This presentation is from an AORN webinar that helps guide perioperative team members through the evidence appraisal and rating process using the AORN appraisal tools and evidence-rating model. The webinar replay is available for free at http://bit.ly/1i9r4En. Get the 2014 edition of Perioperative Standards and Recommended Practices at http://bit.ly/1bJmXAT.

1. Anatomy of the New
Evidence-Rated AORN
Recommended Practices

2. Lisa Spruce, DNP, RN, ACNS, ACNP, ANP, CNOR
Dr. Spruce is the Director of Evidence Based Perioperative Practice
for AORN. Prior to coming to AORN she was the Clinical Manager of Surgical
Services for Universal Health Services where she managed all clinical
practice for 25 perioperative departments throughout the U. S. She was
instrumental in bringing evidence based practice changes to the Universal
Health Care System.
Dr. Spruce was a Clinical Nurse Specialist in the Perioperative
Departments for 5 hospitals in Las Vegas and a Nurse Practitioner in private
practice in Florida. She was a circulating nurse in the OR for 6 years and
worked in pre-op, PACU, and in the Endoscopy Suite. She is a board
certified Acute Care Nurse Practitioner, Adult Clinical Nurse Specialist and as
a CNOR. She has published several articles in the AORN Journal and the
Journal for the American Academy of Nurse Practitioners.

3. Sharon A. Van Wicklin, MSN, RN, CNOR, CRNFA, CPSN, PLNC
Sharon Van Wicklin has more than 36 years of experience as a perioperative nurse. She has
worked in all facets of the operating room environment from scrub person to supervisor. Sharon
received her BSN and MSN from Middle Tennessee State University. She is a member of Phi Kappa
Phi, and the Sigma Theta Tau Honor Society of Nursing. Sharon holds certification in operating room
nursing (CNOR), as an RN first assistant (CRNFA), in plastic and reconstructive surgical nursing
(CPSN), and as a legal nurse consultant (PLNC).
In her previous role as a perioperative educator, Sharon was responsible for the creation and
coordination of educational projects, programs and inservices designed to improve hospital processes
for orientation and development of personnel in nine perioperative departments. Her work as a legal
expert witness involves reading and reviewing medical records and testifying as to the standard of
perioperative nursing care. Sharon is a member of the School of Nursing faculty of Middle Tennessee
State University and the University of Phoenix. She truly enjoys her work as a nursing instructor
helping to shape the hearts and minds of future perioperative nursing professionals.
In her position as a Perioperative Nursing Specialist for the Association of periOperative
Registered Nurses (AORN), Sharon provides consultative services, authors various AORN
publications including recommended practices and Clinical Issues columns; and, represents AORN at
various organizations and functions such as AAMI, IAHCSMM, and AATB. Sharon was recognized by
AORN as a recipient of the Outstanding Achievement in the Application of Perioperative Clinical
Research Award in 2005. This award recognizes a registered nurse whose application of
perioperative clinical research reflects the goal of excellence in patient care.

4. Disclosure Information
Speakers:
Lisa Spruce, DNP, RN, ACNS, ACNP, ANP, CNOR
Director of Evidence-Based Practice, AORN
Sharon A. Van Wicklin, MSN, RN, CNOR, CRNFA,
CPSN, PLNC
Perioperative Nursing Specialist, AORN
Disclose no conflicts
Planning Committee:
Ellice Mellinger, MS, RN, CNOR
Perioperative Education Specialist, AORN
Discloses no conflict
AORN’s policy is that the subject matter experts for this product must disclose any financial relationship in a
company providing grant funds and/or a company whose product(s) may be discussed or used during the
educational activity. Financial disclosure will include the name of the company and/or product and the type of
financial relationship, and includes relationships that are in place at the time of the activity or were in place in the 12
months preceding the activity. Disclosures for this activity are indicated according to the following numeric
categories:
1. Consultant/Speaker’s Bureau
2. Employee
3. Stockholder
4. Product Designer
5. Grant/Research Support
6. Other relationship (specify)
7. Has no financial interest
Accreditation Statement
AORN is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on
Accreditation.
AORN is provider-approved by the California Board of Registered Nursing, Provider Number CEP 13019.
AORN IS PLEASED TO PROVIDE THIS WEBINAR ON THIS IMPORTANT TOPIC. HOWEVER, THE VIEWS
EXPRESSED IN THIS WEBINAR ARE THOSE OF THE PRESENTERS AND DO NOT NECESSARILY
REPRESENT THE VIEWS OF, AND SHOULD NOT BE ATTRIBUTED TO AORN.

5. Objectives
1. Discuss the history of evidence-based
practice.
2. Explain the PICO process for developing a
practice question.
3. Identify research and non-research evidence.
4. Describe the evidence appraisal process using
the AORN Evidence Appraisal Tools.
5. Describe the evidence rating process using
the AORN Evidence Rating Model.

6. History of Evidence-Based
Practice (EBP)
Lisa Spruce, DNP, RN, ACNS, ACNP, ANP, CNOR
Director of Evidence-Based Practice, AORN

7. History of EBP
“It isn’t what we don’t know that gives us
trouble, it’s what we know that ain’t so.”
~Will Rogers

8. In the beginning…
Thomas Beddoes (1760-1808)
• Called for sharing medical experiences,
collecting and archiving them and
- Analyzing
- Reporting
- Publishing

9. In the beginning…
Pierre Charles Alexander Louis (1787-1872)
– Performed the first chart review to disprove
the practice of blood-letting
– Medical science moved from innocence to
awareness
– 20th Century-arrival of the randomized
controlled trial

10. 1948
The first Randomized Controlled Trial (RCT)
• Medical Research Council Tuberculosis
Unit trial of streptomycin treatment for
pulmonary tuberculosis

11. Archie Cochran
Scottish physician
– "I knew that there was no real evidence that
anything we had to offer had any effect on
tuberculosis, and I was afraid that I shortened
the lives of some of my friends by
unnecessary intervention."

12. 1972
Effectiveness and Efficiency: Random
Reflections on Health Services published
Cardiff University Library, Cochrane Archive,
University Hospital, Llandough

13. 1979
Archie Cochrane states,
“It is surely a great criticism of our
profession that we have not organized a
critical summary, by specialty or
subspecialty, adapted periodically, of all
relevant randomized controlled trials.”

14. History of EBP
1980’s• Oxford Database of Perinatal Trials
1992• Cochrane Center opened
1993• Cochrane Collaboration founded

15. Evidence-Based Medicine
Term first used by McMasters University
(Canada)
• 1996-term formally defined by Sackett, et.al.
– “A systematic approach to analyze published
research as the basis of clinical decision making.”

16. Why EBP?
• It takes an average of 17 years to move
research to practice
• Evidence-based practice (EBP) provides
point of care clinicians tools needed to
improve care
• EBP transforms health care based on one
clinician, one encounter at a time

17. Evidence-Based Nursing
Dicenso-1998
- “Process by which nurses make clinical
decisions using best available evidence,
clinical expertise and patient preferences
in the context of available resources.”

18. First Nurse Pioneer for EBP
Florence Nightingale ~ 1860
• Compiled data from the Crimean war on
illness, treatment and cause of death
• Called for the collection of statistics on
hospital outcomes
• Improved sanitary conditions based on
evidence

19. EBP and Perioperative Nursing
• Quality of care
• Continuous inquiry
• Critical thinking
• Individualized care
• Payer and regulatory pressure
• Savvy patients

20. Developing the EBP Question
Lisa Spruce, DNP, RN, ACNS, ACNP, ANP, CNOR
Director of Evidence-Based Practice, AORN

21. PICO Method
P
I
C
O
Patient
Population
Problem
Interventions
-Education
-Self-care
-Best practices
Comparison
-Current practice
-Another intervention
Outcome

22. IM Injections: Aspirate or not?
P
I
C
O
Adult patients
Aspirate when giving
IM injection
No aspiration
Injury
Question:
Among adult patients,
does aspirating while
giving an IM injection
cause injury compared
to no aspiration?

23. Integrative Literature Review
• A simple inquiry leads to a
recommendation for practice!
- Crawford and Johnson-Integrative lit review
reveals that there is no data to support the
use of the aspiration procedure

24. Surgical Masks: Prevent SSI?
P
I
C
O
Patient
Population
Problem
Surgical patients
Interventions
-Education
-Self-care
-Best practices
Wearing a mask
Comparison
-Current practice
No mask
-Another intervention
Outcome
Surgical site
infections

25. PICO Question
Among surgical patients, does wearing a
surgical mask prevent surgical site
infections compared to not wearing a
mask?

26. Literature Search
Lisa Spruce, DNP, RN, ACNS, ACNP, ANP, CNOR
Director of Evidence-Based Practice, AORN
Sharon A. Van Wicklin, MSN, RN, CNOR, CRNFA, CPSN, PLNC
Perioperative Nursing Specialist, AORN

27. Conducting a Search
Databases
Databases
~ Cochrane
~ AHRQ - NGC
~ Pubmed
~ CINAHL®
~ ANA - Medline
~ AORN Journal
~ Medical Library
~ Google Scholar
~ Joanna Briggs
~ Virginia Henderson
International Nursing
Library
~ Embase

28. Search Strategies
Strategies
Results
• Define your topic
• Keywords
• Boolean operators
• No or few results
•
•
•
•
AND
OR
Quotation marks
Truncation
• Avoid long
phrases or
questions
• Choose different
key words

29. Literature Search

30. Literature Search Terms
–
–
–
–
–
–
–
–
–
–
–
–
Sterile field
Sterile technique
Aseptic technique
Aseptic practices
Surgical drapes
Double-gloving
Assisted gloving
Closed gloving
Time-related sterilization
Event-related sterilization
Surgical attire
Protective clothing
- Sterile supplies
- Sterile barriers
- Barrier precautions
- Body-exhaust suits
- Laminar air flow
- Bowel technique
- Glove expansion
- Glove perforation
- Strikethrough
- Spaulding’s criteria
- Product packaging
- Equipment contamination

31. Literature Search
Initial search confined to 2006 to 2011
• Time restriction not considered in subsequent
searches

32. Literature Search
Documents searched
• Meta-analyses
• Randomized and nonrandomized controlled trials and
studies
• Systematic and nonsystematic reviews
• Opinion documents and letters
• Guidelines (eg, government, professional, standards)
• Additional (eg, articles from reference lists)
• Alerts

33. Literature Search
Databases searched
•
•
•
•
MEDLINE®
CINAHL®
Scopus®
Cochrane

34. Literature Search
Articles identified:
– Rejected: 294
– Accepted: 135
429

35. Research Evidence
Sharon A. Van Wicklin, MSN, RN, CNOR, CRNFA, CPSN, PLNC
Perioperative Nursing Specialist, AORN

36. Research
Systematic Reviews
Randomized Controlled Trials
Quasi-Experimental Studies
Non-Experimental Studies
Qualitative Studies

37. Research
Systematic Reviews
• Summarize evidence related to a particular
practice question
• Address strengths and limitations of included
studies
• Review multiple studies
• Utilize rigorous search strategies and precise
appraisal methods

38. Research
Randomized Controlled Trials (RCTs)
• Randomization
- Researcher assigns subjects to a control or
experimental group on a random basis
- Increases validity of the study

39. Research
RCTs
• Manipulation
- Researcher takes an action to influence some aspect
of the dependent variable
Independent variable:
Dependent variable:
Intervention being applied
Phenomenon being studied

40. Research
RCTs
• Control
- Researcher introduces a group of subjects to which
the experimental intervention is not applied

41. Research
Quasi-Experimental
• Lack one element of a RCT
(ie, randomization, manipulation, or control)
- Researcher may attempt to compensate by using
multiple groups, or multiple measures

42. Research
Non-Experimental
• Study naturally occurring phenomenon
• No randomization, manipulation, or control
• Includes
• descriptive (describe observable facts),
• comparative (compare observable facts), and
• correlational (show a relationship) studies.
• Most of nursing research falls into this
category

43. Research
Qualitative
• Data collection includes interviews, group
discussion, field observation, reflection
• Researchers attempt to explore issues,
answer questions and gain in-depth
understanding of certain phenomena by
summarizing, analyzing and interpreting data

44. Non-Research Evidence
Sharon A. Van Wicklin, MSN, RN, CNOR, CRNFA, CPSN, PLNC
Perioperative Nursing Specialist, AORN

45. Non-Research
Clinical Practice Guidelines
Literature Reviews
Expert Opinion
Case Reports
Organizational Experience
Community Standard/Clinician Experience

46. Non-Research
Clinical Practice Guidelines
• Systematically developed statements
• Provide guidance for clinical practice

47. Non-Research
Literature Review
• Summary of published literature without
systematic appraisal of the quality and
strength of the evidence
• May not summarize all available evidence on
the topic in question

48. Non-Research
Expert Opinion
• Expertise must be assessed
- Education
- Work experience
- University affiliations
- Publications
- Citations
- Recognized speaker

49. Non-Research
Case Reports
• In-depth look at a single person, group, or
social unit
• Quantitative or qualitative
• Individual case or multiple cases
• Provide insight but have limited
generalizability

50. Non-Research
Organizational Experience
• Generally the result of efforts to improve
quality of care delivery and outcomes within a
particular organization
• May not be generalizable beyond the
organization

51. Non-Research
Community Standard/Clinician Experience

52. Evidence Appraisal
Sharon A. Van Wicklin, MSN, RN, CNOR, CRNFA, CPSN, PLNC
Perioperative Nursing Specialist, AORN

53. AORN Appraisal Tools
Research
Non-Research

54. AORN Appraisal Tools
Research
The strength of the
research evidence is
indicated by I, II, or III

55. AORN Appraisal Tools
Research
The quality of the
research evidence is
indicated by A, B, or C

56. AORN Appraisal Tools
Research
The final Research
appraisal score is a
combination of I, II, or III
and A, B, or C

57. AORN Appraisal Tools
Non-Research
The strength of the nonresearch evidence is
indicated by IV or V

58. AORN Appraisal Tools
Non-Research
The quality of the nonresearch evidence is
indicated by A, B, or C

59. AORN Appraisal Tools
Non-Research
The final Non-Research
appraisal score is a
combination of IV or V
and A, B, or C

60. Appraisal Score

61. Evidence Rating
Sharon A. Van Wicklin, MSN, RN, CNOR, CRNFA, CPSN, PLNC
Perioperative Nursing Specialist, AORN

62. AORN Evidence Rating Model
Appraisal Score
Research
Non-Research
IA
IB
IIA, IIB
IIIA, IIIB
IVA
Regulatory
IVB
VA, VB
Evidence Rating
Evidence Requirements
1: Strong Evidence
1: Regulatory requirement
Interventions or activities for which effectiveness has been demonstrated by strong
evidence from rigorously-designed studies, meta-analyses, or systematic reviews,
rigorously-developed clinical practice guidelines, or regulatory requirements.

Evidence from a meta-analysis or systematic review of research studies that
incorporated evidence appraisal and synthesis of the evidence in the
analysis.

Supportive evidence from a single well-conducted randomized controlled
trial.

Guidelines that are developed by a panel of experts, that derive from an
explicit literature search methodology, and include evidence appraisal and
synthesis of the evidence.
2: Moderate Evidence
Interventions or activities for which the evidence is less well established than for
those listed under “1: Strong Evidence.”

Supportive evidence from a well-conducted research study.

Guidelines developed by a panel of experts which are primarily based on the
evidence but not supported by evidence appraisal and synthesis of the
evidence.

Non-research evidence with consistent results and fairly definitive
conclusions.
3: Limited Evidence
Interventions or activities for which there are currently insufficient evidence or
evidence of inadequate quality.

Supportive evidence from a poorly conducted research study.

Evidence from non-experimental studies with high potential for bias.

Guidelines developed largely by consensus or expert opinion.

Non-research evidence with insufficient evidence or inconsistent results.

Conflicting evidence, but where the preponderance of the evidence supports
the recommendation.
IC
IIC
IIIC
IVC
VC
No requirement
No requirement
4: Benefits Balanced With Harms
Selected interventions or activities for which the AORN Recommended Practices
Advisory Board (RPAB) is of the opinion that the desirable effects of following this
recommendation outweigh the harms.
No requirement
No requirement
5: No Evidence
Interventions or activities for which no supportive evidence was found during the
literature search completed for the recommendation.

Consensus opinion.

63. AORN Evidence Rating Model
1:
1:
IA
Strong Evidence
Regulatory requirement
IVA
Regulatory
1: Strong Evidence
1: Regulatory requirement
Interventions or activities for which effectiveness has been demonstrated by
strong evidence from rigorously-designed studies, meta-analyses, or systematic
reviews, rigorously-developed clinical practice guidelines, or regulatory
requirements.

Evidence from a meta-analysis or systematic review of research studies
that incorporated evidence appraisal and synthesis of the evidence in the
analysis.

Supportive evidence from a single well-conducted randomized controlled
trial.

Guidelines that are developed by a panel of experts, that derive from an
explicit literature search methodology, and include evidence appraisal and
synthesis of the evidence.

64. AORN Evidence Rating Model
2:
IB
IIA, IIB
IIIA, IIIB
3:
IC
IIC
IIIC
Moderate Evidence
IVB
VA, VB
2: Moderate Evidence
Interventions or activities for which the evidence is less well established than for
those listed under “1: Strong Evidence.”

Supportive evidence from a well-conducted research study.

Guidelines developed by a panel of experts which are primarily based on
the evidence but not supported by evidence appraisal and synthesis of
the evidence.

Non-research evidence with consistent results and fairly definitive
conclusions.
Limited Evidence
IVC
VC
3: Limited Evidence
Interventions or activities for which there are currently insufficient evidence or
evidence of inadequate quality.

Supportive evidence from a poorly conducted research study.

Evidence from non-experimental studies with high potential for bias.

Guidelines developed largely by consensus or expert opinion.

Non-research evidence with insufficient evidence or inconsistent results.

Conflicting evidence, but where the preponderance of the evidence
supports the recommendation.

65. AORN Evidence Rating Model
4:
No requirement
Benefits Balanced with Harms
No requirement
4: Benefits Balanced With Harms
Selected interventions or activities for which the AORN Recommended Practices
Advisory Board (RPAB) is of the opinion that the desirable effects of following
this recommendation outweigh the harms.
V.c. Sterile supplies should be opened for only
one patient at a time in the OR or other
procedure room. [4: Benefits Balanced with Harms]

66. AORN Evidence Rating Model
4:
No requirement
5:
No requirement
Benefits Balanced with Harms
No requirement
4: Benefits Balanced With Harms
Selected interventions or activities for which the AORN Recommended Practices
Advisory Board (RPAB) is of the opinion that the desirable effects of following
this recommendation outweigh the harms.
No Evidence
No requirement
5: No Evidence
Interventions or activities for which no supportive evidence was found during
the literature search completed for the recommendation.

Consensus opinion.

67. Evidence Rating
[3: Limited Evidence]

68. Appraisal Score

69. Evidence Rating
[3: Limited Evidence]

70. Meeting National Guidelines
Clearinghouse Criteria
Lisa Spruce, DNP, RN, ACNS, ACNP, ANP, CNOR
Director of Evidence-Based Practice, AORN

71. Meeting NGC Criteria
• Documentation will need to be provided
showing that the guideline is based upon
a systematic review of the evidence.
• Documentation must contain
an assessment of the benefits and
harms of the recommended care and
alternative care options.

72. Anatomy of an AORN
Recommended Practice
Lisa Spruce, DNP, RN, ACNS, ACNP, ANP, CNOR
Director of Evidence-Based Practice, AORN

73. AORN Evidence Rated RP
Recommendation Number: IV
Recommendation
Rationale
Intervention Letter: IV.a.
Intervention
Supporting Evidence
Activity Number: IV.a.1.
Activity
Evidence Rating
Appraisal Scores

74. AORN Evidence Rated RP

75. AORN Evidence Rated RP

76. AORN
Evidence
Rated RP

77. Questions and Answers

78. References
1. Goodman, K. (2002). Ethics and Evidence-based Medicine. Cambridge
University Press.
2. Crofton, J. (2006). The MRC randomized trial of streptomycin and its legacy: A
view from the clinical front line. Journal of the Royal Society of Medicine, 99(10),
531-534.
3. Archie Cochrane: The name behind the cochrane collaboration,
cochrane.org/about-us/history/archie-cochrane.
4. Claridge, J. A. &Fabian, T. C. (2005). History and development of evidencebased medicine. World Journal of Surgery, 29(5), 547-543.
5. DiCensor A, Cullum N & Ciliska D (1998) Implementing evidence-based nursing:
some misconceptions. Evidence Based Nursing, 38–40.
6. Crawford, C. L. & Johnson, J. A. (2012). To aspirate or not: An integrative review
of the literature. Nursing, 20-25.
7. Recommended practices for sterile technique. In: Perioperative Standards and
Recommended Practices. Denver, CO: AORN, Inc; 2012:e62-e90.
8. Dearholt S, Dang D. Johns Hopkins Nursing Evidence-Based Practice: Model
and Guidelines. 2nd ed. 2012.
9. OR NurseLink-A perioperative community. AORN.
http://www.ornurselink.org/Pages/home.aspx

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Once you have submitted your evaluation, you can print your certificate
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80. Contact Hours
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Not Registered for this Webinar?
Follow the below instructions to obtain access to the evaluation:
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81. Get Your 2014 Edition Today
Perioperative Standards and Recommended Practices
This comprehensive publication provides the evidence-based recommended practices for both patient
and worker safety in all settings where operative and other invasive procedures are performed.
New evidence-rated recommended practices include:
•
•
•
•
Pneumatic Tourniquet-assisted Procedures
Environmental Cleaning
Packaging Systems for Sterilization
Sharps Safety
Updated from 2013 edition:
• Prevention of Transmissible Infections
• Safe Environment of Care
• Sterile Technique
• Sterilization
www.aorn.org/RecommendedPractices