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Introduction

Equipment, drugs, and medical supplies have significant impact on quality of patient care and they account for high proportion of health care costs. Hospitals should make informed choices about what to procure in order to meet priority health needs and avoid wasting the limited resources (Chu, Maine, & Trelles, 2015). Procurement is an important part of managing equipment and products, and stock control, effective storage, and maintenance are also significant factors in health services. Many firms have produced information about important drugs, however, there is less information available about essential equipment and medical supplies (Weinshel, et al., 2015). This results in procurement of items which are inappropriate because they are incompatible with existing equipment, technically unsuitable, and spare parts are unavailable. Despite this, there is little information available about these aspects of management of equipment and medical supplies.

According to “American Association of Critical-Care Nurses (AACN), there is convincing evidence that unhealthy surgery environment contributes significantly to ineffective care delivery, medical errors, and stress among nurses (Magill, O’Leary, Janelle, & Thompson, 2018). This integrative literature review was executed to find evidence between surgery operation environment and products on patient safety. This paper is intended to be resourceful in management and procurement of equipment and medical products at primary health care level. It includes guiding concepts for care and maintenance, selecting products and equipment, and safe disposal of medical waste.

Purpose of research

The integrative literature review aim at analyzing pieces of research which have been conducted on surgical environment and product and their effect on patient safety and outcome.

Background

Although there are various improvement ongoing, the prevalence of healthcare-associated infections (HAIs) remain a risk and cost within hospitals. Unsafe, inappropriate, and negligent surgical products and equipment affect one in ten patients, on average in the US. Despite the advancement in use of surgical techniques and ergonomic improvements in operating rooms, cases of surgical site infections (SSIs) are high and they cause patient mortality and morbidity. Necessarily, there is increased emphasis on prevention of these infections. The risk of error in operating environment is greater. Some of the environmental and products risks include risk of patient falling and risks of infections. In this light, nurses should promote use of evidence-based care to promote patient safety and improve the quality of care.

Patient safety is an important element in health care. Within the principles of WHO, patient safety is the reduction of risk of harm or injury associated with health care. Hospitals are focused in creating healthy and safe environment. A safe environment is an atmosphere which is free of harm to patient seeking medical attention. Study by (Chu, Maine, & Trelles, 2015), shows that 6.5% of permanent dysfunctions and 13.6% of patient deaths in America could be avoided due medical errors. Error in this case is an action which occurs outside planned or incorrect use of plan and cause damage to patient, from need for therapeutic intervention, increase stay in hospital, and even death. Moreover, environment and products used or not used in surgical operation have direct damage which has economic impact such as continued hospital admission.

In order to ensure safety of patient, the WHO recommends use of quality tools and equipment during and after surgery in order to prevent surgical complications. Understanding the interrelationship between nurses and the tools they use is basic in improving operation and its effect on performance of nurses.

Methods

This study is an integrative review because it facilitates and enables search for scientific research which involve publication useful and contributing data on health care. The diversity of sources of data within this integrative review need qualitative methods for evaluation. Methods like case study, content analysis, and meta-synthesis are used to synthesize the findings. The goal of integrative review is to develop comprehensive account on the topic. In other words, the research give a better understanding of the topic by integrating information and data from many methods and sources. Also, this study aim at integrating health scenario and to support decision-making process and improve surgical practice quality.

For the preparation of this integrative review, three stages were considered and this include (1) development of the research question, (2) selection of research articles (exclusion and inclusion criteria), (3) synthesis of knowledge evidenced in the items. The search strategy was designed to get the largest number of primary sources using different search approach.

The evidence of surgical-related infections was conducted online from wide publication in Nursing Database, Medical literature and Retrieval system on line (Medline through Pub Med), and through Virtual Health Library (VHL). Each database was selected based on its potential to inform a model of SSIs. Medline give complete source of biomedical and health research. The period of search was between 2010 and 2019 and the keywords used are “surgical room”, “equipment”, “tools”, and “patient safety”. The research article were selected based on exclusion and inclusion criteria. In the sample inclusion criteria, article considered were published between 2010 and 2019 in English language with full texts available in electronic databases and free guideline.

According to the exclusion criteria, articles not available in electronic sources were not considered. Also, article which did not have any content related to the topic of research were excluded. The inclusion criteria required that data source:

I. Focus on surgical tools and equipment or outcome of new technology

II. Deal with adoption of therapeutic techniques like CT scanning techniques.

III. Focus of healthcare delivery.

To support this analysis, the researcher further considered the titles and abstracted of the articles to refine the journals highlighting purpose of the review. Second, the researcher did exhaustive reading in each journal seeking to get the relevant aspects. After reading, the articles were organized based on data collection methods. The analysis of the journal was important in identifying the issues which are relevant in each article. Third, the article were classified according to the levels of evidence. Level 1 article have evidence from meta-analysis or systematic review of randomized control trials. Level II articles have evidence based on clinical trial done through randomized control. Level III have clinical trial evidence but not have randomization yet they are well-designed. Level IV of evidence have articles which have their evidence based on case-control but they should be well-designed. The last level of evidence is based on authors’ opinion. There was need for a database to enter the information gather which include article title, the year of publication, the result, and development of the research.

Results

Data Evaluation/Reduction

The data sources were coded based on the subjective analysis of source’s relevance to the aim of the study and rigor of data setting, size, and methodology. This methodology was proposed by, who argue that this kind of analysis is best because of the variability in quality, method, and design of data sources. In this case, relevance reflects applicability of data source to the concept in the study while rigor is judgment of confidence in findings of data source according to study methodology. The articles methods, population, setting, and purpose was considered in determining the rigor. 5-point Likert scale was used to show rigor and score of 5 represented the highest rigor.

Rigor

Search outcome

The initial research resulted in 128 article, and irrelevant article excluded. The abstracts and title of 32 articles were read. The articles were selected based on abstract review and compared to the exclusion and inclusion criteria. Full texts were retrieved in cases were there was scanty details in the abstract and out of the 32 articles, 8 met the inclusion criteria. The rest of the articles were excluded because they focused on chronic would instead of surgical wounds, and the article did not discuss the relationship between equipment and SSIs. The 8 articles included were published between 2010 and 2019 and many of them were conducted in America. Three of the selected articles were quantitative studies while the rest are qualitative studies.

Of the 8 publication which were included in the review, 2 report are on evidence-based guideline on the best approach to prevent surgical site infection, 1 report on the application of techniques, and 5 reports on the description of postoperative wound infections. Overall, 2 RCTS, one guideline, two meta-analysis, and one, descriptive study were reviewed. The study characteristics, critical appraisal, data analysis, and synthesis of the studies are presented in separate cases for each research question.

Critical appraisal

One of the RCT (Kapadia, et al., 2016) give detailed patient information, reported on equipment hygiene, and described the adverse reactions. All articles (Zuarez-Easton, Zafran, Garmi, & Salim, 2017; Magill, O’Leary, Janelle, & Thompson, 2018)reported the study objectives, main outcome measures, the patient characteristics, and the estimate of variability of the research outcome measures. One study (Weinshel, et al., 2015) was conducted on Africa and may not represent the treatment which patients review in the US. All articles (Bischoff, Kubilay, Allegranzi, & Egger, 2017; Bischoff, Kubilay, Allegranzi, & Egger, 2017; Weinshel, et al., 2015)were, however, clear about the unplanned data analysis, all recorded the same time between outcome among groups and intervention, and two (Magill, O’Leary, Janelle, & Thompson, 2018) gave detailed statistical analyses. One research, did not perform the statistical analysis and, therefore, it is not show if the results are statistically important. Compliance was an issues in two studies in which patient were subjected to unhygienic equipment.

Data analyses and synthesis

Infection

SSIs were reported in one meta-analysis and this research suggest there is difference in postoperative infection rates between the patient undergoing pre-surgical preparation compared to patient who do not receive the preparation. One study reported there is no infections in patients who use skin preparation.

Summary and main results of studies

Conclusion

It is clear that perioperative nurses play important role in evaluating product safety, environmental concerns, efficiency and effectiveness, and cost of these factors in relation to patient care. Well-informed product purchasing and evaluation is an important way for hospitals to deal with the increase expenses in environmental moderate reimbursements. However, the most challenging aspects of purchasing and evaluating products are balancing quality and cost. Striving towards achieving products and equipment standardization reduce waste but increase cost savings. Another challenge of choosing equipment and safety is keeping up with the ever changing technological advancements while ensuring needs of stakeholders are considered. To this end, all hospital departments should be involved in selecting products which are environmentally friendly and cost effective.

To reconcile these challenges, perioperative nurses can consult “Association of Perioperative Registered Nurses” (AORN)’s for product and equipment selection. Some of the recommendations from this association include:

Recommendation I: There should be a mechanism for product and equipment selection. The mechanism for product selection help in consistent selection of reliable and functional products which promote quality care, safety of patient, cost-effective, and environmental friendly.

Recommendation II: The perioperative Registered Nurses should have competency in product selection and evaluation. The healthcare organizations should have educational programs on specific steps on product and equipment selection, new environmental conditions, safe care and handling of equipment and products, governmental regulations, and product requirements such as repair and reprocessing.

Recommendation III: Hospitals should have quality assurance improvement process to measure equipment and product performance. Also, hospital should conduct post-purchase assessment to ascertain user satisfaction. The evaluation ensure new products meet expected performance criteria.

References Bischoff, P., Kubilay, N. Z., Allegranzi, B., & Egger, M. (2017). Effect of laminar airflow ventilation on surgical site infections: a systematic review and meta-analysis. The Lancet Infectious Diseases, 17(5), 553-561. Chu, K., Maine, R., & Trelles, M. (2015). Cesarean section surgical site infections in sub- Saharan Africa: a multi-country study from Medecins Sans Frontieres. World journal of surger, 39(2), 350-355. Kapadia, B. H., Berg, R. A., Daley, J. A., Fritz, J., Bhave, A., & Mont, M. A. (2016). Periprosthetic joint infection. The Lancet, 387(10016), 386-394. Magill, S. S., O’Leary, E., Janelle, S. J., & Thompson, D. L. (2018). Changes in prevalence of health care–associated infections in US Hospitals. New England Journal of Medicine, 379(18), 1732-1744. Weinshel, K., Dramowski, A., Hajdu, Á., Jacob, S., Khanal, B., & Zoltán, M. (2015). Gap analysis of infection control practices in low-and middle-income countries. infection control & hospital epidemiology, 36(10), 1208-1214. Zuarez-Easton, S., Zafran, N., Garmi, G., & Salim, R. (2017). Postcesarean wound infection:prevalence, impact, prevention, and management challenges. International journal of women's health, 9(81), 1-10.

128 articles

These articles were identified after crossing the descriptors

32 articles

The articles were picked based on title and abstract. However, some covered Chronic wounds and not surgical wounds

8 articles

This meet the inclusion criteria