NURS 225 Week 2 Evidence-Based Practice Project Part 1 Example

Gum Chewing After Abdominal Surgery: PICO Question, Triggers, Team Strengths and Annotated Bibliography

Topic and Triggers

Our group chose postoperative ileus, the sluggish gut that follows many operations and leaves patients nauseated, bloated and sore, delays eating and extends hospital stays. One member works as a patient care technician on a surgical unit where patients after colorectal and gynecologic surgery often wait several days to pass flatus, and nurses there field frequent questions about when patients can eat. The Iowa Model describes the triggers that start an evidence-based practice project, including clinical problems identified in practice and new evidence (Iowa Model Collaborative, 2017). Our project has both. The problem-focused trigger is the unit's experience with delayed bowel recovery and longer stays. The knowledge-focused trigger is a cluster of recent systematic reviews suggesting that chewing gum, a simple form of sham feeding, speeds recovery. Boswell and Cannon (2017) note that evidence-based practice questions often arise where daily practice and new evidence meet, and that is where our topic sits.

PICO Question

In adults after elective abdominal surgery (P), does chewing sugar-free gum three times daily beginning on the day of surgery (I), compared with standard postoperative care without gum (C), shorten the hours until the first passage of gas, the first stool and discharge home (O)?

Population: adults having elective abdominal surgery, including colorectal, general and gynecologic procedures. Intervention: sugar-free gum chewed for about 15 minutes three times a day starting when the patient is awake after surgery. Comparison: usual postoperative care. Outcomes: hours until gas is first passed, hours until the first stool and total days in hospital.

Team Strengths and Weaknesses

Megan has surgical unit experience and can describe current practice and staff attitudes, but she has the least experience with research databases. Jacob is our strongest database searcher and is careful with APA format, but he tends to take on too much and has the busiest work schedule. Priya writes clearly and will edit the page into one voice, but she is new to reading statistics. Daniel understands statistics from a previous degree and will explain effect sizes to the group, but he is reluctant to post drafts early. We agreed that each member will annotate at least one source, that Jacob will check every reference, that Daniel will review the numbers in each annotation and that Priya will edit the final page. Drafts are due in the wiki two days before each deadline.

Annotated Bibliography

Cui, Y., Zhang, C., Zhang, H., Zhang, X., Tang, Y., Wu, Z., Wang, T., Chen, Q., Meng, Y., Wang, B., Liu, M., Yi, J., Shi, Y., Li, R., & Pan, H. (2024). Effect evaluation of different preventive measures for ileus after abdominal operation: A systematic review and network meta-analysis. Heliyon, 10(4), e25412. https://doi.org/10.1016/j.heliyon.2024.e25412

Cui et al. (2024) pooled 105 randomized controlled trials with 18,840 participants to compare many interventions for preventing ileus after abdominal surgery, using a network meta-analysis that ranks interventions against one another as well as against controls. Intravenous analgesia ranked highest for preventing ileus, abdominal massage for shortening the time to first flatus and high-dose opioid antagonists for shortening the time to first bowel movement, while oral opioid antagonists and electroacupuncture combined with gum emerged as effective options overall. The very large evidence base is a strength, but the authors acknowledge methodological limits, and network rankings can mislead when trials differ in surgery types and definitions of ileus. For our project, this review places gum chewing among several options, showing that it is not the most powerful intervention but is one of the few that nurses can begin without an order for a drug or device. We will use it in Part 2 to explain why gum is a reasonable first step within a broader recovery plan.

Emile, S. H., Horesh, N., Garoufalia, Z., Gefen, R., Ray-Offor, E., & Wexner, S. D. (2024). Strategies to reduce ileus after colorectal surgery: A qualitative umbrella review of the collective evidence. Surgery, 175(2), 280-288. https://doi.org/10.1016/j.surg.2023.10.005

This umbrella review gathered 26 systematic reviews of strategies to reduce ileus after colorectal surgery, including early oral feeding, gum chewing, coffee, medications and acupuncture (Emile et al., 2024). Gum chewing was the most frequently studied intervention, associated with a median reduction in postoperative ileus of 45% and median reductions in time to first flatus and defecation of 11.9 and 17.7 hours. Early feeding and alvimopan were also effective, and coffee results were inconsistent. As an umbrella review, it summarizes reviews rather than pooling raw data, so it inherits their weaknesses and may count overlapping trials more than once, and it is limited to colorectal surgery. Even so, it is the broadest summary we found and gives the clearest single picture of where gum stands. We will use its median effects in Part 2 when we judge whether the evidence is sufficient to change practice.

Gao, T., Liu, Q., Wang, H., Liu, J., Jin, Y., & Liu, J. (2025). The effects of coffee versus gum chewing after cesarean on bowel functions: A systematic review and network meta-analysis. International Journal of Surgery, 111(11), 8435-8446. https://doi.org/10.1097/JS9.0000000000002911

Gao et al. (2025) analyzed 20 randomized trials with 2,876 patients after cesarean birth, comparing coffee and gum chewing with usual care. Compared with control, gum shortened the time to first defecation by about 8 hours, to first flatus by about 7.5 hours and to first bowel sounds by about 4.7 hours, while coffee also shortened time to defecation and flatus; the network comparison found no significant difference between gum and coffee. The heterogeneity for the gum comparisons was very high, with I-squared values near 98%, which means the trials varied widely and the pooled numbers should be read as averages across different practices. The study extends the evidence to obstetric surgery, a population our PICO includes through gynecologic procedures. We will use it to show that the effect appears across surgery types and to note that coffee is a possible alternative for patients who dislike gum.

Li, C., Nair, A., Zhu, X. M., Leung, M., Leung, G., Catapano, J., & McRae, M. (2025). The effects of gum chewing in the postoperative period: A systematic review and meta-analysis. ANZ Journal of Surgery, 95(7-8), 1320-1328. https://doi.org/10.1111/ans.70238

Li et al. (2025) reviewed 43 randomized trials of gum chewing in adult surgical patients and performed separate meta-analyses for general and colorectal surgery and for obstetric and gynecologic surgery. In general and colorectal surgery, gum shortened the time to first flatus by about 7.4 hours and to first defecation by about 18.6 hours; in the obstetric and gynecologic group, the reductions were about 6.5 and 9.7 hours. Nearly 70% of the trials reported a significant improvement in at least one ileus outcome. The authors used GRADE to rate evidence quality and limited the search to English-language trials, which may have missed some studies. This review matches our PICO most closely, because it includes both surgical groups in our population and reports our outcomes. It will be our central source in Part 2, and its call for standardized gum protocols will guide the dose and timing we propose.

Sarmiento-Altamirano, D., Arce-Jara, D., Balarezo-Guerrero, P., & Valdivieso-Espinoza, R. (2025). Reduction of postoperative ileus in gastrointestinal surgery: Systematic review and meta-analysis. Journal of Gastrointestinal Surgery, 29(3), 101960. https://doi.org/10.1016/j.gassur.2025.101960

Sarmiento-Altamirano et al. (2025) analyzed 37 studies with 4,647 patients undergoing gastrointestinal surgery to compare coffee, chewing gum, electroacupuncture, a traditional herbal medicine and prokinetic drugs. Gum shortened the time to first flatus by about 14.9 hours and the time to first stool by about 23 hours, while coffee did not significantly change time to flatus. Electroacupuncture and prokinetic agents were also effective. The review followed PRISMA guidelines, but it searched Google Scholar along with standard databases and pooled studies of varying quality, so its larger estimates may reflect weaker trials. For our project, it confirms the direction of effect in gastrointestinal surgery and shows that gum compares well with interventions that require specialist equipment or medications. We will use it with Li et al. (2025) to show consistency across independent reviews. Five reviews by different teams, using different methods, all point the same direction, which is the pattern a practice change needs.

Early Impression

The five reviews agree that gum chewing shortens the time to return of bowel function after abdominal surgery by several hours and that it is safe and inexpensive. They disagree on the size of the effect, and several note wide variation among trials. In Part 2, we will add five more sources and use the Iowa Model to judge whether the research is strong enough to justify trying a gum protocol on the unit.