Anatomy of the New Evidence-Rated AORN Recommended Practices

Anatomy of the New

Evidence-Rated AORN

Recommended Practices

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.

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.

Sharon A. Van Wicklin, MSN, RN, CNOR, CRNFA, CPSN, PLNC

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Speakers:


Director of Evidence-Based Practice, AORN

Sharon A. Van Wicklin, MSN, RN, CNOR, CRNFA,

CPSN, PLNC

Perioperative Nursing Specialist, AORN

Disclose no conflicts

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.

Planning Committee:

Ellice Mellinger, MS, RN, CNOR

Perioperative Education Specialist, AORN

Discloses no conflict

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.

Objectives

History of Evidence-Based

Practice (EBP)



“It isn’t what we don’t know that gives us

trouble, it’s what we know that ain’t so.”

~Will Rogers

History of EBP

In the beginning…

Thomas Beddoes (1760-1808)

• Called for sharing medical experiences,

collecting and archiving them and

- Analyzing

- Reporting

- Publishing

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

1948

The first Randomized Controlled Trial (RCT)

• Medical Research Council Tuberculosis

Unit trial of streptomycin treatment for

pulmonary tuberculosis

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."

1972

Effectiveness and Efficiency: Random

Reflections on Health Services published

Cardiff University Library, Cochrane Archive,

University Hospital, Llandough

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.”

History of EBP

1980’s-

• Oxford Database of Perinatal Trials

1992-

• Cochrane Center opened

1993-

• Cochrane Collaboration founded

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.”

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

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.”

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

EBP and Perioperative Nursing

• Quality of care

• Continuous inquiry

• Critical thinking

• Individualized care

• Payer and regulatory pressure

• Savvy patients

Developing the EBP Question



PICO Method

PPatientPopulationProblem

IInterventions-Education-Self-care-Best practices

CComparison-Current practice-Another intervention

O Outcome

IM Injections: Aspirate or not?

P Adult patients

I Aspirate when giving

IM injection

C No aspiration

O Injury

Question:

Among adult patients,

does aspirating while

giving an IM injection

cause injury compared

to no aspiration?

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

Surgical Masks: Prevent SSI?

PPatientPopulationProblem

Surgical patients

IInterventions-Education-Self-care-Best practices

Wearing a mask

CComparison-Current practice-Another intervention

No mask

O OutcomeSurgical site

infections

PICO Question

Among surgical patients, does wearing a

surgical mask prevent surgical site

infections compared to not wearing a

mask?

Literature Search





Conducting a Search

Databases Databases

~ Cochrane ~ Google Scholar

~ AHRQ - NGC ~ Joanna Briggs

~ Pubmed ~ Virginia Henderson

~ CINAHL® International Nursing

~ ANA - Medline Library

~ AORN Journal ~ Embase

~ Medical Library

Search Strategies

Strategies

• Define your topic

• Keywords

• Boolean operators

• AND

• OR

• Quotation marks

• Truncation

Results• No or few results

• Avoid long

phrases or

questions

• Choose different

key words

Literature Search

Literature Search Terms

– Sterile field - Sterile supplies

– Sterile technique - Sterile barriers

– Aseptic technique - Barrier precautions

– Aseptic practices - Body-exhaust suits

– Surgical drapes - Laminar air flow

– Double-gloving - Bowel technique

– Assisted gloving - Glove expansion

– Closed gloving - Glove perforation

– Time-related sterilization - Strikethrough

– Event-related sterilization - Spaulding’s criteria

– Surgical attire - Product packaging

– Protective clothing - Equipment contamination

Literature Search

Initial search confined to 2006 to 2011

• Time restriction not considered in subsequent

searches

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

Literature Search

Databases searched

• MEDLINE®

• CINAHL®

• Scopus®

• Cochrane

Literature Search

Articles identified: 429

– Rejected: 294

– Accepted: 135

Research Evidence



Research

Systematic Reviews

Randomized Controlled Trials

Quasi-Experimental Studies

Non-Experimental Studies

Qualitative Studies

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

Research

Randomized Controlled Trials (RCTs)

• Randomization

- Researcher assigns subjects to a control or

experimental group on a random basis

- Increases validity of the study

Research

RCTs

• Manipulation

- Researcher takes an action to influence some aspect

of the dependent variable

Independent variable: Intervention being applied

Dependent variable: Phenomenon being studied

Research

RCTs

• Control

- Researcher introduces a group of subjects to which

the experimental intervention is not applied

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

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

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

Non-Research Evidence



Non-Research

Clinical Practice Guidelines

Literature Reviews

Expert Opinion

Case Reports

Organizational Experience

Community Standard/Clinician Experience

Non-Research

Clinical Practice Guidelines

• Systematically developed statements

• Provide guidance for clinical practice

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

Non-Research

Expert Opinion

• Expertise must be assessed

- Education

-Work experience

- University affiliations

- Publications

- Citations

- Recognized speaker

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

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

Non-Research

Community Standard/Clinician Experience

Evidence Appraisal



AORN Appraisal Tools

Research Non-Research

AORN Appraisal ToolsResearch

The strength of the

research evidence is

indicated by I, II, or III


Research

The quality of the


indicated by A, B, or C


Research

The final Research

appraisal score is a

combination of I, II, or III

and A, B, or C


Non-Research

The strength of the non-


indicated by IV or V


Non-Research

The quality of the non-


indicated by A, B, or C


Non-Research

The final Non-Research

appraisal score is a

combination of IV or V

and A, B, or C

Appraisal Score

Evidence Rating



AORN Evidence Rating Model

Appraisal ScoreEvidence Rating Evidence Requirements

Research Non-Research

IA IVA Regulatory

1: Strong Evidence1: 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.

IBIIA, IIBIIIA, IIIB

IVBVA, 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.

ICIICIIIC

IVCVC

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.

No requirement No requirement 4: Benefits Balanced With HarmsSelected 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 EvidenceInterventions or activities for which no supportive evidence was found during the literature search completed for the recommendation. Consensus opinion.


1: Strong Evidence

1: Regulatory requirement

IA IVA Regulatory

1: Strong Evidence1: 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.



3: Limited Evidence

IBIIA, IIBIIIA, IIIB

IVBVA, VB


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.

ICIICIIIC

IVCVC

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.


4: Benefits Balanced with 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]


4: Benefits Balanced with Harms

5: No Evidence


No requirement No requirement 5: No EvidenceInterventions or activities for which no supportive evidence was found during the literature search completed for the recommendation. Consensus opinion.

Evidence Rating

[3: Limited Evidence]

Appraisal Score

Evidence Rating

[3: Limited Evidence]

Meeting National Guidelines

Clearinghouse Criteria



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.

Anatomy of an AORN

Recommended Practice



AORN Evidence Rated RPRecommendation Number: IV

Recommendation

Rationale

Intervention Letter: IV.a.

Intervention

Supporting Evidence

Activity Number: IV.a.1.

Activity

Evidence Rating

Appraisal Scores

AORN Evidence Rated RP

AORN Evidence Rated RP

AORN

Evidence

Rated RP

Questions and Answers

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 evidence-based 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

http://www.ornurselink.org/Pages/home.aspx

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Perioperative Standards and Recommended PracticesThis 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

Get Your 2014 Edition Today

www.aorn.org/RecommendedPractices

Health & Medicine

Anatomy of the New Evidence-Rated AORN Recommended Practices