Analysis and Application of Clinical Practice Guideline: Prevention of Surgical Infections

            Clinical Practice Guidelines (CPGs) are defined as evidence-based documents that are developed to help guide current evidence into the everyday practice of nursing. CPGs play critical roles in guiding evidenced-based practice and contain the recommendations that are based on a systematic review and critical analysis of the literature about a clinical question (Peterson et al., 2014). Peterson et al. (2014) describes evidence-based practice as being‘informed by research findings, clinical expertise, and patients’ values, and its use can improve patients’ outcome and the purpose of determining the level of evidence and then critiquing the study is to ensure that the evidence is credible, reliable, valid and appropriate for inclusion into nursing practice’. This evidence can then be used to help create a clinical practice guideline.

            Over 200 million surgeries world-wide are preformed yearly and the prevalence of surgical acquired infections are still way too high (Kim et al., 2015). Surgical site infections are a common cause of nosocomial infections and the patients that develop a surgical site infection are more likely to end up in an intensive care unit. A majority of infections occur because of errors made before and/or after the intended procedure then by mistakes made during the actual procedure itself (Kim et al., 2015). It is of utmost importance to be able to protect the patient from potential infections and to also protect the healthcare staff as well (Patrick & Hicks, 2013). Breaking the chain of infection needs to occur in order to prevent infections in the surgical setting. Clinicians need continued trainingin order to reduce the numbers of acquired surgical infections.

Scope and Purpose

            This purpose of this guideline was to provide standardized recommendations based on scientific literature to encourage the use interventions to reduce complications during surgeryfor surgeons and nurses during the surgical setting and to offer recommendations to improve or avoid adverse events during surgery by providing safety ("National Guideline Clearinghouse | Clinical practice guideline for the patient safety at surgery settings," 2010).

Stakeholder Involvement

            The professions most involved with this guideline, in all specialty areas, include:

·         Advance Practice Nurses

·         Health Care Providers

·         Allied Health Personnel

·         Hospitals

·         Nurses

·         Physicians

The working group involved in creating this guideline included physicians that are specialized in the areas of anesthesiology, preventative medicine, digestive surgery, general surgery, thoracic surgery, oesophagogastic surgery and bariatric surgery ("National Guideline Clearinghouse | Clinical practice guideline for the patient safety at surgery settings," 2010).

            The target population includes adults undergoing surgery but excluded emergent surgeries and it was not stated as to whether the population was consulted in regards to the study and creation of this guideline.

            I believe that a conflict of interest in the creation of this guideline would be a lack of involvement of healthcare personnel as they might consider it a negative connotation to have to share an adverse event that had occurred during one of their surgical procedures.

 

 

Rigor of Development

In the first phase, guideline authors conducted an initial hand-search of published literature and a search of electronic databases. Each possible CPG identified was evaluated using the Appraisal of Guideline Research and Evaluation (AGREE) tool. This tool was to help assess possible adaptations of proposed recommendations. The working group then extracted all systematic reviews and clinical trials used to develop the original recommendations ("National Guideline Clearinghouse | Clinical practice guideline for the patient safety at surgery settings," 2010). Based on what the working group found they then did another updated search from the following resources ("National Guideline Clearinghouse | Clinical practice guideline for the patient safety at surgery settings," 2010):

·         Cochrane Database of Systematic Reviews

·         Database of Abstracts of Reviews of Effects

·         Health Technology Assessment Database

·         NHS Economic Evaluation Database

·         MEDLINE

·         EMBASE

The working group then conducted a second phase where they completed a search of randomized control and observational studies and used original recommendations along with the filters. No language restrictions were used and searches were carried out until December of 2008 ("National Guideline Clearinghouse | Clinical practice guideline for the patient safety at surgery settings," 2010). This guideline created a grading system to classify the quality of evidence retrieved called the Grading of Recommendations Assessment, Development and Evaluation (GRADE). GRADE didnot base the quality of the evidenced retrieved solely on the design of the studies being considered ("National Guideline Clearinghouse | Clinical practice guideline for the patient safety at surgery settings," 2010).

It is not stated what the number of articles that were identified and analyzed nor were exclusions identified by the authors. The guideline was released in 2010. This guideline was funded via an agreement signed by the Carlos III Institute of a Health and the Agency for Information, Evaluation and Quality in Health within the framework of cooperation that was established in the Quality Plan for the National Health System of the Spanish Ministry of Health, Social Policy and Equality ("National Guideline Clearinghouse | Clinical practice guideline for the patient safety at surgery settings," 2010). Balance sheets and expert consensus was used to formulate recommendations.

Recommendations

            Based on this guideline there are specific recommendations that healthcare personnel should follow before, during and after a surgical procedure in regards to("National Guideline Clearinghouse | Clinical practice guideline for the patient safety at surgery settings," 2010):

·         Preventing infection

·         Use of antibiotic prophylaxis

·         Prevention of cardiovascular complications

·         Preventing venous thromboembolism

·         Blood transfusion

·         Maintaining normothermia

·         Preventing complications from anesthesia

The GRADE system was used to grade the strength of recommendations as strong or weak and the following factors were considered ("National Guideline Clearinghouse | Clinical practice guideline for the patient safety at surgery settings," 2010):

·         The balance between the benefits and the risks

·         The quality of scientific evidence

·         Preference and values

·         Costs

If I were part of the surgical staff taking care of patients my first goal would be is to follow the guidelines to prevent any possible infection or error. In order to make sure this followed I believe that frequent in-services should be conducted in order to make sure that old and new employees stay reminded of what the proper techniques and procedures are.

Implementation

            The NCH guideline states that the ("National Guideline Clearinghouse | Clinical practice guideline for the patient safety at surgery settings," 2010) ‘potential benefits are improved patient safety in surgical settings’.

Barriers to making sure that patient’s do not acquire infections or have surgical errors during their procedures are a result of the unwillingness or incompetence of the healthcare personnel to follow proper procedures at any point. There is usually more than one personnel involved. There are the nurses/doctors taking care of the patient before the procedure, nurses/doctors during the procedures and nurses/doctors taking care afterwards. AT any point during the process can an infection be acquired or an error can be made. That is why there are guidelines and procedures to follow to assure an adverse event from happening. The patient also is part of the procedure from beginning to end.

            The potential cost of not following the guidelines ends up being an increase in monetary cost to the hospital, health insurance and/or patient. We also need to remember that this guideline is and aid for decision making and doesn’t replace a clinician’s clinical judgement.

Conclusion

            Healthcare consistently changes but one thing that will always remain is to ensure exceptional safety and care of the patient. Due to the large number of surgical errors that happen each year there is always going to be a need for improvement and/or implementation of guidelines. Healthcare personnel, from aides to nurses to doctors, have the responsibility of following the clinical practice guidelines that are developed in order to achieve an error free surgery and thus making sure the patient is safe. They also have the responsibility of making sure their fellow employee follows proper procedure and guidelines as well.

 

 

 

References (centered, not bold)

Kim, F. J., da Silva, R. D., Gustafson, D., Nogueira, L., Harlin, T., & Paul, D. L. (2015). Current issues in patient safety in surgery: a review. Patient Safety In Surgery, 9(1), 1-9. doi:10.1186/s13037-015-0067-4

National Guideline Clearinghouse | Clinical practice guideline for the patient safety at surgery settings. (2010). Retrieved from http://www.guideline.gov/content.aspx?id=39241&search=patient+safety+surgical

Patrick, M. R., & Hicks, R. W. (2013). Implementing AORN recommended practices for prevention of transmissible infections. AORN Journal, 98(6), 609-628. doi:10.1016/j.aorn.2013.08.018

Peterson, M. H., Barnason, S., Donnelly, B., Hill, K., Miley, H., Riggs, L., & Whiteman, K. (2014). Choosing the Best Evidence to Guide Clinical Practice: Application of AACN Levels of Evidence. Critical Care Nurse, 34(2), 58-68. doi:10.4037/ccn2014411

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