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NURS6052, Section 40, Essentials of Evidence-Based Practice

February 8, 2015

Identifying a Researchable Problem

Nurses are at the forefront of evidence based practice questions. Everyday healthcare treatments are governed by policies and procedures created as a result of evidence based practice questions. Over the years, many nurses begin to perform their duties not giving much thought to the rationales behind what they are doing. However, under the circumstances, improvements to healthcare are based off the experiences and curiosity of nurses delivering direct patient care. In this assignment, a researchable nursing topic will be identified and an answerable evidence based practice question will be generated to resolve the issue presented.

Area of Interest

Post-operative surgical site infections are ranked among the highest of all healthcare associated infections. In 2011, the Centers for Disease Control and Prevention (CDC) reported an estimated 721,800 infections in acute care hospitals across the United States (CDC, 2011). An estimated 157,500 of the infections were reported as surgical site infections (CDC, 2011).

Due to an increase in post-operative surgical site infections, hospitals, and outpatient surgical clinics have adopted and implemented changes to their skin preparation techniques by using a Chlorhexidine-Gluconate Ethanol or Hibiclens solution versus Povidone-Iodine or Betadine as a pre-operative scrub. The purpose of the pre-operative scrubs is to prevent bacterial contamination of the surgical site (Dizer, Hatipogula, Kaymakcioglu, Tufan, Yava, Iyigum, & Senses, 2009). Both Hibiclens and Betadine have been used for decades. Although Chlorhexidine is highly recommended as the skin preparation solution due to the high risk for an allergic reaction to Povidone-iodine, many healthcare facilities around the world continue its use. As a result of these changes, many healthcare professionals have researched and questioned the advantage of Hibiclens over Betadine.

Feasibility

Below are five questions formulated to determine their feasibility related to the use of Chlorhexidine verses Povidone-iodine in preventing postoperative surgical site infections.

1. How effective is the use of Chlorhexidine verses Povidone-iodine as a preoperative skin solution?

2. Will Chlorhexidine as a preoperative skin preparation solution reduce surgical site infections?

3. Will the use of Chlorhexidine result in overall savings for the hospital?

4. In patients with an unknown allergy to Povidone-iodine, is it safer to use Chlorhexidine to avoid an allergic reaction?

5. What is the impact of starting skin preparation the night before rather than start the skin preparation in the surgical unit?

Based on the analysis, the following questions were formulated: “What is the impact using Chlorhexidine verses Povidone-iodine as a preoperative skin solution?” When creating evidence based research questions, all information is not critical in resolving the problem; however, all data should be documented to complete the research (Polit & Beck, 2012). Researching the use of Chlorhexidine and Povidone-iodine as preoperative solutions will benefit the patients by not only decreasing the risks of infection, but doing so cost effectively.

When implementing research on post-operative surgical site infections, feasibility should be taken into consideration. According to Polit & Beck (2012) analyzing and tracking the length of time established to conduct the study? What costs are associated in conducting research relating to surgical site infection? Are the appropriate facilities and personnel available to perform the research? What is the level of expertise of the researchers involved in the study?

Preliminary PICO Question

The PICOT was used; P for population; I for intervention/issues; C for comparison; O for outcome; and T for time (Polit & Beck, 2012). My PICOT question is “In surgical patients, what effect do skin antiseptics used as preoperative skin preparation that contain Chlorhexidine gluconate compared to those that contain Povidone-iodine on preventing post-operative surgical site infections?” The population is the surgical patients who are at risk of post-op infections. The intervention/issue is the use of Chlorhexidine as a surgical prep. The comparison is the use of Povidone-iodine as a surgical prep and the outcome is the effectiveness in preventing surgical site infections.

Key Terms

Keywords or phrases used in conducting the literature search for surgical site infections are nursing, Chlorhexidine, hibiclens, Povidone, iodine, betadine, surgery, post-operative infections, skin pathogens, antiseptic skin prep, cost, evidence-based, patient education, and healthcare associated infections. Surgical nurses often use the pre-operative solutions to conduct skin preparation. Finding or the types of skin pathogens involved are vital in treatment the infection. Patients with unknown allergies to iodine before its use will avoid life threatening reactions and in term decrease cost. Patient education and comparing how effective is it to conduct skin preparation at home compared to initiating it just prior to surgery

Summary

Developing an answerable PICO question will support the evidence-based practice researched by many healthcare facilities. Conducting research on surgical site infections and developing policies supported by evidence can greatly decrease the number of hospital acquired surgical site infections and in term aid nurses in implementing patient care.

Literature Review

Conducting literature reviews is an integral part of the research process. According the Polit & Beck (2012), literature reviews provide a summary of data that has been researched and analyzed to determine if a theory has been satisfactorily developed. The purpose of this paper is to provide a synthesis of research studies conducted to determine the effect of skin antiseptics used as a pre-operative skin preparation.

History

Hospital acquired infections continue to cause a considerable rise in the morbidity and mortality rates of patients receiving treatment in hospitals around the world. According to the Centers for Disease Control and Prevention (CDC) Healthcare-Associated Infections Prevalence Survey conducted in 2011, approximately 721,800 infections were reported in acute care hospitals in the United States (Centers for Disease Control (CDC), 2011). An estimated 157,500 surgical site infections were among the highest reported (CDC, 2011). As a result, researchers continue to develop policies based on previous and current studies and data reported on preventing post-operative site infections. Several billions of dollars have been spent to research methods necessary to improve patient outcomes. Numerous studies have been conducted comparing the use of Chlorhexidine to Povidone-iodine on preventing post-operative surgical site infections. As a result, many medical professionals may change their procedures on surgical skin preparation.

The Current Evidence

A systematic review of a randomized control trial was conducted by Yeung, Grewal, Bullock, Lai, and Brandes (2013) to evaluate the use of Chlorhexidine-alcohol and Povidone-iodine. The study looked at decreasing the rate of positive cultures from the surgical sites of a genitourinary prosthetic implantation device. A total of 100 patients were chosen to participate. Two groups with 50 in each group were elected. Pre-operative cultures were obtained on all patients prior to any skin preparation. Group one patients received a pre-operative scrub with Chlorhexidine-alcohol and Group two patients received a pre-operative scrub with Povidone-iodine. Both groups of patients received a second set of cultures from the surgical site prior to the beginning of surgery. The results revealed 79% of the patient’s pre-operative skin preparation cultures were positive (Yeung et al., 2013). Group one patients who received the Chlorhexidine-alcohol pre-operative scrub cultures were positive in 8% of the patients, while Group two patients who received the Povidone-iodine pre-operative scrub were positive in 32% of the patients (Yeung et al., 2013). This study resulted in rating Chlorhexidine-alcohol safer than Povidone-iodine in preventing post-operative surgical site infections.

In a larger integrated review conducted by Lee, I., Agarwal, Lee, B., Fisman, and Umscheid (2010), nine randomized controlled trials with a total of 3,614 patients were conducted in a meta-analysis. Qualified studies were obtained from several databases including the Cochrane Library (Lee et al., 2010). Data from these studies were used to create a model to assess the outcomes. The results of these trials also concluded Chlorhexidine as the preferred antiseptic for pre-operative skin preparation.

In a retrospective medical record review conducted by Zinn, Jenkins, Harrleson, Wrenn, Haynes, and Small (2013), four hospitals within the same network participated. Medical records of 129 patients receiving open abdominal surgery were reviewed during the period of December 2008 and December 2010. Four different skin prep solutions were used containing parachoroxylenol (PCMX), Chlorhexidine, Povidone-iodine, and 0.7% iodine and 74% isopropyl alcohol (Zinn et al., 2013). The review concluded with only five patients receiving post-operative site infections within 30 days of surgery (Zinn et al., 2013). No infections were found in any of the patients receiving a pre-operative scrub with PCMX or Chlorhexidine. As a result, PCMX was chosen as the preferred skin prep solution only because Chlorhexidine was no longer available within their network. For this reason, it was concluded that a retrospective review was not as effective as a prospective randomized trial (Zinn et al., 2013).

To improve the effectiveness of pre-operative skin preparations, many studies have been conducted. It has been found that the most common source for pathogens were on the patient’s skin surface. As a result, researchers have conducted several studies to find which pre-operative skin preparation solution and technique are most effective. The majority of articles reviewed found Chlorhexidine as the most effective; however, a disadvantage has been cost associated. In a systematic review conducted by Adbullah & Maqball (2013), an estimated $20,842 cost per patient was associated with each infection as a result of extended hospital stays, medications, nursing care, and interventions necessary for treatment. According to Hemani & Lepor (2009), patients who develop surgical site infections are “likely to spend time in the intensive care unit, are 5 times more likely to be readmitted and are twice as likely to die”.

Conclusion

In 1999, the Centers for Disease Control and Prevention released a set of guidelines for healthcare facilities to follow in preventing surgical site infections (Hemani & Lepor, 2009). It has been suggested that surgical skin preparations should be selected on an individual basis and not because it’s the surgeon’s favorite (Murkin, 2009). All patients should be assessed for allergies and history that may increase their chances for infections. Only medical professionals who have been properly trained should administer pre-operative skin preparation (Murkin, 2009). There have been a number of studies conducted to determine the effectiveness of Chlorhexidine in comparison to Povidone-iodine (Murkin, 2009). Researchers strongly support changing guidelines for the use of Chlorhexidine rather than Povidone-iodine as a pre-operative surgical scrub in preventing surgical site infections. Chlorhexidine has also proven to be cost effective as it relates to the length of hospital stays, medication regimes, and nursing interventions required improving the quality of life for patients.

Summary

A literature review was conducted evaluating documented studies to support the PICOT question of comparing the use of Chlorhexidine to Povidone-iodine as a pre-operative skin preparation solution. The majority of the studies included in the literature review showed evidence that support the change of guidelines for surgical units to use Chlorhexidine as the preferred solution in preventing post-operative surgical site infections and the most cost effective. Although research rates Chlorhexidine as the preferred pre-operative skin preparation solution, additional research is recommended.

Translating Evidence into Practice

Surgical site infections are one of the most common hospital-acquired infections (CDC, 2011). Nurses can play a vital role in decreasing the number of post-operative infections. Adopting and implementing new policies and procedures are the first of several steps necessary to improve patient outcomes. The purpose of this paper is to identify the PICOT question and its significance in nursing practice.

PICOT

The PICOT question for this assignment is “In surgical patients, what effect do skin antiseptics used as preoperative skin preparation that contain Chlorhexidine gluconate compared to those that contain Povidone-iodine on preventing post-operative surgical site infections?”

Nurses play a significant role in preventing surgical site infections. Best practices for nurses in surgical units are to maintain sterility. Good hand washing techniques, the use of personal protective equipment, pre-operative skin cleansing, and post-operative wound care are significant prevention methods. It is normally with the assessment of the nurse; the first signs of an infection are noticed. Therefore, to reduce the number of infections, it has been recommended by the Association of Preoperative Registered Nurses (AORN) that preoperative skin preparation should use an antiseptic agent immediately before surgery (Ramsey, 2001). Both Chlorhexidine gluconate and Povidone-iodine among the most commonly used skin antiseptic agents preferred by surgeons.

Literature Review Summary

Researchers have compared and analyzed the use of skin preparation agents for many years. Several studies have concluded both Chlorhexidine gluconate and Povidone-iodine prevent surgical site infections; however, Chlorhexidine gluconate shows a significant difference in the eradicating bacterial at the surgical site (Yeung, Grewal, Bullock, Lai, and Brandes, 2013). In the study conducted by Yeung et al., 2013, all skin preparation was performed by the circulation nurse or surgeonthe circulation nurse or surgeon performed all skin preparation. Surgical nurses are instrumental in preventing surgical site infections by following both the national and professional guidelines established (Zinn, Jenkins, Harrleson, Wrenn, Haynes, and Small, 2013). This study conducted by Zinn et al., 2013, patients prepped with chlorhexidine had the lowest incidence of surgical site infections. Researcher concluded that “perioperative registered nurses are able to make informed recommendations and appropriate assessments and interventions aimed toward prevention of surgical site infections” (p. 557). By maintaining adequate hand hygiene, decreasing operating room traffic, donning the proper surgical attire, and following guidelines on surgical prepping techniques, nurse’s efforts can aid in decreasing surgical site infections. Nurses adhering to the guidelines which states Chlorhexidine scrub time is two-minutes followed by three-minute drying time (Yeung et al., 2013). Comment by Debbie D. Sullivan: Is this your nursing practice supported by your lit review?

Evidence Based Practice Outcomes

Evidence based practice provides an outline of how research can be utilized in nurse practice. According to Polit & Beck (2012), when nurses provide medical advice, many are offering this advice based on prior research. Many nursing protocols have been created stating the appropriate method and length of time required for Chlorhexidine to effectively disinfect the site. The use of Chlorhexidine has proven superior over the use of Povidone-iodine in preventing surgical site infections.

Failing to use the evidence based practices established will lead in an increase in the number of surgical site infections, which can lead into additional medical costs related to hospital stays and medications. There may also be an increase in the morbidity and mortality rates (Yeung et al., 2013).

Strategy for Dissemination the Evidence Based Practice

Educating the staff will be vital in disseminating and implementing the evidence based practice indentified. Presenting the research and proposed policy changes to the medical directors would be one of the first steps taken to obtain approval. According to Pilot & Beck, 2012, if presenting to administrators, information should include “cost and accessibility” (Pilot & Beck 2012, p. 681). Creating handouts and sending electronic communications of the upcoming updates may ease the staff’s initial shock of the upcoming changes. Providing an in-depth mandatory training for all staff and providing staff monitoring will establish an open line of communication to address any concerns. Nurses my also attend and present at professional conferences and submit their research to journals to have it published (Pilot & Beck, 2012). Comment by Debbie D. Sullivan: How would you would move from disseminating the information to implementing the evidence-based practice within your organization?

Summary

Translating research findings into nursing practice is vital in improving the delivery of healthcare. Selecting the best skin cleansing agent for a surgical unit to adopt is an important step in decreasing the rate of surgical site infections. Research shows Chlorhexidine rating superior to Povidone-iodine. There are several methods researchers can take to present their reports in order to have them implemented as policy changes.

Summary of the Project

Surgical site infections are the most common type of hospital-acquired infection (CDC, 2011). The Centers for Disease Control and Prevention estimated 721,800 hospital acquired infections of which 157,500 were reported as surgical site infections (CDC, 2011). Due to the increased mobility and mortality rates related to surgical site infections, researches have conducted studies to determine with form a surgical skin preparation solution rates superior in decreasing the number of infections.

In order to establish the best evidence-based practice, formulating a PICOT research question supported by creditable literature reviews is essential. The PICOT question states a comparison of Chlorhexidine to Povidone-iodine. The literature reviews conducted in the project support evidence giving a comparison of Chlorhexidine to Povidone-iodine as surgical skin preparation solutions. The studies conducted by Yeung et al., 2013, and others, rated Chlorhexidine superior to Povidone-iodine in decreasing surgical site infections. Due to the nature of this project, it is recommended that further research is conducted.

After in-depth research is concluded and supports the PICOT question, it is important to disseminate and implement the evidence into practice. Developing a dissemination plan is vital. Successfully communicating the plan by educating the staff, submitting the research findings to journals, and attending professional conferences are important steps to translate the results of the study to be accepted and published (Polit & Beck, 2012).

References

Abdullah, M., & Maqbali, A. (2013). Preoperative antiseptic skin preparations and reducing SSI. British Journal of Nursing, 22(21), 1227-1233.

Centers for Disease Control and Prevention. (2011). Healthcare-Associated Infections: Data and Statistics. Retrieved from http://www.cdc.gov/HAI/surveillance/index.html.

Dizer, B., Hatipoglu, S., Kaymakcioglu, N., Tufan, T., Yava, A., Iyigun, E., & Senses, Z. (2009). The effect of nurse-performed preoperative skin preparation on postoperative surgical site infections in abdominal surgery. Journal of Clinical Nursing. 18, 3325-3332.

Hemani, M., & Lepor, H. (2009). Skin preparation for the prevention of surgical site infection: Which agent is better? Reviews in Urology, 11(4), 190-195.

Lee, I., Agarwal, R., Lee, B., Fishman, N., & Umscheid, C. (2010). Systematic review and cost analysis comparing use of Chlorhexidine with use of iodine for preoperative skin antisepsis to prevent surgical site infection. Infection Control Hospital Epidemiology, 31(12), 1219-1229.

Murkin, C. (2009). Pre-operative antiseptic skin preparation. British Journal of Nursing, 18(11), 665-669.

Polit, D., & Beck, C. (2012). Nursing Research: Generating and Assessing Evidence for Nursing Practice. Philadelphia: Lippincott, Williams & Wilkins.

Ramsey, C. (2001, April). Preoperative measures to prevent surgical site infections. Infection Control Today. Retrieved from http://www.infectioncontroltoday.com

Yeung, L., Grewal, S., Bullock, A., Lais, H., & Brandes, S. (2013). A comparison of Chlorhexidine-alcohol versus Povidone-iodine for eliminating skin flora before genitourinary prosthetic surgery: A randomized controlled trial. The Journal of Urology, 189, 136-140. doi: 10.1016/j.juro.2012.08.086.

Zinn, J., Jenkins, J., Harrelson, B., Wrenn, C., Haynes, E., & Small, N. (2013). Differences in intraoperative prep solutions: A retrospective chart review. AORN Journal, 97(5), 552-558.

Running head: NURSING PORTFOLIO 1

NURSING PORTFOLIO 5

Literature Review Summary Table

NURS 6052