PICOT Question and Evidence-based Approach

PICOT Question and Evidence-based Approach

Questions and Evidence-based Approach

Urinary pretension and incontinence are some of the major indications for catheterization in hospitalized patients and outpatients. Urinary catheterization can be done through the urethra or the suprapubic routes. The urethral route is more commonly sued because it is less invasive and takes a shorter time. The principles and goals for catheterization remain the same for men and women.

PICOT Question and Evidence-based Approach

The centers for disease control and prevention (CDC) estimates that about 75% of hospital-acquired nosocomial urinary tract infections are associated with indwelling catheterization and at least 15% of patients receive indwelling urinary catheterization during their hospitalization (CDC, 2019). Catheter-associated UTIs (CAUTI) present significant mortality and morbidity in the efforts to provide safe health care.

The revised guidelines on the prevention of CAUTI in 2019 by the centers for disease control and prevention (CDC) reported women, the elderly, and immunocompromised are at increased risk of developing CAUTI. In the recommendations (Lachance & Grobelna, 2019 PICOT Question and Evidence-based Approach). This paper describes an evidence-based project that aims at comparing the suprapubic catheter. PICOT Question and Evidence-based ApproachPICOT Question and Evidence-based Approach

Formulation of Research Question and Literature Search Strategy

The immediate subsequent evidence-based practice step after topic identification is to formulate the research question. The research question helps in guiding the search for evidence. This project adopted the PICOT format. It stated: “For women requiring long-term urinary catheterization (P), does doing suprapubic catheterization (I) reduce the incidence of catheter-associated UTIs (O) than urethral catheterization (C)?” In this PICO question, the population is the women requiring long-term catheterization. In this project long-term catheterization means indwelling catheter staying in situ for more than 10 days. PICOT Question and Evidence-based Approach

The need to provide care requires that the care is safe for the patient. however, this ideal scenario is not found in the hospitals. Catheter-associated UTI presents a different health challenge in promoting care quality. Suprapubic catheterization is less used in addressing major indications for catheterization. The data presented in annual reports and periodical findings generalize the CAUTIs to all types of catheterizations (Podkovik et al., 2019 PICOT Question and Evidence-based Approach).

Addressing the safety of the two types of catheterizations in highly at-risk populations such as females, the elderly, and immunocompromised are expected to present a different dimension to care. Using the PICOT format to address will allow for a comparison of the two techniques of catheterization.

The process of searching evidence started with the definition of keywords and Boolean operators. Search filters were applied to the search results to ensure that the more recent evidence is accumulated for application into practice. Evidence databases were identified and results were compared for their relevance to the topic. Priority was given to research articles of the highest available evidence levels such as randomized control trials and systematic reviews. PICOT Question and Evidence-based Approach

Evidence Source #1

Gibson and colleagues (2019) set out to compare indwelling suprapubic and transurethral catheterization concerning CAUTI. In their research study, 418 participants in a nursing resident home requiring long-term use of indwelling catheters were enrolled. There were no criteria to assign the participants into the ureteral and suprapubic groups because the use of these techniques was simply informed by clinical decisions in the nursing home.

Eighty-three percent (173 participants had urethral catheters while 17% (35) of the participants had suprapubic catheters. Assessments were done at baseline, two weeks, one month, and one year. The study found after covariate adjustments that the suprapubic group had a lower incidence of CAUTIs than the urethral group 6.6/1000 vs 8.8/1000 cases (Gibson et al., 2019). The suprapubic group also had lower hospitalization rates and the use of antibiotics. However, the study also found out that the rate of multidrug-resistant organisms was higher in the suprapubic group. PICOT Question and Evidence-based Approach

Evidence Source #2

Jian et al.’s (2018) study aimed at comparing the suprapubic tube (ST) and urethral catheterization (UC) in patients who underwent robot-assisted radical prostatectomy (RARP). This study was a systematic review with metanalyses that involved randomized control trials and other studies. Seven articles that included three randomized control trials were included in this review.

The authors found no significant differences in shirt term outcomes between the two urinary drainage techniques. However, the suprapubic tube was associated with sleep and discomfort more than the urethral tube (Jian et al., 2018 PICOT Question and Evidence-based Approach). The incidence of CAUTIs was inferred by the rate of emergency visits and retention that were low in both groups and had no significant differences. This study noted that the suprapubic group had other major concerns such as malfunction and clot retention. PICOT Question and Evidence-based Approach

Evidence Source #3

The third source of evidence was also a systematic review with metanalyses. A study was done by Li et al. (2019) also aimed at comparing suprapubic and transurethral catheters following RARP. It was also a systematic review that included nine studies, three RCTs, and six non-RCTs. Short-term and long-term outcomes were assessed at baseline and periodically. The study found that a suprapubic catheter causes less postoperative pain as compared with the transurethral catheter (Li et al., 2019). However, there were no significant differences in catheter-associated complications such as infection and retention. PICOT Question and Evidence-based Approach

Relevance of the Above Research Findings

Urethral also known as transurethral catheterization is usually the first-choice technique in many practice settings whenever there is a need to drain the urinary bladder (English, 2017). The above findings have confirmed this fact but have also acknowledged the use of suprapubic catheterization. The first source of evidence presented a slightly significant decrease in the incidence of CAUTIs with suprapubic catheterization.

However, the subsequent sources have refuted this finding citing that the difference has been insignificant taking into account various other complications associated with suprapubic catheterization. These studies did not deny the benefits of suprapubic catheterization. These findings are relevant in answering the PICO question. Both the comparison and intervention variables have been extensively addressed.

It can be safely be reported that suprapubic catheterization does not reduce the incidence of CAUTIs as compared with urethral catheterization in any population. This relevance also applies to practice in that the use of suprapubic catheterization will best be applied only where it is indicated and cannot be adopted to population interventions to reduce infections. PICOT Question and Evidence-based Approach

Conclusion

Suprapubic and urethral catheterization aim at similar outcomes but do not differ significantly in complications. This evidence-based practice project has confirmed this hypothesis through analysis of findings from three high evidence level sources. The sources included two sustentation reviews with metanalyses and one control trial. These sources would be summarized that suprapubic catheterization is bets where it is indicated, that is, where urethral catheterization is contraindicated. It does not confer any superiority in the reduction of the incidence of CAUTIs in all patient populations. This conclusion is useful in answering the PICO question and application to practice. Other interventions should be sought to reduce the CAUTI incidence.

PICOT Question and Evidence-based Approach References

  • CDC. (2019, October 1). Catheter-associated urinary tract infections (CAUTI). Cdc.Gov. https://www.cdc.gov/hai/ca_uti/uti.html
  • English, S. F. (2017). Update on voiding dysfunction managed with suprapubic catheterization. Translational Andrology and Urology, 6(Suppl 2), S180–S185. https://doi.org/10.21037/tau.2017.04.16
  • Gibson, K. E., Neill, S., Tuma, E., Meddings, J., & Mody, L. (2019). Indwelling urethral versus suprapubic catheters in nursing home residents: determining the safest option for long-term use. The Journal of Hospital Infection, 102(2), 219–225. https://doi.org/10.1016/j.jhin.2018.07.027
  • Jian, Z., Feng, S., Chen, Y., Wei, X., Luo, D., Li, H., & Wang, K. (2018). Suprapubic tube versus urethral catheter drainage after robot-assisted radical prostatectomy: a systematic review and meta-analysis. BMC Urology, 18(1), 1. https://doi.org/10.1186/s12894-017-0312-5
  • Lachance, C. C., & Grobelna, A. (2019). Management of patients with long-term indwelling urinary catheters: A review of guidelines. Canadian Agency for Drugs and Technologies in Health. https://www.ncbi.nlm.nih.gov/books/NBK545495/
  • Li, Z., Li, K., Wu, W., Wang, Q., Ma, X., Lin, C., Peng, S., Lai, Y., Wang, F., & Huang, H. (2019). The comparison of transurethral versus suprapubic catheter after robot-assisted radical prostatectomy: a systematic review and meta-analysis. Translational Andrology and Urology, 8(5), 476–488. https://doi.org/10.21037/tau.2019.08.25
  • Podkovik, S., Toor, H., Gattupalli, M., Kashyap, S., Brazdzionis, J., Patchana, T., Bonda, S., Wong, S., Kang, C., Mo, K., Wacker, M. R., Miulli, D. E., & Wang, S. (2019). Prevalence of catheter-associated urinary tract infections in neurosurgical intensive care patients – the overdiagnosis of urinary tract infections. Cureus, 11(8), e5494. https://doi.org/10.7759/cureus.5494

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.

 

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 Medicine, 61(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 Reviews, 2019(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 Medicine, 8(10), 1625. https://doi.org/10.3390/jcm8101625
  • McIntosh, K., Collins, J., & Mick, J. (2022). Promoting a culture of clinical inquiry in nursing. Nursing, 52(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 organizations. Nursing, 52(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 Obstetrics, 154 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 Reports, 1(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 One, 16(3), e0247782. https://doi.org/10.1371/journal.pone.0247782

Also Read: Protected Health Information: Privacy, Security, and Confidentiality Best Practices