
Selected References
  • Bloom, B.S., Engelhart, M. D., Furst, E. J.,
    Hill, W. H., Krathwohl, D.R. (1956). Taxonomy
    of educational objectives the classification of
    educational goals Handbook I Cognitive Domain.
    New York Longmans, Green.
  • Sackett, D.L., Strauss, S.E., Richardson, W.S.,
    Haynes, R. B. (1997). Evidence based medicine
    How to practice and teach EBM (2nd ed.). London
    Churchill Livingstone.
  • Shah, S., Manning, M., Leahy, E., Magnusson, M.,
    Rheingold, S. Bell, L. (2002). Central venous
    catheter-associated bloodstream infections in
    pediatric oncology home care. Infection Control
    and Hospital Epidemiology 23(2), 99-101.
  • Tokars, J., Cookson, S., McArthur,M., Boyer, C.,
    McGreer, A.. Jarvis, W. (1999). Prospective
    evaluation of risk factors for bloodstream
    infection in patients receiving home infusion
    therapy. Annals of Internal Medicine, 131(5),
    340-347.

49
Questions? in PICO format, please (just
kidding)
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