NUR 506 Module 2 PICOT Development Paper example

Three Drafts to One Question: Building a PICOT Question on Ice Chips and Mucositis During Fluorouracil Chemotherapy

[Student Name]

Southern New Hampshire University

NUR 506: Evidence-Based Practice

Module Two PICOT Development Paper

[Instructor Name]

[Date]

The organization, setting and figures below are a composite written as a model document. No real employer, client, colleague or patient is described.

Three Drafts to One Question: Building a PICOT Question on Ice Chips and Mucositis During Fluorouracil Chemotherapy

The Practice Problem

In a composite outpatient infusion center, many adults receiving fluorouracil-based chemotherapy for colorectal and other gastrointestinal cancers return for their second cycle with painful mouth sores. Oral mucositis makes eating and drinking difficult, can lead to weight loss and dehydration, and sometimes forces a dose reduction or delay in chemotherapy. Some nurses on the unit offer patients ice chips during the infusion; others do not, and nobody is sure whether it helps or what the right way to do it would be. That inconsistency is the starting point for this question.

Draft One

The first draft was the question as it was asked in the hallway: does ice help prevent mouth sores in chemotherapy patients? A trial search in CINAHL and PubMed using the words ice, mouth sores and chemotherapy returned a scattered mix of results, including articles on radiation to the head and neck, children with leukemia, dental care and cold caps for hair loss. The draft had no defined population, used lay language that researchers rarely use, and had no comparison or measurable outcome. It was a good conversation starter and a poor search.

Draft Two

The second draft used the structure of PICO, which is known to make searches more precise (Schardt et al., 2007): in adults receiving chemotherapy, does oral cryotherapy compared with no cryotherapy reduce oral mucositis? Replacing ice with oral cryotherapy and mouth sores with oral mucositis, the terms used in the research literature, brought up far more relevant studies, including a Cochrane review. But the population was still too broad. Chemotherapy regimens differ in how they cause mucositis, and the review found that cryotherapy had been studied mainly in two groups: adults receiving fluorouracil-based chemotherapy for solid tumors and adults receiving high-dose melphalan before stem cell transplant (Riley et al., 2015). Evidence from one group might not apply to the other, and neither group matched every patient in the center. The draft also lacked a time frame and a clear definition of the outcome.

Draft Three

The final question reads: in adults receiving bolus fluorouracil-based chemotherapy for gastrointestinal cancers (P), does holding ice chips in the mouth for 30 minutes starting just before the bolus dose (I), compared with standard oral care alone (C), reduce the incidence of moderate to severe oral mucositis (O) during the first two treatment cycles (T)?

Each element was revised for a reason. The population now matches the patients actually treated in the center and the group in which cryotherapy has been studied. The intervention names a timing and duration, because the protective effect depends on cooling the mouth while drug levels are highest after a bolus dose, and an international guideline recommends 30 minutes of oral cryotherapy for patients receiving bolus fluorouracil (Elad et al., 2020). The comparison is standard oral care rather than nothing, because every patient already receives mouth care instructions. The outcome is moderate to severe mucositis, which is what limits eating and leads to dose changes, and the time frame covers the early cycles when the problem was noticed.

The Final Question Ready for Searching

The table below breaks the final question into searchable elements for the next module's search.

Table 1

Final PICOT Elements With Search Terms

Note. Subject headings will be confirmed in each database's thesaurus before searching.

Testing the Question With Colleagues

Before finalizing the question, the nurse shared the third draft with two infusion nurses, the unit's oncology pharmacist and a patient advisor who had received fluorouracil. Their comments sharpened it further. The pharmacist confirmed which of the center's regimens include a bolus dose, since some patients receive fluorouracil only as a continuous infusion through a portable pump over two days, and cooling the mouth for 30 minutes would make little sense for them. The nurses pointed out that the center already grades mucositis with a standard toxicity scale at every visit, which means the outcome could later be measured with existing data. The patient advisor raised a practical concern: holding ice for half an hour is uncomfortable, and some patients have sensitive teeth. That comment did not change the question, but it added acceptability and adherence as factors to look for when the studies are read.

Why This Question Matters

The final question addresses a problem that affects many patients in the center, involves an intervention that costs almost nothing and is within nursing's control, and leads to a decision the unit can act on. A preliminary look at the literature suggests the question is answerable: the Cochrane review found that oral cryotherapy probably reduces mucositis of any severity in adults receiving fluorouracil-based chemotherapy, with moderate quality evidence (Riley et al., 2015). Because this is a question about the effect of an intervention, the strongest evidence will come from randomized controlled trials and systematic reviews of those trials, which is where the search will begin.

Lessons From Revising

Three lessons from this process will carry into later questions. First, the words patients and nurses use are rarely the words in the literature, so the first search is often a vocabulary lesson. Second, a population that seems specific at the bedside, such as chemotherapy patients, may hide important differences that researchers treat as separate groups. Third, the details of an intervention, such as its timing and duration, matter as much as its name, because a unit cannot adopt a practice it cannot describe exactly. A question that has survived three drafts and two trial searches is far more likely to produce an answer the infusion center can use.

Conclusion

Revising a PICOT question through several drafts, and testing each one against a database, turned a hallway question about ice into a precise, searchable question about oral cryotherapy during bolus fluorouracil chemotherapy. The final version defines the patients, the intervention's timing and duration, a realistic comparison, a clinically meaningful outcome and a time frame, and it is ready to guide a documented search.

References

Elad, S., Cheng, K. K. F., Lalla, R. V., Yarom, N., Hong, C., Logan, R. M., Bowen, J., Gibson, R., Saunders, D. P., Zadik, Y., Ariyawardana, A., Correa, M. E., Ranna, V., & Bossi, P. (2020). MASCC/ISOO clinical practice guidelines for the management of mucositis secondary to cancer therapy. Cancer, 126(19), 4423-4431. https://doi.org/10.1002/cncr.33100

Riley, P., Glenny, A.-M., Worthington, H. V., Littlewood, A., Clarkson, J. E., & McCabe, M. G. (2015). Interventions for preventing oral mucositis in patients with cancer receiving treatment: Oral cryotherapy. Cochrane Database of Systematic Reviews, (12), Article CD011552. https://doi.org/10.1002/14651858.CD011552.pub2

Schardt, C., Adams, M. B., Owens, T., Keitz, S., & Fontelo, P. (2007). Utilization of the PICO framework to improve searching PubMed for clinical questions. BMC Medical Informatics and Decision Making, 7, Article 16. https://doi.org/10.1186/1472-6947-7-16