Final Project Topic

HCM 440 Final Project Guidelines and Rubric

Overview Healthcare administrators, managers, and executives are responsible for planning, directing, and coordinating health services at various levels for the populations they serve. Interpreting research is integral to the role of a healthcare professional, especially when conducting a needs assessment for program planning.

In this course, you will choose a clinical area of interest related to healthcare administration and create an annotated bibliography. For your final assessment, you will compose an integrated review. In this review, you will discuss the criteria necessary for inclusion or exclusion in the research study, critique the quality of each study, and present a synthesis of the results.

This integrated review will address the following course outcomes:

1. Critique ethical issues in healthcare research for their influence on compliance with rules and regulations 2. Evaluate basic research strategies applicable to healthcare settings for informing research proposals 3. Assess the appropriateness of utilizing secondary databases in healthcare research as an alternative to conducting original research 4. Justify the selection of specific data analysis methodology in published healthcare research for informing healthcare research methodology 5. Select healthcare administration issues to research in validating the need for program evaluation

Prompt Using the six peer-reviewed literature articles from your annotated bibliography, compose an integrated review that focuses on a clinical issue of interest. Ensure that the topic of this integrated review is viewed from the perspective of a healthcare professional who is looking to validate the need for program evaluation at your hospital, even if your annotated bibliography was not this focused.

Specifically, your integrated review should focus on the following critical elements:

I. Abstract Craft a well-drafted abstract. Be sure to adhere to the guidelines from the latest edition of the American Psychological Association’s style guide. Consider the appropriate length for your audience.

II. Introduction a) State the purpose, aims, or objectives of the integrated review. What do you wish to achieve through the drafting of this review? Be explicit in

your answer. b) Introduce the topic of interest. Why is this topic the focus of the review? c) What is the research question you are going to focus on? If you were to prepare a research proposal, what would your hypothesis be? Why? d) What variables are of interest to you? How will these variables help you throughout this integrated review? Be sure to label the types of

variables each of these are. e) Discuss the background and significance of the problem to healthcare administration.

III. Literature Search a) What keywords and combinations were used in the initial search? Which were the most effective? Explain why these keywords and

combinations provided the most useful results. b) Which databases were searched? Why were these the chosen databases? Assess the characteristics that make these databases the most

reliable. c) Evaluate the inclusion and exclusion criteria for the sample. How did you decide to narrow the search and focus the review? How was the final

sample determined? Be sure to include your process.

IV. Methodology Analysis a) What methodology was used in this research? Was it effective for the research question and hypothesis? Why or why not? Consider including

improvements for the methodology. b) What statistical data analyses were employed in these articles? Were they appropriate for the research question and methodology? Why or

why not? c) Evaluate the literature for any gaps that exist. Why do you think these gaps exist? Consider factors such as the location of the research, time the

research was conducted, and so on. d) Evaluate the literature for inconsistencies that exist across the studies. Why do you think these inconsistencies exist? Consider factors such as

the location of the research, time the research was conducted, and so on.

V. Synthesis and Interpretation a) Create an evidence table of your results. Be sure to include the following criteria for each study:

1. Report citation 2. Design 3. Method 4. Sample 5. Data collection 6. Data analysis 7. Validity and reliability

b) Compare and contrast the study findings. Be sure to include pertinent conclusions and statistical findings only. c) Evaluate the research strategies used in the articles, as applicable to healthcare programs. Was the research design appropriate for the study

conducted? Was the statistical analysis employed the best choice for the research questions posed? d) What ethical issues are pertinent specifically to healthcare research? How can these issues influence the research strategies chosen to

investigate clinical topics? Evaluate these research articles and consider how ethical concerns may have limited these clinical investigations. e) What patterns and trends exist in the research? What generalizations can you draw from the research? f) If secondary data was utilized, was the source biased or objective? Why? If original research was conducted, do you think the researchers were

biased or objective? Why? Be sure to support your answer.

g) Synthesize the main findings of the research articles. What were the hypotheses of the research studies? Did the research add any new scholarly information to the existing body of knowledge?

h) Assess whether utilizing secondary data as an alternative to the researchers’ original research would have been a feasible option. If it had been an option, what resource(s) would be the most appropriate to use? What would be some of the strengths and limitations of using secondary data?

i) Assess the literature for any ethical concerns that may be present. Consider things such as conflicts of interest between the researcher and the study sponsors, or the lack of an IRB approval for the study.

VI. Conclusion a) What are the studies’ strengths? Are there patterns in the articles that you chose regarding their strengths? b) What are the studies’ limitations? Are there patterns in the articles that you chose regarding their limitations? c) Were the findings and conclusions reliable and valid? Why or why not? Logically support your answers. d) What are the implications of this research? How will it influence your topic in the overall large picture of healthcare research?

Milestones Annotated Bibliography This milestone is due in Module Four. Submit a summary and analysis of six research articles relevant to the research problem that you have chosen. This milestone is graded with the Annotated Bibliography Rubric.

Integrated Review The final project is due in Module Eight. Using the six peer-reviewed literature articles from your annotated bibliography, compose an integrated review that focuses on a clinical issue of interest. Ensure that the topic of this integrated review is viewed from the perspective of a healthcare professional who is looking to validate the need for program evaluation at your hospital. Remember to use APA format. This final project is graded with the Final Project Rubric.

Final Project Rubric Guidelines for Submission: Submit the integrated review as one complete document, including the title page, abstract, written components, references, and any necessary appendices. The written components of the review (excluding the title page, abstract, references, and appendices) should not exceed 12 pages, double-spaced, with one-inch margins. Be sure to adhere to formatting guidelines from the latest edition of the American Psychological Association (APA) reference manual.

Critical Elements Exemplary (100%) Proficient (85%) Needs Improvement (55%) Not Evident (0%) Value

Abstract Meets “Proficient” criteria, and abstract is appropriate in length for reader’s audience

Crafts well-drafted abstract, adhering to guidelines from the latest edition of the APA style guide

Crafts abstract, but abstract is not well drafted or does not adhere to guidelines from the latest edition of the APA style guide

Does not craft abstract 2.5

Introduction: Purpose

Meets “Proficient” criteria, and purpose, aims, or objectives demonstrate a keen understanding of the integrated review process

Explicitly states the purpose, aims, or objectives of the integrated review

States the purpose, aims, or objectives of the integrated review, but is not explicit in doing so

Does not state the purpose, aims, or objectives of the integrated review

3.8

Introduction: Topic Meets “Proficient” criteria, and explanation is explicitly clear

Explains why the topic is the focus of the review

Explains why the topic is the focus of the review, but explanation is cursory or weak

Does not explain why the topic is the focus of the review

3.8

Introduction: Research Question

Meets “Proficient” criteria, and research question demonstrates depth of understanding of chosen topic

Introduces the research question and hypothesis, including explanation behind hypothesis

Introduces the research question and hypothesis, including explanation behind hypothesis, but explanation is illogical, cursory, or weak

Does not introduce the research question and hypothesis

3.8

Introduction: Variables

Meets “Proficient” criteria, and chosen variables of interest reflect true understanding of chosen topic of interest

Explains labeled variables of interest, including how these variables will be of help throughout the integrated review

Explains variables of interest, but variables are not labeled and explanation of how variables will help throughout integrated review is illogical or weak

Does not explain variables of interest

3.8

Introduction: Background

Meets “Proficient” criteria, and discussion logically links research question to healthcare administration

Discusses the background of the problem and significance of the problem to healthcare administration

Discusses the background of the problem and discusses significance of the problem, but discussion is not thorough or does not relate significance to healthcare administration

Does not discuss the background of the problem and significance of the problem to healthcare administration

3.8

Literature Search: Keywords and Combinations

Meets “Proficient” criteria, and explanation for most useful keywords and combinations demonstrates a nuanced understanding of research databases

Evaluates which keywords and combinations used in the initial search provided the most useful results, including an explanation for why this is true

Evaluates which keywords and combinations provided the most useful results, including an explanation for why this is true, but evaluation is not limited to initial search, or explanation for why this is true is illogical, weak, or cursory

Does not evaluate which keywords and combinations used in the initial search provided the most useful results

3.8

Literature Search: Databases

Meets “Proficient” criteria, and assessment of characteristics shows keen insight into reliability of research databases

Assesses which databases were chosen and what characteristics make them the most reliable

Assesses which databases were chosen and what characteristics make them the most reliable, but assessment is illogical, weak, or not comprehensive

Does not assess which databases were chosen and what characteristics make them the most reliable

3.8

Literature Search: Inclusion and

Exclusion

Meets “Proficient” criteria, and process of determining inclusion or exclusion demonstrates ability to logically evaluate research

Comprehensively evaluates the inclusion and exclusion criteria for the sample

Evaluates the inclusion and exclusion criteria for the sample, but evaluation is not comprehensive

Does not evaluate the inclusion and exclusion criteria for the sample

3.8

Methodology Analysis:

Methodology

Meets “Proficient” criteria and includes improvements for methodology

Logically evaluates the efficacy of methodology used in the research articles

Evaluates the efficacy of methodology used in the research, but evaluation is illogical

Does not evaluate the efficacy of methodology used in the research

3.8

Methodology: Statistical Data

Analyses

Meets “Proficient” criteria, and explanations for appropriateness of data analyses demonstrate a nuanced understanding of statistical techniques

Logically evaluates the appropriateness of the statistical data analyses used in the research articles

Evaluates the appropriateness of the statistical data analyses used in the research articles but the evaluation is not logically sound

Does not evaluate the appropriateness of the statistical data analyses used in the research articles

3.8

Methodology: Gaps Meets “Proficient” criteria and possible explanations for gaps in literature take into consideration factors such as location and time

Comprehensively evaluates the literature for any gaps that exist, including possible explanations for those gaps

Evaluates the literature for any gaps that exist, including possible explanations for those gaps, but evaluation is not comprehensive or explanations are illogical or weak

Does not evaluate the literature for any gaps that exist

3.8

Methodology: Inconsistencies

Meets “Proficient” criteria, and possible explanations for inconsistencies that exist across the studies take into consideration factors such as location and time

Comprehensively evaluates the literature for any inconsistencies that exist across the studies, including possible explanations for those inconsistencies

Evaluates the literature for any inconsistencies that exist across the studies, including possible explanations for those inconsistencies, but evaluation is not comprehensive or explanations are illogical or weak

Does not evaluate the literature for any inconsistencies that exist across the studies

3.8

Synthesis and Interpretation: Evidence Table

Meets “Proficient” criteria, and evidence table of results is organized and visually appealing

Creates a comprehensive evidence table of results

Creates an evidence table of results, but does not include all required components

Does not create an evidence table of results

3.8

Synthesis and Interpretation: Compare and

Contrast

Meets “Proficient” criteria, and comparisons and contrasts of study findings include only significant conclusions and statistically significant findings

Compares and contrasts the study findings, including pertinent conclusions and statistical findings only

Compares and contrasts the study findings, but includes superfluous information

Does not compare and contrast the study findings

3.8

Synthesis and Interpretation:

Research Strategies

Meets “Proficient” criteria, and evaluation is focused on the appropriateness of the research strategies within healthcare programs

Comprehensively evaluates research strategies used in the articles as applicable to a healthcare program

Evaluates research strategies used in the articles, but research strategies do not apply to healthcare programs or evaluation is not comprehensive

Does not evaluate research strategies used in the articles

3.8

Synthesis and Interpretation: Ethical Issues

Meets “Proficient” criteria, and evaluation considers how ethical concerns may have limited clinical investigations specifically in the chosen clinical topic

Evaluates research articles for how possible ethical concerns may have limited clinical investigations

Evaluates research articles for how possible ethical concerns may have limited clinical investigations, but evaluation is limited, illogical, or weak

Does not evaluate research articles for how possible ethical concerns may have limited clinical investigations

3.8

Synthesis and Interpretation:

Patterns and Trends

Meets “Proficient” criteria, and analysis demonstrates nuanced ability to interpret research findings

Analyzes patterns and trends in the research, drawing generalizations from these patterns and trends

Analyzes patterns and trends in the research and draws generalizations from these patterns and trends, but analysis is cursory or generalizations are illogical

Does not analyze patterns and trends in the research

3.8

Synthesis and Interpretation: Secondary Data

Meets “Proficient” criteria, and support for evaluation includes specific examples

Evaluates if sources or researchers were biased or objective, with support for answer

Evaluates if sources or researchers were biased or objective and supports answer, but evaluation is not complete or support is illogical or weak

Does not evaluate if sources or researchers were biased or objective

3.8

Synthesis and Interpretation:

Synthesize

Meets “Proficient” criteria, and synthesis of articles demonstrates nuanced ability to blend multiple articles to support research question

Comprehensively synthesizes the main findings of the research articles

Synthesizes the main findings of the research articles, but synthesis is not comprehensive

Does not synthesize the main findings of the research articles

3.8

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Synthesis and Interpretation:

Utilizing

Meets “Proficient” criteria, and identification of strengths and limitations to using secondary data considers clinical topics in healthcare administration

Assesses whether utilizing secondary data is a feasible alternative to the researchers’ original research, including what resources would be most appropriate to use and the strengths and limitations to using secondary data

Assesses whether utilizing secondary data is a feasible alternative to the researchers’ original research, but assessment is not comprehensive

Does not assess whether utilizing secondary data is a feasible alternative to the researchers’ original research

3.8

Synthesis and Interpretation:

Ethical Concerns

Meets “Proficient” criteria, and assessment includes scenarios such as conflicts of interest between the researcher and study sponsor or the lack of an IRB approval for the study

Comprehensively assesses the literature for ethical concerns

Assesses the literature for ethical concerns, but assessment is not comprehensive

Does not assess the literature for ethical concerns

3.8

Conclusion: Strengths Meets “Proficient” criteria, and evaluation of studies’ strengths demonstrates keen ability to read beyond superficial results of research articles

Thoroughly evaluates the studies for patterns in strengths

Evaluates the studies for patterns in strengths, but evaluation is not thorough

Does not evaluate the studies for patterns in strengths

3.8

Conclusion: Limitations

Meets “Proficient” criteria, and evaluation of studies’ limitations demonstrates keen ability to read beyond superficial results of research articles

Thoroughly evaluates the studies for patterns in limitations

Evaluates the studies for patterns in limitations, but evaluation is not thorough

Does not evaluate the studies for patterns in limitations

3.8

Conclusion: Findings Meets “Proficient” criteria, and assessment demonstrates nuanced understanding of statistical principles

Assesses the findings and conclusions for reliability and validity, logically supporting answers

Assesses the findings and conclusions for reliability and validity and supports answers, but assessment is illogical or support is weak or illogical

Does not assess the findings and conclusions for reliability and validity

3.8

Conclusion: Implications

Meets “Proficient” criteria, and analysis of implications demonstrates a keen understanding of research topic overall

Thoroughly analyzes the implications of the research, including how the research will influence the clinical topic in the overall picture of healthcare research

Analyzes the implications of the research topic, including how the research topic will influence the clinic topic, but analysis is cursory or weak or does not consider how research fits into the overall picture of healthcare research

Does not analyze the implications of the research topic

3.8

Articulation of Response

Submission is free of errors related to citations, grammar, spelling, syntax, and organization and is presented in a professional and easy-to-read format

Submission has no major errors related to citations, grammar, spelling, syntax, or organization

Submission has major errors related to citations, grammar, spelling, syntax, or organization that negatively impact readability and articulation of main ideas

Submission has critical errors related to citations, grammar, spelling, syntax, or organization that prevent understanding of ideas

2.5

Earned Total 100%

Running head: FLUID RESUSCITATION

1

Fluid Resuscitation for Sepsis: Integrated Review

Autumn Teal

HCM 440 – Healthcare Research & Evaluation

Southern New Hampshire University

April 26, 2020

Running head: FLUID RESUSCITATION

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Abstract

Aim: The aim of this integrative review is to conduct a review of the literature using a

systematic approach for current research and synthesize these research studies of albumin

resuscitation compared to saline resuscitation in critical care patients with sepsis to validate a

program Critical Care Center for Patient Innovation at Tennessee Memorial Hospital.

Background: Fluid resuscitation is the primary treatment for patients with septic shock and

sepsis. However, only few studies have described the current initial fluid resuscitation practice.

Design and Data Sources: Systemic literature searches from healthcare evidence-based

databases, CINAHL, MEDLINE, and Cochrane Database of Systemic Review for previously

published peer-reviewed studies throughout the years 2011-2019. The inclusion of healthcare

evidence-based databases was integrated. Articles published beyond 2011 were excluded from

database searches.

Review Method: A five-stage integrative review method was used to review and synthesize

current knowledge. This method consisted of developing a problem formulation using a PICO

format, “In critical care patients, how does albumin resuscitation compared to saline resuscitation

affect sepsis?”

Results: Six papers were included in this research dated between 2011 to 2019. According to the

synthesis, the use of albumin containing products versus saline fluid resuscitation did not show a

reduction in mortality among patients.

Conclusion: The use of albumin-containing fluids compared to normal saline for resuscitation in

patients diagnosed with sepsis of any severity did not demonstrate significant advantage. Due to

the cost-effectiveness of albumin, crystalloids should be the first choice for fluid resuscitation in

septic patients.

Running head: FLUID RESUSCITATION

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Keywords: fluid resuscitation, saline, albumin, sepsis, crystalloids, colloids

Introduction

Background. The problem being addressed in this integrated review is the significance of

mortality rates based on albumin or saline fluid resuscitation in patients diagnosed with sepsis.

The primary treatment and management of patients diagnosed with sepsis is the resuscitation of

fluids. The ideal volume and composition of the resuscitation fluids are currently unknown

(Carlsen & Perner, 2011). The estimated number of patients per year diagnosed with severe

sepsis tops 750,000 in the United States and reaches up to 19 million worldwide. Sepsis presents

with a short-term mortality rate of 20%-30% and exceeds up to 50% when shock is present in the

body. Sepsis death rates continue to rise in the United States and is the leading cause of death

among hospitalized patients in non-coronary intensive care units (Jiang, et al., 2014). However,

early administration of fluid resuscitation interventions is key in the management of sepsis.

Nevertheless, the appropriate use of fluid therapy remains controversial. Therefore, the question

arises, in critical care patients, how does albumin resuscitation compared to saline resuscitation

affect sepsis? The independent variable (IV) in the study is the use of albumin-containing fluids

and the dependent variable (DV) would be how this affects patients diagnosed with sepsis. The

aim of this integrative review is to conduct a review of the literature using a systematic approach

for current research and synthesize these research studies of albumin resuscitation compared to

saline resuscitation in critical care patients with sepsis to validate a Critical Care Center for

Patient Innovation program at Tennessee Memorial Hospital.

Running head: FLUID RESUSCITATION

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Literature Review

Design and Data Sources. Systemic literature searches were performed from CINAHL,

MEDLINE, and Cochrane Database of Systemic Review databases from 2011 to 2019 for

previously published peer-reviewed studies. These databases were chosen for the searching of

evidence-based scholarly-reviewed articles to validate credible and reliable studies. CINAHL

database provides the top nursing and allied health literature available including nursing journals

and publications from the National League for Nursing and the American Nurses Association.

Literature covers a wide variety of topics from biomedicine to allied health disciplines.

MEDLINE is a bibliographic database of life sciences and biomedical information. It includes

academic journals covering medicine, nursing, pharmacy, dentistry, veterinary medicine, and

healthcare. Cochrane Database of Systemic Review is a library consisting of collections of

databases in medicine and other healthcare specialties. Initial key word searches included fluid

resuscitation, sepsis, saline, albumin-containing solutions, and crystalloids. Further restriction of

key words and MeSH terms included meta-analysis, systematic-review, sepsis, albumin, and

resuscitation yielded considerable results with reliable and expedient information. Utilizing

MeSH terms such as albumin and resuscitation and sepsis produced relevant research articles to

include those specific key words in correlation with the PICO being addressed. Inclusion criteria

for this integrated review were journals and articles that were peer reviewed with information on

fluid resuscitation for sepsis patients and published between 2011 and 2019. Exclusions

consisted of any articles beyond the year 2011 in order to narrow the search. Journal and articles

that did not contain information on sepsis patients or did not have supportive data were also

excluded. All articles were evaluated for highest level of evidence (LOE).

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Methodology Analysis

Review method. A five-stage integrative review method was used. This method consisted of (a)

problem formulation was developed using a PICO format, in critical care patients, how does

albumin resuscitation compared to saline resuscitation affect sepsis, (b) searches of these

evidence-based databases, CINAHL, MEDLINE, and Cochrane Library by using the key words

fluid resuscitation, sepsis, saline, albumin-containing solutions, and crystalloids and MeSH terms

included meta-analysis, systematic-review, sepsis, albumin, and resuscitation (c) evaluation of

data, (d) data analysis and interpretation, and (e) presentation of results in an evidence table by

the identification and evaluation of what was used to review and synthesize current knowledge.

Focus of this review on fluid resuscitation in sepsis was narrowed towards articles less than eight

years old with a focus on systematic reviews and meta-analysis for highest level of evidence

(LOE). Any and all articles from blogs, books, and Google or Google Scholar were excluded due

to lack of credibility and reliability. The dependent and independent variable search terms lead to

the majority of articles and journals chosen being systematic reviews and meta-analysis. These

findings indicate that the articles contain high level of evidence (LOE) and reliability.

Synthesis and Interpretation

Results. Using standard process for conducting an integrative review, six peer-reviewed research

studies published in refereed journals were analyzed and synthesized. According to the synthesis

of these studies, the use of albumin-containing products versus normal saline resuscitation

therapy demonstrated no significant advantage in patients with any severity of sepsis.

The research strategies used to gather information consisted of predominantly randomized

controlled trials (RCTs) with secondary data such as systematic reviews and meta-analysis in

Running head: FLUID RESUSCITATION

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quantitative research methods. These studies followed a logical manner with a clear and evident

link beginning with the purpose of the study following through. These sources were objective

with no bias noted in the research studies reviewed, with the exception of Annals of Internal

Medicine and The American Journal of Emergency Medicine. The risk of bias for individual

studies and quality of evidence were assessed and was found within the limitations. These trials

were heterogenous in case mix, fluids evaluated, and duration of fluid exposure. Imprecise

estimates for several comparisons in this network meta-analysis contribute to low confidence in

most estimates of effect (Rochwerg, et al., 2014).

Data was collected in numerous ways however randomized trials was leading. Carlsen & Perner

(2011) consisted of a prospective cohort study of all patients with sepsis or septic shock admitted

in six intensive care units during a three-month period. Patients were divided into two groups

according to the overall median volume of resuscitation fluid administered during the first

twenty-four hours after the diagnosis. Jiang, et al., (2014) consisted of fifteen eligible

randomized controlled trials for analysis. Several predefined subgroup analyses were performed

according to patient age (adult or pediatric), type of resuscitation fluid (crystalloids or gelofusine

or starch), concentration of albumin (4% to 5% solution or 20% to 25% solution), follow-up

interval (intensive care unit mortality, hospital mortality, 28/30 day mortality and ninety day

mortality), disease severity (sepsis, sever sepsis, septic shock), and definition of sepsis. Despite

the subgrouping of this particular study, there was no significant effect of albumin-containing

fluids on mortality in patients with sepsis of any severity. While the difference in mortality

between groups did not reach statistical significance, these findings indicate that 4% to 5%

albumin may be safer than 20% to 25% albumin for fluid resuscitation in patients diagnosed with

Running head: FLUID RESUSCITATION

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sepsis of any severity. Conclusive to this, further studies are implausible to change the existing

conclusion.

Despite best efforts of research and data collection methods, gaps and inconsistences were

present throughout this review process with indications of observable limitations. Rochwerg, et

al., (2014) trials consisted of heterogenous trials, fluids assessed, extent of exposure, and risk of

bias. These factors have the potential to alter conclusions. Liu, et al., (2019) meta-analysis

comprised of potential limitations. Subgroup and sensitivity analyses were of difficulty to

perform due to lack of data. Patients that were included in this meta-analysis presented with

varying levels of secondary trauma such as acute pancreatitis which resulted in heterogeneity.

There was potential for partial recovery of identified research studies, introducing bias. Carlsen

& Perner (2011) impedes strong conclusions regarding the effects of fluid resuscitation for septic

patients. Gaps for this study includes the lack of timing and rate of fluid infusion assessment by

clinicians. The majority of patients in this research method were given broad-spectrum

antibiotics before the absolute diagnosis, but those who had not received them did not present

with an inferior outcome. Despite the limitations and gaps present, this study was solely

observational in design. Delaney, et al., (2011) consisted of a meta-analysis that presented with

non-optimal methodological quality. The results of this analysis differ from those of previous

meta-analyses of albumin in patients with sepsis or severe sepsis. This method focused on a

specific population rather than heterogenous populations such as others. Jiang, et al., (2014)

meta-analysis presented with heterogeneity between different studies and the methodological

quality of all studies included in this research was adaptable.

Running head: FLUID RESUSCITATION

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Ethical Concerns

Ethical concerns. There were no present concerns of ethics in the creation and implementation in

any of these reviewed studies. The ethics committee of Copenhagen and the Danish Data

Protection Agency approved the study of Carlsen & Perner, (2011). All other studies were

deemed ethical and declared no conflict of interest.

Conclusion

Strengths. The strength of these reviews is included in a precise clinical question that is limited

to patients with sepsis rather than critically ill patients as a whole. The strength lies in the focus

of resuscitation rather than the maintenance of fluid therapy. Studies consisted of inclusions of

patients in intensive care units and comprised of follow-up with the National Patient Registry

using national patient identification numbers.

Limitations. The patterns of limitations varied between studies reviewed based on population,

study size, demographics and control or subgroups being most prevalent. Despite the present

gaps and inconsistencies in each study, they were efficient in concluding the result of albumin-

containing products versus saline in fluid resuscitation not demonstrating an increase in mortality

rates in patients with sepsis.

Validity and Reliability. The results of all studies reviewed deemed reliable and valid as

indication of highest level of evidence (LOE). All studies presented with strong level I of

evidence excluding Carlsen & Perner, (2011), which consists of LOE II. Studies revealed reliable

as confirmation of strong sources, authors, and year published. Studies supported each other with

aligning evidence and outcomes in relation to albumin versus saline resuscitation in patients with

sepsis.

Running head: FLUID RESUSCITATION

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Implications. The implications of this research reveal that there is no advantage to administering

albumin versus saline in the reduction of mortality in sepsis patients. Based off of these

conclusions, a sepsis patient can be treated with either available intervention. Factors such as

population, demographic, or available access have no determination in which product is

administered. However, if economic burden is present, the use of crystalloids should be of first

choice due to the cost of albumin-containing products.

Running head: FLUID RESUSCITATION

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References:

Carlsen, S., & Perner, A. (2011). Initial Fluid Resuscitation of Patients with Septic Shock in the

Intensive Care Unit. ACTA Anaesthesiologica Scandinavica, 394–400. doi:

10.1111/j.1399-6576.2011.02399.x

Delaney, A. P., Dan, A. P., McCaffrey, J. P., & Finfer, S. P. (2011). The Role of Albumin as a

Resuscitation Fluid for Patients with Sepsis: A Systematic Review and Meta-Analysis.

Critical Care Medicine, 39(2), 386–391. doi: 10.1097/CCM.0b013e3181ffe217

Jiang, L., Jiang, S., Zhang, M., Zheng, Z., & Ma, Y. (2014). Albumin Versus Other Fluids for

Fluid Resuscitation in Patients with Sepsis: A Meta-Analysis. PloS One, 1–21. doi:

0.1371/journal.pone.0114666

Liu, C., Lu, G., Wang, D., Lei, Y., Mao, Z., Hu, P., … Zhou, F. (2019). Balanced Crystalloids

Versus Normal Saline for Fluid Resuscitation in Critically Ill Patients: A Systematic

Review and Meta-Analysis with Trial Sequential Analysis. The American Journal of

Emergency Medicine, 37(11), 2072–2078. doi: 10.1016/j.ajem.2019.02.045

Rochwerg, B. H., Alhazzani, W. J., Sindi, A. undefined, Heels-Ansdell , D. undefined, Thabane,

L. undefined, Fox-Robichaud, A. undefined, … Annane, D. undefined. (2014). Fluid

Resuscitation in Sepsis: A Systematic Review and Meta-Analysis. Annals of Internal

Medicine, 1–11. doi: 10.7326/M14-0178

Seccombe, A., McCluskey, L., Moorey, H., Lasserson, D., & Sapey, E. (2019). Assessing Fluid

Resuscitation in Adults with Sepsis Who Are Not Mechanically Ventilated: A Systematic

Review of Diagnostic Test Accuracy Studies. Journal of General Internal Medicine,

1874–1883. doi: 10.1007/s11606-019-05073-9

Running head: FLUID RESUSCITATION

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Appendix A

Table 1. Summary Evidence Table Report Citation Design Method Sample Data Collection Data Analysis Validity and

Reliability Carlsen & Perner (2011)

To evaluate the current initial fluid resuscitation practice in patients with septic shock in the intensive care unit (ICU) and patient characteristics and outcome associated with fluid volume.

Prospective cohort and observational study.

Patients with septic shock admitted in six ICUs during a 3- month period.

One-page case report form by the clinician of the patient in the specific ICU and entered into an Excel data sheet by a single research nurse.

Although more severely shocked patients received higher volumes of crystalloids, colloids, and blood products, mortality did not differ between groups.

Level II LOE. Strong size of patient groups.

Delaney, et al. (2011)

To assess whether resuscitation with albumin-containing solutions, compared to other fluids, is associated with lower mortality in patients with sepsis.

Prospective randomized clinical trials with quantitative data synthesis.

Eight studies including patients with sepsis and nine studies of patients with sepsis as a subgroup.

Two reviewers independently extracted data onto data forms designed specifically for the study; data was checked for accuracy by a third reviewer.

Evidence suggests albumin reduces mortality when used as a resuscitation fluid for patients with sepsis.

Level I LOE. Systematic review and meta-analysis with strong reliability.

Jiang, et al. (2014)

To evaluate whether the use of albumin-containing fluids for resuscitation in

Fifteen randomized controlled trials.

Patients with sepsis of any severity.

Extraction of all relevant data was conducted by two authors independently.

The present meta-analysis did not demonstrate significant

Level I LOE. A meta-analysis with strong reliability.

Running head: FLUID RESUSCITATION

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patients with sepsis was associated with a decreased mortality rate.

Methodological quality.

advantage of using albumin- containing fluids for resuscitation in patients with sepsis of any severity.

Liu, et al. (2019).

To compare the efficacy and safety of balanced crystalloids with normal saline.

Nine randomized controlled trials were identified. Methodological quality of included trials was assessed by two reviewers according to the Cochrane Risk of Bias Tool.

Critically ill patients over the age of 18 requiring fluid resuscitation.

Two independent reviewers performed the data extraction using a standardized form.

Among critically ill patients receiving crystalloid fluid therapy, the use of a balanced crystalloid compared with normal saline did not reduce the risk of mortality.

Level I LOE. A systematic review and meta-analysis. Low risk of publication bias. Limited sample size, >18 years.

Rochwerg, et al. (2014).

To examine the effect of different resuscitative fluids on mortality in patients with sepsis.

14 studies (18,916 patients) with 15 direct comparisons.

Adult patients with sepsis or septic shock.

Two reviewers extracted data on study characteristics, methods, and outcomes. Risk of bias and quality of evidence were assessed.

Among patients with sepsis, resuscitation with balanced crystalloids or albumin compared with other fluids seems to be associated with

Level I LOE. A systematic review and network meta- analysis. Risk of bias. Imprecise estimates.

Running head: FLUID RESUSCITATION

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reduced mortality.

Seccombe, et al. (2019)

To assess studies of diagnostic tests that identify the need for fluid resuscitation in adults with sepsis, as defined by the presence of fluid responsiveness.

594 patients within 14 studies. Reported using PRISMA guidelines.

Adults with sepsis without intensive care organ support, who would be appropriate for admission to an acute medical unit.

Data was extracted using a piloted, standardized form, following translation of non-English language articles if required.

Evidence to support fluid assessment in awake adults is lacking.

Level I LOE. A systematic review with high reliability. Median sample size and primarily single- centre.