Dallas, TX • November 2–4, 2012
Literature Review to Improve Infusion
Practice
Regina Nailon RN, PhDClinical Nurse Researcher
Nursing Research & Quality Outcomes
The Nebraska Medical Center
Dallas, TX • November 2–4, 2012
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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Dallas, TX • November 2–4, 2012
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.
Dallas, TX • November 2–4, 2012
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.
Dallas, TX • November 2–4, 2012
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?
Dallas, TX • November 2–4, 2012
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.
Dallas, TX • November 2–4, 2012
Clinical Topic Leads to a Clinical Question
…• What is known about central venous
catheter care provided in out-of-hospital settings?
Dallas, TX • November 2–4, 2012
…and another
• What is known about the outcomes of central venous catheter care provided to patients in out-of-hospital settings?
Dallas, TX • November 2–4, 2012
…and another
• How is central venous catheter care monitored and how are outcomes measured in patients receiving care in out-of-hospital settings?
Dallas, TX • November 2–4, 2012
More Questions…• Are we talking about care provided by
patients themselves? – Family…other caregivers…healthcare
providers?
• ALL aspects of central line care?• Accessing, flushing,
dressing changes…
Dallas, TX • November 2–4, 2012
Everything’s 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
Dallas, TX • November 2–4, 2012
Narrowing the Question
• Narrowing your question– Population of interest– Setting of interest– Intervention of interest– Outcome of interest
• Ask one question at a time!
Dallas, TX • November 2–4, 2012
Asking a “Searchable”
Question• PICO format Population, Intervention, Comparison
Intervention (if any), Outcome
** Sackett et. al, 1997
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Dallas, TX • November 2–4, 2012
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)
Dallas, TX • November 2–4, 2012
Narrow enough?
• What are “central venous catheter-associated adverse events”?
• What is “care”?
• What are “out of hospital settings”?
Dallas, TX • November 2–4, 2012
CVC-associated Adverse Events
• Bloodstream infection (CLABSI)
• Occlusion
• Thrombosis
Dallas, TX • November 2–4, 2012
CVC Care
• Medication Administration– Infusion, chemotherapy, antibiotics
• Hyperalimentation – Total parenteral nutrition– Hydration
Dallas, TX • November 2–4, 2012
CVC Care
• Infection prevention– Accessing– Flushing– Dressing change– Troubleshooting complications
Dallas, TX • November 2–4, 2012
Out of Hospital Settings
• Outpatient infusion center
• Ambulatory care clinic
• Home health
• Skilled nursing facility
• Community based care settings
Dallas, TX • November 2–4, 2012
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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Dallas, TX • November 2–4, 2012
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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Dallas, TX • November 2–4, 2012
Electronic Databases
• MEDLINE (PubMed)– National Library of Medicine’s 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.
Dallas, TX • November 2–4, 2012
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.
Dallas, TX • November 2–4, 2012
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.
Dallas, TX • November 2–4, 2012
Electronic Databases
• SCOPUS– The world’s 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.
Dallas, TX • November 2–4, 2012
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”
Dallas, TX • November 2–4, 2012
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.
Dallas, TX • November 2–4, 2012
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.
Dallas, TX • November 2–4, 2012
Selecting Relevant Literature
(not all evidence is created equally)
Strong
Weak
I. Meta analyses / Systematic reviews
II. Randomized controlled trial
III. Quasi-experimental
IV. Correlational (Case-control, Cohort)
V. Descriptive, Qualitative
VI. Expert opinion, textbooks
Dallas, TX • November 2–4, 2012
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.
Dallas, TX • November 2–4, 2012
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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Dallas, TX • November 2–4, 2012
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.org/
Dallas, TX • November 2–4, 2012
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: ____________________________________________________________
____________________________________________________________________________
Critiquing a Quantitative Design Research Study
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 (8 th 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.
Dallas, TX • November 2–4, 2012
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.
Dallas, TX • November 2–4, 2012
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CVC-related infections in home health patientsCitation 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 EvidenceI - Meta analysisII – RCTIII – Quasi-experimentalIV – Correlational, case control or cohortV - 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 Children’s 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 BSI’s not counted if pt had >1 BSI with same central line and/or same pathogen as 1st BSI
Dallas, TX • November 2–4, 2012
CVC-related occlusions in home health patients
Citation
Study Design and Level of EvidenceI - Meta analysisII – Randomized Controlled TrialIII – Quasi-experimentalIV – 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
Dallas, TX • November 2–4, 2012
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 EvidenceI - Meta analysisII – Randomized Controlled TrialIII – Quasi-experimentalIV – 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 BSI’s not counted if pt had >1 BSI with same central line and/or same pathogen as 1st BSI
Dallas, TX • November 2–4, 2012
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”.
Dallas, TX • November 2–4, 2012
Literature SummaryShah 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 BSI’s 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.
Dallas, TX • November 2–4, 2012
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 BSI’s if the
patient had the same catheter and/or same pathogen as in their first BSI.
Dallas, TX • November 2–4, 2012
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.
Dallas, TX • November 2–4, 2012
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.
Dallas, TX • November 2–4, 2012
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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Dallas, TX • November 2–4, 2012
Why go to all this work?
• Uncovering and implementing best practices is critical to optimizing patient outcomes.
• What the literature doesn’t contain is just as important as what the literature reveals about the clinical topic.
• Uncovering gaps in knowledge is critical to determining research needs.
Dallas, TX • November 2–4, 2012
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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