Formulation of the search question:

Question: Cardiac monitoring post DC (Direct current) cardioversion – does this intervention reduce the number of adverse incidents?

The background to this question begins with the notion that whilst some policies and protocols are evidence-based, some are developed from opinions of clinical staff within institutions without evidence. An example is the routine cardiac monitoring of patients following DC cardioversion. It seems reasonable to think that if a patient has undergone a procedure affecting their cardiac rhythm that their cardiac rhythm should be monitored. Why is this? Is there good reason to do this? Or good reason not to? The question therefore began as “Would cardiac monitoring for a few minutes to record the cardiac rhythm post procedure pose any safety risk to the patient, or change their plan of care, compared to cardiac monitoring for a longer time?”
In modern healthcare it is difficult to justify arbitrary decisions or practices. “In order to make a decision, you need to ask yourself what is the evidence you need to act in this situation. This relates to all types of decisions and you need to be ready to justify your practice” (Aveyard et al. 2009 p.30).
Whittemore and Knafl (2005 p.548) state “…a clear problem identification and review purpose are essential to provide focus and boundaries”. In order to practice with an evidence base, research findings need to be “methodologically sound and clinically relevant” (Meadows-Oliver 2009 p. 352).
These 2 authors highlight that a well-written question will lead to locating appropriate literature that can be helpful in providing an evidence base for nursing practice.
As described by McGrath et al (2012), Roy Brown, a nursing librarian, created a Search Process Checklist to assist nurses to search databases. He breaks the process down to 6 steps, 5 of which are relevant here: 1) Problem/construct the question, 2) Choose the appropriate database(s)/resource 3) formulate search strategy, 4) perform search and 5) evaluate results.
The question as it began, is so long and has so many variables that it would be unviable to either research or to search to see if others have already researched the idea intended by the question. It is therefore necessary to refine the question, and define its parameters.
Refining the question goes through several stages. First, the question is actually two separate questions and should therefore be addressed as two questions. This leads to “Would cardiac monitoring for just a few minutes post DC cardioversion have adverse effects on patient safety compared to monitoring for longer time periods?”
The terms “few” and “longer” are abstract and require defining. A potentially researchable way of defining these parameters would be “would cardiac monitoring for fifteen minutes post DC cardioversion have adverse effects on patient safety, compared to cardiac monitoring for one hour or longer?”
Thinking if such a study has been conducted already indicated that “adverse effects on patient safety” required definite parameters or to be quantifiable. This led to the question as posed “Cardiac monitoring post DC cardioversion – does this intervention reduce the number of adverse incidents? “
This defines the act i.e. cardiac monitoring, it defines the situation i.e. post DC cardioversion and it defines the information sought i.e. adverse incidents post procedure.
The question arises is “adverse incident” an acceptable term. Whilst this could be described as being vague there are justifications for this wording - it will be the purpose of the keywords/search strategy to arrive at inclusion/exclusion criteria in order to capture all relevant literature.
A cursory search on a range of medical databases returns a multitude of examples of adverse events post DC cardioversion. The international guidelines for the delivery of DC cardioversion highlight adverse outcomes associated with the procedure such as temporary atrial stunning, dislodgement of thromboembolism from the left atrial appendage and complications relating to conscious sedation (Camm et al. 2010). This information will contribute to the search strategy.
The value of answering a question could be answered by asking if the question is relevant and justified. In the case of this question it is justified for several reasons. Firstly, if a practice has no benefit to the patient there is not value in using nursing, biomedical equipment and hospital capacity resources. If the practice has no value and ceased the reduced use of nursing, biomedical equipment and hospital capacity could lead to reduced costs for the service provider. Further, immobilisation is never risk free, therefore unnecessary immobilisation is unjustifiable.
Finally, having defined and refined the question, and having justified its reason and relevance the final stage to ensure the question is purposeful and viable is to apply it to a model. In this case the PICO model is used (Sackett et al. 1997). Patient/Population/Problem | Patients of all demographics following elective DC cardioversion | Intervention | Cardiac monitoring post procedure | Comparison | Patients not monitored post DC cardioversion | Outcome | Cessation of unnecessary intervention potentially leading to reduced costs and increased capacity for service provider and earlier ambulation. | Databases / Resourses.
The literature search will initially use the CINAHL (Cumulative Index to Nursing and Allied Health Literature) database. CINAHL has been selected as the question is primarily regarding a nursing activity following a procedure. The type of studies sought are quantitative data, with systematic reviews of such quantitative studies being the optimal aim. CINAHL provides the biggest database of nursing articles, clinical trials and evidence based care sheets available (Knapp 2006). The search facilities on CINAHL allow for thorough inclusion/exclusion of search criteria when searching. The information available from many other sources e.g. Internurse and British Journal of Cardiac Nursing are available via CINAHL.
The search is restricted to online searching due to no available access to on-campus library resources.
The Joanna Briggs Institute (JBI) database will also be searched. The “institute is known for providing reliable evidence healthcare professionals can use to inform their decision making…” (McGrath 2012 p.169), and collates its information from collaboration with over 70 entities across the world (Joanna Briggs Institute 2013).
Search Strategy:
The search strategy shall comprise of two areas, 1) identifying inclusion/exclusion criteria and 2) identifying keywords and all variants thereof.
Inclusion/Exclusion criteria: Before starting a literature search, the reviewer must determine inclusion/exclusion criteria and think why some publications are appropriate for answering the research question and why some are not (Cooper 2010). The inclusion criteria includes:1) all demographics of population as the practice of DC cardioversion and monitoring is not affected by demographics, 2) publications of any age will be included as the indication for DC cardioversion and the electrophysiology of DC cardioversion does not change with time – if a large number of studies are retrieved this inclusion could be reviewed and 3) all publication/source types to maximise likelihood of retrieval of all relevant literature – if several studies are retrieved this can be reviewed to reflect quality of evidence. Exclusion criteria are: 1) studies that include non-DC cardioversion, as the purpose is to review a practice related to DC cardioversion only and 2) non-English language articles in light of the difficulty of translation. Keywords: When selecting keywords Manchester University literature searching guidelines suggest including synonyms, alternative terminology, alternative spelling, related terms and variations in word endings e.g. singular or plural (Manchester University 2012). Using these guidelines the following keywords were arrived at:
Keyword 1: DC cardioversion. Alternatives found were “Electric Countershock”. The “DC” component may exclude valid articles but its exclusion will not exclude articles, therefore “cardioversion” will be searched.
Keyword 2: Post. Alternatives found were “after” and “following”.
Keyword 3: Cardiac Monitoring. Alternatives found were simply “monitoring”.
Keyword 4: Adverse Incident. Alternatives found were “Complication” and “Adverse Health Care Event”.
CINAHL Search:
An initial search with just a CINAHL Heading of “cardioversion” returns 2073 results. A search of the alternative term “electric countershock” returns 1 result.
Using the advanced search facility to determine that either of these keywords should be in the title reduces the results to 485 and 1 respectively. To further narrow the search Boolean operators are used.
As both cardioversion and electric countershock are valid the OR option was facilitated i.e. cardioversion OR electric countershock which predictably produces
486 results i.e. the 485 cardioversion results plus the 1 electric countershock result.
The term “adverse” rather than “adverse incident” was used for the search to maximise the returns and reduce the likelihood of keyword choice causing omission of results. “Adverse” OR “Complication” was used in
Conjunction with the “cardioversion” OR “electric countershock” options. This reduces the results to 116.
Using this method to include all variables of the keywords described end with a search “cardioversion” OR “Electric countershock” AND “Adverse” OR
“Complication” AND “Post” OR “After” OR “Following” AND “Monitor” OR “Cardiac
Monitor” returns just 2 results. In view of this excluding the perhaps non-essential “Post” OR “After” OR “Following” criteria could be considered. However this failed to return any extra results.
Clearly a refinement to 2 articles is very easy to search. Had more results been returned the objective would be to refine to a manageable number of titles to read. In this instance there are 2 – neither of which are relevant to the intent of the question.
Joanna Briggs Institute Search:
The search terms “cardioversion” or “electric countershock” alone retrieved no results. Therefore there is no value in continued searching of this database.
Conclusion: The conclusion of the search is that within the CINAHL and JBI databases there are currently no articles relevant to answering the question posed. Either a different question needs to be asked or perhaps here is a gap in nursing research. It could be that the databases searched were incorrectly or inappropriately identified, as nurse led DC cardioversions are rare. A different strategy could be developed identifying the aforementioned complications and review the literature pertaining to these, to uncover if cardiac monitoring played a role in their identification – this may be more appropriately searched in medical databases such as Medline or the Cochrane library.

References:
AVEYARD, P. et al., 2009. A beginner’s guide to evidence based practice in health and social care professions. Maidenhead: McGraw-Hill, 2009, p.30.
CAMM, A. J. et al., 2010. Guidelines for the management of atrial fibrillation: The Task Force for the Management of Atrial Fibrillation of the European Society of Cardiology (ESC). EP: Europace, 12(10), pp. 1360-1420.
COOPER, H., 2010. Research synthesis and meta–analysis: a step-by-step approach. 4th ed. Los Angeles: Sage.
JOANNA BRIGGS INSTITUTE, 2013. Welcome to the Joanna Briggs Institute. The Joanna Briggs Institute. http://www.joannabriggs.edu.au/ (Accessed on 15.02.13).
KNAPP, M., 2006. CINAHL Plus. Journal of the Medical Library Association. 94(3), pp. 353-354.
MCGRATH, J. et al., 2012. Before you search the literature : How to prepare and get the most out of citation databases. Newborn & Infant Nursing reviews, 12(3), pp. 162-170.
MEADOWS-OLIVER, M., 2009. Does qualitative research have a place in evidence based nursing practice? Journal of Pediatric Health Care, 23(5), p.352.
SACKETT, D.L. et al., 1997. Evidence-based medicine: How to practice and teach EBM. 1st ed. London: Churchill Livingstone.
THE UNIVERSITY OF MANCHESTER, n.d. How to undertake a literature search. The University of Manchester. http://www.library.manchester.ac.uk/academicsupport/howtostructurealiteraturesearch/_files/How-to-undertake-a-literature-search.pdf (Accessed on 15.02.13).
WHITTEMORE, R. and KNAFL, K., 2005. The integrative review: Updated methodology. Journal of Advanced Nursing, 52(5), p.548.