PICO(T) Questions and an Evidence-Based Approach Paper

PICO(T) Questions and an Evidence-Based Approach Paper

Preventive nursing focuses on the early detection of an illness and implementing interventions to stop the illness from occurring or progressing. In a hypothetical case scenario, a nurse had a hard time making a diagnosis for surgical site infection using the warning signs of infection. The patient only had erythema and swelling at the incision site without fever, discharge, or pain. His desire to prevent surgical site infection from occurring in his patient led to his doubt that the signs were not adequate to say for sure that his patient started to have a surgical site infection (SSI). SSIs are a major cause of long patient hospital stays, mortality, morbidity, and increased cost of treatment (Iskandar et al., 2019). Annually, there are more than 100000 cases of surgical site infections (National Healthcare Safety Network, 2022). SSIs surveillance and prevention have been some of the strategies used to intervene to prevent the outcome of SSIs. The purpose of this paper is to formulate a clinical question, identify potential sources, and explain their findings to answer the clinical question.

Definition of Practice Issue

The scenario above involves a situation where the nurses need clinical or scientific evidence to make informed decisions about the patient. To ensure proper patient surveillance, he will need to identify and prevent SSI early in this patient. An alternative way to diagnose SSI is through laboratory investigations. SSIs, like other infections, can cause inflammation that can be detected through blood testing. C-reactive protein (CRP) assays have been a good marker for inflammation in the body. Its assay can suggest inflammation in the body in the setting of SSIs. However, surgery is also an iatrogenic process that can cause inflammation (Chijioke, 2019). As such, the use of CRP in SSI surveillance requires clinical evidence. The benefits of using this protein marker in surgical site infection can be ascertained through evidence-based practice.

Clinical Question

Having defined the clinical issue, the second phase of the John Hopkins EBP model is to research for evidence. This started with the formulation of a practice question. The practice question was formulated in a PICOT format. The PICO question stated: “In postoperative adult patients (P), is C-Reactive Protein assay (I) compared with the use of clinical signs (C) more accurate in early diagnosis of surgical site infections (O)? In this PICO question, the population includes adult patients who have had major surgeries during their inpatient stay in the hospital. The intervention is laboratory testing that measures the serum amount of CRP during this period after the surgery. The comparison intervention will use clinical signs of inflammation such as tenderness, discharge, swelling, redness, and hotness. The time element will not be included in this clinical practice question.

PICO approach will benefit the exploration of the clinical issue by providing the search terms and phrases. The use of the PICO question will improve the specificity of the literature search, thus improving its relevance and credibility (Eriksen & Frandsen, 2018). The conceptual clarity before the search will also improve through PICO as all elements, including comparisons, are declared before literature acquisition. The population, problem, and interventions are defined, thus making the framework of the literature search clearer. Therefore, the returned search results will be high-quality, high-level evidence (Eldawlatly et al., 2018). Finally, using PICO questions will reduce the time required to complete the search.

Evidence-based Sources

A literature search was performed from the Cochrane library, Cumulated Index to Nursing and Allied Health Literature (CINAHL), and PubMed databases. These sources are authoritative and contain peer-reviewed resources, including but not limited to journal articles and books. After the literature search, articles were manually selected, and three sources were presented to attempt to answer the PICO question. The four resources selected were articles by Kim et al. (2021), Malheiro et al. (2020), Okui et al. (2022), and Shetty et al. (2022). These resources were credible because they were current, relevant, authoritative, accurate, and objective research articles (Kurpiel, 2022). Their credibility made them fit to be used to answer the PCIO question. The credibility assessment was performed using the criteria from the CRAAP test. This test assesses the currency, relevance, authority, accuracy, and purpose of an evidence-based source.

Findings from the Articles

The article by Shetty et al. (2022) was from a prospective cohort study involving 51 orthopedic patients. This study found that fifteen patients developed surgical site infections and that CRP rose in all patients after surgery. However, the rise levels differed in both groups after the third post-op day (POD). The rise was gradual, and the difference between the two groups was statistically significant. Therefore, CRP is a good marker of SSI but only after the second day of the postoperative period.

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Kim et al. (2021) excluded patients with comorbidities from their study that involved post-operative patients who underwent posterior lumbar fusion or decompression. Their observational study found a rise in all patients who had these surgeries. However, by POD7, CRP levels had been decreasing in some patients, of which 43% didn’t develop SSIs, and increasing in some patients who eventually developed SSIs. The serial CRP level change rate had a sensitivity of 90.9% and specificity of 68.1% in SSI detection. Therefore, additional clinical patient monitoring is also important.

Okui et al. (2022) found that, on average, patients were being diagnosed with SSI between POD5 and POD9. Patients who had poorer outcomes such as SSI diagnosis, longer hospital stays, and low survival rates had higher CRP levels by the 14^th post-operative day. Early diagnosis with SSI was associated with severe SSI and outcomes. Therefore, early SSI detection is important for patient care outcomes, and CRP levels can be good markers.

Malheiro et al. (2020) compared various factors that would be used to predict the risk of infection, such as post-surgical antibiotic use, positive culture test,  CRP values, body temperature, leukocyte count, surgical re-intervention, admission to the emergency room, and hospital readmission among patients who had undergone colorectal surgeries and cholecystectomies. The study found that antibiotic use and CRP values had the highest sensitivities for SSI risk. These two factors are therefore sensitive to the prediction of SSIs and thus good SSI surveillance markers.

The sources by Malheiro et al. (2020) and Kim et al. (2021) were the most credible because they additionally addressed other confounders, thus suitable for inference making. Additionally, they had the highest sample sizes making their findings more powerful due to increased accuracy. The other sources were also credible, nevertheless.

Relevance of the Findings

The four sources presented more or less related findings and addressed one common intervention, the CRP value use. Each source addressed the various elements of the PICO but only partially. The most addressed element was population and intervention. Only one source (Kim et al., 2021) addressed the comparison intervention. The findings presented by Kim et al. (2021), Okui et al. (2022), and Shetty et al. (2022) are useful in addressing the appropriateness of the intervention from the PICO. Their findings explain to the clinician when to do CRP values and on which patients. The other source by Malheiro et al. 2020) is too general for the PICO question despite using the largest sample size in their study. The source by Kim et al. (20210 remains the most credible in solving the clinical practice issue.

Conclusion

The clinical issue involved a scenario where the use of clinical signs in the early detection of surgical site infection was unreliable. The use of CRP values to screen for SSIs early in the postop period was, therefore, a new intervention that would require evidence-based answers. This activity adopted the John Hopkins EBP model to seek evidence-based answers to the clinical issue. A PICO question was used to improve search accuracy and provide conceptual clarity to the search. The four sources selected based on their credibility answered the PICO question in parts. Of the four sources, one source was outstanding because it was the most credible in that it additionally addressed the comparison intervention. Therefore, the use of the PICO question is a useful intervention in the EBP process as literature search and drawing a conceptual framework for literature acquisition depend on it.

References

Chijioke, A. C. (2019). Evaluation of Serial C-Reactive Protein as a Predictor of Surgical Site Infection Following Emergency Laparotomy in Children in Ile-Ife, Nigeria. World Journal of Surgery and Surgical  Research, 2, 1138.

Eldawlatly, A., Alshehri, H., Alqahtani, A., Ahmad, A., Al-Dammas, F., & Marzouk, A. (2018). The appearance of Population, Intervention, Comparison, and Outcome as a research question in the title of articles of three different anesthesia journals: A pilot study. Saudi Journal of Anaesthesia, 12(2), 283. https://doi.org/10.4103/sja.sja_767_17

Eriksen, M. B., & Frandsen, T. F. (2018). The impact of patient, intervention, comparison, outcome (PICO) as a search strategy tool on literature search quality: a systematic review. Journal of the Medical Library Association: JMLA, 106(4), 420–431. https://doi.org/10.5195/jmla.2018.345

Iskandar, K., Sartelli, M., Tabbal, M., Ansaloni, L., Baiocchi, G. L., Catena, F., Coccolini, F., Haque, M., Labricciosa, F. M., Moghabghab, A., Pagani, L., Hanna, P. A., Roques, C., Salameh, P., & Molinier, L. (2019). Highlighting the gaps in quantifying the economic burden of surgical site infections associated with antimicrobial-resistant bacteria. World Journal of Emergency Surgery, 14(1). https://doi.org/10.1186/s13017-019-0266-x

Kim, M. H., Park, J.-H., & Kim, J. T. (2021). A reliable diagnostic method of surgical site infection after posterior lumbar surgery based on serial C-reactive protein. International Journal of Surgery: Global Health, 4(5), e61–e61. https://doi.org/10.1097/gh9.0000000000000061

Kurpiel, S. (2022, April 13). Research guides: Evaluating sources: The CRAAP test. https://researchguides.ben.edu/c.php?g=261612&p=2441794

Malheiro, R., Rocha-Pereira, N., Duro, R., Pereira, C., Alves, C. L., & Correia, S. (2020). Validation of a semi-automated surveillance system for surgical site infections: Improving exhaustiveness, representativeness, and efficiency. International Journal of Infectious Diseases: IJID: Official Publication of the International Society for Infectious Diseases, 99, 355–361. https://doi.org/10.1016/j.ijid.2020.07.035

National Healthcare Safety Network. (2022, January). Surgical Site Infection Event (SSI). Cdc.gov. https://www.cdc.gov/nhsn/pdfs/pscmanual/9pscssicurrent.pdf

Okui, J., Obara, H., Shimane, G., Sato, Y., Kawakubo, H., Kitago, M., Okabayashi, K., & Kitagawa, Y. (2022). The severity of early diagnosed organ/space surgical site infection in elective gastrointestinal and hepatopancreatobiliary surgery. Annals of Gastroenterological Surgery, 6(3), 445–453. https://doi.org/10.1002/ags3.12539

Shetty, S., Ethiraj, P., & Shanthappa, A. H. (2022). C-reactive protein is a diagnostic tool for postoperative infection in orthopedics. Cureus, 14(2), e22270. https://doi.org/10.7759/cureus.22270

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• Create a 3-5 page submission in which you develop a PICO(T) question for a specific care issue and evaluate the evidence you locate, which could help to answer the question.
Introduction
PICO(T) is an acronym that helps researchers and practitioners define aspects of a potential study or investigation.
It stands for:
• P – Patient/population/problem.
• I – Intervention.
• C – Comparison (of potential interventions, typically).
• O – Outcome(s).
• T – Time frame (if time frame is relevant).
The end goal of applying PICO(T) is to develop a question that can help guide the search for evidence (Boswell & Cannon, 2015). From this perspective, a PICO(T) question can be a valuable starting point for nurses who are starting to apply an evidence-based model or EBPs. By taking the time to precisely define the areas in which the nurse will be looking for evidence, searches become more efficient and effective. Essentially, by precisely defining the types of evidence within specific areas, the nurse will be more likely to discover relevant and useful evidence during their search. When applying the PICO(T) approach, the nurse can isolate the interventions of interest and compare to other existing interventions for the evidenced impact on the outcome of the concern.
You are encouraged to complete the Vila Health PICO(T) Process activity before you develop the plan proposal. This activity offers an opportunity to practice working through creating a PICO(T) question within the context of an issue at a Vila Health facility. These skills will be necessary to complete Assessment 3 successfully. This is for your own practice and self-assessment and demonstrates your engagement in the course.
Reference
Boswell, C., & Cannon, S. (2015). Introduction to nursing research. Jones & Bartlett Learning.
Professional Context
As a baccalaureate-prepared nurse, you will be responsible for locating and identifying credible and scholarly resources to incorporate the best available evidence for the purposes of enhancing clinical reasoning and judgement skills. When reliable and relevant evidence-based findings are utilized, patients, health care systems, and nursing practice outcomes are positively impacted.
PICO(T) is a framework that can help you structure your definition of the issue, potential approach that you are going to use, and your predictions related to the issue. Word choice is important in the PICO(T) process because different word choices for similar concepts will lead you toward different existing evidence and research studies that would help inform the development of your initial question. When writing a PICO(T)-formatted research question, you want to focus on the impact of the intervention and the comparison on the outcome you desire.
Scenario
For this assessment, please use a health care issue of interest from your current or past nursing practice.
If you do not have an issue of interest from your personal nursing practice, then review the optional Case Studies presented in the resources and select one of those as the basis for your assessment.
Instructions
For this assessment, select a health care issue of interest and apply the PICO(T) process to develop the research question and research it.
Your initial goal is to define the population, intervention, comparison, and outcome. In some cases, a time frame is relevant and you should include that as well, when writing a question you can research related to your issue of interest. After you define your question, research it, and organize your initial findings, select the two sources of evidence that seem the most relevant to your question and analyze them in more depth. Specifically, interpret each source’s specific findings and best practices related to your issues, as well explain how the evidence would help you plan and make decisions related to your question.
If you need some structure to organize your initial thoughts and research, the PICOT Question and Research Template document (accessible from the “Create PICO(T) Questions” page in the Capella library’s Evidence Based Practice guide) might be helpful.
In your submission, make sure you address the following grading criteria:
• Define a practice issue to be explored via a PICO(T) approach. Create a PICO(T)-formatted research question
• Identify sources of evidence that could be potentially effective in answering a PICO(T) question (databases, journals, websites, etc.).
• Explain the findings from articles or other sources of evidence as it relates to the identified health care issue.
• Explain the relevance of the findings from chosen sources of evidence to making decision related to a PICO(T) question.
• Communicate using writing that is clear, logical, and professional with correct grammar and spelling using the current APA style.
Example Assessment: You may use the following to give you an idea of what a Proficient or higher rating on the scoring guide would look like:
• Assessment 3 Example [PDF].
Additional Requirements
Your assessment should meet the following requirements:
• Length of submission: Create a 3-5-page submission focused on defining a research question and interpreting evidence relevant to answering it.
• Number of references: Cite a minimum of four sources of scholarly or professional evidence that support your findings and considerations. Resources should be no more than 5 years old.
• APA formatting: Format references and citations according to the current APA style.
Portfolio Prompt: Remember to save the final assessment to your ePortfolio so that you may refer to it as you complete the final capstone course.
Competencies Measured
By successfully completing this assessment, you will demonstrate your proficiency in the course competencies through the following assessment scoring guide criteria:
• Competency 1: Interpret findings from scholarly quantitative, qualitative, and outcomes research articles and studies.
o Explain the findings from articles or other sources of evidence that are relevant to the health care issue.
• Competency 2: Analyze the relevance and potential effectiveness of evidence when making a decision.
o Identify sources of evidence that could be potentially effective in answering a PICO(T) question.
o Explain the relevance of the findings from chosen sources of evidence to making decision related to a PICO(T) question.
• Competency 3: Apply an evidence-based practice model to address a practice issue.
o Define a practice issue to be explored via a PICO(T) approach and develop a PICO(T)-formatted research question.
• Competency 5: Apply professional, scholarly communication strategies to lead practice changes based on evidence.
o Organize content so ideas flow logically with smooth transitions; contains few errors in grammar/punctuation, word choice, and spelling.
o Apply APA formatting to in-text citations and references exhibiting nearly flawless adherence to APA format.

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PICO(T) Questions and an Evidence-Based Approach Scoring Guide

CRITERIA	NON-PERFORMANCE	BASIC	PROFICIENT	DISTINGUISHED
Define a practice issue to be explored via a PICO(T) approach and develop a PICO(T)-formatted research question.	Does not define a practice issue to be explored via a PICO(T) approach.	Identifies a practice issue, but does not frame it within the context of a PICO(T) question or approach.	Defines a practice issue to be explored via a PICO(T) approach. Develops a PICO(T)-formatted research question.	Defines a practice issue to be explored via a PICO(T) approach. Develops a PICO(T)-formatted research question. Notes how the exploration of the practice issue will benefit from a PICO(T) approach.
Identify sources of evidence that could be potentially effective in answering a PICO(T) question.	Does not identify sources of evidence that could be potentially effective in answering a PICO(T) question.	Attempts to identify sources of evidence, but does not connect them to the PICO(T) question, or the connection is unclear.	Identifies sources of evidence that could potentially be effective in answering a PICO(T) question.	Identifies sources of evidence that could be potentially effective in answering a PICO(T) question. Presents criteria or rational used to determine potential to answer the PICO(T) question.
Explain the findings from articles or other sources of evidence that are relevant to the health care issue.	Does not explain the findings from articles or other sources of evidence that are relevant to the health care issue	Lists the findings from articles or other sources of evidence, but does not offer a full explanation.	Explains the findings from articles or other sources of evidence that are relevant to the health care issue.	Explains the findings from articles or other sources of evidence that are relevant to the health care issue. Notes which sources are the most credible.
Explain the relevance of the findings from chosen sources of evidence to making decision related to a PICO(T) question.	Does not explain the relevance of the findings from chosen sources of evidence.	Identifies the relevance of the findings from chosen sources of evidence, but does not offer a full explanation of how it relates to the PICO(T) question.	Explains the relevance of the findings from chosen sources of evidence to making decision related to a PICO(T) question.	Explains the relevance of the findings from chosen sources of evidence to making decision related to a PICO(T) question. Notes which findings are the most relevant or likely to lead to positive outcomes.
Organize content so ideas flow logically with smooth transitions; contains few errors in grammar/punctuation, word choice, and spelling.	Does not organize content so ideas flow logically with smooth transitions. Contains errors in grammar/punctuation, word choice, and spelling.	Attempts to organize content with some logical flow and smooth transitions. Contains several errors in grammar/punctuation, word choice, and spelling.	Organizes content so ideas flow logically with smooth transitions; contains few errors in grammar/punctuation, word choice, and spelling.	Organizes content with a clear purpose. Content flows logically with smooth transitions using coherent paragraphs, correct grammar/punctuation, word choice, and free of spelling errors.
Apply APA formatting to in-text citations and references exhibiting nearly flawless adherence to APA format.	Does not apply APA formatting to headings, intext citations, and references. Does not use quotes or paraphrase correctly.	Applies APA formatting to in-text citations, headings and references incorrectly and/or inconsistently, detracting noticeably from the content. Inconsistently uses headings, quotes and/or paraphrasing.	Applies APA formatting to in-text citations and references exhibiting nearly flawless adherence to APA format.	Exhibits strict and flawless adherence to APA formatting of headings, intext citations, and references. Quotes and paraphrases correctly.