Dallas, TX November 2–4, 2012 Literature Review to Improve Infusion Practice Regina Nailon RN, PhD Clinical Nurse Researcher Nursing Research & Quality

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


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.


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.


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?


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.


Clinical Topic Leads to a Clinical Question

…• What is known about central venous

catheter care provided in out-of-hospital settings?


…and another

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


…and another

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


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…


Candy Store Phenomenon…

I want it all!


Don’t Give Up…We Just Got Started!

(EGBO)


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


Narrowing the Question

• Narrowing your question– Population of interest– Setting of interest– Intervention of interest– Outcome of interest

• Ask one question at a time!


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)


Narrow enough?

• What are “central venous catheter-associated adverse events”?

• What is “care”?

• What are “out of hospital settings”?


CVC-associated Adverse Events

• Bloodstream infection (CLABSI)

• Occlusion

• Thrombosis


CVC Care

• Medication Administration– Infusion, chemotherapy, antibiotics

• Hyperalimentation – Total parenteral nutrition– Hydration


CVC Care

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


Out of Hospital Settings

• Outpatient infusion center

• Ambulatory care clinic

• Home health

• Skilled nursing facility

• Community based care settings


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 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.



• 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.



• 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.



• 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.


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”


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.


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.


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


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.


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.org/


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.


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 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


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


Findings

Implications for practice

Limitations


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.


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


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”.


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.


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.


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.


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.


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 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.


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.


Questions?

… in PICO format, please…

(just kidding)

Documents

Dallas, TX November 2–4, 2012 Literature Review to Improve Infusion Practice Regina Nailon RN, PhD Clinical Nurse Researcher Nursing Research & Quality