Editors: Mayhall, C. Glen

Title: Hospital Epidemiology and Infection Control, 3rd Edition

Copyright ©2004 Lippincott Williams & Wilkins

> Table of Contents > XIV - The Literature in Hospital Epidemiology and

Infection Control > Chapter 92 - Searching the Literature in Hospital

Epidemiology and Infection Control

Chapter 92

Searching the Literature in Hospital

Epidemiology and Infection Control

Cynthia J. Walker

K. Ann McKibbon

Fiona Smaill

R. Brian Haynes

Since the second edition of this book was published in 1999, access to healthcare literature has continued to become easier, faster, and more widespread. The Internet features prominently as a primary repository for healthcare information. Indeed, many of the traditional forms of literature such as journal articles and books are available in theirentirety on the Internet. More quality-filtered and patient-ready resources are available to help streamline the search for information. Finally, a new form of technology has invaded the information scene: the handheld or personal digital assistant (PDA).

In this updated chapter, we explore the improvements in information access to evidence-based resources with relevance to infection control. We review these new resources and improvements in old ones as they relate to three areas in which a healthcare professional would require high-quality information: (a) solving clinical problems, (b) keeping up-to-date, and (c) setting clinical policy.

USING THE LITERATURE TO SOLVE CLINICAL PROBLEMSQuick and efficient access to high-quality reliable information is never so important as when faced with a pressing clinical problem. This is especially true in the rapidly changing field of infection control in which practices and policies are subject to frequent changes and amendments. To make informed clinical decisions, recent reports are needed of systematic reviews or major preplanned humaninvestigations relevant to the clinical setting. One could rely on one'scolleague down the hall—if one has a colleague and he or she is more

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up to date and has time when one needs them… or one can search the literature to find the current best evidence by carefully defining the clinical question, choosing the most appropriate information source, and designing a search strategy (1).

Until recently, textbooks were often sources for basic information that did not change quickly (2). Anatomy plus physiology and other such

basic science subjects lend themselves well to the publication pace of

textbooks. With the publication potential of the Internet, however,

clinical practice textbooks have entered an “evidence-based era.â€

Many textbooks are now available on the Internet and integrate

evidence-based information with specific clinical problems. In addition,

they are updated more or less regularly. Up-To-Date

(http://www.uptodate.com) is an evidence-based electronic textbook

[Web-based and compact disc read-only memory (CD-ROM)] for general

internal medicine and a growing number of other specialties. WebMD

Scientific American Medicine http://www.samed.com) is also available

on the Internet and CD-ROM.

Clinical Evidence, from the BMJ Publishing Group, is a dynamic

electronic synthesis of evidence from randomized trials, published in

print, on CD-ROM, and on the Internet in unabridged, concise, and PDA

formats. Organized by clinical area, the focus of each section is a

selection of clinical questions and answers most often related to

therapies. New and updated topics are posted online each month. The

questions in Clinical Evidence concern the benefits and harms of

preventative and therapeutic interventions, with emphasis on outcomes

that matter to patients.

The Physicians' Information and Education Resource (PIER) is a new

Web-based service from the American College of Physicians-American

Society of Internal Medicine (ACP-ASIM)

(http://www.pier.acponline.org). Volunteer physician editorial

consultants review the literature and prepare PIER modules for specific

topics. The consultants are given recent citations to relevant articles

obtained through filtered electronic searches. The modules are updated

quarterly and made available on the Internet. Coverage includes

diseases, screening and prevention, complementary and alternative

medicine, ethical and legal issues, and procedures. The design of

Clinical Evidence and PIER also make them useful for keeping up with

the medical literature and for providing basic knowledge on healthcare

topics.

The Cochrane Library contains the collected work of the Cochrane

Collaboration, an international organization that prepares, maintains,

and disseminates systematic reviews of controlled trials of healthcare

interventions (note that topics such as

diagnosis and prognosis are not covered). Within the Cochrane Library,

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the Cochrane Database of Systematic Reviews (CDSR) contains reviews that have high standards for finding, rating, summarizing, and reporting the evidence from trials (1). The Cochrane Library is searchable, contains almost exclusively controlled trials and systematic reviews, and is much smaller than MEDLINE, so that methodologic filtering is not needed and a simple, even one-word, search strategy will l ikely retrieve high-quality evidence with a clinical bottom line.Furthermore, the Cochrane Library is cumulative, and the reviews are regularly updated or tagged as no longer current, if not updated within a specified period. The Cochrane Library also contains summaries of non-Cochrane systematic reviews, citations on how to do systematic reviews, and a huge database of citations of clinical trials, many of them not available on MEDLINE. The Cochrane Library is available on CD-ROM and the Internet as a stand-alone resource and in other services, such as Ovid's “Evidence-Based Medicine Reviews.†If one choose not to subscribe to it, one's health sciences or hospital l ibrary likely does. Abstracts of Cochrane reviews and the abstracts of

other systematic reviews (but not the rest of the library) are also

available for free on the Internet at the U.K. Cochrane site

(http://www.cochrane.org) and other Web sites.

MEDLINE is the most likely general source to turn to when one's

specific information sources fail or when one is faced with a nonroutine

clinical problem. It should not be consulted first if one knows of a

specific source that is current, of high quality, and tailored to the

problem being dealt with, as we describe later. MEDLINE is the largest

readily available database of biomedical journal citations and is now

available in full or subset form for free on many Web sites, one of them

produced by the U.S. National Library of Medicine (NLM). It is also

more up-to-date than ever, with leading journals providing electronic

copy for close to date-of-publication posting.

PubMed (http://www.ncbi.nlm.nih.gov/entrez/) is the MEDLINE search

interface produced by the NLM in conjunction with the U.S. National

Center for Biotechnology Information. PubMed provides on-line access

to literature citations and links to full-text journals at Web sites of

participating publishers. (User registration, a subscription fee, or some

other type of fee may be required to access the full text of articles for

some journals.) PubMed also contains PREMEDLINE citations: basic

citation information and abstracts are entered or downloaded daily

before the full records that contain MeSH terms, publication types, and

other indexing data are prepared and added to MEDLINE. Furthermore,

it has a clinical query feature

(http://www.ncbi.nlm.nih.gov/entrez/query/static/clinical.html) that

allows a search strategy to be fine tuned using methodologic terms so

that retrieval will be more clinically applicable. For example, if one's

question has to do with the cause, course, diagnosis, prevention, or

treatment of a clinical problem, one could go directly to the clinical

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query screen and indicate the study category in which one is interested and whether one would like a “sensitive†(maximal retrieval of relevant articles, with a high rate of false-positive articles) or “specific†(lower retrieval of relevant articles with fewer false positives) approach. After content words on the clinical problem of

interest are entered, one proceeds with the search and complex

pretested search strategies are automatically invoked, optimizing the

yield of clinically relevant studies (3). In the near future, updated

clinical queries will be available. These queries will be expanded from

therapy, diagnosis, prognosis, and etiology to include clinical prediction

guides, economics, qualitative studies, and systematic reviews (4).

PubMed also has a “related articles†feature that allows the

searcher to view citations related to an individual citation retrieved in a

search without having to do another search. Thus, if one finds a study

that is right on target, one can click on the [Related Articles] link and

retrieve more articles on the same topic sorted in order of relevance.

Although powerful and free, MEDLINE is not the only large biomedical

database. EMBASE/Excerpta Medica and the Cumulative Index to

Nursing and Allied Health Literature (CINAHL) are also available and

are useful to the infection control professional in search of information.

Both EMBASE and CINAHL (as well as MEDLINE) are available on the

Internet through Ovid (http://www.ovid.com). Ovid provides a front-

end search engine that has user fees, but many health sciences and

hospital libraries provide it because it offers access to several different

databases using the same user-friendly search interface and integration

of database searching with a strong collection of full-text clinical

journals. In addition to databases of citations to articles, Ovid provides

access to books, a diagnosis program, and Evidence-Based Medicine

Reviews, a multifile database that allows simultaneous searching of

evidence-based medicine databases including ACP Journal Club and

databases within the Cochrane Library.

Case Scenario: Solving a Problem of TreatmentAn aggressive, bottom-line obsessed administrator in your hospital is

looking for ways to save money. She requests that you consider

reverting from antimicrobial-coated catheters in the intensive care unit

to less expensive, uncoated catheters. She demands that you show that

the coated catheters are worth their higher cost. You seek to do so as

quickly as possible.

Because you are pushed for time and you know that you want high-

quality, patient-centered information, you start with ACP Journal Club

(http://www.acpjc.org). Your initial search is effective using two

words—“catheter†and “infection.†You retrieve 30 hits, most

of them directly relevant. Two very relevant studies (5, 6) show that

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the coated catheters are effective. The systematic review by Mermel (5) showed that they are more effective than noncoated catheters and Veenstra et al. (6) provided data that showed that the coated ones are cost effective.

Although the http://www.acpjc.org search was successful, it is worth

taking a quick look in the Cochrane Library, another high-quality

information source. You call up the Cochrane Library online, and in the

“searchphrase†window you type “impregnated catheter.â€

There is one review in the CDSR, but it is not very relevant, because it

pertains to umbilical artery catheters in newborns in the neonatal

intensive care unit (7). In the Cochrane Central Register of Controlled

Trials (CENTRAL), there are citations with abstracts to five randomized

trials, all from 1997 to 1999. Running the search again with “coated

catheter†you find no systematic reviews but 11 more randomized

trials in the CENTRAL database. CENTRAL contains specialized registers

of citations submitted by Cochrane groups and other organizations from

many

journals and other sources that are not included in MEDLINE. Potential

records from CENTRAL are assessed with quality control procedures to

ensure that only reports of definite randomized controlled trials or

controlled clinical trials are included.

Just to make sure that you did not miss any important studies on

coated catheters, you go on the Internet and pull up the clinical query

option for PubMed. You pick the therapy category, select the

“sensitivity†search option, and then type “impregnated central

venous catheters†in the search window. You retrieve 23 citations,

several of which look relevant including the already seen systematic

review by Mermel (5) and the cost-effectiveness study by Veenstra et

al. (6).

Another method for effective clinical-based searching is to search only

for articles that are clinical trials. For an article to be indexed with the

publication type “clinical trial,†it must be a “preplanned,

usually controlled clinical study of the efficacy, safety, or optimum

dosage schedule of one or more therapeutic, diagnostic, or prophylactic

drugs, devices, or techniques in humans selected according to

predetermined criteria of eligibility and observed for predefined

evidence of favorable and unfavorable effects†(8). The citations you

retrieve using the clinical query feature in PubMed or the publication

type “clinical trial†are more likely to be ready for clinical

application and to help you make an informed patient-care decision

than if you had not included any methodologic filtering in your search

strategy.

The previous scenario illustrates a search for quality-filtered prevention

literature. Reports of applied clinical research have two features in

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common: they are designed in advance to follow a study protocol and

they are comparative. Criteria exist for studies from each of the four

categories of therapy and prevention, diagnosis, etiology and

causation, and prognosis and natural history, as well as economic

evaluations, decision analysis, quality of life, clinical utilization,

reviews, guidelines, clinical prediction, and qualitative studies (9).

Searching on the Internet is another route to take to help solve patient

problems. However, only a small proportion of the content has been

peer reviewed or provides enough information so that you can do your

own evaluation on the material found. One of the most effective, and

certainly the most used, search engines is Google

(http://www.google.com/). No single search engine searches more than

30% to 40% of the current Web content, so a variety of search

approaches may be warranted for comprehensive Internet searching.

Google's search function lets you type in words or concepts of interest

and then retrieves Web sites that contain these terms ranked in the

order of how many other sites have linked to the original site—sort of

a quality indicator. Typing in the very specific phrase “intravascular

catheter infections prevention†provided access to 3,030 Web pages in

0.14 seconds. The first two link to the U.S. Centers for Disease Control

and Prevention (CDC) “2002 Guidelines for the Prevention of

Intravascular Catheter-Related Infections†(10). This 36-page

guideline includes an analysis of previous studies and cites both the

Mermel and Veenstra et al. studies along with many original studies.

O'Grady et al. (10) stated that although the coated catheters are more

expensive, they reduce infections and costs. All the evidence found to

date seems to support the added initial expense of the coated

catheters.

Another approach to searching the Internet is to use one of the new

question-answering systems (e.g., AskJeeves at http://www.ask.com or

AnswerBus at http://www.coli.uni-sb.de/~zheng/answerbus/). Asking

Jeeves “How do I prevent intravascular infections?†produced links

to both U.S. and Canadian guidelines. The AnswerBus did not provide

links to any site.

KEEPING UP WITH THE MEDICAL LITERATURE

Health professionals typically rate journal reading as their preferred

means of keeping current, but more than 15 years ago, Covell et al.

(11) demonstrated that this was highly overrated as a method for

keeping up-to-date. Journal reading is still recommended for keeping

up-to-date but with a “critical appraisal†approach, so that a

reader quickly and systematically detects the original studies and

reviews that are more likely to be useful to his or her practice (12).

The medical literature has continued to grow at an increasing rate since

the mid-1980s, so the challenge of keeping up-to-date might be

considered greater than ever. However, substantial improvements have

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occurred in information processing as well to compensate somewhat for

the increased amount of publication.

We consider the journal literature first. Publishing in peer-reviewed

print journals is still the most common form of spreading the word

about advances in medicine, although this may change with the advent

of on-line journals. ACP Journal Club, a bimonthly publication of the

ACP, contains 25 structured abstracts and accompanying commentaries

of original studies and systematic reviews of interest to general

internal medicine, including infectious diseases. The articles, both

original studies and systematic reviews, are selected from

approximately 115 journals according to explicit rules of sound

methodology and pertain to the treatment or prevention, diagnosis,

prognosis, or etiology of disease (13). Also included are sound studies

of clinical prediction, economics, differential diagnosis, and quality

improvement. Following our clinical example, studies and reviews of

catheter infections and their prevention have appeared several times a

year in ACP Journal Club and include the Mermel and Veenstra et al.

articles (5, 6).

Evidence-Based Nursing is a quarterly journal published by the BMJ

Publishing Group that aims to bring high quality studies and reviews to

the attention of nurses attempting to keep pace with important

advances in their profession. It follows a production procedure similar

to that of ACP Journal Club. Evidence-Based Medicine, also published

by the BMJ Publishing Group and aimed at primary care physicians,

abstracts studies in family medicine, pediatrics, surgery, psychiatry

and psychology, and obstetrics and gynecology, in addition to internal

medicine. The abstracts for these journals are prepared by research

staff with methodologic expertise and report enough information about

the methods of the studies that readers can judge for themselves the

strength of the research and the applicability of the findings to their

own patients.

Furthermore, in many instances, additional numerical results not

provided in the original article are obtained or calculated and included

in the abstract, such as relative risk reductions, confidence intervals,

and numbers needed to treat to prevent a bad outcome or achieve a

good outcome. The abstracts and commentaries

have several steps in the production process to ensure their accuracy

(13). ACP Journal Club, Evidence-Based Nursing, and Evidence-Based

Medicine are also available on the Web sites of their respective

publishers (http://www.acpjc.org/, http://www.ebn.bmjjournals.com/,

and http://www.ebm.bmjjournals.com/). ACP Journal Club is also

available on Ovid in the “Evidence-Based Medicine Reviews.â€

MEDLINE can also be used to keep up to date, because it is updated

frequently: weekly for most on-line or Internet versions and daily in

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the PubMed system. Searchers can thus run frequent broad-based

searches to obtain the most recent citations on a topic they want to

follow. “Catheter infection†might be a useful search to run weekly

if one wanted to keep current with all the research on the topic. For

example, on January 13, 2003 we ran this search and found another

relevant guideline that had been entered into the MEDLINE system on

January 9, 2003 (14).

Most healthcare organizations have a “Web presence†and many

have current awareness features that one can tap into to keep up to

date. The Web site for the Society for Healthcare Epidemiology of

America, Inc. (SHEA) (http://www.shea-online.org) is a good starting

point for Web searching because it provides a page of links to other

infection control sites including government (state, national, and

international), other organizations, and related information resources.

Furthermore, many of the various organizations have e-mail discussion

lists (listservs) that one can join to receive and participate in

correspondence on topics of interest. One should note that these

discussion lists are anecdotal in nature and are simply exchanges of

opinions among health professionals. It is up to the reader to judge the

validity of individual comments.

The CDC Web site (http://www.cdc.gov) provides a wide array of

documents including the CDC prevention guidelines, the Morbidity and

Mortality Weekly Reports, and links to many other health resources,

both within the United States, including the state departments of

health services, and worldwide. The CDC Web site allows searches

using boolean logic in an advanced search mode (and's and or's), so

that a searcher can combine words to expand or pinpoint retrieval.

For keeping up to date, one can subscribe to a CDC mailing list and

receive only the tables of contents or the entire documents for such

items as the Journal of Emerging Infectious Diseases, human

immunodeficiency virus (HIV)/acquired immunodeficiency syndrome

publications, and Morbidity and Mortality Weekly Report. The Division

of Healthcare Quality Promotion provides information on the prevention

and control of nosocomial infections (http://www.cdc.gov/ncidod/hip).

It has guidelines, recommendations, and answers to frequently asked

questions on topics such as outbreaks, occupational exposure to HIV,

needlestick injuries, and child care. Of note is their “2002 Guideline

for Prevention of Intravascular Catheter-Related Infectionsâ€

(http://www.cdc.gov/ncidod/hip/IV/IV.HTM) already identified in our

Internet search. The CDC Web site also indicates which documents have

recently been added and which are expected soon. It ranks its top

challenge as reducing catheter-associated adverse events by 50%

among patients in healthcare settings.

The Web site for the Hospital Infection Society (http://www.his.org.uk)

in the United Kingdom includes the abstracts of articles in the Journal

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of Hospital Infection, lists future scientific meetings, and has an e-mail

discussion list. The Web site for the Faculty of Medicine at Université

Catholique de Louvain in Brussels

(http://www.md.ucl.ac.be/entites/esp/hosp/infcon.htm) has a database

of many hundreds of selected articles with abstracts in the area of

infection control that is updated quarterly. It also links to journals on

infection control and hospital epidemiology for scanning tables of

contents to identify potentially relevant citations.

The Association for Professionals in Infection Control and Epidemiology

(APIC) has a Web site (http://www.apic.org) that updates professionals

about courses and educational activities, upcoming conferences, and

publications (such as the APIC Text of Infection Control) that can be

ordered from the Internet. Professional resources provided on the APIC

Web site include a discussion forum in which infection control

professionals can discuss issues with each other; find or list job

postings; and access a resource list, a searchable abstract database,

and an open e-mail list server.

The Program for Monitoring Emerging Diseases (ProMED)

(http://www.fas.org/promed) is a free electronic conferencing system

formed by the Federation of American Scientists to create a global

system of early detection and response to disease outbreaks. It also

has a search engine for archived e-mail correspondence.

Individual clinicians can keep in touch with a variety of health

organizations through Web sites as an increasing number of

organizations post their latest information on the Internet. By

subscribing to some of the many list servers and discussion lists of the

aforementioned organizations, one can participate in real time

discussions on topics of interest, and current information such as the

latest journal contents or knowledge of outbreaks comes automatically.

Unfortunately, for most of these services, one will need to do an

assessment of the validity and relevance of the information. The

relevance check is pretty easy, but checking the sources for scientific

merit requires skill and time.

Several of the aforementioned resources are now available in a format

for the latest in computer gadgetry: the handheld or PDA. PDAs have

been embraced by many in the medical community, because they can

store surprisingly large amounts of information and can be used in any

location by virtue of their small size and portability (15, 16). Many

sources of information exist for clinicians interested in PDAs and one

such site is Evidence-Based Medicine Tools for the PDA

(http://www.ils.unc.edu/~caham/ebmtools/ebmtools.html). Categories

of applications and services include drug information (especially

ePocrates http://www.epocrates.com/), news and abstracting services,

healthcare literature summaries and full text, guidelines and

summaries, textbook information, diagnostic aids, statistical and

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numerical calculators, and clinical prediction guides. A listing of

available resources in this chapter would not be very helpful because of

the rapid rate of change, so we urge those who are interested in

acquiring a PDA to consult peers and use the Internet to learn about

and acquire clinical resources for downloading.

SETTING CLINICAL POLICY

Clinical practice guidelines have metamorphosed from their first

appearance on the healthcare stage, as small local health plans or care

maps developed to reduce variability in care, into a healthcare

industry. Practice guidelines have become ubiquitous

and are promoted for a number of reasons, including improving the

quality of healthcare, optimizing patient outcomes, discouraging the

use of ineffective or harmful interventions, improving the consistency

of care, identifying gaps in evidence, helping to balance costs and

outcomes, or simply cutting costs. Clinical practice guidelines for

screening, diagnosis, prevention, and treatment are produced by

diverse organizations, from government departments (such as the U.S.

Agency for Healthcare Research and Quality or the CDC), healthcare

associations and specialty societies (such as the American College of

Physicians, the Society for Healthcare Epidemiology of America, and the

Infectious Disease Society of America), and local hospitals. The

definition from the Institute of Medicine in 1990 (17) still applies,

however, at all levels: “Practice guidelines are systematically

developed statements to assist practitioner and patient decisions about

appropriate healthcare for specific clinical circumstances.†Three

useful Internet sites that list guidelines are the National Guideline

Clearinghouse (http://www.guideline.gov/index.asp), Agency for

Healthcare Research and Quality

(http://www.ahcpr.gov/clinic/cpgsix.htm), and the Canadian Medical

Association (http://www.cma.ca/cma/common/displayPopup.do?

tab=422&=125&pMenuId=4). The first site, the U.S. National Guideline

Clearinghouse, is a valuable site for access to almost any local,

regional, national, or international guideline. It not only lists guidelines

and provides access to the full text of many but also has the capability

of comparing two guidelines in a tabular format.

Infection control is particularly suited to the use of clinical practice

guidelines. If based on sound current evidence, guidelines can greatly

reduce the amount of work of infection control specialists in searching

the literature. Guidelines published in the journal literature are

searchable in MEDLINE by using the publication type field

“guideline†for administrative procedural guidelines and

“practice guideline†for specific healthcare guidelines. The Internet

is also an excellent source in which to locate guidelines, particularly

because the entire document is usually posted on the Web site,

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whereas in MEDLINE only the citation and possibly the abstract to the

document is available. The Future Health Care Web site

(http://www.futurehealthcare.com/pages/guidetobestpractices.htm) is

particularly useful for helping to define “best practices†for quality

assurance activities (18).

We have already identified a recent and relevant clinical practice

guideline on our intravascular coated catheters (10) so we will identify

any more, although several less recent ones exist.

CONCLUSIONS

To conclude our clinical scenario, you give your administrator the data

you find. She is duly impressed with your evidence that the more

expensive coated catheters are actually saving the hospital money and

reducing infections. She thanks you and as you return to your office

and mentally review your information trek. You wonder if this is just

the first of many such evidence assessments you will be asked to

perform.

Persons involved with hospital epidemiology and infection control have

many diverse information needs that include medical and other health-

related clinical materials, basic science information, management and

educational resources, and policy documents from regional and national

agencies. Today, clinicians are working in a rapidly changing

environment with new discoveries, scarce resources, and new

challenges presented by the changing model of healthcare delivery,

multiresistant microorganisms, emerging pathogens, and outbreak

detection. To succeed, one must develop rapid and efficient ways of

acquiring new relevant information. By investing time in experimenting

with the different resources available, one will be able to develop an

individual strategy for dealing with new clinical problems, keeping up-

to-date, and effectively implementing new policies. Clinicians are

indeed fortunate that as the need for information increases, the means

for acquiring it continue to evolve and improve.

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