Zynx Health's mission is to provide evidence-based products and services that empower our clients to measurably improve the quality, safety, and efficiency of patient care. ZynxCare is an Internet-based product that facilitates the integration of "best practices" into hospital-based workflow for nurses and allied health professionals (eg, nutritionists, occupational therapists, physical therapists, respiratory therapists, social workers). The knowledge contained in ZynxCare provides the basis for assessing, planning, and evaluating the care of patients with the most common problems that members of an interdisciplinary care team manage.
ZynxCare content is divided into modules that represent either clinical conditions (eg, Heart Failure – Systolic), procedures (eg, Total Hip Replacement), or problems that are experienced by patients with a variety of medical conditions, events, and procedures (eg, Patient Problems). Each module may contain evidence and plans of care. The methodology for development of each component is described below.
EVIDENCE
Organization of Evidence
Each module contains a series of problems (eg, Anxiety, Constipation, Discharge Planning) that have been identified to support the interdisciplinary team in caring for a patient undergoing a specific procedure or diagnosed with a specific condition. The evidence for each problem is divided into the following component parts: Assessment/Diagnosis, Planning/Implementation, and Evaluation/Outcome.
Content Organization
Evidence pages are divided into the following 3 sections:
1. Reminder
- The reminder is a concise and prescriptive statement summarizing the action to be taken based on the evidence.
- There are 5 levels of reminders pertaining to diagnostic or therapeutic interventions:
- Always use
- Consider using
- No recommendation (evidence is insufficient, inconsistent, conflicting)
- Avoid routine use of
- Never use
- Each reminder level is selected based on the relative weighting of evidence concerning clinical benefit, harm, cost, and expert consensus.
2. Rationale
- The rationale section provides a summary of key messages from all cited references.
- The rationale may be broken down into expandable subheadings, each supported by a section of the overall clinical evidence for that particular component part of the problem.
3. References
- All references are assigned a class of evidence based on the Zynx Health Evidence Classification System.
- The authors, title, and source are stated when applicable.
- For selected articles, a Synopsis or Synopsis+ (a quantitative summary of the study's key metrics) may be written by Zynx and provided via a hyperlink.
- Hyperlinks to the following external sources are provided when they are available in the public domain: PubMed citations, relevant Web sites, and/or Adobe® Acrobat® Portable Document Format (PDF) files.
PubMed is provided by the National Center for Biotechnology Information (NCBI), a division of the National Library of Medicine (NLM) at the National Institutes of Health (NIH). For information on NCBI disclaimers and copyright information, see www.ncbi.nlm.nih.gov/About/disclaimer.html.
Article Identification
The primary supporting evidence for each problem is identified through searches of English-language references pertaining to human subjects, using the following sources:
- Bibliographic Databases and Systematic Reviews:
- National Performance Measures:
Article Selection
The eligibility for inclusion of each reference in a problem is determined based on module specificity and the degree to which each reference contributes to the overall utility of evidence for a given problem.
Module specificity for evidence is defined as either (1) a majority (ie, > 50%) of the patient population having the clinical condition or undergoing the procedure of interest or (2) the condition or procedure is stated in the title of a reference.
Articles are preferentially included in each topic page using the following citation hierarchy:
- Meta-analyses, systematic reviews, and randomized controlled trials
- Nonrandomized prospective studies
- Retrospective studies
This hierarchy is similar to the scheme used by Rhew et al (Evaluating quality indicators for patients with community-acquired pneumonia. Jt Comm J Qual Improv 2001; 27:575-590) and the BMJ Publishing Group (How clinical evidence is put together: searching and appraising the literature. Clinical Evidence 2001; 6:xviii). The following criteria are also applied:
- More recent publications are preferentially cited over older publications.
- The rationale for each component part of a problem may be divided into expandable subheadings in which the evidence pertaining to each subheading follows the same citation hierarchy.
- When there are different studies of the same class of evidence for a given problem, studies that describe clinical outcomes (eg, mortality rates, quality of life) are preferentially cited over studies that describe nonclinical outcomes (eg, laboratory values, radiographic findings, statistical techniques).
- When there is conflicting evidence, articles of varying levels of evidence may be included to address the problem more comprehensively.
- Guidelines and consensus statements from national organizations are cited for each topic when available.
Topic Selection
Topics (ie, pages) are created for processes of care based on available evidence. A topic is created for a given module if the available evidence comprises one or more of the following:
- Class P Criteria (National Performance Measures)
- The topic is addressed as a national performance measure.
- Class E Criteria (Guidelines)
- A reference with recommendations from a national organization (but not an individual author) is published in the form of a guideline, consensus statement, position statement, or technology assessment.
- References with recommendations from national organizations are eligible for inclusion if they are published in journals that are indexed in PubMed or CINAHL. References that are not indexed in PubMed or CINAHL may be cited if an older version of the guideline from the same organization was previously indexed in PubMed or CINAHL or if it is authored by an organization that is listed in the Article Identification section.
- Class M and S Criteria (Meta-Analyses and Systematic Reviews)
- A meta-analysis demonstrates a statistically significant outcome for a clinical endpoint between an intervention group and a comparison group.
- A meta-analysis demonstrates equivalency for a clinical endpoint when an intervention is compared to an alternative intervention that has been shown to be superior to a control group.
- A systematic review addresses a clinical endpoint.
- Meta-analyses and systematic reviews may be used to define new topics irrespective of whether their results demonstrate benefit, harm, or no effect.
- Class A Criteria (Randomized Controlled Trials)
- At least 1 randomized controlled trial demonstrates a statistically significant outcome for a clinical endpoint between an intervention group and a comparison group.
- At least 1 randomized controlled trial demonstrates equivalency for a clinical outcome when an intervention is compared to an alternative intervention that has been shown to be superior to a control group.
- Class B and C Criteria (Nonrandomized Prospective and Retrospective Studies)
- At least 1 nonrandomized prospective study demonstrates a statistically significant outcome for a clinical endpoint between an intervention group and a comparison group.
- At least 1 nonrandomized prospective study demonstrates equivalency for a clinical outcome when an intervention is compared to an alternative intervention that has been shown to be superior to a control group.
- At least 1 retrospective study demonstrates a statistically significant outcome for a clinical endpoint.
- At least 1 retrospective study describes risk factors associated with a patient problem.
- Class Q Criteria (Economic Analyses)
- At least 1 study demonstrates an economic advantage or disadvantage for a process of care.
- Diagnostic Article Criteria
- An article evaluates a diagnostic test that is available for use in a clinical setting, utilizes a reference standard for comparison with the test being evaluated, and reports any of the following test characteristics: area under the receiver operating characteristic curve, sensitivity and specificity, positive likelihood ratio, or negative likelihood ratio.
- Prognostic Article Criteria
- An article that addresses a scoring system, prediction index, risk index, questionnaire, or clinical assessment scale, and provides adequate information regarding psychometric properties (eg, reliability and validity).
PLANS OF CARE
ZynxCare default plans of care comprise problems with expected outcomes and activities that are grouped under goal and intervention sections.
Problems
Problems may be acute or chronic in nature, or represent a functional or organizational risk that can be corrected or ameliorated in a clinical care setting. Problems may be actual or potential and may span 1 or more episodes of care.
Expected Outcomes
Each problem is associated with 1 or more expected outcomes that are grouped under the goal section. Expected outcomes represent measures that can be assessed by the interdisciplinary care team and indicate that progress is being made in resolving the problem. Expected outcomes in Zynx default plans of care may be evidence-based, in which case an "Evidence" hyperlink is provided. Additional common practice expected outcomes may also be added for completeness. National performance measures are denoted by blue ribbon icons with pop-up text descriptions indicating each performance measure's source.
Activities
Each problem is associated with 1 or more activities that are grouped under the intervention section. Activities are specific actions that the interdisciplinary care team carries out to address the problem. Activities may contain additional details to elucidate the key concepts of the activity. Activities in Zynx default plans of care may be evidence-based, in which case an “Evidence” hyperlink is provided. Additional common practice activities may also be added for completeness. National performance measures are denoted by blue ribbon icons with pop-up text descriptions indicating each performance measure's sources.
Zynx Health Catalog
The Zynx Health Catalog is a collection of terms that describes the domains, problems, expected outcomes, and activities used in the plans of care.
PRODUCTION ISSUES
Editorial Process/Quality Control
All components of ZynxCare (evidence and plans of care) are written and maintained by Zynx clinicians. Additionally, a Zynx librarian assists with literature searches and reference cataloging. Zynx editors review all content for technical accuracy and style consistency. External clinician review is also performed for selected modules.
Nursing Editorial Advisory Board
The Zynx Health Nursing Editorial Advisory Board is composed of accomplished and respected nurses who represent a wide spectrum of disciplines and fields of expertise.
Update Process
ZynxCare content is updated every 6 months; additional interim updates may be performed on selected modules and submodules based upon the emergence of new evidence. Hyperlinks to external Web sites and documents are reviewed on a regular basis to verify functionality.