Nursing/medical evidence-based searching : finding the gems August, 2006 Presented by: Beth Lewis, MLS & Sherri Place, MLS Talbot Research Library

What you will learn today….. What is meant by evidence-based literature? Why is it important and helpful? What are sources of EBL? How can I easily locate evidence- based medicine literature on specific topics?

What is Evidence-Based Medicine? Evidence based medicine is the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. The practice of evidence based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research. Sackett DL, Rosenberg WMC, Gray JAM, Haynes RB, Richardson WS. Evidence based medicine: what it is and what it isn't. BMJ Jan 13; 312 (7023): 71-2.Evidence based medicine: what it is and what it isn't

What’s Evidence-based medicine? EBM is not just searching the literature for good information, it is a much more rigorous methodology in gleaning substantive information about patient conditions and analyzing the strength of those results. Bartkowiak, BA Searching for evidence-based medicine in the literature part 1: The Start Clin Med Res 2004; 2(4):

In other words, what it is and what it is not Not “cookbook” medicine – requires integration of clinical expertise and external evidence Identifies and applies interventions to maximize the quality and quantity of life for individual patients Not restricted to randomized trials and meta- analyses – involves tracking down the best external evidence with which to answer clinical questions

Why is evidence-based medicine needed? Time constraints – too many journal articles to keep up with and synthesize (19 articles per day in general medicine alone and one hour a week to read!)

Searching for the Evidence :Drilling through the medical literature Grandage, Karen K, et al., 2002

Evidence-Based Practice Tools Summary

Where can you search for evidence-based literature ? Databases Cochrane databases PubMed (Medline) CINAHL & PsycINFO Textbooks UpToDate Harrison’s Online ACP Medicine ACS Surgery Journals - such as Evidence-Based Nursing & ACP Journal Club Organizations and websites National Guideline Clearinghouse ( Nursing Best Practice Guidelines Oncology Nursing Society Evidence Based Practice Resource Center

But before you search There are some steps to take first!

Very important in searching for evidence based information FRAMING THE QUESTION

Framing the question Literature searches most likely to be successful if they’re based on well- formulated questions Dissecting a question into its component parts to facilitate finding the best evidence – a fundamental skill of evidence-based practitioners Need a focused searchable question

PICOT format – components of an answerable, searchable question Standardized format for constructing clinical questions Patient population of interest Intervention of interest Comparison of interest Outcome of interest Time frame

Patient population Age Gender Ethnicity With certain disorder

Intervention or issue of interest Exposure to disease Risk behavior Prognostic factor

Comparison Issue to be compared Easily identified if question is about therapy; but if question is about meaning or prognosis there may be no comparison

Outcome Desired outcome upon which the issue/intervention and comparison will be evaluated Risk of disease Accuracy of diagnosis Rate of occurrence of adverse outcome

Time Frame May not always be used

Framing the question - focus the clinical query Do steroids help septic patients? In patients with sepsis (population) Does treatment with steroids (intervention) Compared with no steroids (comparison) Alter mortality (outcome)?

Essential steps to a search strategy Formulate a well-built clinical question without jargon or ambiguity Determine the type of db appropriate for the question Determine the type of study design to best answer the question Enter a search term, and begin combining searches to find relevant evidence Further restrict for study design, methods, English, human, etc.

Turning unstructured clinical questions into structured questions Example: smoking cessation Initial question: is the nicotine patch effective? Type of study? Quantitative Improved searchable question: Among young women who are moderate smokers, does nicotine replacement therapy increase the probability of smoking cessation?

Quantitative study or Qualitative study Nature of the question determines quantitative or qualitative study To answer questions of “how many” or “how much” – quantitative studies To answer questions about how people “feel about or “experience” certain situations – qualitative studies

Quantitative questions The population – who are the patients/clients? Individuals, families, groups, etc? Age or sex group? Specific health care problem? Intervention or exposure – which preventive, therapeutic or health services interventions? Outcome – what are patient-relevant consequences of the intervention

Qualitative questions The population – who are the patients/clients? Individuals, families, groups, etc? Age or sex groups? Specific health care problem? The situation – What circumstances, conditions or experiences do you need to know more about?

Sources of evidence Optimal nursing information resources – depends to a large extent on: the type of question you’re asking how much time you have the resources available to you Use “pre-processed resources” (A lot of the work is already done for you)

Pre-filtered or pre-processed info. Sources to consider: Clinical practice guidelines Evidence-Based Nursing and other journals Cochrane Library PubMed Clinical queries CINAHL and PsycInfo (Clinical Queries filters) UpToDate

Unprocessed databases CINAHL PubMed PsycINFO

Some evidence-based terms to know Qualitative study Quantitative study Systematic review Meta-analysis

Systematic review A rigorous method of summarizing the findings of studies that address a focused clinical question Most commonly have been used with quantitative studies When looking for the best evidence – high- quality systematic reviews are preferred to single studies (these reviews address targeted clinical questions using strategies that decrease the likelihood of bias)

Meta-Analyses Meta-analyses are systematic reviews that combine the results of several studies using quantitative statistics

What is best to look for? Systematic Reviews!

Evidence-Based Practice Tools Summary

Let’s search for evidence based Literature Start from the Talbot Research Library home page w/research/library/index.html w/research/library/index.html

You should know… Link to Pubmed from our home page.. Because then you will get our online journal links You don’t need a password to search Cochrane, Cinahl or PsycINFO, or to access the evidence based online journals (that are owned by the TRL)

Cochrane database The first database to search when seeking to find an answer to a clinical question Small database (compared to Medline and CINAHL); only one publication type: systematic reviews (best) including meta- analyses (a type of systematic review)

The Cochrane Library Electronic resource for locating high quality information quickly Focus is primarily systematic reviews of controlled trials of therapeutic interventions Cochrane reviews are also indexed in PubMed; but not as up to date as Cochrane Library Numerous databases Valuable source of synthesized evidence (preappraised) for clinicians Highly esteemed database

Databases in Cochrane Library Cochrane Database of Systematic Reviews – completed & proposed systematic reviews, which have been peer- reviewed to insure they meet rigorous standards of methodology; updated quarterly. More than 3000 full Reviews and 2000 Protocols (Reviews in Progress) Database of Abstracts of Reviews of Effects (DARE) – includes systematic reviews that have been published outside the Cochrane Collaboration The Cochrane Central Register of Controlled Trials – thousands of references to clinical trials what Cochrane investigators have found from a wide range of sources. Considered to be world’s largest database (375,000) of randomly controlled trials.

The Cochrane Collaboration Named in honor of Archie Cochrane, a British medical researcher who contributed to the development of epidemiology as a science and stressed the importance of using evidence from randomized controlled trials (RCTs)

Systematic Reviews and Protocols Register Title Write Protocol ( 3 months) Prepare Review (12 months) Updated Review (24 months) Editorial Board Cochrane Library

Cochrane Review This Cochrane systematic review includes information on the methodology, the inclusion and exclusion criteria, the results, and a discussion

More on Cochrane Library Browse Feature

Cochrane Library on Wiley Advanced Search allows you to specify search field MeSh Searching allowed – Select “MeSH Search” Search by title of Review Search by Cochrane Group Can save searches and set up Alerts Updated quarterly

PubMed Clinical Queries A user-friendly approach to evidence-based searching Don’t need to know Mesh (subject headings) Uses preset research methodology filters which enable searchers to locate relevant methodologically sound studies that meet evidence-based standards for: therapy (or interventions); diagnosis, etiology, and prognosis New systematic review filter – retrieves relevant systematic reviews indexed in PubMed, including those in the Cochrane database

For Advanced PubMed users: TIP! To pull Systematic Reviews from a Search Strategy that you’ve already been working on, just add “AND systematic[sb]” to your existing strategy

More Tips on PubMed Try using “evidence” in the title field combined with another concept Try using the MeSh subject heading, “Evidence-Based Medicine” in combination with your concept Try Using “OR” to combine results from the above 2 searches CAUTION: this can lead to “false drops” so be sure to review your results!

CINAHL Bibliographic database for nursing and allied health Has clinical practice guidelines, journal articles, research instruments, books reviews, and patient ed. materials. Uses CINAHL subject headings Useful limits: publication type systematic review, and subject heading: evidence based practice NEW: clinical queries filter and Evidence Based Practice under Special Interest Category

CINAHL – to get the evidence- based literature Using the “more limits” feature, select under “special interest category” evidence- based practice (seems to get a lot more results) Or, use subject term nursing practice, evidence-based Or, use the new Clinical Queries limit

PsycINFO Scholarly literature in behavioral sciences and mental health Can find relevant evidence to answer specific clinical questions Has useful subject headings, like “evidence based practice” Brand new – clinical queries limit

When searching for evidence based nursing also consider: Clinical Practice Guidelines Professional organizations

Clinical practice guidelines National Guideline Clearinghouse ( - (NGC), a public resource for evidence-based clinical practice guidelineswww.guideline.gov Registered Nurses Association of Ontario Best Practice Guidelines Project

In PubMed & CINAHL: Practice Guidelines can be pulled from the literature as a “publication type” in these databases

National Guideline Clearinghouse Supported by the Agency for Healthcare Research and Quality (AHRQ) Guidelines – systematically developed statements about a plan of care for a specific set of clinical circumstances involving a particular population Best guidelines are based on rigorous scientific evidence (systematic reviews or randomized control trials) NGC has structured abstracts about the guideline; a summary for viewing, and links to full text guidelines

Don’t forget evidence based journals Go to our library home page first

Evidence-Based Nursing (EBN Online) Online access from Quarterly Secondary publication – studies published in any of more than 100 health care journals are identified, critically appraised, and summarized in brief abstracts They include a substantially smaller set of articles than regular databases – because it includes only articles which reviewers have decided meet basic standards of methodological quality

Worldviews on evidence based nursing Online access a primary source of information for using evidence-based nursing practice to improve patient care Includes best evidence available, including specific recommendations that support nursing practice around the world. Teaching EBP feature each month will help you in doing EBP literature searching

Textbooks UpToDate Harrison’s Online ACP Medicine ACP Surgery

UpToDate UpToDate follows a hierarchy of evidence consistent with most evidence-based resources At the top of the hierarchy are randomized trials of high methodological quality, followed by randomized trials with methodological limitations, observational studies, and unsystematic clinical observations Inferences are stronger when the evidence is summarized in systematic reviews of the literature that present all relevant data.

UpToDate Each topic has an author who is an expert in the area discussed, and at least two separate physician reviewers. This group works together to perform a comprehensive review of the literature and carefully select studies for presentation based upon the quality of the study, the hierarchy of evidence discussed above, and clinical relevance

UpToDate Evidence is derived from a number of resources, including but not limited to: Hand-searching of over 330 peer reviewed journals330 peer reviewed journals Electronic searching of databases including MEDLINE, The Cochrane Database, Clinical Evidence, and ACP Journal Club Consensus guidelines Published information regarding clinical trials such as reports from the Food and Drug Administration, as well as other sources of information produced by federal agencies such as the Centers for Disease Control and Prevention and the National Institutes of Health Proceedings of major national meetings The expertise of their authors, editors, and peer reviewers

UpToDate A fundamental principle of evidence-based medicine, as described by Dr. Gordon Guyatt from McMaster University, is that, "Evidence alone is never sufficient to make a clinical decision. Decision makers must always trade the benefits and risks, inconvenience, and costs associated with alternative management strategies, and in doing so consider the patient's values" [1]. This principle has led some evidence-based resources to avoid making specific recommendations for patient care, since the recommendation needs to account for all of the factors cited. UpToDate has taken a different approach. It is the policy of UpToDate to make specific recommendations for patient care whenever possible.

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