Applying the PICO(T) Process: Postoperative Hernia Repair

Diagnosis Explanation: Postoperative Hernia Repair

            Ventral hernia repair is a common post-surgical treatment used to rehabilitate damage to the abdominal wall, usually with the reinforcement of mesh. However, the surgical site infection (SSI) and hernia recurrence are frequent. Common SSIs result in 10-12 per cent of patients, lengthening the time of their stay, cost, and unpleasant events (Hou et al., 2022). With surgical progress, the rate of hernia recurrence occurs in 3-10% of patients (Lu et al., 2024). Such complications can cause a prolonged healing process and reduce the quality of life for patients requiring further surgery: Applying the PICO(T) Process: Postoperative Hernia Repair.

Vulnerable groups such as the elderly, the chronically ill people and those who have low access to good health become more vulnerable. Malnutrition and immune deficiency may slow recovery and increase the risk of infections and recurrence (Whitman et al., 2022). The reason behind these difficulties is inequality in post-surgery care or follow-up, which also exacerbates outcomes (Seidler et al., 2020). These issues should be addressed to enable more effective treatment and prevent unnecessary hospital readmissions.

Development of PICO(T) Research Question

To respond to the complexity of research behind post operation management of hernia repair the following PICO(T) inquiry research question is established: Does use of antibiotic prophylaxis (I) versus no use of antibiotic prophylaxis (C) help in reducing surgical site infection and hernia recurrence (O) in adults who have undergone an operation of ventral hernia repair and has had a mesh implanted (P) within 30 days of such an operation (T)?

The above question will be directly related to a major issue in postoperative hernia repair: the application of antibiotic precautions and whether they can eliminate SSI and the degree to which they cause recurring rates. The 30-day period is pertinent since it is the typical timeframe of the incubation period, during which postoperative complications, including infection and recurrence of the hernia, can occur. This strategy is comprehensive and precise, providing a strong basis for collecting and analyzing the corresponding evidence.

Literature Search Process

An extensive literature review was conducted to investigate the evidence on the effectiveness of antibiotic prophylaxis in preventing SSIs and the process of hernia recurrence after ventral hernia repair. The databases included PubMed, CINAHL, and Cochrane Library. A keyword search was conducted for postoperative hernia repair, antibiotic prophylaxis, hernia recurrence, and prevention of surgical site infections. Targeted systematic reviews and randomized controlled trials (RCTs) published within the last five years were identified to ensure the relevance and quality of the information.

The indicators of credibility included peer-reviewed responses, the sample size, inequalities in the methodology, and study authorization by the IRB. Secondly, systematic reviews were given priority because they provide a more comprehensive picture of the effectiveness of the intervention, as they synthesize the results of multiple studies.

Sources of Evidence

Source #1: T-Line Mesh Study

The article by Lu et al. (2024) presents the research on the adoption of mesh in ventral hernia repair regarding complications that occur after this procedure, especially hernia and postoperative SSIs. Being multi-centre and peer-reviewed, it has a substantial sample size and addresses the effectiveness of mesh repairs in the reduction of SSIs, which is, therefore, relevant. This research reveals that the rate of SSI amongst individuals with meshed rectal repair is 3.5 per cent, which reveals that more prophylactic procedures, like using antibiotics, are needed. This article offers conclusive evidence that interventions are done to minimize SSIs in hernia-repair patients.

Source #2: Review on Infection Prevention

In a recent Cochrane review, Seidler et al. (2020) provide a summarized systematic review of the available evidence regarding infection prevention in the surgical procedure in general and hernia repair in particular. This reliable, up-to-date review advocates employing antibiotic prophylaxis as a means to curtail SSIs, bearing in mind that antibiotics are especially potent in risky surgeries. The evidence presented in this review also aligns with the critical value of prophylactic antibiotics in reducing the incidence of infections and promoting enhanced recovery, thereby accentuating its evidential significance to the PICO(T) question.

Source #3: Review on Antibiotic Prophylaxis in Hernia Repair

The SAGES (Society of American Gastrointestinal and Endoscopic Surgeons) guidelines

in Daly et al.’s (2024) article provide professional guidance, including recommendations on the services to be offered to the patient’s postoperative treatment, involving the surgical work on the

restoration of the hernia. The guidelines promote the use of specified surgical wound care guidelines, including antibiotics, as one of the methods of reducing SSIs and recurrent hernias. Being one of the guidelines formulated by specialists, the source provides practical and evidence-based recommendations that are up-to-date and can be adopted in clinical practice according to the purpose of the PICO(T) question.

Analyzing the PICO(T) Evidence

The findings of the data gathered in the chosen articles are closely aligned with the idea of antibiotic prophylaxis after a repaired ventral hernia to prevent the emergence of SSIs. Lu et al. (2024) report that mesh repair is related to reduced SSI rates and an additional decrease in SSIs given other interventions (prophylactic antibiotics). This finding is confirmed by the Cochrane review conducted by Seidler et al. (2020), which suggests the efficacy of antibiotic prophylaxis in preventing SSI during various surgical procedures, including hernia repair. The SAGES guidelines in Daly et al.’s (2024) article propose more reinforcement of the already widespread postulate of wound antibiotic intervention and propose the same prophylaxis that can improve patient outcomes.

The evidence presents several assumptions from the reviewed studies. For example, the application of antibiotic prophylaxis is presumed to be equally effective across various types of hernia repairs, including those with different mesh materials. Also, the reviewed studies tend to assume that the patients were provided with antibiotics promptly, an aspect that plays a critical role in the prevention of infections. Even though the evidence favors the use of prophylaxis, there are some limitations in some studies, such as limited follow-up time and varied patient demographics, that should be taken into consideration. Therefore, these limitations must be addressed when translating the findings to clinically diverse settings.

Conclusion

The PICO(T) framework outlines moderate-to-high-quality evidence that antibiotic prophylaxis is effective in preventing surgical site infections and hernia recurrence after ventral hernia repair. Lu et al. (2024) and the Cochrane review by Seidler et al. (2020), as well as the SAGES guidelines by Daly et al. (2024), highlight the effectiveness of using antibiotics and standard care regimens in addressing wound care, thereby enhancing patient outcomes. These results have immediate clinical practice implications and suggest the inclusion of evidence-based practices to minimize complications in vulnerable populations, as well as the necessity to continue research and formulate and modify care approaches.

References

Daly, S., Kumar, S. S., Collings, A. T., Hanna, N. M., Pandya, Y. K., Kurtz, J., Kooragayala, K., Barber, M. W., Paranyak, M., Kurian, M., Chiu, J., Ansari, M. T., Slater, B. J., & Kohn, G. P. (2024). SAGES guidelines for the surgical treatment of hiatal hernias. Surgical Endoscopy, 38(9), 4765–4775. https://doi.org/10.1007/s00464-024-11092-3

Hou, Y., Collinsworth, A., Hasa, F., & Griffin, L. (2022). Incidence and impact of surgical site infections on length of stay and cost of care for patients undergoing open procedures. Surgery Open Science, 11(76), 1–18. https://doi.org/10.1016/j.sopen.2022.10.004

Lu, C., Cassidy, J., Embel, V., Ouellette, T., Arumugam, D., & Kipnis, S. (2024). Utilizing T-line mesh for periumbilical hernia repair: Evaluation of short-term outcomes. Plastic & Reconstructive Surgery Global Open, 12(11), e6287. https://doi.org/10.1097/gox.0000000000006287

Seidler, A. L., Hunter, K. E., Cheyne, S., Berlin, J. A., Ghersi, D., & Askie, L. M. (2020). Prospective meta-analyses and Cochrane’s role in embracing next-generation methodologies. Cochrane Database of Systematic Reviews, 10(10). https://doi.org/10.1002/14651858.ed000145

Whitman, A., De Lew, N., Chappel, A., Aysola, V., Zuckerman, R., & Sommers, B. (2022). Addressing social determinants of health: Examples of successful evidence-based strategies and current federal efforts. In Office of the Assistant Secretary for Planning and Evaluation (ASPE) (HP-2022-12). https://aspe.hhs.gov/sites/default/files/documents/e2b650cd64cf84aae8ff0fae7474af82/SDOH-Evidence-Review.pdf

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Create a 3–5 page submission in which you develop a PICO(T) question for the diagnosis you worked with in the first two assessments (Postoperative Hernia Repair) and analyze the evidence you locate to answer the question.

Introduction
PICO(T) is an acronym that helps researchers and practitioners define aspects of a potential study or investigation.

It stands for:

• P – Patient/population/problem.
• I – Intervention.
• C – Comparison (of potential interventions, typically).
• O – Outcomes.
• T – Time frame (if time frame is relevant).

The end goal of applying PICO(T) is to develop a question that can help guide the search for evidence (Boswell & Cannon, 2015). From this perspective, a PICO(T) question can be a valuable starting point for nurses who are beginning to apply an evidence-based model. By taking the time to precisely define the areas in which the nurse will be looking for evidence, searches become more efficient and effective.

Essentially, by precisely defining the types of evidence within specific areas, the nurse will be more likely to discover relevant and useful evidence during their search. When applying the PICO(T) approach, the nurse can isolate the interventions of interest and compare to other existing interventions for the evidenced impact on the outcome of the concern.

Reference

• Boswell, C., & Cannon, S. (2015). Introduction to nursing research. Jones & Bartlett Learning.

Professional Context
As a baccalaureate-prepared nurse, you will be responsible for locating and identifying credible and scholarly resources to incorporate the best available evidence for the purposes of enhancing clinical reasoning and judgement skills. When reliable and relevant evidence-based findings are utilized, patients, healthcare systems, and nursing practice outcomes are positively impacted.

PICO(T) is a framework that can help you structure your definition of the issue, potential approach that you are going to use, and your predictions related to the issue. Word choice is important in the PICO(T) process because different word choices for similar concepts will lead you toward different existing evidence and research studies that would help inform the development of your initial question. When writing a PICO(T)-formatted research question, you want to focus on the impact of the intervention and the comparison on the outcome you desire.

Scenario
For this assessment, please use the diagnosis you worked with in the first two assessments.

Instructions
After reviewing the materials you created to research a specific diagnosis in the first two assessments, apply the PICO(T) process to develop a research question and research it.

Your initial goal is to define the population, intervention, comparison, and outcome. In some cases, a time frame is relevant and you should include that as well, when writing a question you can research related to your issue of interest. After you define your question, research it, and organize your initial findings, select the two sources of evidence that seem the most relevant to your question and analyze them in more depth. Specifically, interpret each source’s specific findings and best practices related to your chosen diagnosis, and explain how the evidence would help you plan and make decisions related to your question.

If you need some structure to organize your initial thoughts and research, the PICO(T) Question and Library Search template (accessible from the Create PICO(T) Questions page) might be helpful.

In your submission, make sure you address the following:

• Review the PICO(T) process.
• Explain your diagnosis from Assessment 1 in terms of outcomes, risks, and complications. In your explanation, be sure to include the risks and complications for vulnerable populations or those affected by healthcare disparities and the impact of those disparities.
• Consider your diagnosis from Assessment 1. Develop a research question using the PICO(T) process to address an issue of your choosing related to your diagnosis.
• Properly format your PICO(T) question to guide your search of the literature.
• Describe your search of the literature, noting search engines, key words, and credibility factors.
• Locate evidence that explores your intervention and comparison of your PICO(T) question with an emphasis on your specific outcome (at least three diagnosis-issue-specific sources of evidence (scholarly articles)).
• Explain the content of each of your scholarly articles.
• Explain the credibility and relevance of each of the articles you chose to your diagnosis issue.
• Analyze the evidence. Determine the answer to your PICO(T) question based on your analysis of the evidence.

Additional Requirements
Your assessment should also meet the following requirements:

• Length of submission: Create a 3–5-page submission focused on defining a research question and interpreting evidence relevant to answering it.
• Number of references: Cite a minimum of four sources of scholarly or professional evidence that support your findings and considerations. Resources should be no more than 5 years old.
• APA formatting: Format references and citations according to the current APA style.

Competencies Measured
By successfully completing this assessment, you will demonstrate your proficiency in the following course competencies and scoring guide criteria:

• Competency 1: Interpret findings from scholarly quantitative, qualitative, and outcomes research articles and studies.
  • Describe a search of the literature noting search engines, key words, and credibility factors.
• Competency 2: Analyze the relevance and potential effectiveness of evidence when making a decision.
  • Explain a diagnosis in terms of outcomes, risks, and complications, including the risks and complications for vulnerable populations or those affected by healthcare disparities, and the impact of those disparities.
  • Explain the content of at least three sources of evidence, including the credibility and relevance of the articles to a specific diagnosis issue.
• Competency 4: Plan care based on the best available evidence.
  • Describe a research question developed using the PICO(T) process to address a chosen issue related to a diagnosis.
  • Analyze evidence to explain the answer to a PICO(T) question.
• Competency 5: Apply professional, scholarly communication strategies to lead practice changes based on evidence.
  • Organize content so ideas flow logically with smooth transitions; contains few errors in grammar/punctuation, word choice, and spelling.
  • Apply APA formatting to in-text citations and references, exhibiting adherence to most aspects of APA format.

Scoring Guide

• Use the scoring guide to understand how your assessment will be evaluated.