Screening for Hepatitis C Virus Infection in Adults, Research Paper Example

Employing Evidence-based Practice (EBP)

Evidence-based practice is “The conscientious, explicit and judicious use of current best evidence in making decisions about the care of the individual patient. It means integrating individual clinical expertise with the best available external clinical evidence from systematic research.” This is the most common definition of Evidence-based Practice (EBP) and is from Dr. David Sackett (Sackett, Rosenberg, Gray, Haynes, & Richardson, 1996).

EBP is the integration of clinical expertise, patient values, and the best research evidence into the decision making process for patient care. Clinical expertise is the clinician’s experience, education and clinical skills. The patient brings preferences and concerns, expectations, and values. Best research evidence is research using sound methodology.

My leadership goal in treatment will be founded on the S.M.A.R.T. principle, namely:

Specific as to what is involved with this goal, where it happens and interventions, if any. I will consult with the patient and a senior physician on several of her ailments. This will take place in the hospital settingbecause part of the patient’s diagnoses is contagious Hepatitis C.

Measurable Speaking with the patient to learn if she has had the symptoms for longer time than reported. How to measure the goal? By consultation with senior physicians, the hospital library, statistics, Human Resources, and patient input.

Attainable Is the goal attainable? The resources are available within the hospital environment. I can summon specialized training and experience to determine best possible outcomes better than in an outpatient situation. A meeting with the unit manager and other professionals such as nurses, doctors, orderlies etc.and review peer reviewed material, articles, and studies available on diabetes and hepatitis C complications to alleviate and/or relieve the symptoms in this patient.

Realistic The resources at our disposal make this goal realistic. There is open access to other hospital studies on the issue of pre-senior female Diabetes Miletus patients suffering from complications brought on by Hepatitis C.

Time-bound I believe that the leadership goal should be constant and reviewed at a two week interval. Once/if we see a change in the patient’s condition, the treatment (goal) can be modified or the specifics of the goal can be revisited. Interventions should be done based on best evidence.

Case example:

The patient is a 57 year old female with type II Diabetes Miletus. She smokes ten (half pack) cigarettes daily, and recently switched to vapour E cigarettes. She was hospitalized when diagnosed for diabetes. The patient arrived at the emergency complaining of a ‘sore stomach’.

Patient Problem:

The patient arrived at the hospital emergency room complaining of a ‘sore stomach’ which was distended. The intern did not associate it with diabetes and wanted to conduct tests.

Intervention, prognostic factor or exposure: 

Presently I am considering x rays of the patient’s swollen stomach. Patient complained of pain in her stomach. The patient is bloated, displaying high water retention. The intern set up appointments for blood and urinalysis, radiology, and ultra sound. No surgery anticipated at this time. Emergency room team will wait for test results and team meeting before moving forward.

Comparison: 

The x rays and ultra sound indicate a fluid build-up within the stomach associated with the liver. This bile appears to weigh about 25 lbs. and clearly visible from the ultra-sonography. It was decided to admit the patient and monitor and treat the liver ailment. The blood testing has indicated that the patient is suffering from Hepatitis C and anti-viral drugs will be prescribed for treatment. A diuretic is being used to control the epidermal fluid retention.

Outcome: 

Anticipated prescription drugs

Sprironolactone 100 mg, ½ tablet daily. Spironolactone tablets belong to a group of medicines called potassium-sparing diuretics (water tablets), which help lose excess fluid from the body. They may be used for: congestive heart failure

Pantoprazole 40mg powder for solution for injection is a selective “proton pump inhibitor”, a medicine which reduces the amount of acid produced in the stomach. It is used for treating acid-related diseases of the stomach and intestine.

Furosemide 40 mg, 1 tablet daily. Tablet is one of a group of medicines called diuretics (water tablets). Furosemide tablets were prescribed to treat oedema where there is too much water in the body possibly due to problems with the kidneys, liver, blood vessels or high blood pressure. Furosemide helps kidneys get rid of extra water not needed in the body.

Atenolol 25 mg, ¾ tablet twice daily. Atenolol belongs to a group of medicines called beta-blockers.

Phytonadione 10 mg,oral twice weekly. It is synthetic vitamin K, which occurs naturally in the body and used to treat vitamin K deficiency and treat bleeding or blood clotting problems.

Hepatitis C cannot be eliminated so the symptoms can only be reduced or managed. The swelling in the general area of the belly can be eliminated as can the water retention in the patient’s skin. There is some possibility of side effects of the drug therapy so care is in order.The type of question is important and can help lead you to the best study design:

For our patient, the clinical question is:

In patients with type 2 diabetes and hepatitis C, will standard medical drug therapy be effective or increase the probability of remission of diabetes?It is atherapy questionand the best evidence would be a randomized controlled trial (RCT). If we found numerous RCTs, then we might want to look for asystematic review.

Evidence-Based Practice requires choosing the best resource from large databases such as PubMed/MEDLINE. Secondary resources such as ACP Journal Club, Essential Evidence, FPIN Clinical Inquiries, and Clinical Evidence provide an assessment of the original study.

I will first look at an appraised resource, such as ACP Journal Club to select from the biomedical literature articles that report original studies and systematic reviews that warrant immediate attention by physicians attempting to keep pace with important advances in internal medicine. These articles are summarized in value-added abstracts and commented on by clinical experts.  Studies included in this small database are relevant, newsworthy and critically appraised for study methodology.

A search of “diabetes and hepatitis C complications” identified this source:

Chou, R., Cottrell, E. B., Wasson, N., Rahman, B., & Guise, J. M. (2013, January 15). Screening for hepatitis C virus infection in adults: a systematic review for the U.S. Preventive Services Task Force. Annals of Internal Medicine, 158 (2), pp. 101-108. Print.

This trial found that hepatitis C patients with type 2 diabetes was based on mothers passing the hepatitis virus on to newborns.

A second citation produced this result:

Chou, R., Hartung, D., Rahman, B., Wasson, N., Cottrell, E. B., & Fu, R. (2013, January 15). Comparative Effectiveness of Antiviral Treatment for Hepatitis C Virus Infection in Adults: A Systematic Review. Annals of Internal Medicine, 158 (2), pp. 114-123. Print.

The purpose of this trial wastocompare benefits and harms of antiviral regimens for chronic HCV infection in treatment-naive adults.

I have access to ACP Journal Club but if I didn’t I would have done the search in Pub/Medline, a very large database with over 22 million citations. Other valuable EBP sources include but not limited to:

Clinical Evidence

Clinical Evidence describes the best available evidence from systematic reviews, RCTs, and observational studies when appropriate for assessing the benefits and harms of treatments.

Dynamed is a point-of-care reference resource designed to provide clinicians with current, evidence-based information to support clinical decision-making.

Essential Evidence is a one-stop reference that includes evidence-based answers to clinical questions concerning symptoms, diseases, and treatment.

Clinical Inquiries provides answers to clinical questions by using a structured search, critical appraisal, clinical perspective, and rigorous peer review. FPIN Clinical Inquiries deliver evidence for point of care use.

Up-to-date is an evidence-based, peer reviewed information resource available via the Web, desktop/laptop computer, and PDA/mobile device.

I also consulted with article databases as well as e-books and e-libraries.

Are the results Valid? Was the sample of patients’ representative?

In this case, the patients groups were clearly defined but not representative of the spectrum of disease. Failure to clearly define the patients who entered the study increases the risk that the sample is unrepresentative. The way the sample was selected should be clearly specified, along with the objective criteria used to diagnose the patients with the disorder.

Were the patients sufficiently homogeneous with respect to prognosticfactors?

Prognostic factors are characteristics of a particular patient that can be used to more accurately predict the course of a disease. These factors, which can be demographic or disease specific, or comorbid can also help predict good or bad outcomes.

Was the follow-up sufficiently complete?

Follow-up should be complete and all patients accounted for at the end of the study. Patients who are lost to follow-up may often suffer the adverse outcome of interest and therefore, if not accounted for, may bias the results of the study.

Were objective and unbiased outcome criteria used?Some outcomes are clearly defined, such as death or full recovery. In between exist a wide range of outcomes that may be less clearly defined. Investigators should establish specific criteria that define each possible outcome of the disease and use these same criteria during patient follow-up.

Employing Evidence Based Practice in clinical settings is not a fly-by-night operation; it requires planning and time investment to gather the resources-human and/or otherwise. It is “the conscientious, explicit and judicious use of current best evidence in making decisions about the care of the individual patient. It means integrating individual clinical expertise with the best available external clinical evidence from systematic research.” (Sackett, Rosenberg, Gray, Haynes, & Richardson, 1996).

References

ACP Journal Club. (n.d.). . Retrieved January 27, 2015. Web.

Chou, R., Cottrell, E. B., Wasson, N., Rahman, B., & Guise, J. M. (2013, January 15). Screening for hepatitis C virus infection in adults: a systematic review for the U.S. Preventive Services Task Force. Annals of Internal Medicine, 158 (2), pp. 101-108. Print.

Chou, R., Hartung, D., Rahman, B., Wasson, N., Cottrell, E. B., & Fu, R. (2013, January 15). Comparative Effectiveness of Antiviral Treatment for Hepatitis C Virus Infection in Adults: A Systematic Review. Annals of Internal Medicine, 158 (2), pp. 114-123. Print.

Sackett, D. L., Rosenberg, W. M., Gray, J. A., Haynes, R. B., & Richardson, W. S. (1996, January 13). Evidence based medicine: what it is and what it isn’t. BMJ, 312 (71). Print.