Expert answer:i need help with evidence base practice in handwas

Solved by verified expert:Integration of Evidence-Based Practice Into Professional Nursing PracticeAs the professional nurse, you realize that your nursing care area often sees patients with the same particularly challenging nursing care issue (not medical care issue). Include all of the following in your answer to this discussion.Identify the nursing care issue or problem and justify why it is a nursing care issue in need of implementation of evidence. Remember, this should not be a medical issue.Explain how you would search CINAHL for evidence on this topic (including search terms you would use) and how you would critically appraise the evidence found in your search. Note:You do not need to perform the search or provide an article for this discussion, but you may do so if you like.
handwashing_evidence_base.pdf

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Evidence appraisal of
Megeus V, Nilsson K, Karlsson J, Eriksson B, Andersson
AE. Hand hygiene and aseptic techniques during
routine anesthetic care— observations in the
Operating room. A n tim icrob Resist Infect Control. 2015;4(1 ):5 .
Evidence
Appraisal
Score:
III B
E d ito r’s note: Reading research a n d incorporating valid research
means to perioperative nursing practice. Clinical ju d g m en t should
results into practice is a vital p a rt o f ensuring that perioperative
be used to determine whether the findings o f an individual study
nursing practice is evidence based. The A O R N Research Evidence
are o f value a n d relevance in a particular setting or pa tien t care
Appraisal Tool, which was adapted with permission fro m the
situation. Itidividuals intending to p u t this study’s findings into
Johns H opkins Evidence-Based Practice M odel a n d Guidelines,
practice are encouraged to review the original article to determine
can help perioperative nurses evaluate research. This tool is used to
its applicability to their setting.
evaluate the evidence upon which A O R N ’s guidelines are based.
The tool can be used to appraise the level o f evidence a n d quality
o f evidence fo r a single research study or a summary o f multiple
research studies. A n abbreviated tool using only the sections o f the
tool relevant to the study appraised is included in this article. Each
section o f the tool is discussed to help readers understand why the
study received a particular appraisal score a n d w hat that rating
H
ospital-acquired infections (HAIs) increase the
patient’s risk for morbidity and mortality. The
occurrence of HAIs prolongs length of hospital
stay, increases medical costs, and contributes to the
use, overuse, and misuse of antibiotics, promo
h ttp ://d x .d o i.O r g /1 0 .1 0 1 6 /j.a o r n .2 0 1 5.0 5.0 1 5
© AORN, Inc, 2015
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July 2015, Vol. 102, No. 1
development of antimicrobial resistance. Hand hygiene has long
been recognized as the most important and cost-effective
measure to prevent HAIs. Introduction of alcohol-based hand
hygiene products has facilitated wider adoption of hand hygiene
practices at the point of care. Reported factors associated with
health care providers’ nonadherence to hand hygiene re­
quirements include high workload, insufficient time, inacces­
sibility of hand hygiene products, skin irritation, forgetfulness,
and skepticism concerning the importance of hand hygiene.
There has been increased interest in studying and reporting
hand hygiene practices in the OR, particularly in the anesthesia
work area because of the frequency of hand-to-surface contacts.
The researchers conducted a study to examine opportunities for
hand hygiene and adherence to hand hygiene guidelines during
routine anesthesia care.
Evidence fo r Practice
nonmalfeasance, beneficence, and justice. The hospital ward
manager obtained informed consent from the participants
before observation.
Intervention. There were no interventions in this study.
Control. There were no controls in this study.
Random assignment. There was no random assignment in
this study. However, to avoid selection bias, the ORs to be
observed were randomly selected each morning.
Level o f evidence. The AORN Research Evidence Appraisal Tool
was used to classify this study as III for level of evidence because
it was a nonexperimental observational study with no manipula­
tion of independent variables and no interventions or controls.
LEVEL OF EVIDENCE: STUDY
QUALITY OF EVIDENCE: STUDY
Because this is a report of a single research study, the Level of
Evidence: Study portion of the AORN Research Evidence
Appraisal Tool was used to appraise this study (Figure 1).
Because this is the report of a single research study, the Quality
of Evidence: Study portion of the AORN Research Evidence
Appraisal Tool was used to appraise this study.
Setting. This study was conducted in a 460-bed general
hospital in West Sweden performing approximately 9,970
surgical procedures annually.
Existing information. The researchers briefly summarized
existing information, acknowledging that there is a paucity
of clinical studies that describe, in detail, implementation of
hand hygiene in the OR setting. A Cochrane Review
concluded that the quality of interventional studies intended
to enhance hand hygiene practice is poor and that meth­
odologically robust implementation studies are needed. Re­
sults from a systematic review of hand hygiene in intensive
care units and general wards showed a mean compliance rate
of 40%. The researchers cited several studies that revealed
low rates of adherence to hand hygiene guidelines and high
rates of hand hygiene opportunities during anesthetic care. A
series of studies identified the hands of anesthesia pro­
fessionals as vectors of cross-transmission between equip­
ment in the anesthesia work area and the patient’s medical
devices. The researchers indicated that hand hygiene op­
portunities during anesthesia care occur most often in rela­
tion to aseptic or cleaning tasks. Therefore, implementing
hand hygiene before an aseptic task and the use of aseptic
technique will protect the patient from transmission of mi­
croorganisms between different body sites and from
contaminated surfaces via the hands of health care personnel,
reducing the risk for HAIs.
Sample size and composition. Structured observational data
on hand hygiene were collected during 94 surgical procedures.
Type of surgical procedure during which anesthesia care was
administered (eg, general surgery, orthopedic surgery, pediat­
ric, urology) was recorded, together with type of anesthesia
care (eg, general, regional, sedation). Participants in the study
included nurse anesthetists, instrument nurses, nursing assis­
tants, anesthesiologists, surgeons, and students. A hand hygiene
action was defined as the use of an alcohol-based hand rub in
relation to a hand hygiene opportunity, defined as the time span
between two risk-prone hand-surface contacts when one or
more of the following five moments for hand hygiene applied:
•
•
•
•
•
before patient contact,
before an aseptic task,
after body fluid exposure risk,
after patient contact, and
after contact with patient surroundings.
The amount of hand hygiene product used and duration of
application were excluded from the observations.
The Regional Ethics Review Board in Gothenburg, Sweden,
gave ethical approval for this study. Participants were given
both oral and written information in accordance with the four
main requirements of the Declaration of Helsinki: autonomy,
w w w .aornjournal.org
Purpose o f the study. The purpose of this study was clearly
stated: to explore and describe the indications and occurrence
of hand hygiene opportunities and the adherence to the
Swedish national hand hygiene guidelines during routine
anesthesia care in the surgical setting.
AORN Journal I 99
E v id e n c e f o r P ra c tic e
J u l y 2015, V o l. 102, N o . 1
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July 2015, Vol. 102, No. 1
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Literature review. The literature review was extensive and
well performed. O f the 60 works cited, 36 (60%) were pub­
lished in the past five years.
Sample sufficiency. The sample size appeared adequate for the
study design. There was no indication that a power analysis
was completed.
Control group. There was no control group in this study.
D a ta collection. The researchers clearly described the methods
of data collection. O ne trained observer, an RN specialized in
perioperative nursing, performed all observations. Initially, 43
full-length operations were observed. However, the focus of the
study shifted midway to include the induction phase as well as
observation of hand hygiene opportunities before patient contact,
after patient contact, and after contact with the patient sur­
roundings, which included 51 observational sessions. Prioritiza­
tion was given to observations o f opportunities for hand hygiene
in relation to aseptic tasks during anesthesia care. In addition,
observations o f the risk for hand transmission o f microorganisms
were recorded. For example, if after manipulation of the airway,
no hand hygiene was carried out and the health care professional
subsequently touched a clean site (eg, stopcocks), this observation
was recorded as both a risk for the transmission of microorganisms
and a missed hand hygiene opportunity. Observations performed
during the induction phase were limited to the period between
the arrival o f the patient into the O R and the anesthesia ready
time after completed induction. The researchers used descriptive
statistical techniques to analyze the data.
Instrum ent validity a n d reliability. To conduct this study,
the researchers used the W orld H ealth Organization (W H O )
evidence-based guidelines for hand hygiene and applied a
modified version o f the W H O ’s standardized observational
method and conceptual framework to assess and quantify hand
hygiene practices. The modification consisted of the additional
recording o f the type o f indication for hand hygiene and
detailed information for glove use. According to the authors,
instrum ent validity had been tested in a previous study, which
they cited.
Response rate. There were no surveys or questionnaires used
in this study.
Tables. The article included five tables that presented
•”
Evidence for Practice
• the number o f opportunities (n) for hand hygiene in relation
to different care procedures and the rate o f adherence
(percent) to hand hygiene guidelines before and after the
procedure;
• the num ber (n) o f hand hygiene opportunities stratified by
profession and the overall rate o f adherence (percent) to
hand hygiene guidelines; and
• the num ber o f hand hygiene opportunities (n) and the rate
o f adherence (percent) during different observations, as
categorized by the “My five moments for hand hygiene.”
The tabular content is consistent with the article narrative.
Results. The results were presented clearly. Data on hand hy­
giene in relation to anesthesia care were collected during 94
surgical procedures and three observation sessions in the pre­
operative area from 2012 to 2013. A total o f2,393 hand hygiene
opportunities were recorded during 6,000 minutes. The mean
(M) num ber o f hand hygiene opportunities was M = 10.9/hour
(standard deviation [SD], 6.1; range, 2.9-34.0; 95% confidence
interval [Cl], 9.1-12.9), with an associated 8.4% rate of
adherence to hand hygiene guidelines. For the induction phase,
M = 77.5/hour (SD, 27.4; range, 21-180; 95% Cl, 69.8-85.2),
with an associated 3.1% rate of adherence to hand hygiene
guidelines. The lowest rate o f adherence was observed during the
induction phase before an aseptic task (2.2%), and the highest
rate of adherence, during full-length surgeries after body fluid
exposure (15.9%). Failure to use gloves when indicated was
observed in 107 (43%) procedures, occurring mostly in relation
to the insertion of venous lines (50.5%) and respiratory care
(39.3%). The overall rate o f adherence to hand hygiene guide­
lines was 5.3%.
Result-based conclusions. The researchers found compelling
evidence that overall adherence to hand hygiene guidelines in the
O R setting is very low (5.3%). Results indicated that hand hy­
giene opportunities occur most frequently in relation to aseptic
and cleaning tasks, for which adherence rates were very low. The
researchers suggested that inadequate work processes can partly
explain the fluctuation in hand hygiene opportunities (eg, when
more personnel than necessary participate in tasks), and that
frequent interruptions when carrying out aseptic tasks can lead to
recontamination o f the hands or gloves. Based on their findings,
the researchers suggested that O R personnel predominantly
implement hand hygiene based on inherent behavior rather than
in relation to evidence for good hand hygiene practices. The staff
• a short description o f the W H O ’s “M y five moments for
hand hygiene,” with examples;
• the num ber (2,393) o f hand hygiene opportunities per type
o f surgery and type o f anesthesia and the rate o f adherence to
hand hygiene guidelines (percent);
www.aornjournal.org
members’ self-reported adherence during the study period was
73.2%. The researchers noted that this discrepancy raises ques­
tions about the usefulness o f self-reported data and indicatorbased strategies that can incentivize personnel to improve
adherence and accurate reporting o f hand hygiene practices.
AORN Journal I 101
Evidence fo r Practice
Study limitations. The researchers identified two important
limitations of the study
• changing the method of the study (ie, to include observation
of the induction phase and hand hygiene opportunities
before patient contact, after patient contact, and after contact
with the patient surroundings) after observation of 43 pro­
cedures, despite the opportunity it provided for researchers to
describe in detail the task-intensive induction phase; and
• using a single observer, which can impede observing events
occurring simultaneously. The researchers noted that using
two observers would produce more reliable data, but
possibly also increase the Hawthorn effect.
Quality o f evidence. The AORN Research Evidence Appraisal
Tool was used to classify this study as B for quality of evidence.
APPRAISAL RESULTS
The AORN Research Evidence Appraisal Tool was used to
score this study as III B.
• The study was scored as III for level of evidence because it
was a nonexperimental observational study.
• The study was scored as B for quality of evidence because
only one observer was used, the observational session was
shortened, and there was a change in the study method after
already observing 43 procedures.
A score of III B indicates that it may be appropriate for peri­
operative nurses to consider this evidence as a secondary source
of evidence when designing policies and procedures for the
perioperative setting provided that it supports other primary
sources of evidence. Clinical judgment should be used to
determine whether the findings of an individual study are of
value and relevance in a particular setting or patient care situ­
ation. Studies of lesser strength or quality are not necessarily
inferior or unacceptable sources of evidence, and a lower rating
does not necessarily mean the evidence is unimportant or
irrelevant.
1021 AO RN Journal
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July 2015, Vol. 102, No. 1
PERIOPERATIVE IMPLICATIONS
The results of this study add to the growing body of knowl­
edge in the perioperative setting suggesting that there is low
adherence to hand hygiene guidelines in the OR environment.
In particular, findings from this study revealed that health care
providers actively participating in anesthesia care of patients in
the OR had a 5.3% rate of overall adherence to hand hygiene
guidelines. As the researchers pointed out, these results provide
compelling evidence of low adherence to hand hygiene
guidelines in the OR setting. Thus, there is an urgent need for
effective implementation strategies to improve hand hygiene
practices. In particular, the researchers suggested that there are
opportunities to enhance hand hygiene during anesthetic care
through education and practical training for carrying out hand
hygiene and aseptic techniques, as well as using gloves
correctly during the induction phase. Perioperative nurses and
managers should consider these findings when developing or
updating policies and procedures related to monitoring and
enforcing hand hygiene guidelines in the perioperative setting
for all personnel. ®
This article was appraised by George Allen, PhD, MS,
BSN, RN, CNOR, CIC, director of infection control,
Downstate Medical Center, and clinical assistant professor,
SUNY College of Health Related Professions, Brooklyn,
NY. Dr Allen has no declared affiliation that could be
perceived as posing a potential conflict o f interest in the
publication o f this article.
The Johns Hopkins Nursing Evidence-Based Practice
Course is offered to AORN members at a special
discounted rate. Learn more at http://www.aorn.org/
JohnsHopkinsNursingEBPCourse.
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NURSING
PRACTICE &
SKILL
Authors
Sara Richards, MSN, RN
Cinahl Information Systems, Glendale, CA
Debra Balderrama, RN, MSCIS
Clinical Informatics Services, Tujunga, CA
Reviewers
Eliza Schub, RN, BSN
Cinahl Information Systems, Glendale, CA
Teresa-Lynn Spears, RN, MSN
Cinahl Information Systems, Glendale, CA
Nursing Practice Council
Glendale Adventist Medical Center,
Glendale, CA
Hand Hygiene: Performing Antiseptic Handwashing
What is Hand Hygiene and Antiseptic Handwashing?
› Hand hygiene (also known as hand antisepsis) refers to a set of practices that are at the
core of standard precautions (formerly called universal precautions), which are first-line
infection control measures that also involve the use of appropriate personal protective
equipment (PPE), safe injection practices, respiratory hygiene/cough etiquette, and
proper disposal of contaminated materials. Standard precautions should be followed
when providing care for all patients, regardless of whether the patient has a known
communicable disease or infection. (For more information, see Nursing Practice & Skill
… Standard Precautions: Following )
• What: Antiseptic handwashing (AH), as defined by the World Health Organization
(WHO), requires washing hands with a detergent or soap that contains an antiseptic
agent (e.g., alcohols, chlorhexidine, hexachlorophene, iodine and iodophors,
chloroxylenol [PCMX], quaternary ammonium compounds, or triclosan) to reduce
or inhibit the growth of microorganisms. In the clinical setting, hand antisepsis is the
process of reducing or inhibiting microorganisms, visible dirt, and toxic substances on
the surface of the hands and is necessary to eliminate tr …
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