Anatomy of the New Evidence-Rated AORN Recommended Practices

1. Anatomy of the New Evidence-Rated AORN Recommended Practices

2. Lisa Spruce, DNP, RN, ACNS, ACNP, ANP, CNOR Dr. Spruce is the Director of Evidence Based Perioperative Practice for AORN. Prior to coming to AORN she was the Clinical Manager of Surgical Services for Universal Health Services where she managed all clinical practice for 25 perioperative departments throughout the U. S. She was instrumental in bringing evidence based practice changes to the Universal Health Care System. Dr. Spruce was a Clinical Nurse Specialist in the Perioperative Departments for 5 hospitals in Las Vegas and a Nurse Practitioner in private practice in Florida. She was a circulating nurse in the OR for 6 years and worked in pre-op, PACU, and in the Endoscopy Suite. She is a board certified Acute Care Nurse Practitioner, Adult Clinical Nurse Specialist and as a CNOR. She has published several articles in the AORN Journal and the Journal for the American Academy of Nurse Practitioners.

3. Sharon A. Van Wicklin, MSN, RN, CNOR, CRNFA, CPSN, PLNC Sharon Van Wicklin has more than 36 years of experience as a perioperative nurse. She has worked in all facets of the operating room environment from scrub person to supervisor. Sharon received her BSN and MSN from Middle Tennessee State University. She is a member of Phi Kappa Phi, and the Sigma Theta Tau Honor Society of Nursing. Sharon holds certification in operating room nursing (CNOR), as an RN first assistant (CRNFA), in plastic and reconstructive surgical nursing (CPSN), and as a legal nurse consultant (PLNC). In her previous role as a perioperative educator, Sharon was responsible for the creation and coordination of educational projects, programs and inservices designed to improve hospital processes for orientation and development of personnel in nine perioperative departments. Her work as a legal expert witness involves reading and reviewing medical records and testifying as to the standard of perioperative nursing care. Sharon is a member of the School of Nursing faculty of Middle Tennessee State University and the University of Phoenix. She truly enjoys her work as a nursing instructor helping to shape the hearts and minds of future perioperative nursing professionals. In her position as a Perioperative Nursing Specialist for the Association of periOperative Registered Nurses (AORN), Sharon provides consultative services, authors various AORN publications including recommended practices and Clinical Issues columns; and, represents AORN at various organizations and functions such as AAMI, IAHCSMM, and AATB. Sharon was recognized by AORN as a recipient of the Outstanding Achievement in the Application of Perioperative Clinical Research Award in 2005. This award recognizes a registered nurse whose application of perioperative clinical research reflects the goal of excellence in patient care.

4. Disclosure Information Speakers: Lisa Spruce, DNP, RN, ACNS, ACNP, ANP, CNOR Director of Evidence-Based Practice, AORN Sharon A. Van Wicklin, MSN, RN, CNOR, CRNFA, CPSN, PLNC Perioperative Nursing Specialist, AORN Disclose no conflicts Planning Committee: Ellice Mellinger, MS, RN, CNOR Perioperative Education Specialist, AORN Discloses no conflict AORN’s policy is that the subject matter experts for this product must disclose any financial relationship in a company providing grant funds and/or a company whose product(s) may be discussed or used during the educational activity. Financial disclosure will include the name of the company and/or product and the type of financial relationship, and includes relationships that are in place at the time of the activity or were in place in the 12 months preceding the activity. Disclosures for this activity are indicated according to the following numeric categories: 1. Consultant/Speaker’s Bureau 2. Employee 3. Stockholder 4. Product Designer 5. Grant/Research Support 6. Other relationship (specify) 7. Has no financial interest Accreditation Statement AORN is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation. AORN is provider-approved by the California Board of Registered Nursing, Provider Number CEP 13019. AORN IS PLEASED TO PROVIDE THIS WEBINAR ON THIS IMPORTANT TOPIC. HOWEVER, THE VIEWS EXPRESSED IN THIS WEBINAR ARE THOSE OF THE PRESENTERS AND DO NOT NECESSARILY REPRESENT THE VIEWS OF, AND SHOULD NOT BE ATTRIBUTED TO AORN.

5. Objectives 1. Discuss the history of evidence-based practice. 2. Explain the PICO process for developing a practice question. 3. Identify research and non-research evidence. 4. Describe the evidence appraisal process using the AORN Evidence Appraisal Tools. 5. Describe the evidence rating process using the AORN Evidence Rating Model.

6. History of Evidence-Based Practice (EBP) Lisa Spruce, DNP, RN, ACNS, ACNP, ANP, CNOR Director of Evidence-Based Practice, AORN

7. History of EBP “It isn’t what we don’t know that gives us trouble, it’s what we know that ain’t so.” ~Will Rogers

8. In the beginning… Thomas Beddoes (1760-1808) • Called for sharing medical experiences, collecting and archiving them and - Analyzing - Reporting - Publishing

9. In the beginning… Pierre Charles Alexander Louis (1787-1872) – Performed the first chart review to disprove the practice of blood-letting – Medical science moved from innocence to awareness – 20th Century-arrival of the randomized controlled trial

10. 1948 The first Randomized Controlled Trial (RCT) • Medical Research Council Tuberculosis Unit trial of streptomycin treatment for pulmonary tuberculosis

11. Archie Cochran Scottish physician – "I knew that there was no real evidence that anything we had to offer had any effect on tuberculosis, and I was afraid that I shortened the lives of some of my friends by unnecessary intervention."

12. 1972 Effectiveness and Efficiency: Random Reflections on Health Services published Cardiff University Library, Cochrane Archive, University Hospital, Llandough

13. 1979 Archie Cochrane states, “It is surely a great criticism of our profession that we have not organized a critical summary, by specialty or subspecialty, adapted periodically, of all relevant randomized controlled trials.”

14. History of EBP 1980’s• Oxford Database of Perinatal Trials 1992• Cochrane Center opened 1993• Cochrane Collaboration founded

15. Evidence-Based Medicine Term first used by McMasters University (Canada) • 1996-term formally defined by Sackett, et.al. – “A systematic approach to analyze published research as the basis of clinical decision making.”

16. Why EBP? • It takes an average of 17 years to move research to practice • Evidence-based practice (EBP) provides point of care clinicians tools needed to improve care • EBP transforms health care based on one clinician, one encounter at a time

17. Evidence-Based Nursing Dicenso-1998 - “Process by which nurses make clinical decisions using best available evidence, clinical expertise and patient preferences in the context of available resources.”

18. First Nurse Pioneer for EBP Florence Nightingale ~ 1860 • Compiled data from the Crimean war on illness, treatment and cause of death • Called for the collection of statistics on hospital outcomes • Improved sanitary conditions based on evidence

19. EBP and Perioperative Nursing • Quality of care • Continuous inquiry • Critical thinking • Individualized care • Payer and regulatory pressure • Savvy patients

20. Developing the EBP Question Lisa Spruce, DNP, RN, ACNS, ACNP, ANP, CNOR Director of Evidence-Based Practice, AORN

21. PICO Method P I C O Patient Population Problem Interventions -Education -Self-care -Best practices Comparison -Current practice -Another intervention Outcome

22. IM Injections: Aspirate or not? P I C O Adult patients Aspirate when giving IM injection No aspiration Injury Question: Among adult patients, does aspirating while giving an IM injection cause injury compared to no aspiration?

23. Integrative Literature Review • A simple inquiry leads to a recommendation for practice! - Crawford and Johnson-Integrative lit review reveals that there is no data to support the use of the aspiration procedure

24. Surgical Masks: Prevent SSI? P I C O Patient Population Problem Surgical patients Interventions -Education -Self-care -Best practices Wearing a mask Comparison -Current practice No mask -Another intervention Outcome Surgical site infections

25. PICO Question Among surgical patients, does wearing a surgical mask prevent surgical site infections compared to not wearing a mask?

26. Literature Search Lisa Spruce, DNP, RN, ACNS, ACNP, ANP, CNOR Director of Evidence-Based Practice, AORN Sharon A. Van Wicklin, MSN, RN, CNOR, CRNFA, CPSN, PLNC Perioperative Nursing Specialist, AORN

27. Conducting a Search Databases Databases ~ Cochrane ~ AHRQ - NGC ~ Pubmed ~ CINAHL® ~ ANA - Medline ~ AORN Journal ~ Medical Library ~ Google Scholar ~ Joanna Briggs ~ Virginia Henderson International Nursing Library ~ Embase

28. Search Strategies Strategies Results • Define your topic • Keywords • Boolean operators • No or few results • • • • AND OR Quotation marks Truncation • Avoid long phrases or questions • Choose different key words

29. Literature Search

30. Literature Search Terms – – – – – – – – – – – – Sterile field Sterile technique Aseptic technique Aseptic practices Surgical drapes Double-gloving Assisted gloving Closed gloving Time-related sterilization Event-related sterilization Surgical attire Protective clothing - Sterile supplies - Sterile barriers - Barrier precautions - Body-exhaust suits - Laminar air flow - Bowel technique - Glove expansion - Glove perforation - Strikethrough - Spaulding’s criteria - Product packaging - Equipment contamination

31. Literature Search Initial search confined to 2006 to 2011 • Time restriction not considered in subsequent searches

32. Literature Search Documents searched • Meta-analyses • Randomized and nonrandomized controlled trials and studies • Systematic and nonsystematic reviews • Opinion documents and letters • Guidelines (eg, government, professional, standards) • Additional (eg, articles from reference lists) • Alerts

33. Literature Search Databases searched • • • • MEDLINE® CINAHL® Scopus® Cochrane

34. Literature Search Articles identified: – Rejected: 294 – Accepted: 135 429

35. Research Evidence Sharon A. Van Wicklin, MSN, RN, CNOR, CRNFA, CPSN, PLNC Perioperative Nursing Specialist, AORN

36. Research Systematic Reviews Randomized Controlled Trials Quasi-Experimental Studies Non-Experimental Studies Qualitative Studies

37. Research Systematic Reviews • Summarize evidence related to a particular practice question • Address strengths and limitations of included studies • Review multiple studies • Utilize rigorous search strategies and precise appraisal methods

38. Research Randomized Controlled Trials (RCTs) • Randomization - Researcher assigns subjects to a control or experimental group on a random basis - Increases validity of the study

39. Research RCTs • Manipulation - Researcher takes an action to influence some aspect of the dependent variable Independent variable: Dependent variable: Intervention being applied Phenomenon being studied

40. Research RCTs • Control - Researcher introduces a group of subjects to which the experimental intervention is not applied

41. Research Quasi-Experimental • Lack one element of a RCT (ie, randomization, manipulation, or control) - Researcher may attempt to compensate by using multiple groups, or multiple measures

42. Research Non-Experimental • Study naturally occurring phenomenon • No randomization, manipulation, or control • Includes • descriptive (describe observable facts), • comparative (compare observable facts), and • correlational (show a relationship) studies. • Most of nursing research falls into this category

43. Research Qualitative • Data collection includes interviews, group discussion, field observation, reflection • Researchers attempt to explore issues, answer questions and gain in-depth understanding of certain phenomena by summarizing, analyzing and interpreting data

44. Non-Research Evidence Sharon A. Van Wicklin, MSN, RN, CNOR, CRNFA, CPSN, PLNC Perioperative Nursing Specialist, AORN

45. Non-Research Clinical Practice Guidelines Literature Reviews Expert Opinion Case Reports Organizational Experience Community Standard/Clinician Experience

46. Non-Research Clinical Practice Guidelines • Systematically developed statements • Provide guidance for clinical practice

47. Non-Research Literature Review • Summary of published literature without systematic appraisal of the quality and strength of the evidence • May not summarize all available evidence on the topic in question

48. Non-Research Expert Opinion • Expertise must be assessed - Education - Work experience - University affiliations - Publications - Citations - Recognized speaker

49. Non-Research Case Reports • In-depth look at a single person, group, or social unit • Quantitative or qualitative • Individual case or multiple cases • Provide insight but have limited generalizability

50. Non-Research Organizational Experience • Generally the result of efforts to improve quality of care delivery and outcomes within a particular organization • May not be generalizable beyond the organization

51. Non-Research Community Standard/Clinician Experience

52. Evidence Appraisal Sharon A. Van Wicklin, MSN, RN, CNOR, CRNFA, CPSN, PLNC Perioperative Nursing Specialist, AORN

53. AORN Appraisal Tools Research Non-Research

54. AORN Appraisal Tools Research The strength of the research evidence is indicated by I, II, or III

55. AORN Appraisal Tools Research The quality of the research evidence is indicated by A, B, or C

56. AORN Appraisal Tools Research The final Research appraisal score is a combination of I, II, or III and A, B, or C

57. AORN Appraisal Tools Non-Research The strength of the nonresearch evidence is indicated by IV or V

58. AORN Appraisal Tools Non-Research The quality of the nonresearch evidence is indicated by A, B, or C

59. AORN Appraisal Tools Non-Research The final Non-Research appraisal score is a combination of IV or V and A, B, or C

60. Appraisal Score

61. Evidence Rating Sharon A. Van Wicklin, MSN, RN, CNOR, CRNFA, CPSN, PLNC Perioperative Nursing Specialist, AORN

62. AORN Evidence Rating Model Appraisal Score Research Non-Research IA IB IIA, IIB IIIA, IIIB IVA Regulatory IVB VA, VB Evidence Rating Evidence Requirements 1: Strong Evidence 1: Regulatory requirement Interventions or activities for which effectiveness has been demonstrated by strong evidence from rigorously-designed studies, meta-analyses, or systematic reviews, rigorously-developed clinical practice guidelines, or regulatory requirements.  Evidence from a meta-analysis or systematic review of research studies that incorporated evidence appraisal and synthesis of the evidence in the analysis.  Supportive evidence from a single well-conducted randomized controlled trial.  Guidelines that are developed by a panel of experts, that derive from an explicit literature search methodology, and include evidence appraisal and synthesis of the evidence. 2: Moderate Evidence Interventions or activities for which the evidence is less well established than for those listed under “1: Strong Evidence.”  Supportive evidence from a well-conducted research study.  Guidelines developed by a panel of experts which are primarily based on the evidence but not supported by evidence appraisal and synthesis of the evidence.  Non-research evidence with consistent results and fairly definitive conclusions. 3: Limited Evidence Interventions or activities for which there are currently insufficient evidence or evidence of inadequate quality.  Supportive evidence from a poorly conducted research study.  Evidence from non-experimental studies with high potential for bias.  Guidelines developed largely by consensus or expert opinion.  Non-research evidence with insufficient evidence or inconsistent results.  Conflicting evidence, but where the preponderance of the evidence supports the recommendation. IC IIC IIIC IVC VC No requirement No requirement 4: Benefits Balanced With Harms Selected interventions or activities for which the AORN Recommended Practices Advisory Board (RPAB) is of the opinion that the desirable effects of following this recommendation outweigh the harms. No requirement No requirement 5: No Evidence Interventions or activities for which no supportive evidence was found during the literature search completed for the recommendation.  Consensus opinion.

63. AORN Evidence Rating Model 1: 1: IA Strong Evidence Regulatory requirement IVA Regulatory 1: Strong Evidence 1: Regulatory requirement Interventions or activities for which effectiveness has been demonstrated by strong evidence from rigorously-designed studies, meta-analyses, or systematic reviews, rigorously-developed clinical practice guidelines, or regulatory requirements.  Evidence from a meta-analysis or systematic review of research studies that incorporated evidence appraisal and synthesis of the evidence in the analysis.  Supportive evidence from a single well-conducted randomized controlled trial.  Guidelines that are developed by a panel of experts, that derive from an explicit literature search methodology, and include evidence appraisal and synthesis of the evidence.

64. AORN Evidence Rating Model 2: IB IIA, IIB IIIA, IIIB 3: IC IIC IIIC Moderate Evidence IVB VA, VB 2: Moderate Evidence Interventions or activities for which the evidence is less well established than for those listed under “1: Strong Evidence.”  Supportive evidence from a well-conducted research study.  Guidelines developed by a panel of experts which are primarily based on the evidence but not supported by evidence appraisal and synthesis of the evidence.  Non-research evidence with consistent results and fairly definitive conclusions. Limited Evidence IVC VC 3: Limited Evidence Interventions or activities for which there are currently insufficient evidence or evidence of inadequate quality.  Supportive evidence from a poorly conducted research study.  Evidence from non-experimental studies with high potential for bias.  Guidelines developed largely by consensus or expert opinion.  Non-research evidence with insufficient evidence or inconsistent results.  Conflicting evidence, but where the preponderance of the evidence supports the recommendation.

65. AORN Evidence Rating Model 4: No requirement Benefits Balanced with Harms No requirement 4: Benefits Balanced With Harms Selected interventions or activities for which the AORN Recommended Practices Advisory Board (RPAB) is of the opinion that the desirable effects of following this recommendation outweigh the harms. V.c. Sterile supplies should be opened for only one patient at a time in the OR or other procedure room. [4: Benefits Balanced with Harms]

66. AORN Evidence Rating Model 4: No requirement 5: No requirement Benefits Balanced with Harms No requirement 4: Benefits Balanced With Harms Selected interventions or activities for which the AORN Recommended Practices Advisory Board (RPAB) is of the opinion that the desirable effects of following this recommendation outweigh the harms. No Evidence No requirement 5: No Evidence Interventions or activities for which no supportive evidence was found during the literature search completed for the recommendation.  Consensus opinion.

67. Evidence Rating [3: Limited Evidence]

68. Appraisal Score

69. Evidence Rating [3: Limited Evidence]

70. Meeting National Guidelines Clearinghouse Criteria Lisa Spruce, DNP, RN, ACNS, ACNP, ANP, CNOR Director of Evidence-Based Practice, AORN

71. Meeting NGC Criteria • Documentation will need to be provided showing that the guideline is based upon a systematic review of the evidence. • Documentation must contain an assessment of the benefits and harms of the recommended care and alternative care options.

72. Anatomy of an AORN Recommended Practice Lisa Spruce, DNP, RN, ACNS, ACNP, ANP, CNOR Director of Evidence-Based Practice, AORN

73. AORN Evidence Rated RP Recommendation Number: IV Recommendation Rationale Intervention Letter: IV.a. Intervention Supporting Evidence Activity Number: IV.a.1. Activity Evidence Rating Appraisal Scores

74. AORN Evidence Rated RP

77. Questions and Answers

78. References 1. Goodman, K. (2002). Ethics and Evidence-based Medicine. Cambridge University Press. 2. Crofton, J. (2006). The MRC randomized trial of streptomycin and its legacy: A view from the clinical front line. Journal of the Royal Society of Medicine, 99(10), 531-534. 3. Archie Cochrane: The name behind the cochrane collaboration, cochrane.org/about-us/history/archie-cochrane. 4. Claridge, J. A. &Fabian, T. C. (2005). History and development of evidencebased medicine. World Journal of Surgery, 29(5), 547-543. 5. DiCensor A, Cullum N & Ciliska D (1998) Implementing evidence-based nursing: some misconceptions. Evidence Based Nursing, 38–40. 6. Crawford, C. L. & Johnson, J. A. (2012). To aspirate or not: An integrative review of the literature. Nursing, 20-25. 7. Recommended practices for sterile technique. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2012:e62-e90. 8. Dearholt S, Dang D. Johns Hopkins Nursing Evidence-Based Practice: Model and Guidelines. 2nd ed. 2012. 9. OR NurseLink-A perioperative community. AORN. http://www.ornurselink.org/Pages/home.aspx

79. Contact Hours You must complete the Learner Evaluation online to earn the 1.0 nursing contact hour. Registered for this webinar? Complete the evaluation by using the link in your purchase confirmation e-mail or by visiting the AORN website: o Visit www.aorn.org and login using your AORN Web Login. o Navigate to My AORN and select “Manage Your Education”. o Earn your Contact Hour by selecting and completing the appropriate webinar evaluation. Once you have submitted your evaluation, you can print your certificate immediately, or you can visit MY AORN > View All Contact Hours > select the session > click Print Your Certificate at any time.

80. Contact Hours You must complete the Learner Evaluation online to earn the 1.0 nursing contact hour. Not Registered for this Webinar? Follow the below instructions to obtain access to the evaluation: – – – – – Visit www.aorn.org and login using your AORN Web Login. Go to the Product Catalog > Search by name of the webinar or other key word >Select the webinar you just attended that has ‘EVAL’ under it. Follow the shopping cart instructions to complete your transaction. You will then receive an e-mail containing a link to the online evaluation. You may complete the evaluation by using the link in the purchase confirmation e-mail or by visiting the AORN website: www.aorn.org > Navigate to My AORN > select “Manage Your Education”. Once you have submitted your evaluation, you can print your certificate immediately, or you can visit MY AORN > View All Contact Hours > select the session > click Print Your Certificate at any time. If you have any questions or require assistance, please contact AORN Customer Service at (800) 755-2676 or custsvc@aorn.org.

81. Get Your 2014 Edition Today Perioperative Standards and Recommended Practices This comprehensive publication provides the evidence-based recommended practices for both patient and worker safety in all settings where operative and other invasive procedures are performed. New evidence-rated recommended practices include: • • • • Pneumatic Tourniquet-assisted Procedures Environmental Cleaning Packaging Systems for Sterilization Sharps Safety Updated from 2013 edition: • Prevention of Transmissible Infections • Safe Environment of Care • Sterile Technique • Sterilization www.aorn.org/RecommendedPractices

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