PICO(T) Questions and an Evidence-Based Approach

Evidence-based Approach: Clinical Inquiry

The current paradigm of nursing practice is based on clinical and scientific evidence to make clinical decisions and improve patient care. Evidence-based practice (EBP) promotes high quality in health care. Therefore, a nursing workplace environment should create and embrace a culture of evidence-based practice (McIntosh et al., 2022). The initial steps in EBP include clinical inquiry.

PICO(T) Questions and an Evidence-Based Approach

Clinical inquiry sets the stage for the quest for literature and clinical evidence to answer clinical problems (Mick et al., 2022). This paper aims to describe a practice issue, present a clinical inquiry for this clinical problem, and discuss the findings of selected sources to answer this clinical question.

Practice Issue

Hypertensive disorders in pregnancy form a significant portion of incidence rates of maternal mortalities nationally and worldwide. The most common hypertensive diseases in pregnancy that have a higher risk of maternal mortality are preeclampsia and eclampsia.

Preeclampsia occurs when the maternal blood pressure exceeds the upper limits after 20 weeks of gestation. Otherwise, hypertensive disease can be referred to as chronic hypertension. Various strategies have been used by practitioners to prevent these conditions in pregnancy.

The United States Preventive Services Task Force (USPSTF) and the American College of Obstetricians and Gynecologists (ACOG) have recommended the use of aspirin among those with moderate to severe risk of preeclampsia in pregnancy (Van Doorn et al., 2021).

However, the use of aspirin in pregnancy, especially after 19 weeks, is also controversial as various items of literature have reported renal problems in the fetus related to nonsteroidal anti-inflammatory drugs (NSAIDS) use, a drug class to which aspirin belongs. This adverse effect has been associated with daily doses above 100mg (Short et al., 2021). Doses below 80mg are considered relatively safe.

According to Van Doorn et al. (2021), many guidelines recommend the use of aspirin before or at 16 weeks of pregnancy. Because of the risk and benefits documented about aspirin and preeclampsia in pregnancy, a quality, evidence-based clinical decision is required to ensure maternal and fetal care is safe before administering aspirin to pregnant mothers at risk of preeclampsia. This evidence-based project sets out to consolidate clinical evidence-based literature that documents high-quality findings about aspirin use and preeclampsia prevention.

Clinical Inquiry

A clinical inquiry was formulated in a PICOT format to guide the literature search for the above clinical practice issue. The PICOT question stated as follows: among pregnant women with moderate to high risk of preeclampsia (P), does the use of aspirin (I) reduce the incidence of preeclampsia (O) as compared with no use of aspirin (C) when administered before 16 weeks of gestation (T)? The population in this clinical inquiry is pregnant women at risk of preeclampsia.

This population included pregnant mothers who had preeclampsia in the previous pregnancy or pregnancies, those younger than 20 years, older than 35 years, have obesity, have a chronic disease such as diabetes mellitus, hypertension, or renal disease, who have a family history of preeclampsia, and multifetal pregnancies.

A mother with moderate risk for preeclampsia has a body mass index (BMI) greater than 35, has multifetal pregnancies, is older than 39 (≥40) years, has been nulliparous, has a pregnancy interval of more than 10 years, or has a positive family history of preeclampsia.

Severe risk cases involve a combination of two or more of the moderate factors listed above (Fox et al., 2019). In intervention, prophylactic use of aspirin involves the use of low-dose aspirin (LDA), including doses between 75 mg and 150mg daily (Poon et al., 2021). This intervention is usually implemented after 12 weeks of gestation until parturition.

Literature Search Strategy

The literature search was done from three sources: The Cochrane Library, PubMed, and ScienceDirect databases. These sources have a reputation for providing quality and credible nursing and allied health resources, including journals, books, reports, reviews, and editorial articles. Search terms used in the literature search were aspirin, preeclampsia, preterm preeclampsia, and moderate preeclampsia.

Additional search filters were applied to return results that included research articles only published within the last five years. Resources were manually selected based on their level of evidence in the hierarchy. Priority was given to systematic reviews and meta-analyses because they provide the highest level of research evidence (Melnyk & Fineout-Overholt, 2018). Four resources were selected for this evidence-based project.

Evidence Synthesis

Choi & Shin (2021) conducted a systematic review and meta-analyses study that involved 35 placebo-controlled randomized trials (RCTs). In their study, Choi & Shin compared maternal and neonatal outcomes of mothers at risk of preeclampsia who received low-dose of aspirin (LDA) and those who received a placebo. This study found that LDA, when imitated before 20 weeks of gestation, reduces preeclampsia incidence without risk of bleeding. Specific outcomes improved by LDA were preterm birth, intrauterine growth retardation (IUGR), and neonatal mortality.

A systematic review by Van Doorn et al. (2021) evaluated LDA impacts on preterm preeclampsia and gestational eclampsia. Their study included a meta-analysis of 23 RCTs. This study found that LDA of doses higher than the currently recommended doses of 81mg daily produced higher reductions in preeclampsia incidence.

The maximum used doses were ups to 150mg daily. However, the incidence of gestational age hypertension reduced significantly with all diseases between 81mg and 150 mg. Therefore, LDA reduces preeclampsia and gestational age hypertension. However, controversy still exists in the set optimal dose of LDA for this population.

Short et al. (2021) conducted a multisite double-blinded, placebo-controlled randomized trial in different low and middle-income countries. This study included 5943 nulliparous pregnant women in the intervention (81mg LDA) and 5936 nulliparous pregnant women in the placebo group. Short and colleagues found that LDA (81mg) is a well-tolerated and safe medication that reduces the risk of preterm preeclampsia.

A significant safety risk reported was hives and rashes, which were significantly higher in the intervention group. The use of LDA did not significantly impact the risk of unexpected emergency medical visits due to preeclampsia. The participants in this study received 81mg from 6 to 36 weeks of gestation.

Duley et al. (2019) conducted a systematic review and meta-analysis of 77 RCTs to assess the impact of antiplatelet agents that included aspirin and dipyridamole among pregnant women at risk of preeclampsia in terms of maternal and fetal or neonatal outcomes. This study found that LDA reduces preeclampsia incidence, risk of preterm births, reduce risk of low birth weight, and perinatal mortality. This systematic review graded this evidence as high-quality evidence considering the sources used.

Relevance of the Findings

The presented findings have an essential value in preventive maternal, neonatal, and fetal health. Maternal and child health nursing aims to prevent maternal, prenatal, and childhood deaths and improve the quality of life of pregnant women, postpartum mothers, neonates, and children. Maternal bleeding and hypertensive disorders in pregnancy and the peripartum period are among the top causes of maternal mortality and morbidity. Therefore, a prevention strategy needs to prevent preeclampsia and not risk hemorrhage.

These findings presented the outcomes of the administration of outcomes on maternal health, fetal health, and neonatal outcomes. The synthesized resources have presented the dosage and timing of aspirin administration to prevent preeclampsia and poor neonatal outcomes.

Therefore, these findings can be used to formulate guidelines, policies, and programs to prevent preeclampsia in pregnant women at risk of developing this hypertensive disorder. More importantly, to this EBP project, these findings provide clinical answers to my clinical inquiry by addressing the population, intervention, comparison, outcomes, and timeframe.

Conclusion

Preeclampsia causes maternal and fetal/neonatal mortality and morbidity nationally and worldwide. This evidence-based approach has presented evidence that supports the use of LDA in the prevention of preeclampsia, among other causes of maternal and neonatal mortality and morbidity.

This project started with the formulation of a clinical inquiry that led to a selection of four high-level evidence sources that included three systematic reviews and meta-analyses and one RCT. The currently recommended dose for LDA is 81mg daily before 12 weeks throughout the pregnancy period. The synthesized evidence supported the use of this intervention in preeclampsia prevention. The safety issue of concern presented was related to the risk of bleeding, especially with high doses.

Nevertheless, the benefits of this intervention went beyond the prevention of preeclampsia and included improvement in fetal outcomes. Therefore, compared with no use of LDA, low-dose aspirin reduces the risk and incidence of preeclampsia and improves fetal and maternal outcomes when started before 16 weeks of gestation.

References

  • Choi, Y. J., & Shin, S. (2021). Aspirin prophylaxis during pregnancy: A systematic review and meta-analysis. American Journal of Preventive Medicine61(1), e31–e45. https://doi.org/10.1016/j.amepre.2021.01.032
  • Duley, L., Meher, S., Hunter, K. E., Seidler, A. L., & Askie, L. M. (2019). Antiplatelet agents for preventing pre-eclampsia and its complications. Cochrane Database of Systematic Reviews2019(10). https://doi.org/10.1002/14651858.CD004659.pub3
  • Fox, R., Kitt, J., Leeson, P., Aye, C. Y. L., & Lewandowski, A. J. (2019). Preeclampsia: Risk factors, diagnosis, management, and the cardiovascular impact on the offspring. Journal of Clinical Medicine8(10), 1625. https://doi.org/10.3390/jcm8101625
  • McIntosh, K., Collins, J., & Mick, J. (2022). Promoting a culture of clinical inquiry in nursing. Nursing52(9), 31–35. https://doi.org/10.1097/01.NURSE.0000854000.91255.f6
  • Melnyk, B. M., & Fineout-Overholt, E. (2018). Evidence-based practice in nursing & healthcare: A guide to best practice (4th ed.). Lippincott Williams and Wilkins.
  • Mick, J., Ceasar, S., Collins, J., Giegerich, C. A., Gilroy, H., Holub, M., Rittenhouse, C., & Thayer, V. B. (2022). EBP activities to develop a culture of clinical inquiry in healthcare organizationsNursing52(10), 50–55. https://doi.org/10.1097/01.NURSE.0000872472.81240.bb
  • Poon, L. C., Magee, L. A., Verlohren, S., Shennan, A., von Dadelszen, P., Sheiner, E., Hadar, E., Visser, G., Da Silva Costa, F., Kapur, A., McAuliffe, F., Nazareth, A., Tahlak, M., Kihara, A. B., Divakar, H., McIntyre, H. D., Berghella, V., Yang, H., Romero, R., … Hod, M. (2021). A literature review and best practice advice for second and third-trimester risk stratification, monitoring, and management of pre-eclampsia: Compiled by the Pregnancy and Non-Communicable Diseases Committee of FIGO (the International Federation of Gynecology and Obstetrics): Compiled by the Pregnancy and Non-Communicable Diseases Committee of FIGO (the International Federation of Gynecology and Obstetrics). International Journal of Gynaecology and Obstetrics: The Official Organ of the International Federation of Gynaecology and Obstetrics154 Suppl 1(S1), 3–31. https://doi.org/10.1002/ijgo.13763
  • Short, V. L., Hoffman, M., Metgud, M., Kavi, A., Goudar, S. S., Okitawutshu, J., Tshefu, A., Bose, C. L., Mwenechanya, M., Chomba, E., Carlo, W. A., Figueroa, L., Garces, A., Krebs, N. F., Jessani, S., Saleem, S., Goldenberg, R. L., Das, P. K., Patel, A., … Derman, R. J. (2021). Safety of daily low-dose aspirin use during pregnancy in low-income and middle-income countries. AJOG Global Reports1(1), 100003. https://doi.org/10.1016/j.xagr.2021.100003
  • Van Doorn, R., Mukhtarova, N., Flyke, I. P., Lasarev, M., Kim, K., Hennekens, C. H., & Hoppe, K. K. (2021). Dose of aspirin to prevent preterm preeclampsia in women with moderate or high-risk factors: A systematic review and meta-analysis. PloS One16(3), e0247782. https://doi.org/10.1371/journal.pone.0247782

PICO(T) Questions and an Evidence-Based Approach

Create a 3-5 page submission in which you develop a PICO(T) question for preeclampsia 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 healthcare 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.

• 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. • 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.

• Identify sources of evidence that could be potentially effective in answering a PICO(T) question.

• Explain the relevance of the findings from chosen sources of evidence to making decisions related to a PICO(T) question.

• Competency 3: Apply an evidence-based practice model to address a practice issue. • 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.

• Organize content so ideas flow logically with smooth transitions; contains few errors in grammar/punctuation, word choice, and spelling. Apply APA formatting to in-text citations and references exhibiting nearly flawless adherence to APA format.