Evidence-Based Practice Network

Show Me The Evidence

The Blog of Lippincott's Evidence-Based Practice Network

Today, I listened in on the Ovid Webcast, Beyond the Search: Maximizing the Quality of Systematic Reviews. Dr. Edoardo Aromataris, PhD, Director of Synthesis Science at the Joanna Briggs Institute in Adelaide, Australia and Dr. Craig Lockwood, PhD, RN, BN, GDip, ClinNurs, MNSc, Director of Translation Science at the Joanna Briggs Institute in Adelaide, Australia successfully gave me a better understanding of systematic reviews. 
Whether you are reading journal articles, completing educational requirements, or performing research yourself, it is important to be aware of the components of a comprehensive systematic review. Why? The presence of specific defining features indicates a high level of rigor in the research which helps ensure that the review is reproducible (same results) and transparent (same conclusion). 
So what are these defining features of a systematic review?
  1. A prespecified question 
  2. Defined inclusion and exclusion criteria
  3. An extensive literature search that includes international research
  4. Selection of studies based on the inclusion criteria
  5. Assessment of the quality of the included studies
  6. Extraction of the data
  7. Analysis of the data
  8. Presentation of the results
  9. Interpretation of the results
We are fortunate that these two experts also co-authored books in the Lippincott-Joanna Briggs Institute Synthesis Science in Healthcare Book Series. It was a pleasure learning from them today! Also, for those of you performing systematic reviews, remember to check out the JBI tools here on the Evidence-Based Practice Network to help you appraise and synthesize the evidence. 
Egger, M., Smith, G., & Altman, D. (2001). Systematic Reviews in Health Care: Meta-analysis in context. London: BMJ Publishing Group.
Glasziou, P., & et al. (2004). Systematic Reviews in Health Care: A Practical Guide. Cambridge: Cambridge University Press.

Posted by Lisa Morris Bonsall on 3/12/2013 1:34:52 PM
Tags: evidence,evidence-based practice,systematic reviews
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Systematic reviews, especially with meta-analysis, are often considered scholarly works at the top of the pyramid (See the Oxford Centre for Evidence-Based Medicine for example.) This is because they typically combine randomized controlled trials (RCTs) that may be limited by small sample sizes, enabling stronger conclusions to be better derived.  Yet, this seemingly golden offering of scholarly literature may have its limitations. 

A systematic review by Boyd, Quigley, and Brocklehurst (2007) on donor breast milk for preterm infants compared to formula is a frequently quoted reference on the subject. The seven studies examined included five randomized controlled trials. The section of the review that receives the most ongoing attention in the literature is the combined effects of three of the studies by meta-analysis on the variable of confirmed necrotizing enterocolitis (NEC), a complication of high concern in premature infants. This analysis combined two RCTs and one observational study. Separately, the sample sizes for these studies ranged from 39 to 162; the combined sample size became 268.  Individual study results did not meet the minimal level of statistical significance of p=0.05. Combined evidence from these studies created a relative risk (RR) of 0.21, 95% CI of 0.06-0.76, p=0.017. The conclusion was that donor milk reduces NEC by about 79% compared to formula. At face value, this is an enticing result. Why the worry?

The concerns with this analysis are partially acknowledged by the authors. The articles used for this study are dated no later than the early 1980’s with data from the 1970’s and the beginning of the 1980’s. Babies included in the studies were 30-33 weeks of age and 1310-1954g, much larger than the premature infant surviving today in our neonatal intensive care units. These studies involved non-fortified milk and exclusive feeding of the control and treatment groups. This too is contrary to today’s practices as fortification is much more the standard practice now. 

One of the authors (Quigley) went on to perform an updated review. This review (Quigley, Henderson, Anthony, McGuire, 2007) is published in the Cochrane Database of Systematic Reviews, a much revered source of scholarly literature. Here five studies were combined in meta-analysis with the addition of a more recent study (Schanler, 2005) of sizeable impact. Unlike several of the other comparisons in this document, the heterogeneity is assessed to be low (I2 of 0.00%) and results favored donor breast milk, with a RR of 2.46, 95% CI 1.19-5.08, p=0.015. This confidence interval was much better than some of the singular studies that reported such wide variances as 0.11 to 60.38. Yet, more limitations exist in this review. Growth restricted preterm infants that are already at high risk for NEC were noted here as excluded.  Again, many of the studies came from the pool described in the article by Boyd and colleagues and infant size and age along with the fortification issue remain. Preparation of the donor milk may also have differed in the early studies compared to today. In summary, the golden scholarly product is tarnished. 

A final note is that evidence reviews cannot end with the statistical analysis. Donor milk costs $3.50 per ounce or more via standard milk banks.  Cost effectiveness needs to be evaluated in order to make this costly recommendation. Given the limitations of the literature and the cost involved, a local team of experts decided against widespread adoption of donor breast milk for premature infants. 


Boyd, C. A., Quigley, M. A., & Brocklehurst, P. (2007).  Donor breast milk versus infant formula for preterm infants:  Systematic review and meta-analysis.  Archives of Diseases in Childhood, Fetal and Neonatal Edition, 92, F169-F175.  doi:  10.1136/adc.2005.089490

Quigley, M., Henerson, G., Anthony, M. Y., McGuire, W.  (2008).  Formula milk versus donor breast milk for feeding preterm or low birth weight infants.  Cochrane Database of Systematic Review 2007, Issue 4.  Art. No.:  CD002971.  doi:  10.1002/14651858.CD002971, pub2

Submitted by: 
Kathy Russell-Babin, MSN, RN, ACNS-BC, NEA-BC
Sr. Manager, Institute for Evidence-Based Care
Meridian Health System


Posted by Lisa Morris Bonsall on 9/12/2012 8:13:30 AM
Tags: breast milk,donor breast milk,NEC,NICU,systematic review
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Recently I had the pleasure of attending Nursing2012 Symposium in Orlando, Florida. One of the sessions, titled Faculty-Guided Poster Tour: Ask the Experts, was a highlight for me. This session was exactly what the title implies; an informal tour of the posters being presented at the conference. Three experts – Frank Myers, MA, CIC; Cheryl Dumont, PhD, RN; and Anne Dabrow Woods, MSN, RN, CRNP, ANP-BC – led the session which was held right in the exhibit hall where the posters were displayed. Frank Myers who critiqued each presentation first, initially broke the ice by sharing that he’s taken about 15 research courses throughout his career and education and asked “What does that make me?” While I thought “an expert,” “amazing,” and “impressive,” he answered for us all by saying “Boring!” It certainly was a fun and interactive session!

The leaders shared their reactions and feedback on 6 of the posters. They pointed out key features of the posters themselves as well as the research being presented. It was helpful to get tips about what a poster should look like, what the elements should be, and a little bit more of the intricacies of research and evidence. Here are some of the things that I learned and I hope that you find them useful too!

The poster should…
  • Be visually attractive.
  • Be about 1/3 pictures and/or graphs.
  • Have about 20% white space.
  • Be legible from 3-4 feet away.
  • Be organized so that the content flows in a logical manner.
  • Include your references.
Regarding the research…
  • Be clear about what you are testing.
  • Make sure you have a good reason to do the research.
  • Get approval from the Internal Review Board (IRB) if needed.
  • Understand the difference between an observation study and an intervention study.
  • When using graphs to show your data, note the intervention period on the graph.
  • When considering endpoints, pay attention to other fields or disciplines.
  • Know what the “popcorn effect” is – remember that during the first weeks of an intervention, people are more likely to like it and perform it.
  • Use rate (for example, amount/1000 patient days) rather than just a number when reporting results.
  • Understand the difference between statistical significance and clinical significance.
  • Compare mean and median to balance outliers. It’s generally okay to discard outliers when they are 2 standard deviations from median or when you disclose that you’ve done so (ask yourself if patient who is an outlier matches your patient population).
  • With regard to sample size, it should never be smaller than 30 and more than 1,500 won’t impact your findings. The more covariants you have, the bigger your sample size needs to be.
  • Anytime something “jumps” out, such as a peak or downward trend, explain it.
Other tips…
  • Spell out acronyms with first use.
  • Remember your audience; not everyone is an expert in statistical analysis.
  • Don’t cut and paste from statistical analysis programs; create new tables and graphs.
  • Supplement your poster with print copies and also copies of any tools you developed for the intervention.
  • Include information about the financial impact of your intervention to “sell” it to administration.
  • Be savvy with terminology – use “cost avoidance” rather than “cost savings.”
Poster presentations can be used as a “stepping stone” to publication. Consider turning your research into a poster and presenting it at an appropriate conference. It’s a wonderful way to get feedback from your peers which you can then incorporate into a manuscript.

Posted by Lisa Morris Bonsall on 5/7/2012 10:35:21 PM
Tags: poster presentation,research
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When a patient has a peripheral line placed in an emergency, whether it is out in the field or in an acute care setting, the intravenous infusion device is discontinued and replaced as soon as possible and certainly within 48 hours (CDC, 2002). This policy from the Centers for Disease Control  and Prevention has been the mainstay of our practice for many years, but is it still best practice? The Infusion Nurses Society thinks differently and recommends that without signs of catheter-related complications, pre-hospital peripheral catheters should not be routinely replaced (Mermel, Farr, & Sheretz. 2001).

A study published in the Journal of Trauma Nursing, Assessing Guidelines for the Discontinuation of Prehospital Peripheral Intravenous Catheter, examined this issue.Their study was a descriptive, archival, retrospective study that reviewed 365 trauma patients, over the age of 17 years, who were admited to an urban level 1 trauma center. The results demonstrated that less than 1% of the patients had complications related to a prehospital peripheral intravenous catheter being left in place longer than 48 hours (Clemin, Heldt, & Jones, et. al., 2012).

What are the implications for practice? Although one study should not change practice, there is evidence in the literature that the current policy needs to be further investigated through research and revised. I encourage all of you to base your practice on evidence and recognize that evidence is not stationary, it evolves every day. What was evidence-based practice 10 years ago, may not be best practice today.

Centers for Diseas control and Prevention, 2002.
Guidelines for the prevention of intravascular catheter-related infections. MMWR,  (5)1, 1-29.

Clemin, Heldt, & Jones, et. al., 2012.
Assessing Guidelines for the Discontinuation of Prehospital Peripheral Intravenous CathetersJournal of Trauma Nursing, (19)1, 46-49.

Mermel, L., Farr, B., & Sherentz, R. et. al., 2001.
Guidelines for the management of intravascular catheter-related infections
. Journal of Infusion Nursing, (24)3, 180-205.

Submitted by:
Anne Dabrow Woods, MSN, RN, CRNP, ANP-BC
Chief Nurse and Publisher
Wolters Kluwer Health / Lippincott Williams & Wilkins / Ovid Technologies

Posted by Lisa Morris Bonsall on 4/9/2012 9:56:00 AM
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I read with interest an original research article published in the February issue of the American Journal of Nursing, Nurses' Presenteeism and Its Effects on Self-Reported Quality of Care and Costs (Letvak, Ruhm, & Gupta, 2012). I was not familiar with the term presenteeism but I was familiar with concept. Presenteeism is defined as reduced productivity on the job as a result of health problems (Letvak, et al., 2012). The most common causes of presenteeism are depression and musculoskeletal pain. How many times have you gone to work when you were not feeling well, had aches and pains or were feeling depressed? The guilt in us as nurses compels us to go to work even when we are sick or not up to it.

This study shows that nurses who go to work when they are experiencing health problems are not doing their patients any favors. Presenteeism increases the number of patient falls, increases the number of medication errors, decreases overall quality of care, and increases costs (Letvak, et al., 2012). The evidence is clear on this matter, going to work with health problems negatively impacts the quality of patient care. The next time you have a health problem and are debating about calling in sick or taking a leave of absence to deal with your health issue, think twice and do your patient a favor – call in sick.

Letvak, S., Ruhm, C., Gupta, S. 2012.
Nurses presenteeism and its effects on self-reported quality of care and costs. American Journal of Nursing, 112(2).

Submitted by:
Anne Dabrow Woods, MSN, RN, CRNP, ANP-BC
Chief Nurse and Publisher
Wolters Kluwer Health / Lippincott Williams & Wilkins / Ovid Technologies

Posted by Anne Dabrow Woods on 2/25/2012 4:33:48 AM
Tags: presenteeism
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