NUR 550 Module 3 Milestone One Example

Milestone One: A Repeatable Literature Search for Evidence on Multicomponent Delirium Prevention in Older Medical Inpatients

[Student Name]

Southern New Hampshire University

NUR 550: Evidence-Based Practice and Scholarly Inquiry

Milestone One

[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.

Milestone One: A Repeatable Literature Search for Evidence on Multicomponent Delirium Prevention in Older Medical Inpatients

A literature search is evidence in its own right: if it cannot be repeated, its conclusions cannot be trusted. This milestone documents the search for the PICOT question developed in Module 2: for adults 70 and over admitted to an acute medical unit, would a bundle of nursing actions aimed at the main delirium risk factors, rather than usual care, lower the rate of positive daily 4AT screens during the stay? The search was built from the question's concept blocks, run in three databases with stated limits and screened against written criteria, and it retained nine sources that together cover effectiveness, detection and real-world implementation, with one clear gap: little evidence from units staffed without volunteers.

Databases and Dates

Three databases were searched in one session: PubMed, for medical and nursing research indexed with MeSH headings; CINAHL Complete, for nursing literature and quality improvement reports; and the Cochrane Library, for systematic reviews. The main search covered January 2010 to the date of the search, with seminal studies before 2010 added through reference lists. Limiting by date keeps the evidence current, while allowing seminal work prevents the loss of foundational trials.

Concept Blocks and Search Terms

The PICOT question produced four concept blocks. Terms within each block were combined with OR, and the blocks were combined with AND. Table 1 shows the terms used in PubMed; equivalent CINAHL headings replaced MeSH where they differed.

Table 1

Concept Blocks, Subject Headings and Keywords

Note. Asterisks mark truncation. Blocks combined with AND; terms within blocks with OR.

Limits and Their Reasons

Four limits were applied. English language, because the team can appraise only English sources, which the paper acknowledges as a bias. Adults aged 65 and older, slightly wider than the question's 70, to avoid losing studies that report older age bands differently. Publication from 2010 onward for the main search, as described. And exclusion of intensive care and surgical settings at screening rather than as a database limit, because database setting filters are unreliable and could remove relevant mixed-population studies. Recording the reason for each limit lets a reader judge what the search might have missed.

Beyond the Databases

Database searching was supplemented in two ways. First, the reference lists of every full text assessed were scanned, a step often called backward citation chasing, which is how the 1999 controlled trial and the 1990 validation of the Confusion Assessment Method entered the set despite predating the date limit. Second, the most relevant review was checked in a citation index for later papers that cited it, forward citation chasing, which surfaced one implementation report not found in the databases.

A test of the search's sensitivity was also run. Before screening, three key papers already known to the team were checked against the results; all three appeared, which suggests the strings were broad enough. Had any been missing, the terms would have been revised and the search rerun. Recording this check, along with the supplementary methods, gives a reader more confidence that the search found what it should have found.

Screening and Selection

Records were screened in two stages, titles and abstracts and then full texts, against written criteria. Studies were included if they tested or reviewed multicomponent non-drug delirium prevention in hospitalized older adults outside intensive care, or evaluated a delirium detection tool for such patients, and reported delirium incidence or detection accuracy. Studies were excluded if they tested drugs only, involved only intensive care or surgical patients, treated delirium after onset or were opinion pieces without data. Table 2 reports the numbers at each stage, following the flow that the PRISMA 2020 statement recommends for reporting searches transparently (Page et al., 2021).

Table 2

Screening Flow From Records Identified to Sources Retained

Note. Counts from the author's search log.

Sources Retained

The nine sources fall into four groups. For effectiveness, the search retained the original controlled trial of a multicomponent intervention in older medical patients, in which delirium developed in 9.9% of intervention patients and 15.0% of usual-care patients (Inouye et al., 1999), a Cochrane review of non-drug prevention in hospitalized patients outside intensive care (Burton et al., 2021) and two meta-analyses of multicomponent programs. For detection, it retained the original validation of the Confusion Assessment Method and a meta-analysis of the 4AT. For implementation, it retained two reports of the Hospital Elder Life Program replicated in community hospitals, one of which reported a 35% relative reduction in delirium on a 40-bed unit (Rubin et al., 2006). A narrative review of delirium in older people completed the set. The next modules will appraise and synthesize these sources.

Gaps and Limitations

The search revealed a gap that matters for this unit: most implementation reports describe programs staffed partly by trained volunteers, and few describe units delivering the components with nursing staff alone. The search itself has limitations. It was run by one person, so screening decisions were not checked by a second reviewer, and restricting to English may have excluded relevant European studies. Gray literature, such as hospital reports and conference abstracts, was not searched systematically. Each limitation is recorded so the synthesis can take it into account (Melnyk & Fineout-Overholt, 2023).

Conclusion

The search was built directly from the PICOT question, documented block by block and screened against written criteria, and each stage is recorded with numbers so it can be repeated. It retained nine sources covering effectiveness, detection and implementation, and it revealed a practical gap about staffing that the implementation plan will have to address. Module 4 begins the appraisal with the landmark trial.

References

Burton, J. K., Craig, L. E., Yong, S. Q., Siddiqi, N., Teale, E. A., Woodhouse, R., Barugh, A. J., Shepherd, A. M., Brunton, A., Freeman, S. C., Sutton, A. J., & Quinn, T. J. (2021). Non-pharmacological interventions for preventing delirium in hospitalised non-ICU patients. Cochrane Database of Systematic Reviews, 2021(7), Article CD013307. https://doi.org/10.1002/14651858.CD013307.pub2

Inouye, S. K., Bogardus, S. T., Charpentier, P. A., Leo-Summers, L., Acampora, D., Holford, T. R., & Cooney, L. M. (1999). A multicomponent intervention to prevent delirium in hospitalized older patients. New England Journal of Medicine, 340(9), 669-676. https://doi.org/10.1056/NEJM199903043400901

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

Page, M. J., McKenzie, J. E., Bossuyt, P. M., Boutron, I., Hoffmann, T. C., Mulrow, C. D., Shamseer, L., Tetzlaff, J. M., Akl, E. A., Brennan, S. E., Chou, R., Glanville, J., Grimshaw, J. M., Hróbjartsson, A., Lalu, M. M., Li, T., Loder, E. W., Mayo-Wilson, E., McDonald, S., . . . Moher, D. (2021). The PRISMA 2020 statement: An updated guideline for reporting systematic reviews. BMJ, 372, Article n71. https://doi.org/10.1136/bmj.n71

Rubin, F. H., Williams, J. T., Lescisin, D. A., Mook, W. J., Hassan, S., & Inouye, S. K. (2006). Replicating the Hospital Elder Life Program in a community hospital and demonstrating effectiveness using quality improvement methodology. Journal of the American Geriatrics Society, 54(6), 969-974. https://doi.org/10.1111/j.1532-5415.2006.00744.x