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

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Objectives

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

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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.

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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.

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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?

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Clinical Topic for aResearch 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.

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Clinical Topic Leads to a Clinical Question

• What is known about central venous catheter care
  provided in out-of-hospital settings?

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and another

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

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and another

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

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More Questions

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

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Candy Store PhenomenonI want it all!
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Dont Give UpWe Just Got Started! (EGBO)
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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
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Narrowing the Question

• Narrowing your question
• Population of interest
• Setting of interest
• Intervention of interest
• Outcome of interest
• Ask one question at a time!

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Asking a Searchable Question

• PICO format
• Population, Intervention, Comparison
  Intervention (if any), Outcome
• 
  Sackett et. al,
  1997

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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)
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Narrow enough?

• What are central venous catheter-associated
  adverse events?
• What is care?
• What are out of hospital settings?

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CVC-associated Adverse Events

• Bloodstream infection (CLABSI)
• Occlusion
• Thrombosis

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CVC Care

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

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CVC Care

• Infection prevention
• Accessing
• Flushing
• Dressing change
• Troubleshooting complications

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Out of Hospital Settings

• Outpatient infusion center
• Ambulatory care clinic
• Home health
• Skilled nursing facility
• Community based care settings

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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

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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

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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.

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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. 

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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.

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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.

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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

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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.

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Selecting Relevant LiteratureHow 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.

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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
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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.

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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.

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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/

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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.
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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.

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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
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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
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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
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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.

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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.

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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.

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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.

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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.

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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!

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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.

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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.

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Questions? in PICO format, please (just
kidding)