The Treatment of Acute Exacerbation of COPD - Research Paper Example

The Treatment of Acute Exacerbation of COPD Introduction I work as a paramedic in a private hospital and have developed an interest in the attributes and use of hydrocortisone in the treatment of acute exacerbation of COPD. This research paper will demonstrate both a high level of proficiency in searching and not only an understanding of hierarchy of evidence but also how the findings are applicable to the management of acute exacerbation of COPD. In the medical emergency units, paramedics are not allowed to give patients of acute exacerbation of COPD hydrocortisone as treatment although the drug is critical in bridging the gap between time of arrival at the hospital and the commencement of actual treatment. However, Sahn (2012) conducted research that showed the pre-hospital administration of hydrocortisone may improve. This could possibly be a result of evidence-based practice (EBP) and the purpose of this paper is to present results of research into the topic. The paper’s conclusion will discuss the use of EBP in the campaign for change in the treatment of acute exacerbation of COPD. EBP is relevant in practice mainly because it is informed by recently researched data that has been approved by professionals and the industry. PICO and the Search for Evidence According to Moyer (2008), managing acute exacerbation of COPD is a common practice that demands the critical search for evidence in the healthcare setting. In agreement to this opinion, Gregory and Mursell (2010) emphasise that medical practitioners should formulate relevant questions about the treatment of acute exacerbation of COPD. Based on this, this essay will search and answer the question “would the outcome of patients with acute exacerbation of COPD be improved by the pre-hospital administration of hydrocortisone in the UK?” Specifically applied to this question, the PICO model defines not only the problem but also the population at which the population is targeted. This was significant in the shaping of the literature search because it narrowed down the scope to a more defined area with specific expected outcomes. Yoder-Wise (2007) points out that it is critical in detailing the interventions and risk factors that must be considered by paramedics in their procedure. This is as opposed to stereotyping the management of acute exacerbation of COPD to a particular long-used procedure (Goldacre, 2013). This aspect also contributed towards the shaping of the literature search because it targeted arriving at patient-oriented results rather than traditionally occurring scenarios. Ideally, the PICO worksheet that was refered to in this search can be outlined as follows: P: Problem, patient or population. This entails who receives the intervention as well as the problem being addressed. I: Intervention, assessment tool and risk factor. This entails what the paramedic does for the patient and the treatment procedure. C: Comparison. This entails available alternatives to the intervention and may as well mean no intervention. O: Outcome. This defines what the goals are. It is also concerned with the process, perception or structure that the paramedics may wish to better understand or improve. The significance of the PICO model is emphasised because the question asked is more of a foreground question than a background question. Aveyard (2009) offers an explanation to this when they describe background questions as those that are concerned with general knowledge and are usually in two parts. The first is a question root that addresses elements such as why, who, what, how, when and where. The second is concerned with aspects of healthcare such as treatment, test and disorder, and these questions are easily answered by referring to clinical databases or textbooks. On the other hand, foreground questions usually take the form of specific-knowledge questions including sociologic, psychological and biological issues that impact on clinical decisions. As Aveyard and Sharp (2013) showed, these questions will often require searching primary medical literature. Hence, according to Cluzeau, Grimshaw and Eccles (2013), the PICO model is best suited for the search. Cranston (2010) showed that clinical effectiveness must be based on answering healthcare questions basing on evidence. This supports the need of using the PICO tool to answer the search question and as Evans (2011) asserts, quality research is also supported by tests. This served the purpose of the search because it was based on the fact that exacerbations are significant outcome measures in acute COPD. According to Straus (2008), appropriate and considerably tested measures can be used to not only practice but teach EBP. Therefore, PICO was a critical tool because its use acknowledges the significance of effectively identifying a question, searching strategies and applying the research evidence to practice. Essentially, this ensures the appropriate prediction of the possible causes of given health conditions and their related issues. According to Cazzola (2009), this calls for the expert opinion on the consistence or inconsistence of what the predictions result in. This opinion essentially requires the development of a hierarchy of evidence as shown in the table below. Level Rank Methodology STRONGEST 1 Systematic Reviews and meta-Analyses 2 Randomize Controlled Trials 3 Case- Controlled Studies 4 Non-Experimental Designs 5 Expert Opinion WEAKEST 6 Views of colleagues Table 1: Hierarchy of Evidence (Cazzola 2009). The search will mainly be conducted by systematic reviews and meta-analyses but will also include randomize controlled trials and case-controlled studies. As Pauwels et al (2009) explained, the hierarchy of evidence emphasises that some strategies used in research may not be as effective or yield credible results as others. For example, Appleby (2005) describes systematic reviews and meta-analyses as thorough documentations of extensive research with the capacity of providing highly reliable evidence. As Polit (2010) asserts, systematic reviews and meta-analyses minimise situations usually compromise the credibility of search findings by enhancing the ability to integrate evidence into their decision-making procedures. Randomised controlled trials are also highly reliable (Glassman 2008) because they are basically clinical experiments. They address issues ranging from different types of interventions to their effectiveness. According to French (2007), case-controlled studies are usually constrained to specific circumstances and the findings may not be generally applicable to the wider number of cases that occur with the general population. Moving down the hierarchy, non-experimental designs, expert opinion and views of colleagues are not reliable and will require extensive discussion and support from evidence provided by other research for them to be valid (Cluett 2007). Although Missal et al (2010) agree that asking the right search question is not always an obvious skill they also insist that it is the fundamental step towards evidence-based process of decision-making. Basing on this argument, the PICO model was used to narrow down the focus of the search and also enable it to concentrate on relevant and information found in an amount of literature that is convenient. Hence, as Dickenson-Hazard (2008) found, PICO is instrumental in filtering out bulk and largely generalised literature and the approach helped in identifying and describing the group that was the subject of the search. As Trinder and Reynolds (2000) had earlier observed, it is imperative to identify what the intervention is intended to do for the group, and this led to the search and analysis of specific diagnostic tests, therapy and recommendations. Salmond (2009) later supported this observation and contributed that PICO is appropriate because its underlying design acknowledges that intervention is the key consideration. Practice Guidelines This search will critique and then compare and contrast guidelines provided on one hand by the American Thoracic Society (ATS) and on the other by the Canadian Thoracic Society (CTS). The CTS is made up of a collection of established organizations of lung health. Their guideline, “Prevention of Acute Exacerbation of Chronic Obstructive Pulmonary Disease”, provides the first evidence-based recommendations intended to prevent acute COPD exacerbations. This is unlike earlier guidelines that had their primary focus on managing COPD exacerbations rather than preventing acute exacerbations. Therefore, the developers’ new and more detailed focus enabled the guideline to score highly in the domain of scope and purpose. The credibility of the guideline is enhanced by the fact that it still addresses both the old and new therapies that are available for use in preventing COPD exacerbations but with an emphasis of addressing the void that existed previously. The guideline provides details of both its general and specific objectives. This contributes to its rating because it clearly outlines its target population and the intended outcomes, which effectively answers the health question founded on the prevention of acute COPD. For example, while the guideline agrees with previous guidelines that treatment should start with increasing the dosage of inhaled bronchodilators as well as oral corticosteroids, it also insists on and explains the significance of continuous prevention. Terms are clearly defined as the guideline first offers a descriptive overview of acute COPD before getting into the more detailed recommendations. Further, since the contents address different populations with relevant information depending on whether it is meant for practitioners, patients and the general public, the information is easily located because of the logical arrangement. The guideline also scores well on the stakeholder involvement domain because the participants in its development were drawn from different areas. It included medical scholars, physicians, nurses, patients and their families and the general public that had had either a direct or indirect experience with acute COPD. From this perspective, the score was boosted by the inclusion of the consideration of the views of all that were involved data collection. It is worth noting that the CTS is composed of various organizations and, collectively, they work with similar institutions beyond the Canadian border. This enabled the research that was used to develop the guideline take place in a number of states in the US, although limitations that included interference by the funding organizations’ views were pointed out. To address the management of acute exacerbation of COPD, the American Thoracic Society (ATS) developed a guideline that categorises the condition into mild, moderate and severe. This aspect of this guideline, “Management of COPD Exacerbation”, scored highly because it is in conformity with the American Association of Family Physicians’ (AAFP’s) criteria for evidence-based medical education (Gerrish 2012). Further, the research towards its development included an extensively wide scope of stakeholders both in the US and Canada. The involved stakeholders included physicians, nurses, patients, the society and medical students and scholars. The questions were designed by the scholars and physicians basing on documented events. It also scored well in scope and purpose because it offers definition and classification of COPD, etiology, initial evaluation and, more importantly, therapeutic options. The scope and purpose domain of the guideline is highly detailed in its description of long-term prevention of complications, lowering the risk of subsequent exacerbation and offering clear guidance on the most appropriate and effective management of COPD. The high rating was mainly from the intents of the guideline, the stated expected outcome and the population it targets. According to Loyd (2008), guidelines are potentially beneficial depending on their quality. The ATS guidelines are of high quality since it names the sources used in its development and they include journals, databases and direct interviews. From this, the developers were able to provide clear descriptions of circumstances and how to handle them. For example, The ATS guideline also shows that short and systemic course of corticosteroids will considerably increase the time before exacerbation and at the same time decrease the rate of failure of treatment (Sahn 2010a). Concurring, Voelkel (2013) has also shown that there will be improved forced respiratory volume and hypoxemia. However, a key weakness of the guideline is that even though it is largely representative in terms of stakeholders and relevant context, there is no explanation of the inclusion criteria for the study design, comparison and target population. Then, more importantly, the guideline does not point out its own limitation either in study design or applicability. The sampling might have been done over a wide geographical area but the guideline does not give an assurance that there was no bias. While the guideline answers the health question and satisfies the stakeholders domain, highlighting on the rationale for inclusion would have earned a better score. Comparing the two guidelines, they both answered the research question sufficiently and were both endorsed by reputable national bodies. They both conducted extensive geographical studies and gathered information from a wide range of stakeholders. Both the ATS and CTS guidelines are logically arranged in a manner that makes it easier for users to access relevant information. However, contrasting the two, the ATS does not state any limitation, which is very unlikely in a study. Stating limitations will make users aware of where they will probably but not necessarily find issues with the guideline. The CTS guideline points out that there were limitations in compiling data in the US and that the data seemed mostly biased. Further, while the ATS had its focus on a similar management topic has been researched previously by other studies the CTS guideline was slightly more advanced because it focused on prevention of acute exacerbations. Unlike the ATS guideline, the CTS guideline includes rationale for inclusion and the user is able to understand why some aspects and concepts were used in the development. Hence, while both studies have their strengths and weaknesses, this search chose the CTS over the ATS because the ability to point out weaknesses suggests credibility. Manipulating the Evidence The manipulation of evidence is in acknowledgement that it can be manipulated both in a variety of ways and for a variety of reasons. According to Melnyk et al (2009), manipulation can be based on where the data came from, the kind of research that was conducted, what the research involved, and the basic results and how the researchers interpreted them. The two studies were conducted by researchers from two countries with similar interests in the medical field just as the DH (2009) had earlier suggested. Each was mainly funded by the umbrella body and government pledges, but also included support from the host country when they went beyond their national borders. However, due to the effects of the media reporting, the data was gathered from people with widely varying levels of information depending on location, education level and willingness to be open. This has the potential to highly compromise the validity and reliability of the findings. For example, in the US where both studies were conducted in part, acute COPD has consistently been reported among the leading cause of death. Inevitably, such attention generates massive volumes of information on the subject on various resources ranging between the Internet, websites, magazines, journals, awareness programs on television and books. However, different populations will access these sources of information differently and at varying levels and make their own interpretations of the information they consume. Earlier, Dale (2006) had shown that relying on such information is not always appropriate because the people will have understood the message in different ways. For example, some respondents based their understanding of acute COPD on information they got from online media without being given any comprehensive clarification of what they read. Essentially, their understanding of the situation is shaped by the media, which also does not clearly explain the source of what it publishes. Further, Woolcock (2008) opines that in this information age, almost everyone is able and free to air their opinion especially when it comes to caring for themselves. This means that the information people access may not always be accurate and, especially in this case, those who have never had any personal experience with acute COPD will simply rely on whatever information the media offers them. In the guideline evaluation, it was shown that both studies scored well in stakeholder involvement. However, referring to earlier findings by Craig and Smyth (2012), this could be a threat to the reliability of the outcomes because it was not shown how the respondents to the study obtained their information. For example, Fitzpatrick (2007) advices that interviewing a respondent who has actually participated in a certain procedure will not give the same quality of results as interviewing one who has only read of the process in the media. Although the study made use of systematic reviews and meta-analyses, randomize controlled trials, case-controlled studies, non-experimental designs, expert opinion and views of colleagues, it is imperative to consider the credibility of the sources of information of the respondents. Appleby (2005) explains that the source of information will reflect in the quality of evidence being developed. Another aspect that arises in this particular search is the reported limitation by CTS in their study in the US. Apparently, it was reported that majority of the respondents denied ever having had personal experience with acute OCPD, yet the ATS acknowledges the problem among the leading cause of death in the nation. Here, it can be said that this is a clear case of bias perhaps arising from stigma or other circumstances. Therefore, the findings from the American respondents may not be representative of the true picture and that has an impact on the process of the development of the guideline. According to the cause and effect theory, it may not be readily established that the feedback they gave was as a result of their own volition and true and honest understanding of the question being researched on. The sample size might have been large, which actually improves validity, but the subject has underlying factors, especially stigma, that may lead to withholding of honest information. Hence, it is imperative that the scientific endeavor that is a key concept of cause and effect is established. EBP is explained by Hoffmann, Bennett and Del (2010) as the integral approach to arriving at quality decisions and appropriately incorporating them in the treatment and caring of patients. However, the guidelines only mention the use of information from two different jurisdictions but neither gives an indication how the data collected from the two jurisdictions was balanced in developing the respective guidelines. On their part, the developers indicate that they interpreted the data as it was given, even after pointing out the limitation. This questions the validity of the guideline. On its part, the ATS did not provide the rationale for not including their study guide, which again questions validity. Conclusion/Opportunities The EBP skills acquired can translate into change opportunities because it will employ the use of tested methods to champion for change. For example, it has been shown that focusing on a specific research question will result in more accurate results that address the target problem and population. Basing on the randomised controlled trials, such as those conducted by Greaves et al (2006), it can be demonstrated that cases of biased outcomes can be reduced and reliability and validity promoted. However, Goroll (2007) Hunter and King (2010) explain the significance of systematic reviews and meta-analyses, which poses the challenge of choice of methodology. On the other hand, Jennings and Loan (2001) the PICO model can be used to design the appropriate question that points at a particular population and describe the expected outcomes. This is of help when it comes to selecting the research methodology, which may necessarily be more than one in a single study. This will appropriately shape the literature search whenever change is required because it narrows down the scope to a more defined and relevant area and specifies the expected outcomes. For example, in this area of practice, Yoder-Wise (2007) points out that it is critical in detailing the interventions and risk factors that must be considered by paramedics in their procedure. Further, rather than basing procedures on stereotyping the management of acute exacerbation of COPD to a particular long-used procedure Goldacre (2013) agrees that EBP skills encourage functional change that can be approved of by many. 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