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. 1996 Jan 13; 312 (7023): 71-2.

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):254-255

In other words, what it is and what it is notNot “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 (www.guideline.gov) 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 http://pubutils.fccc.edu:8180/slide/files/www/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 ProtocolsRegister 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 (

www.guideline.gov) - (NGC), a public resource for evidence-based clinical practice guidelines

Registered Nurses Association of Ontario Best Practice Guidelines Project http://www.rnao.org/bestpractices/index.asp

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 1998- 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 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.

Librarians are here to help you Training in CINAHL,

PUBMED, PsycINFO We do searches! Call us x2710 or send

an e mail lib_reference@fccc.edu