Victoria M. Steelman

Infusing research into practice to promote quality care

This article describes the Iowa Model of Research in Practice, a heuristic model used at the University of Iowa Hospitals and Clinics for infusing research into practice to improve the quality of care. The components of the model are presented with examples. The impact of the model on patient, staff, and fiscal outcomes is delineated.

Clinical significance of positive cranial bone flap cultures and associated risk of surgical site infection after craniotomies or craniectomies.

OBJECT The risk of surgical site infection (SSI) after craniotomies or craniectomies in patients in whom contaminated bone flaps have been reimplanted has not been determined. The objectives of this study were to identify the prevalence of bone flaps with positive cultures--especially those contaminated with Propionibacterium acnes--to assess the risk of SSI after reimplanting (either during the initial operation or subsequently) bone flaps with positive cultures, and to identify risk factors for SSI following the initial craniotomies or craniectomies. METHODS The authors conducted a retrospective review of cases in which patients underwent craniotomy/craniectomy procedures between January and October 2007 in the neurosurgery department at the University of Iowa Hospitals and Clinics. They also reviewed processes and procedures and did pulsed field gel electrophoresis of P. acnes isolates to look for a common source of contamination. They then conducted a prospective cohort study that included all patients who underwent craniotomy/craniectomy procedures between November 2007 and November 2008 and met the study criteria. For the cohort study, the authors obtained cultures from each patients bone flap during the craniotomy/craniectomy procedures. Data about potential risk factors were collected by circulating nurses during the procedures or by a research assistant who reviewed medical records after the procedures. An infection preventionist independently identified SSIs through routine surveillance using the Centers for Disease Control and Preventions definitions. Univariate and bivariate analyses were performed to determine the association between SSI and potential risk factors. RESULTS The retrospective review did not identify specific breaks in aseptic technique or a common source of P. acnes. Three hundred seventy-three patients underwent 393 craniotomy/craniectomy procedures during the cohort study period, of which 377 procedures met the study criteria. Fifty percent of the bone flaps were contaminated by microorganisms, primarily skin flora such as P. acnes, coagulase-negative staphylococci, and Staphylococcus aureus. Reimplanting bone flaps that had positive culture results did not increase the risk of infection after the initial craniotomy/craniectomy procedures and the subsequent cranioplasty procedures (p = 0.80). Allowing the skin antiseptic to dry before the procedures (p = 0.04, OR 0.26) was associated with lower risk of SSIs. Female sex (p = 0.02, OR = 3.49) was associated with an increased risk of SSIs; Gliadel wafer implants (p = 0.001, OR = 8.38) were associated with an increased risk of SSIs after procedures to treat tumors. CONCLUSIONS Operative factors such as the way the skin is prepared before the incision rather than the skin flora contaminants on the bone flaps may play an important role in the pathogenesis of SSIs after craniotomy/craniectomy. Gliadel wafers significantly increased the risk of SSI after procedures to treat tumors.

Designing a Safer Process to Prevent Retained Surgical Sponges: A Healthcare Failure Mode and Effect Analysis

A retained surgical sponge is a sentinel event that can result in serious negative outcomes for the patient. Current standards rely on manual counting, the accuracy of which may be suspect, yet little is known about why counting fails to prevent retained sponges. The objectives of this project were to describe perioperative processes to prevent retained sponges after elective abdominal surgery; to identify potential failures; and to rate the causes, probability, and severity of these failures. A total of 57 potential failures were identified, associated with room preparation, the initial count, adding sponges, removing sponges, the first closing count, and the final closing count. The most frequently identified causes of failures included distraction, multitasking, not following procedure, and time pressure. Most of the failures are not likely to be affected by an educational intervention, so additional technological controls should be considered in efforts to improve safety.

Priority Patient Safety Issues Identified by Perioperative Nurses

Much of the work done by perioperative nurses focuses on patient safety. Perioperative nurses are aware that unreported near misses occur every day, and they use that knowledge to prioritize activities to protect the patient. The purpose of this study was to identify the highest priority patient safety issues reported by perioperative RNs. We sent a link to an anonymous electronic survey to all AORN members who had e-mail addresses in AORNs member database. The survey asked respondents to identify top perioperative patient safety issues. We received 3,137 usable responses and identified the 10 highest priority safety issues, including wrong site/procedure/patient surgery, retained surgical items, medication errors, failures in instrument reprocessing, pressure injuries, specimen management errors, surgical fires, perioperative hypothermia, burns from energy devices, and difficult intubation/airway emergencies. Differences were found among practice settings. The information from this study can be used to inform the development of educational programs and the allocation of resources to enhance safe perioperative patient care.

Retained Surgical Sponges: Findings from Incident Reports and a Cost-Benefit Analysis of Radiofrequency Technology

BACKGROUND Retained surgical items (RSIs) are serious events with a high potential to harm patients. It is estimated that as many as 1 in 5,500 operations result in an RSI, and sponges are most commonly involved. The adverse outcomes, additional medical care needed, and medico-legal costs associated with these events are substantial. The objective of this analysis was to advance our understanding of the occurrence of RSIs, the methods of prevention, and the costs involved. STUDY DESIGN Incident reports entered into the University HealthSystem Consortium (UHC) Safety Intelligence database on incorrect surgical counts and RSIs were analyzed. Reported cases of retained surgical sponges at organizations that use radiofrequency (RF) technology and those that do not were compared. A cost-benefit analysis on adopting RF technology was conducted. RESULTS Five organizations that implemented RF technology between 2008 and 2012 collectively demonstrated a 93% reduction in the rate of reported retained surgical sponges. By comparison, there was a 77% reduction in the rate of retained sponges at 5 organizations that do not use RF technology. The UHC cost-benefit analysis showed that the savings in x-rays and time spent in the operating room and in the medical and legal costs that were avoided outweighed the expenses involved in using RF technology. CONCLUSIONS Current standards for manual counting of sponges and the use of radiographs are not sufficient to prevent the occurrence of retained surgical sponges; our data support the use of adjunct technology. We recommend that hospitals evaluate and consider the use of an adjunct technology.

Selection of a Method to Rate the Strength of Scientific Evidence for AORN Recommendations

The use of scientific evidence to support national recommendations about clinical decisions has become an expectation of multidisciplinary health care organizations. The objectives of this project were to identify the most applicable evidence-rating method for perioperative nursing practice, evaluate the reliability of this method for perioperative nursing recommendations, and identify barriers and facilitators to adoption of this method for AORN recommendations. A panel of perioperative nurse experts evaluated 46 evidence-rating systems for quality, quantity, and consistency. We rated the methods that fully covered all three domains on five aspects of applicability to perioperative nursing practice recommendations. The Oncology Nursing Societys method was rated highest for all five aspects of applicability, and interrater reliability of this method for perioperative recommendations was 100%. Potential barriers to implementation of the rating method include knowledge deficit, staff resources, resistance to change, and fear of showing that lower levels of evidence support some recommendations. Facilitators included education, resource allocation, and starting small. Barriers and facilitators will be considered by the implementation team that will develop a plan to achieve integration of evidence rating into AORN documents. The AORN Board of Directors approved adoption of this method in June 2010.

Prion Diseases—An Evidence-based Protocol for Infection Control

Prion diseases are fatal, infectious, neurodegenerative disorders with special implications for infection control in the OR. The causative agent is highly resistant to disinfection and sterilization processes and has been transmitted during health care interactions. It is important to use evidence gained through research and case reports to minimize risk of infection. This article describes an infection control protocol developed for identifying high-risk patients, providing perioperative care, decontaminating the OR, and protecting health care personnel. This protocol provides multidisciplinary team members with a guideline for preventing transmission of these fatal diseases.

The Gap between Compliance with the Quality Performance Measure "Perioperative Temperature Management" and Normothermia.

Abstract: The National Quality Forum (NQF) has endorsed the process performance measure Perioperative Temperature Management, which is used by the Joint Commission and the Centers for Medicare and Medicaid Services. Compliance requires either using active warming intraoperatively or achieving normothermia near the end of anesthesia. Compliance may actually be achieved by using forced-air warming incorrectly and without maintaining normothermia. The aim of this study was to determine to what extent compliance with the NQF-endorsed quality performance measure, is congruent with normothermia at the end of the surgical procedure. This study describes the relationship between compliance with this measure and the outcome of normothermia upon admission to the postanesthesia care unit. A retrospective review was undertaken of patients undergoing surgery with general or neuraxial anesthesia during a 48-month period of time in a community hospital. A total of 5.8% of patients for whom the quality performance measure was met were hypothermic upon admission to the postanesthesia care unit. The greatest gaps between compliance with the measure and normothermia were found in urology (8.5%) and orthopedics (7.7%). Patients who receive care compliant with the quality performance measure by receiving active warming are still at risk for hypothermia.

Iowa Model of Evidence‐Based Practice: Revisions and Validation

Background The Iowa Model is a widely used framework for the implementation of evidence-based practice (EBP). Changes in health care (e.g., emergence of implementation science, emphasis on patient engagement) prompted the re-evaluation, revision, and validation of the model. Methods A systematic multi-step process was used capturing information from the literature and user feedback via an electronic survey and live work groups. The Iowa Model Collaborative critically assessed and synthesized information and recommendations before revising the model. Results Survey participants (n = 431) had requested access to the Model between years 2001 and 2013. Eighty-eight percent (n = 379) of participants reported using the Iowa Model and identified the most problematic steps as: topic priority, critique, pilot, and institute change. Users provided 587 comments with rich contextual rationale and insightful suggestions. The revised model was then evaluated by participants (n = 299) of the 22nd National EBP Conference in 2015. They validated the model as a practical tool for the EBP process across diverse settings. Specific changes in the model are discussed. Conclusion This user driven revision differs from other frameworks in that it links practice changes within the system. Major model changes are expansion of piloting, implementation, patient engagement, and sustaining change. Linking Evidence to Action The Iowa Model-Revised remains an application-oriented guide for the EBP process. Intended users are point of care clinicians who ask questions and seek a systematic, EBP approach to promote excellence in health care.BACKGROUND The Iowa Model is a widely used framework for the implementation of evidence-based practice (EBP). Changes in health care (e.g., emergence of implementation science, emphasis on patient engagement) prompted the re-evaluation, revision, and validation of the model. METHODS A systematic multi-step process was used capturing information from the literature and user feedback via an electronic survey and live work groups. The Iowa Model Collaborative critically assessed and synthesized information and recommendations before revising the model. RESULTS Survey participants (n = 431) had requested access to the Model between years 2001 and 2013. Eighty-eight percent (n = 379) of participants reported using the Iowa Model and identified the most problematic steps as: topic priority, critique, pilot, and institute change. Users provided 587 comments with rich contextual rationale and insightful suggestions. The revised model was then evaluated by participants (n = 299) of the 22nd National EBP Conference in 2015. They validated the model as a practical tool for the EBP process across diverse settings. Specific changes in the model are discussed. CONCLUSION This user driven revision differs from other frameworks in that it links practice changes within the system. Major model changes are expansion of piloting, implementation, patient engagement, and sustaining change. LINKING EVIDENCE TO ACTION The Iowa Model-Revised remains an application-oriented guide for the EBP process. Intended users are point of care clinicians who ask questions and seek a systematic, EBP approach to promote excellence in health care.

Effectiveness of active and passive warming for the prevention of inadvertent hypothermia in patients receiving neuraxial anesthesia: A systematic review and meta-analysis of randomized controlled trials

OBJECTIVE Perioperative hypothermia is a common complication of anesthesia that can result in negative outcomes. The purpose of this review is to answer the question: Does the type of warming intervention influence the frequency or severity of inadvertent perioperative hypothermia (IPH) in surgical patients receiving neuraxial anesthesia? DESIGN Systematic review and meta-analysis. SETTING Perioperative care areas. PATIENTS Adults undergoing surgery with neuraxial anesthesia. INTERVENTION Perioperative active warming (AW) or passive warming (PW). MEASUREMENTS PubMed, CINAHL, Embase, and Cochrane Central Register of Controlled Trials were searched. Inclusion criteria were: randomized controlled trials; adults undergoing surgery with neuraxial anesthesia; comparison(s) of AW and PW; and temperature measured at end of surgery/upon arrival in the Postanesthesia Care Unit. Exclusion criteria were: no full-text available; not published in English; studies of: combined neuraxial and general anesthesia, warm intravenous or irrigation fluids without using AW, and rewarming after hypothermia. Two independent reviewers screened abstracts and titles, and selected records following full-text review. The Cochrane Collaborations tool for assessing risk of bias was used to evaluate study quality. A random-effects model was used to calculate risk ratios for dichotomous data and mean differences for continuous data. MAIN RESULTS Of 1587 records, 25 studies (2048 patients) were included in the qualitative synthesis. Eleven studies (1189 patients) comparing AW versus PW were included in the quantitative analysis. Meta-analysis found that intraoperative AW is more effective than PW in reducing the incidence of IPH during neuraxial anesthesia (RR=0.71; 95% CI 0.61-0.83; p<0.0001; I2=32%). The qualitative synthesis revealed that IPH continues despite current AW technologies. CONCLUSIONS During neuraxial anesthesia, AW reduces IPH more effectively than PW. Even with AW, IPH persists in some patients. Continued innovation in AW technology and additional comparative effectiveness research studying different AW methods are needed.