Clinical Guidelines – How can we link research and practice

1. Clinical Guidelines – How can we link research and practice Preben Ulrich Pedersen,RN, P.HD. Associate professor Centre for Clinical Guidelines – National Danish Clearinghouse for Nursing

2. Components in High Quality Care • Accessibility • Acceptability • Efficient • Effective • Appropriate (Sidani & Brade, 1998)

3. Evidence-based Practice • Evidence-based practice is an approach that enables clinicians to provide the highest quality of care in meeting the multifaceted needs of their patients and families. Melnyk et al, 2005

4. Obstacles to use research • Number of articles • Difficulties of accessing journals • Skills to determine the quality and validity of research • Read literature in English • Be able to synthesise evidence into explicit recommendation • Have the time to do all this

5. Clinical guidelines • “Systematically developed statements to assist practitioner and patients decisions about appropriate health care for specific clinical circumstances” www.clinicalguidelines.dk

6. Clinical guidelines contribution to quality improvements • Provide knowledge about care options • Outline a course of intervention • Providing indicators for measuring quality and cost Thomson et al, 2002; Pedersen, 2009

7. Develop a clinical guideline • Ask the burning clinical question • Collect the most relevant and best evidence • Critical appraise the evidence – make an résumé of the findings • Make recommendation for clinical practice • Make suggestions to methods for monitoring the quality of care. Melnyk et al., 2005; Pedersen, 2009

8. The burning clinical questions • What is the evidence that contaminated hands are a cause of hospital acquired infections? • Which hand cleaning agents are the most effective at removing/-reducing potential pathogenic bacteria? • When must hands be cleaned in relation to patient care activities? • What is the most effective hand washing/handrubbing technique for removal/reducing microorganisms on hands?

9. Continued… • Which hand cleaning agents are least toxic to hospital staff hands • How can contamination of hands be prevented? • When and how should gloves be used? • What are the prerequisites for performing correct hand hygiene?

10. Collect the best evidence • Develop a search strategy • Search in databases • Search terms • Criteria for in- and exclusion of literature • Validation for literature • Strategy for selections of papers www.clinicalguidelines.dk, Laustsen et al, 2009

11. Search terms • Infection control, cross infection, hand hygiene, hand rub, hand-rubbing, alcohol-based hand-rub , hand wash, handwashing (MESH), non-sterile gloves, hand cream, hand emollient, nails, skin and corresponding Danish searching terms.

12. Collect the best evidence • Develop a search strategy • Search in databases • Search terms • Criteria for in- and exclusion of literature • Validation for literature • Strategy for selections of papers www.clinicalguidelines.dk, Laustsen et al, 2009

13. Resumé of findings • Handwashing: RCTs demonstrated that handwashing is significantly more effective to remove visible dirt on hands than alcohol-based handrubbing. (15;39-41). RCTs documented how handwashing should be performed (39;42). There is inconsistency and lacking evidence on how to dry hands after handwashing. But it seems important to press hands into the single use paper towel instead of rubbing to reduce friction of the skin (32;43). Controlled studies confirm that handwashing always should be followed by alcohol-based handrubbing since handwashing dries out the skin and thus risking contamination and possible colonisation of the skin on hands (44;45). www.clinicalguideline.dk, Laustsen et al, 2009

14. Make recommendation for clinical practice • Indications for hand-washing • - when hands are visibly soiled or at risk of being soiled with blood, secretion, excretions or other biological materials (15;39-41)(A) • Hand-washing should always be followed by alcohol-based hand-rubbing (44;45)(B)

15. Recommendation • Hand-washing technique • wet hands and wrists with water (cold or lukewarm) • apply 1-2 pump pushes of soap (39)(A) • rub mechanically the water and soap palm to palm, around the fingertips and thumbs, around the wrists and on the back of the hands, and between fingers for about 15 seconds. Rinse thoroughly with water (39;42)(A) • hands and wrists should be carefully pressed dry with a single use paper towel (32;43)(D)

16. Monitoring the quality of care Indicators (standards %) • Proportion of performed alcohol-based hand-rubbing before clean procedures (85%) • Proportion of performed alcohol-based hand-rubbing after unclean procedures (85%)

17. Centre for Clinical Guidelines • To insure high quality of developed clinical guidelines – by peer viewing the guidelines before publication • To maintain a data based of all reviewed www.clinicalguidelines.dk

18. High quality of a clinical guidelines • Cclinicians can have the confidence to the recommendations • Peer-review in – and external • Validated instrument (The AGREE-Instrument)

19. Centre ofClinical Guidelines • Bridges the gab between research and clinical practice by providing: • Clinical guidelines based on a critical appraisal of the existing research • Trustworthy clinical guidelines as they are peer reviewed internal and external • Research based indicators for measuring the quality of care.

20. Thank you for your attentionThis presentation and the clinical guidelines can be found at:www.clinicalguidelines.dk