NSG/455 Week 1: Clinical Question and PICOT, sample paper

"We Have Always Used Heparin": Turning a Routine at an Outpatient Infusion Center Into a PICOT Question About Locking Implanted Ports

[Student Name]

University of Phoenix

NSG/455: Evidence-Based Practice and Statistics

Week 1 Assignment

[Instructor Name]

[Date]

The infusion center, staff and figures are a composite written for a model paper.

At a composite hospital-based outpatient infusion center, nurses access and care for about 90 implanted ports each week in adults receiving chemotherapy or long-term infusions. After each use, and monthly for patients between treatments, the nurses lock each port with 5 mL of heparin 100 units/mL, as the center's procedure has specified for many years. A new nurse from another hospital asked why, since her previous unit locked ports with saline only. No one on the unit knew the evidence behind the choice. A procedure repeated thousands of times a year had become so familiar that no one remembered it was a decision, and decisions can be tested. This paper turns that question into a focused clinical question.

Why Evidence Should Outrank Habit

Evidence-based practice integrates the best available research with clinical expertise and patient preferences to guide care (Melnyk & Fineout-Overholt, 2023). Habit is not the same as expertise. Practices can persist long after the reasons for them have changed, and some were never tested at all. The heparin lock is a good example of a practice worth examining, because heparin has risks: it can cause heparin-induced thrombocytopenia, contributes to bleeding risk in patients with low platelet counts, has been involved in medication errors when concentrations are confused and costs more than saline. If saline locks work as well at keeping ports open, the center could reduce those risks. If heparin works better, the center would have evidence to support its current practice.

From a Vague Question to a PICOT Question

The first version of the question was simply: "Is heparin better than saline for ports?" It was too vague to search effectively. Better for what? In whom? Measured how?

The second version added the population and outcome: "In adults with implanted ports, does heparin prevent occlusion better than saline?" This was closer but still incomplete, since it did not specify the setting or the time over which occlusion is measured.

The final version, following the PICOT format described by Melnyk and Fineout-Overholt (2023), reads: In adults with totally implanted venous access ports receiving care in an outpatient oncology setting (P), does locking with 0.9% sodium chloride (I), compared with heparin 100 units/mL (C), result in no higher rate of catheter occlusion or catheter-related bloodstream infection (O) over the life of the port (T)?

The PICOT Elements Explained

Population. Adults with totally implanted ports in an outpatient oncology setting. This excludes children and patients with other central lines, such as peripherally inserted central catheters, because devices and populations differ, and evidence from one may not apply to another.

Intervention. Locking with 0.9% sodium chloride alone, the proposed change.

Comparison. Heparin 100 units/mL, the current practice. Stating the comparison precisely matters because heparin concentrations and volumes vary.

Outcome. Catheter occlusion is the primary outcome, since preventing occlusion is the purpose of the lock. Catheter-related bloodstream infection is included because a lock solution could affect it and because it is a serious harm. Secondary outcomes to watch include the need for thrombolytic treatment to restore patency and port removal because of dysfunction.

Time. The life of the port, because occlusion can develop over months of use.

Question Type

This is a therapy or intervention question comparing two treatments. The best evidence for such questions comes from systematic reviews of randomized controlled trials and from well-designed randomized trials, which minimize bias in comparing interventions (Melnyk & Fineout-Overholt, 2023). The question is also framed in a non-inferiority form: the center does not need saline to be better than heparin, only no worse on the outcomes that matter, since saline has other advantages, and non-inferiority studies are judged against a margin chosen in advance rather than by a simple test of difference (Polit & Beck, 2021). That framing will affect how study results are interpreted in later weeks.

Local Data Behind the Question

Before searching the literature, the nurse gathered local data to see whether the question mattered in her setting. Over the past year, the center performed about 4,700 port locks. Pharmacy records showed 38 doses of alteplase given to restore blood return in ports that would flush but not draw back, a common form of partial occlusion, and two ports removed for dysfunction. Two patients had been found to have heparin-induced thrombocytopenia during their cancer treatment, although the heparin source in each case was uncertain, and one near miss had occurred when a vial of heparin 1,000 units/mL was stocked next to the 100 units/mL vials. The annual cost of heparin lock syringes was modest but not trivial. These numbers do not answer the question, but they show that both the current practice and the proposed change carry real consequences for patients, which justifies the time needed to search and appraise the evidence. They also provide a baseline against which any change could later be measured.

Stakeholders and Relevance

The question matters to several groups. Patients with cancer receive dozens of port locks, so any risk from heparin accumulates over time. Nurses perform the procedure and would change their workflow. Pharmacy prepares and supplies the solutions. Oncologists and the infection prevention team care about occlusion and infection outcomes. The infusion therapy standards of practice, which the center follows, will also be reviewed, since they guide locking solutions for central devices (Gorski et al., 2021).

What Comes Next

The PICOT question will guide the next weeks: a documented search of databases using terms drawn from each element, appraisal of the evidence found and a synthesis leading to a recommendation. A well-built question makes each of those steps more efficient, because the search terms, inclusion criteria and outcomes are already defined.

Conclusion

A routine that had gone unquestioned for years became a clinical question when a new nurse asked why. Refining that question into PICOT form, adults with implanted ports in outpatient oncology, saline versus heparin locks, occlusion and infection over the life of the port, turned curiosity into a searchable, answerable question. Identifying it as a therapy question in non-inferiority form clarifies what evidence to seek and how to interpret it. Evidence should outrank habit, and a well-formed question is where that begins.

References

Gorski, L. A., Hadaway, L., Hagle, M. E., Broadhurst, D., Clare, S., Kleidon, T., Meyer, B. M., Nickel, B., Rowley, S., Sharpe, E., & Alexander, M. (2021). Infusion therapy standards of practice, 8th edition. Journal of Infusion Nursing, 44(1S), S1-S224. https://doi.org/10.1097/NAN.0000000000000396

Melnyk, B. M., & Fineout-Overholt, E. (2023). Evidence-based practice in nursing & healthcare: A guide to best practice (5th ed.). Wolters Kluwer.

Polit, D. F., & Beck, C. T. (2021). Nursing research: Generating and assessing evidence for nursing practice (11th ed.). Wolters Kluwer.