PICOT question Literature Research Review Example Essay- t-PA and Heparin in stroke / diabetes patients
Literature Research Review
Lisa Clemente
Walden University
Literature Research Review
Literature reviews are conducted for numerous reasons. For the scholar, these reviews accentuate the integrity of the writer in his or her field. An in-depth review can govern how to make a significant addition to existing evidence. Researchers typically conduct research within the context of existing knowledge by undertaking a thorough literature review (Polit & Beck, 2017, p. 85). The purpose of this paper is to provide a synthesis of what the studies reveal about the current state of knowledge on the said PICOT question. This paper will also identify inconsistencies and contradictions in the review and offer possible explanations for such. The preliminary conclusion will provide evidence that either substantiates practice change or calls for
further research. PICOT question Literature Research Review Example Essay- t-PA and Heparin in stroke / diabetes patients
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PICOT Question
What is the difference between the administration of t-PA and Heparin in patients diagnosed with stroke and success in the prevention of disabilities?
- Population/Patient Problem: Stroke is diagnosed
- Intervention: plan; testing computed axial tomography (CT) scan, physical examination, history and physical, laboratory studies, and neurology consult.
- Comparison: thrombolytic (t-PA) vs. anticoagulant (heparin)
- Outcome: prevention of disability
- Time: when patient presents to the emergency department within 3 hours when last seen normal was within 2 hours.
Why develop a PICOT question? A crucial first step in evidence-based practice involves converting information needs into well-worded clinical questions that can be answered with research evidence (Polit & Beck, 2017, p. 31). Evidence-based practice (EBP) is the integration of the best research evidence with clinical expertise and patient values (Twycross & Shorten, 2016). Formalizing a clinical question in particulars of the specific patient problem assists the researcher in finding clinically significant evidence in the literature PICOT question Literature Research Review Example Essay- t-PA and Heparin in stroke / diabetes patients.
Literature Reviews: Finding and Critiquing Evidence
The aptitude to find research documents on a topic is an important skill that requires flexibility and patience. A flexible approach to “data collection” and thinking creatively about ideas for new sources of information, is one way to conduct a qualitative study. An important
advantage of survey research is its flexibility (Keough & Tanabe, 2011, p. 37). Despite the method or approach used, primary and secondary questions will need to be addressed. The systematic review of literature is a valuable resource for all nurses to influence policy decisions, and effectuate change. Several organizations that provide helpful guidelines for the conduct of systematic reviews of the literature, including the Cochrane Collaboration, the Johanna Briggs Institute, Cumulative Index to Nursing and Allied Health Literature (CINAHL), MEDLINE, ProQuest, and PubMed. For nurses to assume a leadership role in synthesizing scientific evidence for evidence-based policy development and refinement, nursing education will need to assume a more active role in teaching systematic review methodology (Houde, 2009, p. 9). PICOT question Literature Research Review Example Essay- t-PA and Heparin in stroke / diabetes patients. Using evidence hierarchies rank evidence sources according to the strength of the evidence they provide, and in most cases, randomized controlled trial’s (RCTs) are near the top of these hierarchies (Polit & Beck, 2017, p. 25). Filtered and unfiltered data searches using key search words were utilized. Key search words such as; stroke, thrombolysis, heparin, rehabilitation, brain, hypertension, and hemorrhage revealed a Boolean phrase: stroke AND thrombolysis AND heparin. This initial search generated 22 hits, 5 had relevance to the chosen topic.
Identified Studies
The first study evaluated: Drug Treatment of Acute Ischemic Stroke by Basal, Sangha, and Khatri, identified acute ischemic stroke (AIS) as the fourth leading cause of death and the leading cause of adult disability in the USA. The discussion of the medications related to ischemic stroke care in the context of overall treatment. Ischemic stroke, accounts for 85% of all strokes (American Heart Association, 2011). This study evaluated therapies regarding emergent management of hypertension as one modifiable risk factor. This study also stressed the importance of maintaining glycemic control. Identified barriers in the study emphasized the importance of preventative care.
The second study titled, Treatment Discontinuation with New Oral Agents for Long-term Anticoagulation: Insights from a Meta-analysis of 18 Randomized Trials Including 101, 801 Patients. The objective of this study was to systematically examine discontinuation rates with new US Food and Drug Administration-approved oral anticoagulants (NOACs). This is a randomized control study comparing NOACs to placebo or traditional therapy. Conducted by two authors, the conclusion was that drug discontinuations were not statistically significant from those with conventional drug therapies. PICOT question Literature Research Review Example Essay- t-PA and Heparin in stroke / diabetes patients. Poor compliance to medication regimens by patients is the leading cause of treatment failure.
The third study titled, Acute Stroke Reperfusion Therapy Trends in the Expanded Treatment Window Era, hails from the American Heart Association/American Stroke Association (AHA/ASA). From the year 2007 to 2012, there were 182,235 AIS patients (median age, 72 years; 51.5% women) in the database at the time of analysis (AHA/ASA, 2011). There was a trend for increased use of IV rt-PA in the 0.3 hours and the 3-4.5 hours’ time window. The conclusion infers that widening the window for thrombolysis increases the likelihood of administration. The strength of this study rests in the significant number of patients and the multistate data from a variety of hospitals. One weakness includes outcomes assessment by clinical features rather than formal scales such as the modified Rankin scale (mRS) score. The NIHSS score was only recorded in 55.5% of patients in the cohort, which is a hindrance in the establishment of baseline disability.
The fourth study: Barriers to the utilization of thrombolysis for acute ischemic stroke. This study was published in the Journal of Clinical Pharmacy & Therapeutics. This is a systematic review regarding what is currently known about the use of thrombolytic. Several barriers to utilization were identified. Pre and post admissions barriers were identified. The major barrier is the late presentation to the emergency department, placing the patient outside the treatment window. Current utilization is suboptimal at <3%.
The final study, Comments, Opinions, and Reviews, A Qualitative Study of Stroke, is a literature review of published articles. This is a qualitative study method with the aim of understanding social research on behavior. This was unstructured with focus group interviews and ethnographic observation. With these methods conceptual data is obtained. The key words in this study search were: stroke, cerebrovascular accident, and qualitative. Each paper was reviewed independently by two authors with experience in researching stroke. The findings of 113 papers with 18 excluded, left 95 papers in the study. The conclusion calls for further education of the general public as to stroke identification and recognition. Early detection is the key to initiation of appropriate treatment. PICOT question Literature Research Review Example Essay- t-PA and Heparin in stroke / diabetes patients.
Synthesis of What the Studies Reveal About the Current State of Knowledge
The selected studies were conducted in acute care settings due to the nature of the acuity. All subjects included were patients that suffered a stroke. The primary purpose was to identify the current knowledge in using t-PA versus heparin, and the resulting disabilities. There is considerable debate as to what treatment is best practice. These medications carry significant risk, and the benefit to these risks are not often quickly identified. The inclusion criteria are designed to maximize the benefits while recognizing the risk factors. The recurring theme in this literature research is the essence and importance of time. Public education is one area where gains have been made but reinforcement of this teaching is required. The ‘Act FAST’ public education campaign was introduced to reduce the time to presentation in patients with stroke, and thereby increase the opportunity for thrombolysis and rapid initiation of secondary prevention (Harbison & Hossain, 2003).
Inconsistencies and contraindications with explanations
There were no major discrepancies identified, the explanation for this is a direct result of the problem stated. The majority of acute ischemic stroke patients do not receive thrombolytic therapy due to late arrival to emergency departments and currently there is a lack of acute interventions for them. Further clinical trials may lead to medical breakthroughs to limit the extent of damage PICOT question Literature Research Review Example Essay- t-PA and Heparin in stroke / diabetes patients.
Preliminary Conclusion
Currently, best practice dictates the use of thrombolysis in acute ischemic stroke. The interdisciplinary team approach offers the best opportunity to initiate treatment swiftly and minimize or prevent disability. Continued research efforts will bring new treatments that offer hope where there otherwise may not be. PICOT question Literature Research Review Example Essay- t-PA and Heparin in stroke / diabetes patients.
Literature Review Research Summary Table
| Citation | Type of Study
Design Type
Framework/Theory |
Setting | Key Concepts/Variables | Findings | Hierarchy of Evidence Level |
| Bansal, S., Sangha, K., & Khatri, P. (2013). Drug Treatment of Acute Ischemic Stroke. American Journal of Cardiovascular Drugs, 13(1), 57-69 13p. doi:10.1007/s40256-013-007-6 | Type of Study: Randomized Clinical Trial- European Cooperative Acute Stroke Study (ECASS) III and the large scale registry SITS-ISTR
Design Type: randomized controlled-experimental
Framework/Theory: Descriptive tabulations of data are presented and interpreted
|
Acute Care Facility | Concepts: medication efficacy comparison
Independent Variable: Physical exam, testing, Blood Pressure, Temperature t-PA vs heparin
Dependent Variable: Time frame of presentation
Controlled Variable: Wilcoxon-Mann-Whitney Rank Test
|
Urgent anticoagulation for Acute ischemic stroke (AIS) has generally not shown benefits that exceed the hemorrhage risks in the acute setting. Urgent antiplatelet use for AIS has limited benefits and should only promptly be initiated if alteplase was not administered, or after 24hours if alteplase was administered. | Level 1
Systematic review |
| Chatterjee, S., Sardar, P., Girl, J.S., Ghosh, J., & Mukherjee, D. (2014). Treatment Discontinuations with New Oral Agents for Long-term Anticoagulation: Insights from a Meta-analysis of 18 Randomized Trials Including 101, 801 Patients. Mayo Clinic Proceedings, 89(7), 896-907 12p. doi: 10.1016/j.mayocp.2014.01.030 |
Type of Study: Meta-analysis RCT
Design Type: systematic examination open label, double blind
Framework/Theory Independent extraction of relevant data was performed by 2 authors: |
Acute PICOT question Literature Research Review Example Essay- t-PA and Heparin in stroke / diabetes patientscare facility | Concepts: comparing
New oral anticoagulants with conventional therapy
Independent Variable: choice of medication
Dependent Variable: outcome of treatment, +/- disability
|
Discontinued due to adverse events, consent withdrawal, and nonadherence. | Level 1
Systematic review |
| PICOT question Literature Research Review Example Essay- t-PA and Heparin in stroke / diabetes patients George, M., Tsai, A., & Peacock, J. (2014). Acute Stroke Reperfusion Therapy Trends in the Expanded Treatment Era. ScienceDirect, 23, 2316-2321. http://dx.doi.org/10.1016/j.strokecerebrovasdis.2014.04.023 |
Type of Study: The study population included patients admitted with a diagnosis of acute ischemic stroke from 2007-2012, there were 182,235 AIS patients in the Paul Coverdell National Stroke Registry.
Design Type: European Cooperative Acute Stroke Study III Trial
Framework/Theory: Trends in rates of IV rt-PA versus IA therapy were examined.
|
Acute Care Facility in 6 states
Georgia, Mass, Michigan, Minnesota, North Carolina, and Ohio |
Concepts: With an expanded treatment window of 4.5 hours, more stroke patients are eligible for treatment with t-PA. The expanded treatment window allows for increased treatment opportunities. It is a must to ascertain last seen normal
Independent Variable: Age, race, stroke scale
Dependent Variable: t-PA therapy, no t-PA therapy
Controlled Variable: Wilcoxon-Mann-Whitney Rank Test
|
Guideline recommendations on IV reperfusion after AIS in an expanded time window are slowly being adopted into community practice. Future studies can examine further trends in IV and IA treatments for AIS now that recent studies have shown no superiority of IA therapies to traditional interventions. | Level II prognosis study |
| Krass, I., & Bajorek, B. (2012). Barriers to the utilization for thrombolysis for acute ischemic stroke. Retrieved from web.b.ebscohost.com.ezp.waldenulibrary.org |
Type of Study: Medline, Embase, International Pharmaceutical Abstracts and Google Scholar
Design Type: retrospective observational studies in clinical audits, RCT study
Framework/Theory: NINDS trial |
Systemic integrated multidisciplinary approach.
2 tiered search strategy |
Concept: Several barriers to the utilization of thrombolysis in stroke care have been identified in the literature and can be classified as preadmission barriers and post-admission barrier. Thrombolysis significantly decreases disability from AIS. | As expected, thrombolysis is contraindicated in patients with a high risk of bleeding, including patients on therapeutic anticoagulation, recent gastrointestinal bleeding. | Level II
Therapy and etiology |
| McKevitt, C., Redfern, J., Mold, F., & Wolfe, C. (2004). Qualitative Studies of Stroke a Systematic Review. Retrieved from stroke.ahajouranls.org/content/35/6/1499.full |
Type of Study: Qualitative
Design Type: Literature Review of published articles identified by systematically searching online database using key words
Framework/Theory: European Stroke Initiative (EUSI) and recommendations for medical stroke management. Qualitative social science framework |
Acute Care Setting
PICOT question Literature Research Review Example Essay- t-PA and Heparin in stroke / diabetes patients |
Concepts: EUSI recommendations identify the increasing recognition of stroke as an acute emergency, and call for education of the general public to allow them to recognize symptoms more quickly and to seek urgent treatment.
Independent Variable: identification of last seen normal
Dependent Variable: efficacy of treatment on +/- of disability
|
Qualitative studies have addressed a wide range of issues related to the impact of stroke on individuals, and to the organization and delivery of care. | Level II
Meaning and process questions |
References
American Heart Association. Heart disease and stroke statistics-2011 update. Circulation. 2011;123: e18-209 http://dx.doi.org/10.1161/CIR.ob013e3182009701
Bansal, S., Sangha, K., & Khatri, P. (2013). Drug Treatment of Acute Ischemic Stroke. American Journal of Cardiovascular Drugs, 13(1), 57-69 13p. doi:10.1007/s40256-013-007-6
Chatterjee, S., Sardar, P., Girl, J.S., Ghosh, J., & Mukherjee, D. (2014). Treatment Discontinuations with New Oral Agents for Long-term Anticoagulation: Insights from a Meta-analysis of 18 Randomized Trials Including 101, 801 Patients. Mayo Clinic Proceedings, 89(7), 896-907 12p. doi: 10.1016/j.mayocp.2014.01.030
George, M., Tsai, A., & Peacock, J. (2014). Acute Stroke Reperfusion Therapy Trends in the Expanded Treatment Era. ScienceDirect, 23, 2316-2321. PICOT question Literature Research Review Example Essay- t-PA and Heparin in stroke / diabetes patientshttp://dx.doi.org/10.1016/j.strokecerebrovasdis.2014.04.023
Harbison, J., & Hossain, O. (2003). Is the ’Act FAST’ stroke campaign working? Retrieved from sfxhosted.exilbrisgroup.com/waldenu? ID=pmid:25385853&&genre=article&atitle=
Houde, S. (2009). The Systematic Review of the Literature: A Tool for Evidence-Based Policy. Journal of Gerontological Nursing, 35. Retrieved from web.a.ebscohost.com.ezp.waldenulibrary.org
Keough, V., & Tanabe, P. (2011). Survey Research: An Effective Design for Conducting Nursing Research. Journal of Nursing, 1, 37. Retrieved from web.a.ebscohost.com.ezp.waldenulibrary.org
Krass, I., & Bajorek, B. (2012). Barriers to the utilization for thrombolysis for acute ischemic stroke. Retrieved from web.b.ebscohost.com.ezp.waldenulibrary.org
McKevitt, C., Redfern, J., Mold, F., & Wolfe, C. (2004). Qualitative Studies of Stroke a Systematic Review. Retrieved from stroke.ahajouranls.org/content/35/6/1499.full PICOT question Literature Research Review Example Essay- t-PA and Heparin in stroke / diabetes patients
Polit, D., & Beck, C. (2017). Nursing Research Generating and Assessing Evidence for Nursing Practice (10th ed.). Philadelphia, PA: Wolters Kluwer.
Twycross, A., & Shorten, A. (2016). Using observational research to obtain a picture of nursing practice. Evidence-Based Nursing, 19, 66-67. http://dx.doi.org/10.1136/eb-2016-102393 PICOT question Literature Research Review Example Essay- t-PA and Heparin in stroke / diabetes patients