Abstract of the thesis entitled

An evidence-based practice on using alcohol based surgical hand antiseptic

preparation in operation theatre

Submitted by

LEUNG MEI YEE

For the degree of Master of Nursing at the University of Hong Kong

In July 2016

Hand eczema is a common occupational disease due to frequent hand

washing with water and soapy detergent in health care setting. Peri-operative

health care providers who need to perform surgical hand scrubbing may damage

their hand skin due to frequent contact water and soap with the use of povidine

iodine lotion or chlorhexidine gluconate lotion, therefore the peri-operative health

care providers often cite skin irritation and dryness. The irritation or damage of

hands may result of a high risk health care associated infections.

The alcohol surgical hand antiseptic preparation for surgical scrubbing is

not widely used in Hong Kong but it was reviewed by some studies for it’s

characteristics on reducing hand skin irritation. This translational research aims to

evaluate the latest evidence of this scrubbing agent, to develop an evidence-based

guideline in operation theatre and, to make implementation and evaluation plans.

Two electronic databases including Pubmed and Cochrane Library were

used and finally five latest studies meet the inclusion criteria in this dissertation.

All the studies had appraised by the Scottish Intercollegiate Guideline Network

(SIGN). The data were then summarised and extracted to assess the

implementation potential in terms of the transferability, feasibility and cost-benefit

analysis. An evidence-based guideline was then setup and a communication plan

is prepared for gaining consensus with various stakeholders in order to set up

i

working group, prepared equipments and obtaining approval before implementing

the innovation. Besides, a pilot programme and evaluation plan will carry out to

exam the implementation potential of the guideline. The evaluation includes the

hand skin condition and participant’s satisfaction of the programme. The proposed

innovation is expected as worthwhile for adoption in the operation theatre and will

benefit not only the peri-operative health care providers but also the patients.

ii

An evidence-based practice on using alcohol based surgical hand antiseptic

preparation in operation theatre

By

LEUNG MEI YEE

(B. Nurs.)

A thesis submitted in partial fulfilment of the requirements for the Degree of

Master of Nursing

at The University of Hong Kong

July 2016

Declaration

I declare that this thesis represents my own work, except where due

acknowledgment is made, and that it has not been previously included in a thesis,

dissertation or report submitted to this University or to any other institution for a

degree, diploma or other qualifications.

Signed : _________________________

LEUNG MEI YEE

Acknowledgement

Thanks be to God for giving me a great supervisor, Dr Veronica Lam

through the master study in the University of Hong Kong. I would like to express

my deepest gratitude to her for all those discussions that helped me to finish and

enjoy this fruitful study journey. I am heartily thankful to her for her patience,

understanding, guidance and support.

I am grateful to the group mates for the sharing and supports in the class.

I would also like to express my heartfelt gratitude to my family and my

friends from church for their prayers and love. I could not complete this

dissertation without their warm support. Thank you for their encouragement.

Content

Page Abstract i

Declaration iv

Acknowledgement v

Content vi

Chapter 1 : Introduction 1

Background 1

Affirming Needs 3

Significance 6

Objectives 8

Research Question 8

Chapter 2 : Critical Appraisal 9

Search Strategies 9

Search Results 10

Quality Assessment 11

Summary of Data 15

Synthesis of Data 21

Chapter 3 : Implementation Potential and Clinical Guideline 24

Transferability of the Finding 24

Feasibility 27

Cost-Benefit Analysis 30

Evidence-Based Practice Guideline 33

Chapter 4 : Implementation Plan 35

Communication Plan 35

Pilot Programme 38

Evaluation Plan 42

Basis for Implementation 44

Conclusion 46

References 47

vi

Appendix 1 : PRISMA Chart 53

Appendix 2 : Table of Evidence 54

Appendix 3 : SIGN Methodology Checklist 58

Appendix 4 : Visual Scoring of Skin Condition Table 61

Appendix 5: Gantt Chart 62

Appendix 6 : Hand Skin Self-evaluation Form with VSS system 63

Appendix 7 : Budget Plan 64

Appendix 8 : Evidence-Based Practice Guideline 65

Appendix 9 : SIGN: Level of Evidence and Grades of Recommendations 71

Appendix 10 : Satisfaction questionnaire for participants 72

vii

Chapter 1: Introduction

Background

Hands are known as the most important source of micro-organism from

the skin of healthcare staff (Hubner et al., 2011)；the five moments of hand hy-

giene is the key action on preventing health care associated infection (HCAI) (Pit-

tet & Donaldson, 2005).

Operation theatre is one of the areas that required staff to do surgical hand

scrubbing which has been recommended as a measure to reduce infection result-

ing from surgery (Widmer et al., 2010). World Health Organisation (WHO) (2009)

also stated that before each operation, all members of the surgical team who

would contact the sterile surgical field, sterile surgical instruments or the wound

should scrub their hands and arms to the elbows with an antimicrobial scrubbing

agent, though surgical hand scrubbing cannot completely sterilise the skin, it will

decrease the bacterial load and risk of wound contamination from the hands. Fre-

quent hand scrubbing increase the incidence of hand eczema (Van der Meer et al.,

2011).

One of the skin’s functions is as a protective barrier of the body to against

mechanical, thermal and physical injury (Health and Safety Executive, 2014).

When hand skin of nurses have wounds or cuts due to frequent hand washing,

cross infection between nurses and patients can easily happen as loss of skin pro-

tection barrier occurred (Larson et al., 2006).

!1

The currently antimicrobial scrubbing agent for hand scrubbing used in the

operation theatres are the 7.5% povidine iodine and 4% chlorhexidine gluconate

(CHG) lotion. Nurses in operation theatre are required to perform a four minutes

surgical hand scrubbing before each surgical procedures (Centre for Disease Con-

trol and Prevention, 2002) which may increase skin roughness, increasing of

transdermal water loss rate (TEWL) and loss of hand skin hydration in the peri-

operative health care providers after using the hibiscrub scrubbing lotion (Pietsh,

2001)

WHO. (2009) also stated the peri-operative health care providers should

ensure the skin on hands does not become dry and damaged as the bacterial load

is high and the bacteria was difficult to be removed than people with healthy in-

tact skin. Thus, the poor hand skin condition is not only harmful to the nurses

themselves, it may affect the safety of patients. Hence, a literature review is need-

ed for searching a better intervention on reducing the hand skin irritation.

!2

Affirming Needs

There were 71825 elective surgeries performed between year 2014 to the

first quarter of year 2015 in the Hospital Authority’s hospitals excluding the

emergency surgeries (Cheng, 2015). Literatures reported that peri-operative health

care providers performed five to eight times for surgical hand scrubbing in a day

and frequently exposed their hands with irritants such as performed hand hygiene

by hand washing with soap and water (Larson et al., 2006; Pietsch, 2001; Van der

Meer et al., 2011; Widmer, 2013). According to my hospital’s infection control

team’s (ICT) guideline, five moments of hand hygiene should strictly perform be-

fore and after reaching each patient, touching patient’s surrounding such as bed

side rails, before and after commencing a clean or aseptic techniques, after body

fluid exposure risk. In addition, peri-operative health care providers in operation

theatre usually wear gloves to prevent cross infection due to ease of exposure to

deep body fluid when assisting the anaesthesia procedure, putting position of pa-

tient, handling of blood soaked gauze during surgery and removing blood soaked

drapes after surgery, etc. According to ICT’s guideline, washing hands still needed

after removing the gloves. Repetitive hand washing could be easily imagined.

Besides, conventional surgical hand scrubbing with 7.5% povidine iodine

lotion or 4% CHG lotion are currently used in my working unit (operation the-

atres). Both of the above antimicrobial scrubbing lotions were reported as an irri-

tant to hand skin (Van der Meer et al., 2011; Larson et al., 2006; Widmer et al.,

2010). Our colleagues always reported that they have skin irritation, which in-

clude dryness of hand skin, roughness, cracking of hand skin especially at the

!3

edge of fingernails, laceration due to dryness of hand skin are always experience

in reality.

Other reports showed similar findings that peri-operative health care

providers who had excessive exposure of their skin to the irritants or frequent

washing hands, which leads their skin becoming red, dry, rough and experienced

unpleasant sensations such as stinging or burning, etc, was a classic signs of de-

tergent damage and developing occupational hand dermatitis (Widmer, 2013;

Szepietowski & Salomon, 2005). A study of Smith and Nedorost. (2008) also

identified that an estimation of 80% of the health care providers are prone to suf-

fer irritant contact hand dermatitis after exposure to irritants such as soaps or de-

tergents, etc.

Despite the occupational health of the health care providers, literatures had

reported that the damage of health care providers’ hand skins would increase bac-

teria counts on skin and reduce compliance rate to perform hand hygiene due to

wound pain (Visscher, Canning, Said, Wickett & Bondurant, 2006; Widmer et al.,

2010; Wolfennsberger, Durisch, Mertin, Schaeffler & Sax, 2015). The skin prob-

lems were burdening the individual health care provider, the poor skin condition

leads to sick leave or affecting the social life (Van der Meer et al., 2011). In my

working unit, one of the staff is suffering severe dermatitis and long term sick

leave was granted. At least three staff are following up in dermatology depart-

ment. Staff who suffer from hand eczema without receiving medical attention are

countless. Causes by severe dermatitis, one staff transferred to other department.

Involuntary job rotation due to hand skin problems leads our department loss of

!4

well-trained competent nurses as a result of decreasing quality care in operation

theatre.

Alcohol based surgical hand rub was reported as a hand skin tolerable

preparation for peri-operative health care providers to perform surgical hand

scrubbing (Widmer et al., 2010; Kampf & Kramer, 2004; Chamorey et al., 2011).

There was 73% of good skin tolerance and 83% increased skin hydration reported

after used of alcohol based hand rub in the study by Lecheheb, Cunat, Hartmann

and Hautemaniere. (2012). Van der Meer et al. (2011) also reported an increasing

compliance rate on surgical hand scrubbing because of better hand skin condition

after use of surgical alcohol hand rub. Since the above new evidence derived from

the recent studies have not been reviewed and there was no local studies found.

Therefore, the effectiveness on reducing hand skin irritation in operation theatres

by using alcohol based hand antiseptics to perform surgical hand scrubbing was in

best interest to study.

!5

Significance

Surgical hand scrubbing is vulnerable to a peri-operative nurses. Severe

hand skin problems could cause decreasing effectiveness of a nurse to deliver

nursing care. Skin function defence disease with complete skin integrity. Any

breakage of the skin will lost the natural defence function and may cause infec-

tions (Gould, Morale, Drey & Chudleigh, 2010). HCAI is one of the major causes

of mortality and morbidity which would be easily transmitted by patients to health

care providers because of decreasing compliance of hand hygiene or surgical hand

scrubbing due to improper hand scrubbing procedures under poor skin condition

(Allen, 2005). In addition, the use of brush and nail pick with the antimicrobial

scrubbing lotions for surgical hand scrubbing could further damage of hand skin

(Allen, 2005). Furthermore, hand eczema sufferers often experience psychosocial

consequences such as long term sick leave, involuntary job rotation, correlation

negatively to the quality of life according to the severity of the disease (Mollerup,

Veien & Johansen, 2012). Mollerup et al. (2012) also stated that long term sick

leave leads shortage of manpower in daily shifts which will affect the efficiency to

deliver nursing care and loss quality of life will lead the nurse emotional imbal-

ance and may affect the relation among team.

WHO (2009) also recommended to use the alcohol based hand rub rather

than use the conventional antimicrobial soap for performing surgical hand scrub-

bing. Study showed that the alcohol based hand rub resulting the microbial analy-

ses were more effective than the traditional povidine iodine lotion or the CHG

lotion used in surgical hand scrubbing procedures (Lai, Foo, Low & Naidu, 2012).

Reports showed that the alcohol based surgical hand rub could also increase the

!6

hand skin tolerance, reduced dryness of hand skin and reduced irritation of hand

skin in the above mentioned situation (Boyce, Kelliher & Vallande, 2000; Grove ,

Zerwecka, Heilmanb & Pyrekb, 2001; Gupta, Czubatyj, Brisk & Malani, 2007;

Mulberry, Snyder, Hellman, Pyrek & Stahl, 2001; Parienti et al., 2001). As a result

it may improve the compliance rate of surgical hand scrubbing as health care

providers would perform surgical scrubbing procedure properly without hesitation

on worser the hand skin condition by using the conventional antimicrobial soap or

lotion. Moreover, ICT has no recommendations on change of the surgical antimi-

crobial agent related to reduce hand skin irritation while the hand skin problems

became an occupational safety problems in the department, it is essential to con-

duct a literature review in order to plan an effective interventions to minimise the

existing problems and to promote health care providers’ occupational health.

!7

Objectives

The objectives of this study are:

1. To perform literature review (evidence based) on the effectiveness of the al-

cohol based hand rub in reducing irritation on hand skin.

2. To conduct quality appraisal for the selected studies.

3. To summarise and synthesis results from the selected studies.

4. To extract evidence from the selected studies for evaluating the effectiveness

of alcohol based surgical hand rub could reduce hand skin problem.

5. To develop an evidence-based guideline for using the alcohol based hand anti-

septic preparation in operation theatre.

6. To prepare an implementation and evaluation plan for the use of the alcohol

based surgical hand antiseptic preparation.

Research Question

‘Does alcohol based surgical hand rub effective in reducing hand skin

problem?’

PICO Components

According to PICO’s framework, the population (P) refers to the scrub

persons in operation theatre. The intervention (I) refers to the use of alcohol based

surgical hand rub to perform surgical hand scrubbing before operation. The com-

parison (C) refers to the use of currently conventional soapy antiseptic hand lotion

to perform surgical hand scrubbing. The outcome (O) refers to reduce hand skin

irritation after performing surgical hand scrubbing.

!8

Chapter 2: Critical Appraisal

Search Strategies

A systematic literature searching was performed. Two electronic databases

were searched i.e. Pubmed and Cochrane Library. Two groups of keywords were

used for the searching. The first group included ‘hand asepsis’, ‘alcohol based

hand rub’, ’hand antisepsis’, ‘hand sanitisation’ and ‘surgical hand washing’ were

used with conjunction ‘OR’. The other group included ‘eczema’, ‘skin irritation'

and ‘dermatitis’ were used conjunction ‘OR’. Two groups of keywords were used

to search with the conjunction ‘AND’ in Pubmed and Cochrane Library accord-

ingly to extract the relevant articles. Google Scholar Engine was used for search-

ing with the same sets of keywords. Extracted relevant articles were further se-

lected by the use of inclusion and exclusion criteria.

Inclusion Criteria

1. Articles Published from year 2000 to year 2015 were included due to limited

randomised control trail (RCT) research studies within 10 years.

2. Research method design as RCT or cohort study.

3. Full text of articles.

4. Alcohol based hand rub as intervention in the studies.

5. Articles performed in hospital settings especially in operation theatre.

6. Health care providers as the target group.

Exclusion criteria

1. Articles were not written in English and Chinese.

!9

2. Interventions focus on operative wound skin antisepsis but not surgical hand

asepsis related skin problems or operative wound skin problems.

3. Articles comparing surgical hand scrubbing products without alcohol based

hand rub.

Search Results

A total of 7272 articles identified in Pubmed, 843 articles identified in

Cochrane Library when combined searching the key words of ‘hand asepsis’,

‘hand antisepsis’, ‘hand sanitisation’, ‘ alcohol hand rub’ and ‘surgical hand wash-

ing’ with conjunction ‘or’.

A total of 15033 articles identified on Pubmed, 2447 articles identified on

Cochrane Library when combined searching the key words ‘eczema’, ‘skin irrita-

tion' and ‘ dermatitis’ with conjunction ‘or’.

By combining two groups of key words with ‘and’ to search in Pubmed,

98 articles were identified. 44 articles were identified in Cochrane Library data-

base. The same sets of keywords were searched in Google Scholar Engine and 13

articles were found.

101 duplicating articles were removed. Besides, 43 articles were excluded

after screening with title and abstracts. According to the exclusion criteria, six full

text articles were excluded in which three of them were not comparing the alcohol

based hand rub products, one of them recruited non-health workers as target group

and two of them were not studied in hospital background.

A total of five relevant articles were assessed for an eligible review. All

articles were published between year 2000 to year 2015.

!10

A PRISMA flow chart diagram in Appendix 1 was illustrated to show the

workflow on searching and selecting relevant literatures. Data was extracted from

the 5 articles and summarised in a table of evidence which shown in Appendix 2.

Quality Assessment

Five of the identified studies are RCT studies.

Appraisal Strategy

The Methodology Checklist 2 for controlled trails from The Scottish Inter-

collegiate Guideline Network (SIGN) (2015) was use to rate the validity and

overall quality of the five studies. A summarised table of the appraisal results is in

Appendix 3 whereas the following sections will analysis in detail.

Research Question

All selected studies had addressed clear and appropriate research questions

(Boyce et al., 2000; Grove et al., 2001; Gupta et al., 2007; Mulberry et al., 2001;

Parienti et al., 2001).

Four of the studies were comparing the skin conditions after using the al-

cohol based hand rub and conventional hand scrubbing with 4% or 7.5% povidine

iodine lotion or 4% CHG lotion (Boyce et al., 2000; Grove et al., 2001; Gupta et

al., 2007; Parienti et al., 2001).

Three of the studies were comparing the antimicrobial efficacy between

alcohol based hand rub and conventional surgical hand scrubbing with 4% povi-

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dine iodine lotion or 4% CHG lotion (Gupta et al., 2007; Mulberry et al., 2001;

Parienti et al., 2001).

Randomisation Method

Randomisation method had mentioned in five of the RCT studies (Boyce

et al., 2001; Grove et al., 2001; Gupta et al., 2007; Mulberry et al., 2001; Parienti

et al., 2001).

Grove et al. (2001) had arranged randomly assigned subject’s left or right

hand for the intervention solution and the other hand for the control solution for 5

consecutive days.

Gupta et al. (2007) had assigned antimicrobial hand rub or lotion at ran-

dom to one of the study group for 5 consecutive days then switched the solution

for another 5 consecutive days. The randomisation method had not mentioned in

the study.

Randomly assigned antimicrobial hand rub or lotion to each study groups

for 5 consecutive days and 2 weeks were mentioned in the study of Mulberry et al.

(2001) and Boyce et al. (2000).

Boyce et al. (2000) had described in detail to use “roll a dice” for grouping

of participants. Those with odd number will assign to the soap group and those

with even number will assign to the alcohol based group.

Parienti et al. (2002) used a random number table to assign a 2 digit ran-

dom number to participants, for the one who got higher number would assign to

the traditional hand washing preparation group.

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Concealment Method

None of RCT studies had described in detail of the concealment method in

the studied.

Blinding Method

Four out of five studies had mentioned using of blinding method (Boyce et

at.,2000; Mulberry et al., 2001; Parienti et al., 2002; Grove et al., 2001).

Blinding to the research assistant who conducted visual assessment on

participants’ hand skin condition for the type of the antimicrobial lotion or rub

was mentioned in four studies (Boyce et al., 2000; Mulberry et al., 2001; Parienti

et al., 2002; Grove et al., 2001). However, Gupta et al. (2007) had mentioned

blinding was impossible in the studies due to the differences of the solutions’ na-

ture and method of application.

Measurement Tools

All studies clearly stated the outcomes and measurement tools (Boyce et

al., 2001; Grove et al., 2001; Gupta et al., 2007; Mulberry et al., 2001; Parienti et

al., 2001).

Boyce et al. (2000), Grove et al. (2001), Mulberry et al. (2001) and Parien-

ti et al. (2002) used the Visual Scoring of Skin (VSS) (see Appendix 4) which are

commonly used in dermatology, as an assessment tool on dryness of skin by sub-

jects and also by an expert grader for assessing the skin’s dryness, erythema and

roughness status of the subjects. The VSS scoring from 0 to 5 which 0 interpret

normal with no observable scale or irritation, 1 interpret very slightly scaly with

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occasional scale, 2 interpret slightly scaly with scale in sulk and on plateaus, 3

interpret scaly with visible scale with whitish appearance of skin, 4 interpret scaly

to very scaly with more scale and separation of scale edges from skin and 5 inter-

pret very scaly with extensive cracking of skin.

Gupta et al. (2007) measured the outcome by used of a designed question-

naire with grading scale from 1 (strongly disagree) to 5 (strongly agree) for pre-

senting the satisfaction of skin condition by subjects. Both validity or reliability of

the questionnaire were not mentioned in the studies.

A self assessment questionnaire to evaluate the effectiveness of the study

on the skin condition was used to measure the study outcome was mentioned in

the study by Mulberry et al. (2001), no detail of the validity or reliability of the

questionnaire was mentioned.

Besides observation measurement tools, Grove et al. (2001) used a vali-

dated electrical conductance meter and a non-invasive computerised evaporimetry

to measure the hydration status of the skin and the TEWL. Boyce et al. (2000)

used a validated corneometer to assess the dryness of skin by measuring the epi-

dermal water content at the mid-dorsum and the web-space area between the base

of the thumb and forefinger of subject’s dominant hand. Mean of five readings

were taken with both sites.

Dropout Rate

Drop out rate was mentioned in two studies (Gupta et al., 2007 & Boyce et

al., 2000). The range was from 9.3% to 11%. The reason of drop out was due to

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severe adverse reactions. Drop out rate was not mentioned in the studies of Grove

et al. (2001), Mulberry et al. (2001) and Parienti et al. (2002).

Generalisability

One of the five articles is a multiple centre study where study conducted in

six hospitals. Three hospitals were randomly selected to conduct intervention

studies and the other three hospitals conduct control studies at the same time

(Parienti et al. 2002). Four of five articles are single centre studies (Boyce ed al.,

2001; Grove et al., 2001; Gupta et al., 2007; Mulberry et al., 2001).

Summary of Data

Country of Study

Four of the RCT studies were conducted in United States of America

(Boyce et al., 2000; Grove et al., 2001; Gupta et al., 2007; Mulberry et al., 2001).

One of the RCT studies were conducted in France (Parienti et al., 2002).

Study Design

Four of the studies conducted their studies in a crossover setting (Boyce et

al.,2000; Grove et al., 2001; Gupta et al., 2007; Parienti et al., 2002).

One study crossover subjects’ left and right hand by conducting the inter-

vention antimicrobial hand rub on one hand and the control hand washing lotion

on another hand at Phase 1, then switched antimicrobial agent using on the hand

at phase 2 (Grove et al., 2001).

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Three studies mentioned crossover design as participants had randomly

assigned in group intervention or control groups firstly then switched groups after

finished the phase 1 of the trail (Boyce et al., 2000; Gupta et al., 2007 & Parienti

et al., 2002).

Sample Size

The sample size of the five studies ranged from thirty-six participants

(Grove et al., 2001) to seventy-seven participants (Parienti et al., 2002).

Participants Characteristics

Participants in five studies were age 18 to 65 (Boyce et al., 2000; Mulber-

ry et al., 2001; Grove et al., 2001; Gupta et al., 2007; Parienti et al., 2002).

Participants in all studies had mentioned as volunteers of either sex (Boyce

et al., 2000; Mulberry et al., 2001; Grove et al., 2001; Gupta et al.,2007; Parienti

et al., 2002).

All of the five studies had ensured that participants were free from allergy

of the testing products (Boyce et al., 2000; Mulberry et al., 2001; Grove et al.,

2001; Gupta et al., 2007; Parienti et al., 2002).

All of the studies excluded participants who suffered severe hand eczema

or dermatitis and, received systemic or topical antibiotics before study (Boyce et

al., 2000; Mulberry et al., 2001; Grove et al., 2001; Gupta et al., 2007; Parienti et

al., 2002).

Participants who were suffered mild or moderate dermatitis were recruited

in one of five studies (Boyce et al., 2000).

!16

Participants in four studies were working in operation theatre and have

surgical scrubbing experience (Grove et al., 2001; Gupta et al., 2007; Mulberry et

al., 2001; Parienti et al.,2002).

Mulberry et al. (2001) excluded participants who are always expose to

solvents, acids or alkalis and those bathed in chlorinated pools, spas or hot tubs

before the intervention and included participants who were cooperative, willing to

follow instructions.

Participants in five studies were full time nurses or daily working hour

more than thirty hours in order to ensure the studied group were frequent hand

washing health care providers (Mulberry et al., 2001; Grove et al., 2001; Gupta et

al., 2007; Parienti et al., 2002 & Boyce et al., 2000).

Participants in one of the five studies were working in intensive care unit,

cardiothoracic intensive care unit and the step-down unit, a standard ward with

many haematology malignancies where frequent hand washing were needed

(Boyce et al., 2000).

Intervention

Three studies used 3 millilitre (ml) 1% ethyl alcohol with 61% CHG hand

rub (Grove et al., 2001; Gupta et al., 2007; Mulberry et al., 2001), one studies

used 3 ml 62% ethyl alcohol and emollient (Boyce et al., 2000) and the other one

used 3 ml 75% propanol-1, propanol-2 with mecetronium ethylsulfate (Parienti et

al., 2002), for each hand and rubbed till the hands were dried in the intervention

group.

!17

Control

Four studies used conventional 5 ml 4% CHG lotion or 5 ml 4 or 7.5%

povidine iodine lotion for at least three minutes contact time in the control groups

(Grove et al., 2001; Gupta et al., 2007; Mulberry et al., 2001; Parienti et al., 2002)

and one study used soap and water (Boyce et al., 2000).

Methods of Hand Washing or Rubbing

Four studies used surgical hand scrubbing technique in control group and

intervention group (Grove et al., 2001; Gupta et al., 2007; Mulberry et al., 2001;

Parienti et al., 2002).

One study used social hand washing technique and hand hygiene tech-

nique in control group and intervention group (Boyce et al., 2000).

All five studies mentioned that the contact time of both intervention and

control antimicrobial hand rub or lotions were followed the manufacturer’s rec-

ommendations (Boyce et al., 2000; Grove et al., 2001; Gupta et al., 2007; Mulber-

ry et al., 2001; Parienti et al., 2002).

Outcome Measures

All five studies measured the hand skin condition i.e. dryness, intactness,

cracking, irritation, scaling, tactile roughness between intervention and control

groups (Boyce et al., 2000; Grove et al., 2001; Gupta et al., 2007; Mulberry et al.,

2001; Parienti et al.,2002). Moreover, three studies measured subjects’ skin toler-

ance by participants themselves (Boyce et al., 2000; Mulberry et al., 2001; Gupta

et al., 2007).

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One studies measured participants’ comments on the ease for use of the

alcohol preparation, satisfaction of the skin condition after used the alcohol prepa-

ration and preference on selecting the antimicrobial agent between intervention

and control group (Gupta et al., 2007).

One study measured the TEWL which was measuring the rate of water ex-

change through the skin by using an evaporimetry to monitor changes in stratum

corner barrier function (Grove et al., 2001), the larger rate of TEWL obtained was

equivalent to the more dryness of skin. In addition, another study measured the

skin surface hydration by measuring the conduction of current in the stratum

corneum (Grove et al., 2001), the bigger conduction current recorded was equiva-

lent to a better skin hydration condition. While one studies measured the epider-

mal water content through monitoring the electrical capacitance at the mid-dor-

sum and the web-space area between the base of the thumb and forefinger by a

corneometer (Boyce et al., 2001), the bigger capacitance recorded the better skin

hydration condition observed.

Three studies also measured the antimicrobial efficacy of the alcohol

based hand rub by counting the colony forming units on subjects’ hands (Gupta et

al., 2007; Mulberry et al., 2001; Parienti et al., 2002).

Result

All studies showed that the hand skin condition measurement in the alco-

hol hand rub group was significantly less dry, skin intact can be maintained, less

cracking, less irritation, less scaling, less tactile roughness (Boyce et al., 2000;

Grove et al., 2001; Gupta et al.,2007; Mulberry et al., 2001; Parienti et al., 2002).

!19

Alcohol based hand rub was significantly rated as more tolerable on skin

than the povidine iodine, CHG and soapy water by participants (Boyce et al.,

2000; Mulberry et al., 2001; Gupta et al., 2007).

One out of five studies showed that participants rated the alcohol hand rub

was easier to use, they were more satisfied of their skin condition after used and

would prefer to use again whereas negative feedbacks obtained in control group

(Gupta et al., 2007).

For measurement of the TEWL, a greater skin water loss rate in control

group was observed when comparing with intervention group (Grove et al., 2001).

For measurement of the skin surface hydration, a significant improvement in skin

conductance scores with the intervention group was observed when compared

with the control group (Grove et al., 2001).

For measurement of the epidermal water content, electric capacitance de-

ceased significantly in control group but in contrast, the electric capacitance in the

intervention group had shown slightly improvement (Boyce et al., 2001).

Two out of five studies showed the alcohol based hand rub was effective in

removing bacteria flora from the hands of participants and used for hand asepsis

by peri-operative health providers (Gupta et al., 2007; Mulberry et al., 2001).

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Synthesis of Data

By integrating the data from the above five studies, the findings were im-

plied to develop the new guideline through the below three categories.

Target Population

All of the studies were conducted in developing countries i.e. United

States of America and France which the operation theatre setting in the hospital is

similar to my working hospital (Boyce et al., 2000; Grove et al., 2001; Gupta et

al., 2007; Mulberry et al., 2001; Parienti et al.,2002). Participants in all five stud-

ies were age between 18 to 65 (Boyce et al., 2000; Grove et al., 2001; Gupta et al.,

2007; Mulberry et al., 2001; Parienti et al.,2002). Similar inclusion criteria were

mentioned in majority of studies such as participants have surgical scrubbing ex-

perience in operation theatre (Grove et al., 2001; Gupta et al., 2007; Mulberry et

al., 2001; Parienti et al., 2002). All studies also included participants who were

full time or daily working hour more than 30 hours, volunteer of either sex and,

participants who did not suffered severe dermatitis, eczema and received systemic

or topical antibiotics (Boyce et al., 2000; Grove et al., 2001; Gupta et al., 2007;

Mulberry et al., 2001; Parienti et al., 2002).

Similar exclusion criteria were mentioned in all of the studies i.e.

participants who had allergy history to the intervention antimicrobial agent would

be excluded (Boyce et al., 2000; Grove et al., 2001; Gupta et al., 2007; Mulberry

et al., 2001; Parienti et al., 2002).

!21

Intervention

Majority of the studies were conducted in operation theatres (Grove et al.,

2001; Gupta et al., 2007; Mulberry et al., 2001; Parienti et al., 2002).

All of the studies performed surgical hand rub with 3 ml of 1% ethanol

and 61% CHG for each hand and rubbed till the hands were dried (Boyce et al.,

2000; Grove et al.,2001; Gupta et al.,2007; Mulberry et al., 2001; Parienti et al.,

2002). Majority of the studies to perform surgical hand scrubbing in the control

group with 5 ml 4% or 7.5% povidine iodine or 5 ml 4% CHG for at least three

minutes contact time (Grove et al.,2001; Gupta et al.,2007; Mulberry et al., 2001;

Parienti et al., 2002).

Measurement Tool

Majority of the studies used VSS as a self assessment tool by participants

to assess the skin condition such as dryness of skin, cracking of skin or scaling of

skin, etc and showed significant different between intervention group and control

group (Boyce et al., 2000; Grove et al., 2001; Mulberry et al., 2001; Parienti et al.,

2002).

Conclusion

In conclusion, all five of the studies showed that the intervention alcohol

based hand rub could reduce hand irritation such as dryness, skin cracking and

scaling effectively (Boyce et al., 2000; Grove et al., 2001; Gupta et al., 2007;

Mulberry et al., 2001; Parienti et al., 2002). On the contrary, all five of the studies

showed that the control hand washing lotion which is not alcohol based could in-

!22

crease dryness of skin, cracking of skin, roughness of skin or scaling of skin

(Boyce et al., 2000; Grove et al., 2001; Gupta et al., 2007; Mulberry et al., 2001;

Parienti et al., 2002). After extracting evidence from the articles, it is therefore

recommended to use the alcohol based surgical hand rub which is more effective

in reducing hand skin irritations than the currently used surgical antimicrobial

agent as a best practice for peri-operative health care providers when performing

surgical hand scrub in operation theatre.

!23

Chapter 3: Implementation Potential and Clinical Guideline

The literature review in the previous chapter has shown that the use of al-

cohol based hand rub for surgical hand scrubbing can effectively reduce hand irri-

tation such as dryness, skin cracking and scaling. In this chapter, the implementa-

tion potential, the transferability, feasibility and cost-benefit analysis of the inter-

vention will be reviewed.

Transferability of the Finding

Target Setting and Audience

The target setting is the Operation Theatre Service Department (OTS) of a

public hospital in Hong Kong. It is the teaching hospital of a local university and

is governed by the Hospital Authority (HA). It provides scheduled operation ser-

vices and 24-hours emergency operation services. There are 15 theatres available

for operations, two of which are designated for emergency operations. The target

audiences are peri-operative health care providers who perform surgical hand

scrubbing in the operation theatre.

Similarity of Target Setting

The OTS setting of the target hospital in Hong Kong is similar to those in

the majority of the selected studies. Although the studies were conducted in de-

veloped countries, i.e., France and the United States of America (Parienti et al.,

2002; Boyce et al., 2000; Grove et al., 2001; Gupta et al., 2007; Mulberry et al.,

2001) and Hong Kong is a developing region, the OTS settings are similar and

comparable to those countries. In addition, the target setting hosts complex surg-

!24

eries and carries a heavy case load of approximately 600 scheduled operations

monthly, similar to the majority of the selected articles (Grove et al., 2001; Gupta

et al., 2007; Parienti et al., 2002).

Similarity of Target Audiences

Participants in all five selected studies were working full time or for more

than 30 hours per week, which is similar to the target audience who are full time

staff or work 44 hours per week (Boyce et al., 2000; Grove et al., 2001; Gupta et

al., 2007; Mulberry et al., 2001; Parienti et al., 2002). The peri-operative health

care providers in the proposed target are aged between 18 to 60 which is similar to

the participant ages of 18 to 65 for all 5 selected studies (Boyce et al., 2000;

Grove et al., 2001; Gupta et al., 2007; Mulberry et al., 2001; Parienti et al., 2002).

The majority of the participants in the reviewed studies were peri-operative health

care providers with surgical hand scrubbing experiences, which is similar to the

proposed target audiences, which include peri-operative nurses and scrubbed

technicians (Grove et al., 2001; Gupta et al., 2007; Mulberry et al., 2001; Parienti

et al., 2002).

Target Population

A total of 125 nurses and 10 scrub technicians work in the department as

of February 2016. Peri-operative health care providers perform approximately 3 to

8 surgical hand scrubbing for scheduled operations every day along with countless

hand washes after the hands are visibly soiled. All 135 peri-operative health care

providers can benefit from the proposed innovation.

!25

Philosophy of Care

The aim of the proposed innovation is to minimise the hand skin irritation

of OTS health care providers. The mission of the HA is “Healthy people, happy

staff, trusted by community” (Hospital Authority, 1991). The HA also focuses on

the employees, ensuring their occupational safety and remain motivated at work.

Moreover, Two of the missions of my working hospital are facilitating research in

healthcare and providing an appropriate environment, staff and facilities for the

education, training and development of nurses, allied health workers, medical and

dental undergraduates and post-graduates (Queen Mary Hospital, 1941). Further-

more, occupation safety and health (OSH) is one of the important focuses in OTS,

and any intervention that can reverse the existing problems should be pursued.

The proposed innovation can be one of the measures to uphold all the

missions and visions mentioned above. It can promote better patient care through

staff members reduce hesitation to perform surgical hand scrubbing due to less

experience of skin wound pain from the antimicrobial scrubbing agent. In addi-

tion, building rapport between management and the frontline staff can be en-

hanced as management personnel seek to address the employees’ needs.

Duration of implementation and Evaluation

With reference to the five selected studies, the proposed innovation will

take about 26 weeks to implement (Boyce et al., 2000; Grove et al., 2001; Gupta

et al., 2007; Mulberry et al., 2001; Parienti et al., 2002). The innovation will be

divided into 3 phases: the preparation phase, the implementation phase and the

evaluation phase. A working group will be organised after the proposed innova-

!26

tion obtaining approval from DOM and WMs. The working group will led by an

advanced practice nurse (APN) and four registered nurses (RN) as group mem-

bers.

The preparation phase includes obtaining consensus from different stake-

holders, gaining approval from department heads and obtaining the related con-

sumables for the implementation within 8 weeks. This will be followed by promo-

tion of the innovation and staff training for the following 4 weeks. A one month

pilot programme will then commence, and will then be evaluated in the following

week. The implementation of the innovation will last for 4 weeks and the evalua-

tion period will takes another 4 weeks. The timeline is illustrated in Appendix 5.

Feasibility

Freedom to Carry Out or Terminate the Intervention

With previous success projects such as the change of patient transportation

mode to OTS and EBP on instruments steam sterilisation method, nurses are

proved to have freedom and are ready to carry out new innovation which can ben-

efit to patients or staff. Peri-operative nurses form the majority of the peri-opera-

tive health care team, and they perform frequent daily surgical hand scrubbing in

the OTS; thus, poor hand skin status occurs more often among peri-operative

nurses. The proposed project is an evidence-based practice to minimise the hand

skin irritation. With the support of management, nurses will have the freedom to

carry out or terminate the intervention if undesirable outcomes are observed.

!27

Organisational Climate, Management Support and Consensus Among Staffs

As mentioned previously, the proposed target setting is the teaching hospi-

tal of a local university, which currently facilitating research in health care. The

use of evidence-based practices in the clinical area is strongly recommended by

Department Operation Manager (DOM) and Ward Managers (WM) to improve

the quality of patient care and staff performance. The DOM and WM usually sup-

port the evidence-based innovation e.g. they have previously approved the wall

painting in operation theatre suite to relieve anxiety in paediatric patients and in-

troducing iPads for internal training.

The proposed project will have minimal interference with current peri-op-

erative nursing care. The procedures for surgical hand scrubbing are similar to

hand hygiene procedures, and do not lengthen the scrubbing time or delay prepa-

ration of sterile instruments. The participants will only be required to complete a

hand skin condition self-assessment form before and at the completion of the in-

tervention period. Thus, consensus among management and staff are easier to ob-

tain.

Although the innovation should be supported by the department, it is im-

portant to obtain consensus among the administrators and staff to understand the

need to change the antimicrobial scrubbing agent for surgical hand scrubbing. The

use of 4% CHG and 7.5% povidine iodine antimicrobial scrubbing agent with

running water is the current practice performed in surgical hand scrubbing at OTS

in Hong Kong. The peri-operative health care providers are well accustomed to

the conventional preparation and may reluctant to change. They may have also

!28

misunderstood the proposed innovation, believing that it can further damage the

hand skin compared to the currently preparation.

Resistance to the Innovation

Although the proposed innovation is focused on reducing hand irritation

after the surgical hand scrubbing, the efficacy of the bactericidal effect in the se-

lected hand preparation product is an essential consideration, as the purpose of

surgical hand scrubbing is to decrease the bacterial load on hands and thus de-

crease the risk of surgical site infection (SSI). This is a recommended standard of

practice by WHO (2009). Thus, obtaining the support and cooperations of the in-

fection control team (ICT) for the use of the selected product will be a top priority.

In addition, potential challenges by surgeons will be anticipated since they will

have the same consideration as ICT on SSI issue.

Skills Needed to Implement the Innovation Among Nursing Staff

The surgical hand scrubbing technique of the innovation is similar to the

hand hygiene and for conventional surgical hand scrubbing. There are some points

of difference to be noted between conventional products and the proposed prod-

uct, such as allowing the alcohol preparation to dry before donning gloves without

wiping the hands with towels, or reapplying the alcohol based preparation to all

surfaces of both hands up to the wrists instead of applying the product up to the

elbows as conventionally done. Potential difficulties in implementing the inter-

vention may include the need to clarify the steps to all peri-operative nurses

through a training session. Along with the difficulty of arranging training sessions

!29

during tightly scheduled and busy office hours, staff might be reluctant to use

their own time to attend the training. But these problems will be easily solved af-

ter gaining supports from management level.

Availability of the Intervention Equipment

The suggested alcohol based preparation is not currently available in the

hospital. After obtaining the support of the department management and ICT, as-

sistance with purchasing the required alcohol based preparation could be obtained

from ICT.

Availability of evaluation measuring tools

A free of charge VSS (Boyce et al., 2000) will be adopted as the measure-

ment tool for evaluating skin condition in terms of itching, dryness, burning or

stinging, skin tightness, and bleeding, using a scoring system of 0 to 3, where 0

means symptom not present and 3 indicates extreme presence of symptom, see

Appendix 6. Participants will conduct the self-evaluation using the VSS before

and after the intervention.

Cost-Benefit Analysis

Potential Risks to Participants during the Implementation of the Innovation

The risk of participant is very minimal. Although 2 of the selected studies

reported a drop out rate of 9.3% and 11% as participants developed adverse reac-

tions such as skin rash, burning sensation on their hands, metallic taste in their

!30

mouth and palpitations (Gupta et al., 2001 & Boyce et al., 2000). The condition of

the hand skin irritation could also even worse if remain using the current antimi-

crobial scrubbing agent, which in turn, would increase chances to establish HCAI

between patients and OTS health care providers.

Potential Benefits of the Implementation of the Innovation

Based on the findings from the 5 selected studies, the new innovation is

expected to benefit both patients and peri-operative health care providers (Boyce

et al., 2000; Grove et al., 2001; Gupta et al., 2007; Mulberry et al., 2001; Parienti

et al., 2002). Healthy hand skin conditions can reduce bacterial loading on the

skin. Thus a thorough elimination of bacteria through surgical hand scrubbing can

be achieved and health care providers can perform proper surgical hand scrubbing

without fear of pain from loss of hand skin integrity. The result is reduced cross

infection of HCAI and SSI. In addition, reducing the sick leave of staff due to un-

pleasant hand skin irritation will benefit the department by helping ensure ade-

quate manpower on each shift, so as to maintain the quality of peri-operative care.

The Risk of Maintaining Current Practices

In contrast, with the current practice of using 4% CHG and 7.5% povidine

iodine for hand scrubbing, hand skin irritation is still occurring for peri-operative

health care providers. Poor hand skin condition increases the chance of HCAI

cross infection and affects the health of both the peri-operative health providers

and their patients. Moreover, the altered social life of sufferers and involuntary

internal transfers to other departments will continue to happen if the problems

!31

continue (Van der Meer et al., 2011). As a consequences, the loss of trained, com-

petent staff will lead to a decrease in the quality of nursing care.

Material Costs of Implementing the Innovation

The material cost includes antiseptic lotion, the lotion dispenser, poster,

assessment forms, and manpower costs. The material cost include mainly the

charges for manpower. Since the innovation will not interfere the function of staff

so that extra time was not necessary to be included in the cost, but the cost of time

of the training session will be included. The total material cost of a 30 minutes

training for 125 nurses is $12125 ,which the average hourly paid is $194. The de-

tails of the budget plan are shown in Appendix 7.

Material Costs of Not Implementing the Innovation

500 ml povidine iodine and 500 ml CHG gluconate antiseptics provide 33

scrubs with 15 ml of the lotion used for every surgical scrubbing. At a cost of

$184 and $79 per bottle, respectively, this translates to costs of $5.6 and $2.4 per

surgical hand scrub. In addition, approximately 10 litres (L) of tap water are used

for every surgical scrubbing, which costs $1. The towels used for drying hands are

free, as they are packed along with the gowns. Thus, the total cost of conventional

scrubbing is $6.6 and $3.4 for povidine iodine and CHG gluconate, respectively.

On the other hand, the cost for each scrubbing with the use of alcohol based anti-

septics is $5.9 without the use of towels or tap water. 9 ml of the alcohol based

antiseptics will be used from a 1.2 L preparation for every surgical scrubbing.

From the above calculation, the cost of the alcohol based hand rub is lower than

!32

the povidine iodine antimicrobial scrubbing agent. Thus, the innovation can effec-

tively lower the cost of the scrubbing. In addition, as mentioned above, paid sick

leave day can be reduced by maintaining the healthy hand skin conditions.

Nonmaterial Costs and Benefits of Implementing the Innovation

The nonmaterial cost include mainly the staff morale.

Staff morale is associated with a desirable working environment. The oc-

cupational disease of hand irritation leads to involuntary internal transfers of peri-

operative health care providers, as mentioned before. Decreased compliance rates

for surgical scrubbing procedures and hand hygiene has occurred due to the poor

skin conditions.

The proposed innovation of using of alcohol based antiseptics was found

in all of the selected studies to not only reduce hand skin irritation but also im-

prove skin conditions such as the moisture of the skin (Boyce et al., 2000; Grove

et al., 2001; Gupta et al., 2007; Mulberry et al., 2001; Parienti et al., 2002). It was

well accepted by the participants when compared with the conventional antisep-

tics, which improved staff morale. It can also enhance evidence-based practice in

the clinical area, as research with the peri-operative nurses will be conducted.

Evidence-Based Practice Guideline

This guideline is developed based on the 5 selected evidence-based studies

selected from Chapter 2. The evidence suggests that using an alcohol based hand

rub can effectively reduce hand skin irritation such as dryness, skin cracking and

scaling after performing surgical hand scrubbing procedures. An evidenced-based

!33

guideline for the use of the alcohol based antimicrobial scrubbing agent for opera-

tion theatre staff will be developed.

The following recommendations were synthesised by the SIGN. Accord-

ing to SIGN, the levels of evidence are classified from 1 (the highest level) to 4

(the lowest level). The symbols of “++,” “ +,” and “-” represent the quality of ar-

ticles, with very low, low and high risk of bias , respectively, after assessing the

methodological design of the studies. Grading scores of “A,” “B,” “C,” and “D”

are used to indicate the most highly recommended practice, where “A” is the

highest grade and “D” is the lowest grade for recommendation. The details of the

recommendations and the details of the SIGN grading system are attached in Ap-

pendix 8 and Appendix 9.

!34

Chapter 4: Implementation Plan

After creating the evidence based practice (EBP) guideline on using alco-

hol based hand antiseptic preparation in operation theatre, developing a communi-

cation plan is essential in order to make the guideline’s implementation success-

ful. The communication plan includes the identification of stakeholders, the com-

munication process with the identified stakeholders, and the development of the

pilot programme and evaluation plans before the proposed guideline may be put

into practice.

Communication Plan

Identification of Stakeholders

The first step in making the implementation successful is to engage stake-

holders because they can provide a better understanding of the department’s cul-

ture, expectations and perspectives and engenders buy-in throughout the innova-

tion process (Burke & Levin, 2010). In my proposal, three levels of potential

stakeholders are identified, including the administrative level, the management

level and the users of the intervention.

The administrative level of the stakeholders in operation theatre includes

the DOM and WMs. These are key persons who are responsible for changing

policies, granting approvals and acting as the project resource personnel. More-

over, they are also act as the communication channels who can establish cross-de-

partmental contact that may smooth the communication process so that to increase

the successful rate of the implementation. In addition, they are the key person to

!35

allocate human and material resources that can facilitate the setup of the working

group and purchase the alcohol based hand antiseptic lotions and dispensers for

the implementation. The proposed implementation of the guideline will address

post-operative SSI among surgery patients, thus, the in charge of the ICT would

be included as an administrative level stakeholder and she will be consulted for

granting the approval of the implementation.

The management level of the stakeholders includes Advanced Practice

Nurses (APN), who are responsible for managing all EBP guidelines and monitor-

ing its compliance in the operation theatre. They are a group of experienced front

line staff members who have experience in conducting different EBPs in the de-

partment; thus, they should be included in the implementation of the proposed

guideline. They will serve as the resource persons who can provide instructions or

answer enquiries on the scrubbing techniques with the use of the alcohol based

hand antiseptic preparation.

The users of the intervention include all of the scrubbing nurses or techni-

cians who work in operation theatres. They are the majority of operation theatre

staff members who perform surgical hand antisepsis frequently. Therefore, they

are the key users in this new innovation.

Communication Process

The power of an effective communication can influence a wider environ-

ment by informing and changing attitudes in the various target groups (Suzanne &

Ann-Elisabeth, 2011). Effective communication among stakeholders should be

established to gain their support and understanding for a smooth implementation.

!36

Communicating with the Stakeholders

The administrative level stakeholders (i.e., the DOM and WM) in the OTS

will firstly be contacted to obtain approval and provide funding for the interven-

tion. A presentation that includes the background, the objective and the affirming

need of the proposed intervention and the EBP guideline of the alcohol based

hand antiseptic preparation, budget plans and its potential benefits will be pre-

pared and clearly explained in DOM and WM meeting. Then, with their help to

discuss the innovation to the in charge ICT and obtain their approval in adopting

the innovation. Furthermore, their feedback and comments of the EBP guideline

will be collected and made amendments accordingly.

Setting Up a Working Group

After obtaining the approval from the administrative level of stakeholders,

a working group will establish an approach for preparing, planning and launching

the proposed project. This group will include one APN who should have more

than 3 years of APN experience in the operation theatre and four registered nurses

(RN) who are required to have more than 3 years of operation theatre experience

and obtained the Post Registration Certificate Course (PRCC) in peri-operative

nursing.

Communicating with the Staff Members

The working group will introduce the guideline to management level of

the department (i.e., APNs) in the monthly APN meeting by using the powerpoint

presentation, in order to obtain their consensus and acquire their assistance in

!37

promoting the intervention. The details of the project, such as its implementation

plan and the detailed proposed timeline, will be also presented to them.

After obtaining the approval from the management level, a two weeks

promotion of the intervention will be launched through each weekday staff stand-

ing handover to gain attention from the users. During the promotion period, the

working group will collect users comments during their lunch break and the daily

handover meeting so that a better preparation of the training workshops and pilot

programme can be plan. Then, the working group will conduct training workshops

to present the guideline and to ensure users’ understanding of the proposed guide-

line. After the workshop, a pilot programme will then take place in the following

month. The working group will also identify any users who are allergic to the pro-

posed antiseptic preparation and will not recruit in the innovation.

In the scrub room, the working group will also put up posters that depict

the alcohol based preparation scrubbing technique and place the training informa-

tion onto iPads for users to revise at any time. The group will distribute any up-

dates and reminders through internal email.

Pilot Programme

After obtaining approval from the DOM, WMs and ICT and establishing a

working group, a pilot programme will be conducted. A pilot programme permits

the preliminary testing of the proposed intervention that leads to a refined inter-

vention afterward. It also permits a thorough check of the planned implementation

!38

procedures, which gives a chance to evaluate and alter the workflow of the im-

plementation and avoids unexpected difficulties when launching the project.

Preparation Before the Pilot Programme

The working group, which will be led by the APN, will purchase the alco-

hol based antiseptic preparations in a month after the administrative stakeholders

grant approval. The group will also obtain consensus with other APNs through a

guideline introduction meeting in weekdays. Then, the group will promote the in-

tervention by making and posting the scrubbing technique posters, loading infor-

mation about the scrubbing procedures onto iPads and preparing a workshop with-

in the next 3 weeks. The training workshops will be conducted once a day at the

afternoon in different theatres over the course of the following week to eliminate

the chances of users missing training session due to sick leave, day off or annual

leave.

Time Frame

The pilot programme will take place in a 4-week period. It will be

launched after all of the scrubbing nurses and technicians have attended the brief-

ing workshop. Gantt chart was illustrated in Appendix 5.

Participants

The criteria for recruiting eligible participants for the pilot programme are

based on the inclusion and exclusion criteria as following.

!39

The inclusion criteria for participants are aged 18 to 60, full time working

in OTS and have at least 3 months surgical hand antisepsis experience nurses or

scrubbing technicians. The exclusion criteria for participants are having allergic

history on the alcohol based antiseptic preparation. All scrubbing nurses and tech-

nicians who meet the inclusion criteria will be recruited in the pilot programme. It

will be launched in 2 of the 15 theatres in my working hospital.

Sample Size for Pilot Study

A total of 125 nurses and 10 scrub technicians work in 15 theatres which

located in 6 different floors within the department. One of the floors which have 2

theatres will be selected where approximately more than 150 operations have been

done every months. Thus, frequent hand scrubbing by health care providers in this

selected floor will be assumed. By dividing the total of 135 health care providers

in 15 theatres, there will be 9 health care providers in each theatre. Eighteen

health care providers, including scrubbing nurses and scrubbing technicians, will

be predicted to be recruited in the one month pilot programme.

In the first three weeks of the pilot programme, the working group will

support and facilitate the recruited participants’ knowledge of the new scrubbing

technique by promoting using iPads and scrub room posters as scrubbing tech-

nique reminder. One of the working group members will also be assigned to work

in those pilot theatres to provide immediate guidance or answers enquires of the

innovation.

!40

Evaluation of the Pilot Programme

A self-evaluated VSS evaluation form (Appendix 6) regarding the hand

skin will be distributed at the end of the fourth week. A satisfaction questionnaire

(Appendix 10) to solicit participants’ comments and opinions towards the alcohol

based antiseptic intervention will also be provided in order to measure the satis-

faction level from participants regarding the launch of the intervention, the clarity

and precision of the guidelines, the ease of implementing the project and any

comments about the intervention. The analysis of both the hand skin evaluation

and questionnaires will be done at the fifth week of the pilot programme. After

analysing the participants’ completed questionnaires, a meeting will be arranged

for the participants to resolve the concerns regarding the proposed intervention.

The meeting will be focused on the bactericidal effectiveness of the alcohol-based

hand preparation, as well as the advantages of using it in comparison to the cur-

rent soapy antiseptic formulation, in order to reduce the resistance to commence

the proposed innovation. Furthermore, necessary refining of the implementation

plan will be made according to the results of the analysis and discussion in the

working group in the following week. The discussion will include the logistics of

the intervention, the clarity of the guideline and the interference with the current

workflow that the protocol may cause.

!41

Evaluation Plan

Evaluation is the final process of the intervention plan and it determines

the success of the suggested protocol.

Outcome Evaluation

With reference to the selected studies (Boyce et al., 2000; Grove et al.,

2001; Gupta et al., 2007; Mulberry et al., 2001; Parienti et al., 2002), the reduc-

tion of hand skin irritation will be the primary outcome of the intervention and it

is a significant representation of the effectiveness of the proposed protocol. The

participants are invited to evaluate the condition of their hand skin at the end of

the intervention period. The signs and symptoms of hand skin irritation include

cracking, dryness, itching, burning or stinging, tightness or bleeding. This hand

skin evaluation will be performed by the participants according to the 4-point VSS

system, which ranges from 0, which indicates no symptoms, to 3, which indicates

severe symptoms (Appendix 6).

The second outcome is to measure the participants’ level of satisfaction

towards the project. The participants will be asked to complete a satisfaction ques-

tionnaire (Appendix 10) in order to assess the acceptance of the proposed inter-

vention. The questionnaire includes 10 questions with a 5-point Likert scale,

whereas the total score ranges from 10 to 50. A score of 1 indicates strong dis-

agreement, while a score of 5 indicates strong agreement. The questionnaire will

also invite participants to provide detailed comments.

!42

Sample Size for Full-scale Implementation

The group of participants who are eligible for the evaluation plan is identi-

cal to the target population, which is based on the previously reviewed studies

(Boyce et al., 2000; Grove et al., 2001; Gupta et al., 2007; Mulberry et al., 2001;

Parienti et al., 2002). A one-sample t test will be used to estimate the sample size

with the use of G*Power (Heinrich Heine University Dusseldorf, 2014) sample

size calculator, as the analysed data will be retrieved from the same single group

within the sample. By taking the effect size of 0.2 from Boyce et al. (2000) which

this study had a higher evidence level than other reviewed studies and considering

a 5% level of significance with the power of 80% and selecting the sigma of 5, the

sample size is 51. Furthermore, the reported dropout rate in the reviewed studies

ranged from 9.3% to 11% (Gupta et al., 2007 & Boyce et al., 2000), so the 15%

dropout rate will be used as a protective measure; thus, the sample size will be

around 120 nurses and technician within the department.

Data Analysis

All of the collected data will be verified and reviewed by the research

group prior to data analysis. The Statistical Package for Social Science (SPSS)

version 22 will be utilised to analyse the data. A one-sample t test will be used to

measure the mean score of the participants’ hand skin condition. Moreover, the

participants’ satisfaction questionnaire will be analysed as a mean score and esti-

mated by the one-sample t test. Prior to qualitative data analysis, the working

members will code, transcribe and categorise the comments into themes.

!43

Timelines of the Evaluation Plan

The full scale project will be implemented after the pilot programme. The

intervention will last for 4 weeks. The hand skin evaluation form will be sent to

the participants on the first day and at the end of the project, as well as during the

pilot programme phase, for their self evaluation. The participants’ satisfaction

questionnaire will also be sent to the end of project in order to determine the pos-

sibilities of adopting the guideline in the operation theatre after full implementa-

tion of the project. A gantt chart is illustrated in Appendix 4.

Basis for Implementation

The main objective of this project is to reduce hand irritation by using an

alcohol based hand antiseptic in operation theatres. The intervention will be

adopted in future if the project can effectively achieve its objective.

With reference of the reviewed studies (Boyce et al., 2000; Grove et al.,

2001; Gupta et al., 2007; Mulberry et al., 2001; Parienti et al., 2002), the VSS re-

sult after use of alcohol based antiseptics was found not only to reduce hand skin

irritation, but also to improve skin conditions, such as a lack of the moisture. The

effectiveness of the project can be assessed by determining the VSS mean score

after using the alcohol based hand antiseptic. The mean score of VSS in the re-

viewed studies is 5 after the intervention. Therefore, the guideline will be regard-

ed as effective when the mean VSS score, after implementation, is lower than or

equal to 5.

!44

The acceptance of the intervention is also significant when deciding the

effectiveness of the intervention. The project will be considered to be effective if

the mean score of the participants’ satisfaction questionnaire is 35 or above out of

the total of 50 based on previous evidence-based protocols in the department.

These high levels of satisfaction indicate that the participants in operation theatre

accept the project.

!45

Conclusion

Surgical hand scrubbing is a cornerstone of an aseptic technique of the

surgery which to eliminate micro-organisms and reduce skin flora to prevent post

operative SSI. Traditional surgical hand scrubbing consists of using brush or

without brush, using povidine iodine or CHG lotion which could led hand skin

problems. The health care providers who work in OTS are repetitive exposure to

povidine iodine and CHG which the poor condition of hand skin are affecting

both physical and psychological aspect of the staff. After reviewing five studies,

the alcohol based surgical hand antiseptic preparation demonstrated a positive ef-

fect in reduction of hand skin irritation. It should be as a viable alternative to tra-

ditional povidine iodine and CHG antiseptic preparation in the department.

!46

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!52

Records identified on

Pubmed &

Cochrane Library

(n=142)

Screening

Included

Eligibility

Identification Additional records identified

through Google Scholar engine

(n= 13)

Records after duplicates removed(n =54)

Records screened with title

and abstracts(n =11)

Records excluded (n =43)

Full-text articles assessed

for eligibility(n = 5)

Full-text articles ex-

cluded, with reasons (n =6)

Studies included in

qualitative synthesis (n = 5)

Appendix 1 - PRISMA Chart

53

Appendix 2 - Table of evidence

Citation Study design/ level of evidence

Sample Characteristics Intervention(s) Control Length of follow up

Outcome Effect Size (Intervention - Control)

Boyce et al., 2000

RCT / 2++ 1. Nurses in ICU 2. Full time or >=30

working hours/week 3. Age 18-65 4. Volunteer of either sex 5. Free of allergy from

testing products 6. Hands are free from

severe dermatitis, eczema or receiving systematic or topical antibiotics

7. Hands have mild to moderate dermatitis

3 ml #Alcohol hand gel hand disinfection on each hand

(n=32)

Soap and water hand washing

(n=32)

2 weeks 1. VSS assessment on hand skin

2. Measuring epidermal water content of dorsal surface

1. Intervention group:0.2 (P=0.05); Control group 1.03(P 0.05)

2. Intervention group 0.37( P=0.0003)

Grove et al., 2001

Randomised blinded trail / 2++

1. Scrubbed technician in OTS

2. Full time or >=30 working hours/week

3. Age 18-65 4. Volunteer of either sex 5. Have surgical

scrubbing experience 6. Free of allergy from

testing products 7. Hands are free from

severe dermatitis, eczema or receiving systematic or topical antibiotics

One hand and forearm use of 3 ml ABWL

(n=18)

The other hand and forearm use 5 ml of 4 % CHG; applied product for 3 minutes with sponge side of a scrub brush

(n=18)

5 days 1. VSS rating scoring 0-3

2. Expert grader assessment with VSS: Erythema, dryness and scaling, tactile roughness

3. HSA 4. TEWL

measurement by computerised evaporimetry

At day 5: 1. -1.4 (P=0.0002) 2. -0.6 (P=0.0039) 3. -1.1 (P=0.0023) 4. -0.9 (P=0.1971)

�54

Gupta et al., 2007

RCT / 1+ 1. Surgical staff in general procedure operation suite

2. Full time or >=30 working hours/week

3. Age 18-65 4. Volunteer of either sex 5. In service before study

start 6. Free of allergy from

testing products 7. Hands are free from

severe dermatitis, eczema or receiving systematic or topical antibiotics

1. Participants assigned at random to one of two group (group 1 and group 2)

2. Using the assigned products in the group for 5 consecutive days

3. Rotating to another group for next week till participants used all products in the study

Group 1: Three 2 ml application of ABWL on two hands (n=36)

Group 2: Brush application of 5 ml 7.5% povidine iodine aqueous scrub

(n=36)

2 weeks Microbial analysis by using “glove juice” method Immediately prior scrubbing, after scrubbing and 6 hours later 1. On day 1 2. On day 2 3. On day 5

Anonymous questionnaire: Graded scale from 1(strongly disagree) to 5 (strongly agree) 1. Satisfaction of

skin condition of intervention lotion compare to control lotion

2. Ease to use of intervention lotion compare to control lotion

Microbial analysis 1. -0.9 (P=0.03) 2. 0.7(P=0.02) 3. 0.7(P=0.01)

Anonymous questionnaire 1. 2.3 (P<0.001) 2. 2.4 (P<0.001)

�55

Mulberry et al., 2001

RCT / 1+ 1. Nurses or scrubbed technician in OTS

2. Full time or >=30 working hours/week

3. Age 18-65 4. Volunteer of either sex 5. Have surgical

scrubbing experience 6. Free of allergy from

testing products 7. Hands are free from

severe dermatitis, eczema or receiving systematic or topical antibiotics

1. Use 3 ml of AWBL on each hand

2. 11 simulated surgical hand rub for 5 days: 1 time for day 1,5; 3 times for day 2/3/4

(n=27)

1. Use 10 ml of 4% CHG surgical scrub on both hands

2. 11 simulated hand scrub for 5 days: 1 time for day 1,5; 3 times for day 2,3,4

(n=25)

5 days Bacteria log reduction assessed by CFU on the used gloves: 1. 6 hours on Day

1 2. 6 hours on Day

2 3. 6 hours on Day

3

VSS Skin condition assessed by self assessment questionnaire at day 4

Bacteria CFU counting: 1. -0.3 (P= 0.0095) 2. -1 (P=0.0003) 3. -0.3 (P=0.2236)

Skin condition comment: ABWL have less drying of skin, better appearance, intactness, moisture content and sensation scores

�56

ASS=Aqueous alcoholic solution which contain 75% propanol-1, propanol-2 with mecetronium ethylsulfate ABWL=Alcohol based waterless which contain 1% chlorhexidine glugonate and 61% ethyl alcohol CHG= Chorhexidine gluconate CFU= Colony forming unit HSA=Hand skin assessment ICU= Intensive care unit OTS=Operation theatre service TEWL= Transepidermal water loss RCT=Randomised control trail VSS=Visual scoring of skin #=Alcohol hand gel contain 62% ethyl alcohol and emollients *= Outcome measure after one crossover which included one month intervention period and one month control period

Parenti et al., 2002

Randomised controlled equivalence trail / 1-

1. Staff members in OTS 2. Full time or >=30

working hours/week 3. Age 18-65 4. Volunteer of either sex 5. Have surgical

scrubbing experience 6. Free of allergy from

testing products 7. Hands are free from

severe dermatitis, eczema or receiving systematic or topical antibiotics

Hand rubbing with 3 ml liquid ASS till hands dry

crossover design:

- 3 centres randomly assigned in the group for one month

- Provide only intervention group hand rub in the setting

- Switch group at the end of each month

- For 16 months

(n=34)

Traditional hand scrubbing:

Five minutes scrub using 5ml of either 4% povidine iodine or 4% chlorhexidine gluconate

crossover design: -3 centres randomly assigned in the group for one month -Provide only control group scrubbing lotion in the setting - Switch group at

the end of each month

- For 16 months

(n=33)

*2 months VSS 1. Skin dryness 2. Skin irritation

After first crossover

ASS group: 1. Skin dryness

decreased by 0.9 cm (95% C.I./ P=0.046)

2. Skin irritation decreased by 1.5 cm (95% C.I./ P=0.03)

Traditional group: 1. Skin dryness

increased by 0.4 cm (95% C.I.)

2. Skin irritation increased by 0.4 cm (95% C.I.)

�57

Appendix 3 - SIGN Methodology checklist

Control Trail Boyce et al. (2000)

Grove et al.(2001)

Gupta et al.(2007)

Mulberry et al. (2001)

Parienti et a,. (2002)

1.1 The study addresses an appropriate and clearly focused question Yes Yes Yes Yes Yes

1.2 The assignment of subjects to treatment groups is randomised Yes Can’t say Can’t say Yes Yes

1.3 An adequate concealment method is used No No No No No

1.4 The design keeps subjects and investigators ‘blind’ about treatment allocation

Yes Yes No Yes Yes

1.5 The treatment and control groups are similar at the start of the trail Yes Yes Yes Yes Yes

1.6 The only difference between groups is the treatment under investigation Yes Yes Yes Yes Yes

1.7 All relevant outcomes are measured in a standard, valid and reliable way Yes Yes Yes Yes Yes

1.8 What percentage of the individuals or clusters recruited into each treatment arm of the study dropped out before the study was completed?

11% Not mention 9.3% Not mention Not mention

1.9 All the subjects are analysed in the groups to which they were randomly allocated (often referred to as intention to treat analysis)

Not applicable Not applicable Not applicable Not applicable Not applicable

1.10 Where the study is carried out at more than one site, result are comparable for all sites

Not applicable Not applicable Not applicable Not applicable Yes

58

2.1 How well was the study done to minimise bias? Acceptable Acceptable Acceptable Acceptable Low quality

2.2 Taking into account clinical considerations, your evaluation of the methodology used and the statistical power of the study, are you certain that the overall effect is due to the study intervention?

Yes. Study background are in good clinical setting. Statistic method mention

Yes. Study background are in good clinical setting. Statistic method mention

Yes. Study background are in good clinical setting. Statistic method mention

Yes. Study background are in good clinical setting. Statistic method mention

Yes. Study background are in good clinical setting. Statistic method not mention

2.3 Are the results of this study directly applicable to the patient group targeted by this guideline?

Yes Yes Yes Yes Yes

59

2.4 Notes. Summarise the author’s conclusions. Add any comments on your own assessment of the study and the extent to which it answers your question an mention any areas of uncertainty raised above

Alcohol hand Regime is well tolerated and didn’t result in skin irritation and dryness of user’s hands.

According to the result of the author, the new regime can be launch in the actual setting.

Randomised not specified. The alcohol based hand preparation had fulfilled the requirements as a surgical scrub and mild hand wash for health care personnel in respect of the hand skin.

According to the result of the author, the new regime can be launch in the actual setting.

Participants like the feel of Alcohol based preparation and did not dry skin but have a disagreeable odour. Participants found that its easier to use. Products may increase staff compliance but cost effective.

According to the result of the author, the new regime can be launch in the actual setting.

The new waterless, scrub less alcohol based hand preparation can respect to change from baseline moisture content.

According to the result of the author, the new regime can be launch in the actual setting.

Alcohol hand preparation improved the tolerance of and compliance with hand antisepsis protocols and skin irritation decreased.

According to the result of the author, the new regime can try .

60

Appendix 4 - Visual Scoring of Skin (VSS) condition table

(Larson et al., 1997)

Score Assessment Description

0 Normal No observable scale or irritation

1 Very slightly scaly Occasional scale

2 Slightly scaly Scale in sulk and on plateaus; scale more uniformly distributed but with no widespread uplifting

3 Scaly Visible scale with whitish appearance of skin; uplifting of edges or scale sections; hand rough to touch

4 Scaly to very scaly More scale and separation of scale edges from skin; some evi-dence of cracking in sulk and on plateaus; skin may appear irritated with some reddening

5 Very Scaly Extensive cracking of skin surface; scale may be large; skin may appear very irritated with reddening and/or bleeding

61

Appendix 5 : Gantt Chart - Schedule illustration of the project

APN: Advanced Practice Nurse

Phase Week

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26

Preparation Phase

Obtain approvals / consensus

Setup research group

Equip antiseptic preparation and obtain consensus with APNs

Promotion period

Training workshop

Implementation Phase

Pilot programme

Pilot programme evaluation

Refinement of project

Implementation

Evaluation Phase Implementation evaluation

62

Appendix 6 : Hand skin evaluation form with VSS system

Form no: Pre test / Post test

XXX Hospital

Operation Theatre Service

Hand skin self-evaluation form on using alcohol based hand antiseptic

Participant’s name:

Date :

(Boyce et al., 2000)

Skin condition Score

0 (Normal skin: no

symptoms)

1 (Slightly occur)

2(Moderately oc-

cur)

3 ( Severely oc-

cur)

Itching

Dryness

Burning or stinging

Skin tightness

Bleeding

63

Appendix 7 - Budget Plan

* The quantity of the antiseptic lotion was for one month basis in all fifteen theatres.

Category Items Price per unit Quantity Amount (HKD)

Material Cost 1 page of promotion paper $0.2/ page 14 2.8

1 page of scrubbing steps poster 17 3.4

1 page of evaluation form 135 27

6 pages of evidence guideline 3 3.6

1.2 L Alcohol based antiseptic preparation with dispenser

$780/ bottle 15 * 11700

Manpower for the 0.5 hours training session

$194/ hour(Nurse)

125 12125

$99/ hour (Scrubbed technician)

10 495

Manpower for preparing promotion tools i.e. making of poster, loading data into iPads, disseminate new innovation through email

$194/ hour 5 970

Total 25326.8

64

Appendix 8 - Evidence-based Guideline

Title

The clinical guideline of alcohol based surgical hand rub for peri-operative

health care providers perform surgical hand antisepsis in operation theatre

Target Populations

Peri-operative nurses and scrubbed technicians who will perform surgical

hand antisepsis in operation theatres

Objective

1. Formulate clinical practice instructions for using the alcohol based hand rub

for peri-operative health care providers during surgical hand scrubbing

2. Promote occupational health of the hand skin of the peri-operative health care

providers

65

Recommendations

Recommendation 1: Characteristics of target Population

Recommendation 1.1: Peri-operative nurses or scrubbed technicians who aged

between 18 to 60, full-time working in OTS and have at least 3 months surgical

hand antisepsis experience (Grading of recommendation: A )

Available evidence:

Participants aged between 18 to 65 who have surgical hand scrubbing ex-

periences and working in OTS were recruited in 4 of the selected studies to esti-

mate the efficacy of the new alcohol-based antiseptic preparation with reduction

of hand skin irritation result (Grove et al., 2001[2++]; Gupta et al., 2007[1+];

Mulberry et al., 2001[1+]; Parienti et al., 2002[1-]). According to HA’s official

retirement age is 60 whereas the youngest employment age of a scrubbed techni-

cian is 18.

Recommendation 1.2 : Peri-operative nurses or scrubbed technicians who are free

of allergy of the alcohol based preparation (Grading of recommendation: A )

Available evidence:

All of the selected studies exclude the participants who had allergy of the

testing products (Boyce et al., 2000[2++]; Grove et al., 2001[2++]; Gupta et al.,

2007[1+]; Mulberry et al., 2001[1+]; Parienti et al., 2002[1-]).

66

Recommendation 1.3 : Peri-operative nurses or scrubbed technician who are not

suffering severe hand skin eczema, dermatitis or receiving systemic or topical an-

tibiotics (Grading of recommendation: A)

Available evidence:

All of the selected studies exclude the participants who had pre-existing

severe hand skin eczema, dermatitis or, currently on systemic or topical antibiotics

(Boyce et al., 2000[2++]; Grove et al., 2001[2++]; Gupta et al., 2007[1+]; Mul-

berry et al., 2001[1+]; Parienti et al., 2002[1-]).

Recommendation 1.4 : Peri-operative nurses or scrubbed technician who are full

time employed or working hour more than thirty hours per week (Grading of rec-

ommendation: A)

Available evidence:

All of the selected studies recruit full time or working hour more than thir-

ty hours weekly nurses or scrubbed technicians in the studies (Boyce et al.,

2000[2++]; Grove et al., 2001[2++]; Gupta et al., 2007[1+]; Mulberry et al.,

2001[1+]; Parienti et al., 2002[1-]).

Recommendation 2: Initial assessment

Recommendation 2: An initial self-assessment with VSS (see Appendix 6) would

be done a day before implementation of innovation, as a hand skin baseline

67

measurement record for comparison upon completion of the intervention period

(Grading of recommendation: A)

Available evidence:

Four out of 5 selected studies had addressed the necessary to obtain the

baseline of hand skin conditions before the implementation of the intervention in

order to compare the hand skin conditions at the end of implementation day

(Boyce et al., 2000[2++]; Grove et al., 2001[2++]; Mulberry et al., 2001[1+];

Parienti et al., 2002[1-]).

Recommendation 3: Implementation

Recommendation 3.1: Washing hand with soap and water if visibly soil indicated

before performing surgical hand antisepsis with alcohol based hand antiseptic

preparation (Grading of recommendation: A)

Available evidence:

Alcohol based antiseptics are not appropriate for use when hands are visi-

bly dirty or contaminated with proteinaceous materials (CDC, 2002). All of the

selected studies had mentioned the above CDC recommendation before perform-

ing surgical hand antisepsis with alcohol based preparation. The importance of the

recommendation was addressed and adopted to the guideline (Boyce et al.,

2000[2++]; Grove et al., 2001[2++]; Mulberry et al., 2001[1+]; Parienti et al.,

2002[1-]).

68

Recommendation 3.2: To perform every surgical hand scrubbing by using 3 ml of

1% ethanol and 61% CHG lotion on each hand, and rub until dry

(Grading of recommendation: A )

Available evidence:

Majority of the studies consisted of having the products applied according

to their manufacturer’s directions for use (Boyce et al., 2000[2++]; Grove et al.,

2001[2++]; Gupta et al., 2007[1+]; Mulberry et al., 2001[1+]). The amount of

hand antiseptics used to performed hand antisepsis is 3 ml after referred to the re-

view studies (Grove et al., 2001[2++]; Gupta et al., 2007[1+]; Mulberry et al.,

2001[1+]). Thus, same preparation was used in the innovation.

Recommendation 3.3: Implementing the 1% ethanol and 61% CHG preparation

for one month (Grading of recommendation: A)

Available evidence:

Implementation period from 5 days (Grove et al., 2001[2++]; Mulberry et al.,

2001[1+]), 2 weeks (Boyce et al., 2000[2++]; Gupta et al., 2007[1+]) to 2 months

(Parienti et al., 2002[1-]) were observed in the selected studies, which depended

on the scale of the study. A month of implementation period was adopted as it is

the mean of length of the implementation period from the selected studies.

Recommendation 3.4: Terminating the implementation by participants when ad-

verse health reaction occurs (Grade of recommendation: A)

69

Available evidence:

Termination of the implementation by participants had observed in 2 of the select-

ed articles due to adverse reaction such as skin rash, burning sensation, metallic

taste in mouth and palpitations occurred an hour after first attempt (Boyce et al.,

2000[2++] & Gupta et al., 2001[1+]). Reinforcement on termination of the im-

plementation by participants if adverse reaction observed in the training work-

shop.

Recommendation 4: Evaluation

A final self-assessment with VSS will be done at the end of implementation day

(Grading of recommendation: A)

Available evidence:

The final VSS data is used to compare with the initial VSS baseline data in

order to evaluate the efficacy of the alcohol based antiseptic preparation in reduc-

ing hand skin irritation (Boyce et al., 2000[2++]; Grove et al., 2001[2++]; Mul-

berry et al., 2001[1+]; Parienti et al., 2002[1-]). The result can make meaningful

and enduring improvements in hand antisepsis practices which patients can re-

ceive safe nursing care and the health care providers can stay healthy.

70

Appendix 9 - SIGN: Level of Evidence and Grades of Recommendations

Level of evidence

1++ High quality meta-analyses, systematic reviews of RCTs, or RCTs with a very low risk of bias

1+ Well-conducted meta-analyses, systematic reviews, or RCTs with a low risk of bias

1- Meta-analyses, systematic reviews, or RCTs with a high risk of bias

2++ High quality systematic reviews of case control or cohort studiesHigh quality case control or cohort studies with a very low risk of confounding or bias and a high probability that the relationship is causal

2+ Well-conducted case control or cohort studies with a low risk of confounding or bias and a moderate probability that the relationship is casual

2- Case control or cohort studies with a high risk of confounding or bias and a significant risk that the relationship is not causal

3 Non-analytic studies, e.g. case reports, case series

4 Expert opinion

Grades of recommendations

A At least one meta-analysis, systemic review, or RCT rated as 1++, and directly applicable to the target population; or

A body of evidence consisting principally of studies rated as 1+, directly applicable to the target population and demonstrating overall consistency of results

B A body of evidence including studies rated as 2++, directly applicable to he target population and demonstrating overall consistency of results; or

Extrapolated evidence from studies rated as 1++ or 1+

C A body of evidence including studies rated as 2+, directly applicable to the target population and demonstrating overall consistency of results; or

Extrapolated evidence from studies rated as 2++

D Evidence level 3 or 4; or

Extrapolated evidence from studies rated as 2+

71

Appendix 10 : Satisfaction questionnaire for participants Form no:

XXX Hospital

Operation Theatre Service Satisfaction questionnaire on EBP project: The use of alcohol based hand antiseptic

Please tick in the appropriate column.

Other comments:

~Thank you for your opinions~

Questions Strongly disagree

(1)

Disagree (2)

Neutral (3)

Agree (4)

Strongly agree (5)

1 The training workshop can equip you to perform the EBP in clinical area.

2 The amount of resources needed is accessible e.g. iPads, posters, emails, research group.

3 The guideline is clear and easy to understand.

4 Participants’ meeting after pilot programme can clarify misunderstanding of the intervention.

5 The hand skin self evaluation form is easy to use.

6 The intervention didn’t interfere my clinical work.

7 The intervention can reduce hand skin irritation of the scrubbing health care providers.

8 The EBP project is properly arranged.

9 The research group is supportive throughout the project.

10 Overall, I am satisfied with the intervention

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