PICOT PAPER 1

PICOT Paper

Diana VanRhee

Ferris State University

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Abstract

This paper encompasses nursing knowledge that was used in a PICOT question which

was researched through health data bases. The PICOT question explores whether using pre-

operative versed (midazolam) in pediatric patients provides better post-operative pain control

than not using versed (midazolam). The methodology, levels of evidence and a review of the

research literature is produced in detail. Using the results of the research, the significance to

nursing and future research are demonstrated and suggestions for changing current practices are

noted.
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Introduction

Nursing care is directed by Evidence Based Practice (EBP) which in turn is founded on

evidence based research. When new data is produced from research it must clearly be

communicated within the healthcare setting. Nursing and related personnel must collaborate

efficiently in supporting the EBP and incorporating it in their everyday practice. “The purpose of

this assignment is to reflect how nursing knowledge is disseminated for use in personal and

professional practice” (Ursuy, 2014). This paper explores whether using preoperative versed

(midazolam) in pediatric patients provides better post-operative pain control than not using

versed (midazolam).

Clinical Question

Working in the Surgery, Prep and Recovery Unit of a local hospital, I encounter pediatric

patients that are having surgical procedures. Children under the age of 10 years old have their IV

started in the operating room under general anesthesia, while children over the age of 10 years

old have their IV started in the preoperative area. Both categories of children could be given oral

midazolam preoperatively, however, due to limited IV access, IV midazolam is not given, only

oral midazolam. The anesthesiologist is the one who evaluates the children and orders the

midazolam, however there is no set policy or protocol for that. I began to notice inconsistencies

of the children being medicated with midazolam prior to surgery and it appeared the children

who were medicated with midazolam preoperatively had better post-operative pain control.

When questions arise for discussion or research, the acronym PICOT is a common way to

format the question. P stands for the population/patient, I stands for the area of

interest/intervention, C stands for the comparison/current practice, O stands for the desired
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outcome and T denotes the time frame (Niewswiadomy, 2012, p. 282). The PICOT question

being explored in this paper is “Does medicating with oral versed (midazolam) preoperatively

reduce post-operative pain compared to patients who do not receive preoperative versed

(midazolam) in pediatric patients?” P is represents pediatric patients, I is represented by the

administration of oral versed, C is comparing not medicating preoperatively, O signifies post-

operative pain management and T is during the post-operative period. It is believed the quality

and safety of the pediatric population undergoing surgical procedures would be improved if there

were consistent preoperative medication policies and procedures in place. Post-operative pain

could be improved, thus patient and parent satisfaction could also potentially increase.

Methodology

When researching the PICOT question at hand, I utilized three databases relevant to the

nursing/medical field, which were Cinahl, Cochrane Reviews and Pub-Med. In each database, I

would use the advance search when possible and included key words or phrases. At first, using

the word versed did not reveal many articles, but upon advancing the search to include

midazolam and adding parenthesis around the key words provided more options. So, the search

included (versed or oral midazolam), (pediatric or children) and (post-operative pain or

preoperative pain).

The selection process was further narrowed down after reading the abstracts of numerous

articles. The abstracts provided me with valuable information that easily allowed me to either

include or exclude the article. I tried to include articles that were current, 12 years ago to present.

Levels of evidence is a way to categorize articles based on types of trials, studies, and

expert opinions by using a numerical hierarchy. Each article reviewed was assigned a level of
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evidence using the following level of evidence chart, one being the highest level and seven being

the lowest level.

Levels of Evidence

Level 1- Systematic review and meta-analysis of randomized controlled trials

Level 2- One or more randomized controlled trials

Level 3- Controlled trial (no randomization)

Level 4- Case-control or cohort study

Level 5- Systematic review of descriptive and qualitative studies

Level 6- Single descriptive or qualitative study

Level 7- Expert opinion

(Melnyk & Fineout-Overholt, 2011)

Choosing the levels of evidence to assign to the chosen articles was not an easy process

and the articles chosen for the PICOT question were not done so based only on the level of

evidence given to them. Nursing articles were favored along with the content relevant to the

PICOT question in conjunction with the level of evidence assigned.

Resource utilization is something all nurses in healthcare should participate in according

their scope of practice (White & O’Sullivan, 2012, p. 194). Nurses often shy away from research

and quality related utilization because change is often difficult and why change something that is

working just fine? At the registered nurse level, an RN should evaluate evidence in deciding the

level of care and interventions for the patient outcomes (White & O’Sullivan, 2012, p. 194).
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Discussion of Literature

Article One

The first article reviewed is called “Premedicating children for painful invasive

procedures” by Elizabeth R. Klein, which is nursing research. Klein used a descriptive

survey/questionnaire for her research questions and there were 108 participants. The participants

were broken down to include 55 physicians and 53 nurses. The physicians were pediatric

professors and staff oncologists while the nurses involved were clinical nurses or clinical nurse

specialists (Klein, 1992, p. 172). Questions included on the questionnaire reflected current

premedicating practices in their pediatric clients and then they were asked about the patients post

procedure pain using the Likert Scale of 1 to 5 (1 being no pain and 5 being excruciating pain)

(Klein, 1992).

Several drug combinations were used along with oral and intravenous midazolam in

practices of premedicating pediatric patients prior to painful procedures, such as lumbar

punctures. Although the article is only an evidence level of six (Melnyk & Fineout-Overholt,

2011), the results are significant and can be useful to pediatric nurses. The results revealed that

there was a significant reduction of pain if a pediatric patient was medicated prior to a painful

procedure with agents such as midazolam. Further implications for nursing are standardizing

premeditation care and practices for pediatrics undergoing painful procedures (Klein, 1992, p.

177).

Article Two

The second article, “Pre-anesthetic medication with intranasal dexmedetomidine and oral

midazolam as an anxiolytic. A clinical trial” (Linares et al., 2014) is a comparison trial between
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two medications for preoperative anxiety. This trial was a prospective, randomized, double-

blind, controlled trial that was conducted on children 2-12 years of age (Linares et al., 2014).

There were 108 pediatric patients in the trial and their anxiety was assessed using a modified

Yale scale. Anxiety is closely related to pain and pain perception with children.

Evidence level is a four (Melnyk & Fineout-Overholt, 2011) and the trial was done in

2013, so I chose to include the article based that the information was relevant to the PICOT

question. Although the findings were suggestive of the dexmedetomidine being superior to the

midazolam in reducing anxiety, which could also reduce the pain perception for the children, the

findings were significant and supportive to the issue that pediatric patients could have better post

procedure pain if they were medicated preoperatively. Further research and studies need to be

conducted and standardized practices should be made available.

Article Three

The last article to be discussed is by Fazi et al., “A comparison of oral clonidine and oral

midazolam as preanesthetic medications in the pediatric tonsillectomy patient.” This trial was

randomized and controlled and was a comparative study (Fazi, Jantzen, Rose, Kurth, & Watcha,

2001). It is located in The Cochrane Central Register of Controlled Trials. The study participants

were the ages of 4-12 years old and all were medicated prior to anesthesia with either the

midazolam or clonidine.

Evidence level was rated as a two (Melnyk & Fineout-Overholt, 2011), but the results

were significant to the PICOT question and nursing in comparing the preanesthetic sedation and

post-operative recovery. The children in the midazolam group required less postoperative

analgesia and thus midazolam was considered superior to clonidine as an oral preanesthetic

medication (Fazi et al., 2001). Although this trial was limited to patients receiving
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tonsillectomies, it is indicative of the need for future research on standardizing care practices on

medicating children preoperatively to help manage post-operative pain.

Significance to Nursing

When research is conducted, evidence can be supported by Evidence Based Practice

(EBP) and thus nursing practice could potentially be changed to increase the safety and efficacy

of care. “Interprofessional collaboration will make the research stronger and will increase the

likelihood that a satisfactory practice change can eventually be implemented” (White &

O’Sullivan, 2012, p. 137). In today’s nursing practice, nurses have the “capabilities to address a

wide variety of health issues” (Black, 2014, p. 114), however, nurses must act within their Scope

of Practice as defined by the American Nurses Association and outline by The Code of Ethics for

Nurses and the Standards of Nursing Practice (White & O’Sullivan, 2012). That is why it is

important that nurses participate in nursing research.

Quality and Safety Education for Nurses (QSEN) emphasizes providing quality nursing

education to nursing students and that quality is the responsibility of all individuals in healthcare

(White & O’Sullivan, 2012). QSEN targets the knowledge, skills and attitude for nurses and

incorporates six core competencies. These six competencies are Patient-Centered Care,

Teamwork and Collaboration, Evidence Based Practice, Quality Improvement, Safety and

Informatics (Quality and Safety Education for Nurses, 2013). With the inquiry of this PICOT

question, patient-centered care, evidence based practice, quality improvement and safety were all

explored and utilized. I have gained knowledge and insight to information that is not only

significant to my own nursing practice, but that could potentially impact others.
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Conclusion

The PICOT question explored had supportive and non-supportive data revealed. Material

was overwhelming supportive of pediatric patients being medicated prior to painful procedures

or surgery. Reducing anxiety and pain preoperatively and postoperatively is imperative for the

healing process and patient satisfaction. Midazolam may or may not be the medication of choice

to reduce the pain and anxiety, but it is evident that further research is needed in order to

establish a set of standardized care practices in regards to medicating pediatric patients

preoperatively. This is significant to nurses caring for children to provide optimal and quality

care.
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References

Black, B. P. (2014). Professional Nursing Concepts & Challenges (7th ed.). St. Louis, Missouri:

Elsevier Saunders.

Fazi, L., Jantzen, E. C., Rose, J. B., Kurth, C. D., & Watcha, M. F. (2001, January). A

Comparison of oral clonidine and oral midazolam as preanesthetic medications in the

pediatric tonsillectomy patient. Anesthesia and Analgesia, 92.

Klein, E. R. (1992). Premedicating children for painful invasive procedures. Journal of Pediatric

Oncology Nursing, 9(4).

Linares, S. B., Garcia, C. M., Ramirez, C. I., Guerrero, R. J., Botello, B., Monroy, T. R., &

Ramirez, G. X. (2014, January). Pre-anesthetic medication with intranasal

dexmedetomide and oral midazolam as an anxiolytic. A clinical trial. An Pediatr (Barc).

http://dx.doi.org/10.1016/j.anpedi.2013.12.006

Melnyk, B. M., & Fineout-Overholt, E. (2011). Evidence-based practice in nursing and

healthcare: A guide to best practice. Philadelphia: Lippincott, Williams & Wilkins.

Niewswiadomy, R. M. (2012). Foundation of Nursing Research (6th ed.). Upper Saddle River,

NJ: Pearson Education, Inc.

Quality and Safety Education for Nurses. (2013). Retrieved from www.qsen.org

Ursuy, P. (2014). Class Syllabus. Ferris State University. Retrieved from

www.myfsu/ferrisconnect/blackboardlearn

White, K. M., & O’Sullivan, A. (2012). The essential guide to nursing practice. Washington

D.C.: American Nurses Association