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Department: INSPIRING CHANGE

Using PICO and the brief report to answer clinical questions

Elkins, Mary Y. MPH, RN, CIC

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doi: 10.1097/01.NURSE.0000369871.07714.39
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AS A BUSY NURSE CLINICIAN, you need practical information about how to apply evidence-based practice (EBP) to your daily routine. This article will explain how you can use the acronym PICO and a brief report to quickly assess current best practices, share information with colleagues, and improve patient outcomes.

A matter of time

Using the brief report method for disseminating systematic reviews can help you to overcome the barrier of lack of time when it comes to reading and synthesizing literature.1 Findings can be e-mailed to nursing staff to provide easy access to research. Brief reports can be designed and written to be understood in small doses, which will engage rather than overwhelm the nurse, encourage appreciation for research, and increase awareness of EBP.1 This method is a simple, visible way to share information efficiently throughout the hospital nursing department.

For maximum clarity and efficiency, the acronym PICO can be used to frame and focus clinical questions. PICO stands for:

P:Patient or Population

I: proposed Intervention of Interest

C:Comparison group or Current standard

O:Outcome desired.

The PICO acronym is based on the 1992 Centre for Evidence-Based Medicine recommendation for asking focused questions and finding the right evidence to answer them.2 Nursing researchers support the use of PICO.3

Using the brief report method, you can focus the question with PICO, get the best evidence from the literature, critically appraise the information, and write the findings in a one-page summary. The final step includes sharing the summary with other clinicians so that everyone can appraise the evidence and decide whether to integrate it into practice.

Now let's examine how one group used PICO and the brief report to assess the evidence for one practical application.

A shower of evidence

I used PICO in my medical-surgical unit to determine whether to change current procedure for the preoperative shower. This question formed the basis of the investigation: For the surgical patient, will the use of chlorhexidine gluconate (CHG) shower preoperatively, compared with the current standard practice of an antibacterial soap or plain soap shower preoperatively, prevent postoperative surgical site infections (SSIs)?

Council members reviewed the question using a PICO template tailored for questions of prevention. (See Practical PICO pointers.) The question was framed in the PICO format as follows:

P: for the surgical patient

I: will the use of CHG shower preoperatively

C: compared with the current standard practice of an antibacterial soap or plain soap shower preoperatively

O: prevent postoperative SSIs?

Next, the group completed a review of the literature and found a relevant review of six clinical trials on the topic in the Cochrane Database of Systematic Reviews.4 A systematic review is the top level in the rating system for the hierarchy of evidence/levels of evidence; it's the strongest evidence to use for basing clinical decisions.

The Cochrane Database of Systematic Reviews supplies simple, plain-language reviews of research. These final findings help clinicians decide whether to apply the findings to practice or to reject them as not applicable.5

After a discussion of the findings, a brief report was written using Oermann and colleagues' format: a one-page summary of what intervention is done, what outcome is examined, who's studied, who the researchers are, and what the results are.1 It was sent as an attachment via e-mail to the nursing staff for their review.1Anatomy of a brief report shows what we sent, including a more user-friendly PICO.

Reaching a conclusion

Findings were used in the nursing department decision to not change current practice but to continue the use of CDC recommendations for the reduction of SSI.6 These Category IB recommendations from the CDC require patients to shower or bathe with an antiseptic agent on at least the night before the operative day.6

Based on return receipts received, 49% of the nursing staff read the report and a few of them made positive comments.

A versatile system, PICO can be used for very simple studies, such as the CHG review, as well as complex research studies. PICO has been in use for a long time and is used in many well-written research reports without being identified as such.7

An example is a grant-funded research project on the outcomes of ICU working conditions. The study question was, "What is the effect of variation on ICU working conditions and organizational climate on patient safety [of older adults] while controlling for patient severity of illness, healthcare setting characteristics, and the nurse labor market?"7

One possible PICO for this study may be formulated as:

P: for the older patients in the ICU

I: does changing workforce staffing ratios

C: compared with the current workforce staffing ratios

O: decrease the patient's length of stay?

Practice and collaboration using PICO will help hone this new skill.

Putting PICO into practice

PICO is a method every nurse can adapt for use. Borrowing another's idea and adapting it to your own use and role modeling are effective methods of learning.8 So, the next time someone on staff asks a clinical question, suggest putting it into PICO and go from there to find the best evidence. Write the findings in a one-page summary and share results with other nurses. With PICO methodology, you can incorporate EBP into your daily practice.

PRACTICAL PICO POINTERS

Nursing EBP leaders Bernadette Melnyk and Ellen Fineout-Overholt have provided PICO templates for nurse clinicians to use when answering clinical questions. These templates as well as a detailed explanation of PICO can be found in their book, Evidence-Based Practice in Nursing and Healthcare: A Guide to Best Practice.3 These templates explain how to develop a PICO for questions relating to therapy, diagnosis, prevention, prognosis, and meaning.

Duke University Medical Center Library has a website of helpful information called Evidence-Based Clinical Practice Resources. It can be accessed at http://www.mclibrary.duke.edu/subject/ebm/ebmpyramid.html.

ANATOMY OF A BRIEF REPORT

P: for surgical patients

I: does showering with CHG preoperatively

C: compared with showering with regular soap or antibacterial soap preoperatively

O: reduce the risk for a postoperative SSI?

  1. What intervention is studied? Use of CHG for showering preoperatively is compared with regular or no special soap as a measure to reduce SSIs.
  2. What outcome is measured? Support for use of CHG as a new gold standard for reducing SSIs
  3. Who's studied? 10,226 hospital participants in 6 clinical trials: 1,092 participants comparing CHG with no washing, 1,443 participants comparing CHG with bar soap, and 7,691 participants using CHG or placebo.
  4. Who are the researchers? Two authors using randomized control trials in a systematic review
  5. What are the results? Plain-language summary stated in the Cochrane Database of Systematic Reviews: "[SSI] is a serious complication of surgery and may be associated with increased length of hospital stay for the patient and higher hospital costs. The use of an antiseptic solution for preoperative bathing or showering is widely practiced in the belief that it will help to prevent [SSI]. However, the review found six trials that included 10,226 patients that didn't show clear evidence of benefit for the use of [CHG] over other wash products."4
  6. What's the final analysis/practical application? According to EBP studies, purchasing CHG as a preoperative bath product isn't supported in the literature as a cost-effective way to ensure reduction of SSIs.

REFERENCES

1. Oermann MH, Floyd JA, Galvin EA, Roop JC. Brief reports for disseminating systematic reviews to nurses. Clin Nurse Spec. 2006;20(5):233–238.
2. Oxman AD, Sackett DL, Guyatt GH. Users' guides to the medical literature. I. How to get started. The Evidence-Based Medicine Working Group. JAMA. 1993;270(17):2093–2095.
3. Melnyk B, Fineout-Overholt E. Evidence-Based Practice in Nursing and Healthcare: A Guide to Best Practice. Philadelphia, PA: Lippincott Williams & Wilkins; 2005.
4. Webster J, Osborne S. Preoperative bathing or showering with skin antiseptics to prevent surgical site infection. Cochrane Database Syst Rev. 2007;(2):CD004985.
5. Sackett DL, Rosenberg WM. The need for evidence-based medicine. J R Soc Med. 1995;88(11):620–624.
6. Mangram AJ, Horan TC, Pearson ML, Silver LC, Jarvis WR. Guideline for prevention of surgical site infection, 1999. Hospital Infection Control Practices Advisory Committee. Infect Control Hosp Epidemiol. 1999;20(4):250–278.
7. Stone PW. Popping the (PICO) question in research and evidence-based practice. Appl Nurs Res. 2002;15(3):197–198.
8. Berwick DM. Disseminating innovations in health care. JAMA. 2003;289(15):1969–1975.
© 2010 Lippincott Williams & Wilkins, Inc.