1Identifying the EvidenceCone Health © 2020Last reviewed April 2020

Start with a Burning QuestionBefore there can be inquiry and research, there first must be an informational need. You have a question that needs answering or some knowledge that is sought. The first step is to write down what your question is. What is it that you want to know?

Write out your Problem/Issue/Question:

________________________________________________________________________________________________________

P-I-C-ONow, refine your question in the PICO format. Referring to your question, identify the PICO components. This will help focus your question as well as benefit your efforts when searching.

PICO Components Describe PICO Components in Your QuestionP – Patient, Population, Problem or Program: What is the Patient Population your burning question pertains to? (Try to be specific)(older adult, adult, children, pregnant women, etc.)

I – Intervention: What are you proposing regarding the patient’s care? What is the therapy, intervention, treatment, screening text or exposure?

C – Comparison Intervention (If Applicable)Do you want to compare a current practice vs. a new practice? Do you want to compare products? Are alternatives being considered

O – OutcomeWhat is the outcome you are questioning? What do you think might happen? What to measure, accomplish, improve or affect.

EXAM

PLES

Que

stio

n

Among older adults who are at risk for skin breakdown, do special linens decrease the

incidence of pressure ulcers?

Will a protocol to remove urinary catheters in adult Med-Surg patients decrease device days?

Among adult Med-Surg patients with NG tubes, what device adheres best—pink tape or the

packaged device (as evidenced by infrequent changing of the device or replacement of the NGT)?

P older adults Med-Surg patients adult Med-Surg patients

I special linens to some patients; regular linens to others a removal protocol securing device

C special linens vs regular linens protocol vs. current practice pink tape vs. packaged device

O decrease incidence of pressure ulcers decrease device days best as measured by how often the tube is replaced

or how often the device has to be changed, etc.

My Burning Question is…

________________________________________________________________________________________________________

2Identifying the EvidenceCone Health © 2020Last reviewed April 2020

Search the Literature

Useful databases for searching literature related to nursing topics.

CINAHL Literature pertaining to nursing and other allied health professions.

PubMed/MEDLINE Comprehensive database of biomedical literature.

Cochrane LibrarySystematic reviews of randomized control trials. These systematic reviews are often considered the highest level of evidence.

Cone Health Medical LibraryContact the Medical Library for assistance. Medical.library@coneheatlh.com 336-832-7496

Why Not Only Rely on Google or Other Resources on the Internet?

Although Google, Google Scholar, and other Web sites or resources on the Internet might seem easier and at your fingertips, they are not the best sources for finding comprehensive evidence to guide clinical practice. Sources on the Internet may not be appropriately referenced or scientific; in addition, the author may not be the most reputable.1,2 Anyone can add to Wikipedia or create a Web site. Hence, although they are accessible 24 hours a day/7 days a week and somewhat easier to use, they should only be used after careful evaluation and only be one of the sources that are used for a good comprehensive search of the health care literature.11,12 It is also important to remember that unless the site is regularly updated (daily is best), the information on a Web site can easily become outdated. In addition, because of the way the World Wide Web is financed, the results that come up first in a search can be related to the advertising and not the most important to your search. If you are going to use materials from the Web, it is important to evaluate them appropriately. Find out who wrote the information. Are they an appropriate expert in the field of interest? Are there disclosures on the Web site? Do they tell you their affiliations or reveal their conflicts of interest? The Web is often a source of merchandize, so it is important to understand the purpose of the materials on a Web site that you use for your search. Do they tell you how current the research they report is? Knowing the answers to these questions will be helpful in understanding how much you will want to rely on these materials as being unbiased and useful in your search or not.1,2

Table and Excerpt from Jacqueline M. McGrath, Roy E. Brown, Haifa A. Samra, Before You Search the Literature: How to Prepare and Get the Most Out of Citation Databases, Newborn and Infant Nursing Reviews, Volume 12, Issue 3, September 2012, Pages 162-170.

3Identifying the EvidenceCone Health © 2020Last reviewed April 2020

Search the Literature: Tips, Boolean Operators & Limits

Suggestions

Keep concepts separate – this will make it easier to manipulate your search to get desired results.Always come up with synonyms for your search terms/concepts.Use Subject Headings/Controlled Vocabulary whenever possible. Start your search broad and then make it more focused as you see what is in the literature.Never hesitate to adjust your search strategy once you evaluate your results

Finding Too Many Articles?Ways to Decrease/Focus Your

Results

Not Finding Enough?Ways to Expand/Increase Your Results

Do not explodeRestrict subject heading to major focusChoose any relevant subheadingsUtilize limits to English language, human subjects, review articles, etc.

Explode whenever possibleDo not restrict subject headings to major focusDo not choose subheadingsConsider searching back in time, look at citationsConsider doing a keyword search-particularly for more obscure terms

AND(Pressure Ulcer AND Nursing

Home)

OR(Pressure Ulcer OR Nursing Home)

NOT(Pressure Ulcer NOT Nursing Home)

Retrieves records that contain BOTH terms entered

Retrieves records that contain either ENTERED term

Retrieves records that exclude the term following the operator

LIMITS

All databases (like the ones provided by the Medical Library) have options for narrowing search results even further by allowing you to apply limits or filters. Consider additional aspects about the information you’re searching for and then be on the lookout for ways to apply them during your searching.

Gender: Male FemaleSpecies: Humans Animals

Years: Last 5 Years A Specific Date

Age Groups: (may differ by database) All Ages Newborn ( < 1 month) Infant (1 - 23 months) Child (6 - 12 yrs.) Adolescent (13—18 yrs.)

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RangeLanguages:

English Only Other Languages:

_______

Adult (19 - 44 yrs.) Elderly (65 - 79 yrs.) Aged ( > 80 yrs.)

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Understand the Literature - Types of StudiesThe table below describes the different types of studies you will come across.

Type Of Study Definition

More Informati

on

Systematic Review

A document often written by a panel that provides a comprehensive review of all relevant studies on a particular clinical or health-related topic or question. The systematic review is created after reviewing and combining all the information from both published and unpublished studies (focusing on clinical trials of similar treatments) and then summarizing the findings.

Pros/Cons & Examples

NOTE: There’s a distinction between a “Review” article and the more rigorous, detailed and transparent “Systematic Review”

Randomized Controlled Trial (RCT)

A study design that randomly assigns participants into an experimental group or a control group. As the study is conducted, the only expected difference between the control and experimental groups in a randomized controlled trial (RCT) is the outcome variable being studied.

Pros/Cons & Examples

Cohort Study

A study design where one or more samples (called cohorts) are followed prospectively and subsequent status evaluations with respect to a disease or outcome are conducted to determine which initial participants exposure characteristics (risk factors) are associated with it. As the study is conducted, outcome from participants in each cohort is measured and relationships with specific characteristics determined

Pros/Cons & Examples

Case Control or

Retrospective Study

A study that compares patients who have a disease or outcome of interest (cases) with patients who do not have the disease or outcome (controls), and looks back retrospectively to compare how frequently the exposure to a risk factor is present in each group to determine the relationship between the risk factor and the disease.

Pros/Cons & Examples

Case Report An article that describes and interprets an individual case, often written in the form of a detailed story.

Pros/Cons & Examples

Types of Questions and the Ideal Study Types to Answer ThemType of Question Idea Type of Study

TherapyHow to select treatments that do more good than harm and that are worth the efforts and costs

Randomized Controlled Trial (RCT)

Prevention How to prevent a disease or condition

RCT > Cohort Study > Case Control

Diagnosis How to select and interpret diagnostic tests

Prospective, Blind Controlled Trial Comparison to Gold Standard

Prognosis Cohort Study > Case Control > 6

Identifying the EvidenceCone Health © 2020Last reviewed April 2020

How to estimate the patient's likely clinical course over time and anticipate likely complications

Case Series/Case ReportEtiology/Harm How to identify causes for disease

RCT > Cohort Study > Case Control

Cost Analysis Economic costs of all facets of a intervention or disease treatment

Economic Analysis

Meta-analyses and systematic reviews, when available, often provide the best answers to clinical questions.(Schardt, Connie and Angela Myatt. EBM and the Medical Librarian, 2011.Web.) http://himmelfarb.gwu.edu/tutorials/studydesign101/

 

Understand the Literature - Levels of EvidenceThere are different levels of quality that correspond to the type of study or source of the information.

7Identifying the EvidenceCone Health © 2020Last reviewed April 2020

Secondary / Filtered

Primary Studies

No Design

Quality of the Evidence

Clinical Practice Guideline

Expert Opinion / Background Info.

Review Article

Case Report / Case Series

Case Controlled Study

Cohort Study / Cross-Sectional Study

Randomized Control Trial (RCT)

Critically Appraised Topic

Meta-Analysis / Systematic Review

Review the LiteratureUse the Literature Review Worksheet below to to make high level notes on the articles that you read.Print out one for each article.

Author(s):

Article Title:

Publication InformationName:Date: Volume: Issue: Pages: Database:Link/DOI:

Brief Summary of the Article: (e.g. type of study, overall description)

Methodology: (e.g. what was done, sampling: size & populations)

Results/Findings: e.g. (e.g. outcomes, implications)

Your evaluations (e.g. strengths, limitations, relevance to your question)

8Identifying the EvidenceCone Health © 2020Last reviewed April 2020

Grade the LiteratureGrading the Quality of an Article1. What Level of Confidence Should I Have in This Article?

STUDY DESIGN QUALITY INITIAL CONFIDENCE

Systematic Review (SR) Pros/Cons & ExamplesA type of comprehensive literature review that uses systematic methods to collect all available relevant research on a specific topic, critically appraise the research studies, and synthesize their findings.

Best HIGHEST A

Randomized Controlled Trial (RCT) Pros/Cons & ExamplesA study in which people are allocated at random (by chance alone) to receive one of several clinical interventions. One of these interventions is the standard of comparison or control.

Very Good A-

Cohort Studies Pros/Cons & ExamplesAn observational study where samples (cohorts) are followed and characteristics (risk factors) are studied to estimate how often disease or life events (e.g. incidence rate, relative risk or absolute risk) happen in a certain population.

Good B+

Case Control/Retrospective Pros/Cons & ExamplesA study that looks back in time to find the relative risk between a specific exposure (e.g. secondhand tobacco smoke) and an outcome (e.g. cancer). A control group of people who do not have the disease or who did not experience the event is used for comparison.

Fair B

Case Report Pros/Cons & ExamplesA detailed report of the symptoms, signs, diagnosis, treatment, and follow-up of an individual patient. Case reports may contain a demographic profile of the patient, but usually describe an unusual or novel occurrence.

Poor B-

OpinionBased on the author’s clinical experience and expertise.

Very Poor

LOWEST C+

2. Consider lowering or raising the level of confidence looking at factors such as these. 3. Final Confidence level Rating

Lower if Raise if

Question • Difficult to determine; not clearly focused or defined.

• Easily identified; Focused and well defined. Extremely

High A

References

• Missing or minimal. • They are extensive and from the primary literature. Very High A-

Sample Size

• Very small (not appropriate); large # dropouts.• Selection & exclusion criteria missing.

• Appropriately large; small # dropouts.• Reflects demographics of larger population. High

Moderate B+

Methods• You can’t follow; understand what they did.• Very low response rates to data collection.

• You can easily follow and understand.• Appropriately high response rates to data

collection. Moderate B

9

Article Title:

Bias• Is there any evidence of bias or conflict of

interest?• There is no disclaimer to conflict of interest.

• There is clear evidence and acknowledgement of no (or minimized) bias and conflict of interest. Low B-

Results • They are incomplete, difficult to understand.• No statistical significance shown.

• Easily interpreted, variables identified.• Statistical significance is shown. Very Low C+

Conclusions

• Are unclear. • Are an honest objective interpretation of results. • Provide implications for your practice.

Synthesize the LiteratureUse the Literature Review Matrix to synthesize information on all articles and help you select the BEST.

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Article Title PurposeType, Design, Population,

Comparisons

Conclusions, Implications Main Idea Additional Notes

Grade or

Quality

Indicator

11