Evidence Based Practice in Nursing Portfolio Su.docx

Evidence Based Practice in Nursing Portfolio: Surgical Site
InfectionsWalden University
NURS6052, Section 40, Essentials of Evidence-Based Practice
February 8, 2015
Identifying a Researchable Problem
Nurses are at the forefront of evidence based practice
questions. Everyday healthcare treatments are governed by
policies and procedures created as a result of evidence based
practice questions. Over the years, many nurses begin to
perform their duties not giving much thought to the rationales
behind what they are doing. However, under the circumstances,
improvements to healthcare are based off the experiences and
curiosity of nurses delivering direct patient care. In this
assignment, a researchable nursing topic will be identified and

an answerable evidence based practice question will be
generated to resolve the issue presented.
Area of Interest
Post-operative surgical site infections are ranked among
the highest of all healthcare associated infections. In 2011, the
Centers for Disease Control and Prevention (CDC) reported an
estimated 721,800 infections in acute care hospitals across the
United States (CDC, 2011). An estimated 157,500 of the
infections were reported as surgical site infections (CDC,
2011).
Due to an increase in post-operative surgical site
infections, hospitals, and outpatient surgical clinics have
adopted and implemented changes to their skin preparation
techniques by using a Chlorhexidine-Gluconate Ethanol or
Hibiclens solution versus Povidone-Iodine or Betadine as a pre-
operative scrub. The purpose of the pre-operative scrubs is to
prevent bacterial contamination of the surgical site (Dizer,
Hatipogula, Kaymakcioglu, Tufan, Yava, Iyigum, & Senses,
2009). Both Hibiclens and Betadine have been used for
decades. Although Chlorhexidine is highly recommended as the
skin preparation solution due to the high risk for an allergic
reaction to Povidone-iodine, many healthcare facilities around
the world continue its use. As a result of these changes, many
healthcare professionals have researched and questioned the
advantage of Hibiclens over Betadine.
Feasibility
Below are five questions formulated to determine their
feasibility related to the use of Chlorhexidine verses Povidone-
iodine in preventing postoperative surgical site infections.
1. How effective is the use of Chlorhexidine verses Povidone-
iodine as a preoperative skin solution?
2. Will Chlorhexidine as a preoperative skin preparation
solution reduce surgical site infections?
3. Will the use of Chlorhexidine result in overall savings for the
hospital?
4. In patients with an unknown allergy to Povidone-iodine, is it

safer to use Chlorhexidine to avoid an allergic reaction?
5. What is the impact of starting skin preparation the night
before rather than start the skin preparation in the surgical unit?
Based on the analysis, the following questions were formulated:
“What is the impact using Chlorhexidine verses Povidone-
iodine as a preoperative skin solution?” When creating
evidence based research questions, all information is not critical
in resolving the problem; however, all data should be
documented to complete the research (Polit & Beck, 2012).
Researching the use of Chlorhexidine and Povidone-iodine as
preoperative solutions will benefit the patients by not only
decreasing the risks of infection, but doing so cost effectively.
When implementing research on post-operative surgical site
infections, feasibility should be taken into consideration.
According to Polit & Beck (2012) analyzing and tracking the
length of time established to conduct the study? What costs are
associated in conducting research relating to surgical site
infection? Are the appropriate facilities and personnel available
to perform the research? What is the level of expertise of the
researchers involved in the study?
Preliminary PICO Question
The PICOT was used; P for population; I for
intervention/issues; C for comparison; O for outcome; and T for
time (Polit & Beck, 2012). My PICOT question is “In surgical
patients, what effect do skin antiseptics used as preoperative
skin preparation that contain Chlorhexidine gluconate compared
to those that contain Povidone-iodine on preventing post-
operative surgical site infections?” The population is the
surgical patients who are at risk of post-op infections. The
intervention/issue is the use of Chlorhexidine as a surgical prep.
The comparison is the use of Povidone-iodine as a surgical prep
and the outcome is the effectiveness in preventing surgical site
infections.
Key Terms
Keywords or phrases used in conducting the literature
search for surgical site infections are nursing, Chlorhexidine,

hibiclens, Povidone, iodine, betadine, surgery, post-operative
infections, skin pathogens, antiseptic skin prep, cost, evidence-
based, patient education, and healthcare associated infections.
Surgical nurses often use the pre-operative solutions to conduct
skin preparation. Finding or the types of skin pathogens
involved are vital in treatment the infection. Patients with
unknown allergies to iodine before its use will avoid life
threatening reactions and in term decrease cost. Patient
education and comparing how effective is it to conduct skin
preparation at home compared to initiating it just prior to
surgery
Summary
Developing an answerable PICO question will support the
evidence-based practice researched by many healthcare
facilities. Conducting research on surgical site infections and
developing policies supported by evidence can greatly decrease
the number of hospital acquired surgical site infections and in
term aid nurses in implementing patient care.
Literature Review

Conducting literature reviews is an integral part of the
research process. According the Polit & Beck (2012), literature
reviews provide a summary of data that has been researched and
analyzed to determine if a theory has been satisfactorily
developed. The purpose of this paper is to provide a synthesis
of research studies conducted to determine the effect of skin
antiseptics used as a pre-operative skin preparation.
History
Hospital acquired infections continue to cause a considerable
rise in the morbidity and mortality rates of patients receiving
treatment in hospitals around the world. According to the
Centers for Disease Control and Prevention (CDC) Healthcare-
Associated Infections Prevalence Survey conducted in 2011,
approximately 721,800 infections were reported in acute care
hospitals in the United States (Centers for Disease Control
(CDC), 2011). An estimated 157,500 surgical site infections
were among the highest reported (CDC, 2011). As a result,
researchers continue to develop policies based on previous and
current studies and data reported on preventing post-operative
site infections. Several billions of dollars have been spent to
research methods necessary to improve patient outcomes.
Numerous studies have been conducted comparing the use of
Chlorhexidine to Povidone-iodine on preventing post-operative
surgical site infections. As a result, many medical professionals
may change their procedures on surgical skin preparation.
The Current Evidence
A systematic review of a randomized control trial was
conducted by Yeung, Grewal, Bullock, Lai, and Brandes (2013)
to evaluate the use of Chlorhexidine-alcohol and Povidone-
iodine. The study looked at decreasing the rate of positive
cultures from the surgical sites of a genitourinary prosthetic
implantation device. A total of 100 patients were chosen to
participate. Two groups with 50 in each group were elected.
Pre-operative cultures were obtained on all patients prior to any
skin preparation. Group one patients received a pre-operative
scrub with Chlorhexidine-alcohol and Group two patients

received a pre-operative scrub with Povidone-iodine. Both
groups of patients received a second set of cultures from the
surgical site prior to the beginning of surgery. The results
revealed 79% of the patient’s pre-operative skin preparation
cultures were positive (Yeung et al., 2013). Group one patients
who received the Chlorhexidine-alcohol pre-operative scrub
cultures were positive in 8% of the patients, while Group two
patients who received the Povidone-iodine pre-operative scrub
were positive in 32% of the patients (Yeung et al., 2013). This
study resulted in rating Chlorhexidine-alcohol safer than
Povidone-iodine in preventing post-operative surgical site
infections.
In a larger integrated review conducted by Lee, I., Agarwal,
Lee, B., Fisman, and Umscheid (2010), nine randomized
controlled trials with a total of 3,614 patients were conducted in
a meta-analysis. Qualified studies were obtained from several
databases including the Cochrane Library (Lee et al., 2010).
Data from these studies were used to create a model to assess
the outcomes. The results of these trials also concluded
Chlorhexidine as the preferred antiseptic for pre-operative skin
preparation.
In a retrospective medical record review conducted by Zinn,
Jenkins, Harrleson, Wrenn, Haynes, and Small (2013), four
hospitals within the same network participated. Medical records
of 129 patients receiving open abdominal surgery were reviewed
during the period of December 2008 and December 2010. Four
different skin prep solutions were used containing
parachoroxylenol (PCMX), Chlorhexidine, Povidone-iodine, and
0.7% iodine and 74% isopropyl alcohol (Zinn et al., 2013). The
review concluded with only five patients receiving post-
operative site infections within 30 days of surgery (Zinn et al.,
2013). No infections were found in any of the patients receiving
a pre-operative scrub with PCMX or Chlorhexidine. As a result,
PCMX was chosen as the preferred skin prep solution only
because Chlorhexidine was no longer available within their
network. For this reason, it was concluded that a retrospective

review was not as effective as a prospective randomized trial
(Zinn et al., 2013).
To improve the effectiveness of pre-operative skin preparations,
many studies have been conducted. It has been found that the
most common source for pathogens were on the patient’s skin
surface. As a result, researchers have conducted several studies
to find which pre-operative skin preparation solution and
technique are most effective. The majority of articles reviewed
found Chlorhexidine as the most effective; however, a
disadvantage has been cost associated. In a systematic review
conducted by Adbullah & Maqball (2013), an estimated $20,842
cost per patient was associated with each infection as a result of
extended hospital stays, medications, nursing care, and
interventions necessary for treatment. According to Hemani &
Lepor (2009), patients who develop surgical site infections are
“likely to spend time in the intensive care unit, are 5 times more
likely to be readmitted and are twice as likely to die”.
Conclusion
In 1999, the Centers for Disease Control and Prevention
released a set of guidelines for healthcare facilities to follow in
preventing surgical site infections (Hemani & Lepor, 2009). It
has been suggested that surgical skin preparations should be
selected on an individual basis and not because it’s the
surgeon’s favorite (Murkin, 2009). All patients should be
assessed for allergies and history that may increase their
chances for infections. Only medical professionals who have
been properly trained should administer pre-operative skin
preparation (Murkin, 2009). There have been a number of
studies conducted to determine the effectiveness of
Chlorhexidine in comparison to Povidone-iodine (Murkin,
2009). Researchers strongly support changing guidelines for the
use of Chlorhexidine rather than Povidone-iodine as a pre-
operative surgical scrub in preventing surgical site infections.
Chlorhexidine has also proven to be cost effective as it relates
to the length of hospital stays, medication regimes, and nursing
interventions required improving the quality of life for patients.

Summary
A literature review was conducted evaluating documented
studies to support the PICOT question of comparing the use of
Chlorhexidine to Povidone-iodine as a pre-operative skin
preparation solution. The majority of the studies included in the
literature review showed evidence that support the change of
guidelines for surgical units to use Chlorhexidine as the
preferred solution in preventing post-operative surgical site
infections and the most cost effective. Although research rates
Chlorhexidine as the preferred pre-operative skin preparation
solution, additional research is recommended.
Translating Evidence into Practice
Surgical site infections are one of the most common hospital-
acquired infections (CDC, 2011). Nurses can play a vital role in
decreasing the number of post-operative infections. Adopting
and implementing new policies and procedures are the first of
several steps necessary to improve patient outcomes. The
purpose of this paper is to identify the PICOT question and its
significance in nursing practice.
PICOT
The PICOT question for this assignment is “In surgical patients,
what effect do skin antiseptics used as preoperative skin
preparation that contain Chlorhexidine gluconate compared to
those that contain Povidone-iodine on preventing post-operative
surgical site infections?”
Nurses play a significant role in preventing surgical site
infections. Best practices for nurses in surgical units are to
maintain sterility. Good hand washing techniques, the use of
personal protective equipment, pre-operative skin cleansing,
and post-operative wound care are significant prevention

methods. It is normally with the assessment of the nurse; the
first signs of an infection are noticed. Therefore, to reduce the
number of infections, it has been recommended by the
Association of Preoperative Registered Nurses (AORN) that
preoperative skin preparation should use an antiseptic agent
immediately before surgery (Ramsey, 2001). Both
Chlorhexidine gluconate and Povidone-iodine among the most
commonly used skin antiseptic agents preferred by surgeons.
Literature Review Summary
Researchers have compared and analyzed the use of skin
preparation agents for many years. Several studies have
concluded both Chlorhexidine gluconate and Povidone-iodine
prevent surgical site infections; however, Chlorhexidine
gluconate shows a significant difference in the eradicating
bacterial at the surgical site (Yeung, Grewal, Bullock, Lai, and
Brandes, 2013). In the study conducted by Yeung et al., 2013,
all skin preparation was performed by the circulation nurse or
surgeonthe circulation nurse or surgeon performed all skin
preparation. Surgical nurses are instrumental in preventing
surgical site infections by following both the national and
professional guidelines established (Zinn, Jenkins, Harrleson,
Wrenn, Haynes, and Small, 2013). This study conducted by
Zinn et al., 2013, patients prepped with chlorhexidine had the
lowest incidence of surgical site infections. Researcher
concluded that “perioperative registered nurses are able to make
informed recommendations and appropriate assessments and
interventions aimed toward prevention of surgical site
infections” (p. 557). By maintaining adequate hand hygiene,
decreasing operating room traffic, donning the proper surgical
attire, and following guidelines on surgical prepping techniques,
nurse’s efforts can aid in decreasing surgical site infections.
Nurses adhering to the guidelines which states Chlorhexidine
scrub time is two-minutes followed by three-minute drying time
(Yeung et al., 2013). Comment by Debbie D. Sullivan: Is
this your nursing practice supported by your lit review?
Evidence Based Practice Outcomes

Evidence based practice provides an outline of how
research can be utilized in nurse practice. According to Polit &
Beck (2012), when nurses provide medical advice, many are
offering this advice based on prior research. Many nursing
protocols have been created stating the appropriate method and
length of time required for Chlorhexidine to effectively
disinfect the site. The use of Chlorhexidine has proven superior
over the use of Povidone-iodine in preventing surgical site
infections.
Failing to use the evidence based practices established will lead
in an increase in the number of surgical site infections, which
can lead into additional medical costs related to hospital stays
and medications. There may also be an increase in the morbidity
and mortality rates (Yeung et al., 2013).
Strategy for Dissemination the Evidence Based Practice
Educating the staff will be vital in disseminating and
implementing the evidence based practice indentified.
Presenting the research and proposed policy changes to the
medical directors would be one of the first steps taken to obtain
approval. According to Pilot & Beck, 2012, if presenting to
administrators, information should include “cost and
accessibility” (Pilot & Beck 2012, p. 681). Creating handouts
and sending electronic communications of the upcoming updates
may ease the staff’s initial shock of the upcoming changes.
Providing an in-depth mandatory training for all staff and
providing staff monitoring will establish an open line of
communication to address any concerns. Nurses my also attend
and present at professional conferences and submit their
research to journals to have it published (Pilot & Beck, 2012).
Comment by Debbie D. Sullivan: How would you would
move from disseminating the information to implementing the
evidence-based practice within your organization?
Summary
Translating research findings into nursing practice is vital
in improving the delivery of healthcare. Selecting the best skin
cleansing agent for a surgical unit to adopt is an important step

in decreasing the rate of surgical site infections. Research
shows Chlorhexidine rating superior to Povidone-iodine. There
are several methods researchers can take to present their reports
in order to have them implemented as policy changes.
Summary of the Project
Surgical site infections are the most common type of
hospital-acquired infection (CDC, 2011). The Centers for
Disease Control and Prevention estimated 721,800 hospital
acquired infections of which 157,500 were reported as surgical
site infections (CDC, 2011). Due to the increased mobility and
mortality rates related to surgical site infections, researches
have conducted studies to determine with form a surgical skin
preparation solution rates superior in decreasing the number of
infections.
In order to establish the best evidence-based practice,
formulating a PICOT research question supported by creditable
literature reviews is essential. The PICOT question states a
comparison of Chlorhexidine to Povidone-iodine. The literature
reviews conducted in the project support evidence giving a
comparison of Chlorhexidine to Povidone-iodine as surgical
skin preparation solutions. The studies conducted by Yeung et
al., 2013, and others, rated Chlorhexidine superior to Povidone-
iodine in decreasing surgical site infections. Due to the nature
of this project, it is recommended that further research is
conducted.
After in-depth research is concluded and supports the
PICOT question, it is important to disseminate and implement
the evidence into practice. Developing a dissemination plan is
vital. Successfully communicating the plan by educating the
staff, submitting the research findings to journals, and attending
professional conferences are important steps to translate the
results of the study to be accepted and published (Polit & Beck,
2012).

References
Abdullah, M., & Maqbali, A. (2013). Preoperative antiseptic
skin preparations and reducing SSI. British Journal of Nursing,
22(21), 1227-1233.
Centers for Disease Control and Prevention. (2011). Healthcare-
Associated Infections: Data and Statistics. Retrieved from
http://www.cdc.gov/HAI/surveillance/index.html.
Dizer, B., Hatipoglu, S., Kaymakcioglu, N., Tufan, T., Yava,
A., Iyigun, E., & Senses, Z. (2009). The effect of nurse-
performed preoperative skin preparation on postoperative
surgical site infections in abdominal surgery. Journal of
Clinical Nursing. 18, 3325-3332.
Hemani, M., & Lepor, H. (2009). Skin preparation for the
prevention of surgical site infection: Which agent is better?
Reviews in Urology, 11(4), 190-195.
Lee, I., Agarwal, R., Lee, B., Fishman, N., & Umscheid, C.
(2010). Systematic review and cost analysis comparing use of
Chlorhexidine with use of iodine for preoperative skin
antisepsis to prevent surgical site infection. Infection Control
Hospital Epidemiology, 31(12), 1219-1229.
Murkin, C. (2009). Pre-operative antiseptic skin preparation.
British Journal of Nursing, 18(11), 665-669.
Polit, D., & Beck, C. (2012). Nursing Research: Generating and
Assessing Evidence for Nursing Practice. Philadelphia:
Lippincott, Williams & Wilkins.
Ramsey, C. (2001, April). Preoperative measures to prevent
surgical site infections. Infection Control Today. Retrieved
from http://www.infectioncontroltoday.com
Yeung, L., Grewal, S., Bullock, A., Lais, H., & Brandes, S.
(2013). A comparison of Chlorhexidine-alcohol versus
Povidone-iodine for eliminating skin flora before genitourinary
prosthetic surgery: A randomized controlled trial. The Journal
of Urology, 189, 136-140. doi: 10.1016/j.juro.2012.08.086.

Zinn, J., Jenkins, J., Harrelson, B., Wrenn, C., Haynes, E., &
Small, N. (2013). Differences in intraoperative prep solutions:
A retrospective chart review. AORN Journal, 97(5), 552-558.
Running head: NURSING PORTFOLIO 1
NURSING PORTFOLIO 5
Literature Review Summary Table
NURS 6052
Citation
Type of Study
Design Type
Framework/Theory
Setting
Key Concepts/Variables
Findings
Hierarchy of Evidence Level
Yeung, L., Grewal, S., Bullock, A., Lai, H., & Brandes, S.
(2013). A comparison of Chlorhexidine-alcohol versus
Povidone-iodine for eliminating skin flora before genitourinary
prosthetic surgery: A randomized controlled trial. The Journal
of Urology, 189, 136-140. doi: 10.1016/j.juro.2012.08.086.

Type of Study:
Observational Study
Design Type:
Prospective Randomized Controlled
Framework/Theory:
None specified
100 male patients receiving genitourinary prosthetic
implantation surgery
Concepts: Compare Chlorhexidine-alcohol to Povidone-iodine
in decreasing the rate of positive bacterial skin cultures at the
surgical site
Independent Variable:
Male patients
Preoperative skin preparation with Chlorhexidine-alcohol or
Povidone-iodine
Dependent Variable:
Pre-operative and Post operative skin culture results
Controlled Variable:
Skin preparations with Chlorhexidine-alcohol yield less post-
operative surgical site infection than with Povidone-iodine.
Post-preparation cultures were positive in 8% in the
Chlorhexidine-alcohol group compared to 32% in the Povidone-
iodine group.
Level 3
Abdullah, M., & Maqball, A. (2013). Preoperative antiseptic
skin preparations and reducing SSI. British Journal of Nursing,

22(21), 1227-1233.
Type of Study:
Systematic Review
Design Type:
Randomized Controlled Trials
Framework/Theory:
None specified
Limited to 6 years; from 2005 – 2011. Adult patients 18 years
and older.
Concepts: To determine the best antiseptic agent for skin
preparation by reviewing the latest evidence and evaluating the
literature about the effect of using Chlorhexidine compared with
Povidone-iodine in reducing the risk of surgical site infections.
Independent Variable: Skin antiseptic agents
Dependent Variable:
Patient allergies, skin condition, environmental risk, and type of
surgery
The literature suggests that Chlorhexidine with alcohol appears
to have a great effect in reducing surgical site infections than
Povidone-iodine. However, further randomized controlled trials
with larger numbers or participants are necessary.
Level 1
Citation

Study
Design Type
Framework/Theory
Setting
Key Concepts/Variables
Findings
Hierarchy of Evidence Level
Murkin, C. (2009). Pre-operative antiseptic skin preparation.
British Journal of Nursing, 18(11), 665-669.
Type of Study:
Systematic Review
Design Type:
Randomized Controlled Trials
Framework/Theory:
Literature research using the Cochrane Library Database located
six eligible randomized controlled trials.
Concepts: To emphasize the importance of skin preparation and
the correct application.
Independent Variable: Trained professional administering skin
preparation.
Dependent Variable:
Techniques used to administer skin preparation solution, skin
integrity, patient history of allergies
Tackling surgical site infections through training and education
of the theatre team in antiseptic skin preparation is crucial in
reducing the risk of a surgical site infection. Guidelines for a
national evidence-based recommendation should be
implemented for Chlorhexidine for skin preparation.
Level 1

Zinn, J., Jenkins, J., Harrlelson, B., Wrenn, C., Haynes, E., &
Small, N. (2013). Differences in intraoperative prep solutions:
A retrospective chart review. AORN Journal, 97(5), 552-558.
Type of Study:
Observational Study
Design Type:
Retrospective Medical Records Review
Framework/Theory:
None specified
Patients ages 18 years and older who had undergone elective
open abdominal procedures from December 2008 to December
2010 at four acute care community hospitals in southeastern
United States.
Concepts: To identify which f four intraoperative prep solution
used with the health network resulted in the lowest incidence of
surgical site infections 30 days after surgery.
Independent Variable: Patient ages 18 years and older, elective
open abdominal surgical procedures
Dependent Variable:
Four different prep solutions, patient medical history.
A final sample of 162 patients medical records were reviewed.
Five patients had a documented surgical site infection. Three of
the infections occurred in patients prepped with 0.7% iodine
and 74% isopropyl alcohol. Two of the infections occurred in

patients prepped with Povidone-iodine. No infections were
found in patients prepped with either Parachoroxylenol or
Chlorhexidine.
Level 3
Lee, I., Agarwal, R., Lee, B., Fishman, N., Umscheid, C.
(2010). Systematic review and cost analysis comparing use of
Chlorhexidine with use of iodine for preoperative skin
antisepsis to prevent surgical site infection. Infection Control
Hospital Epidemiology, 31(12), 1219-1229.
Type of Study:
Systematic Review and Cost Analysis
Design Type:
Systematic Reviews, Meta-analysis, Randomized Controlled
Trials
Framework/Theory:
None specified
Conducted Literature search from various websites and
databases up to January 2010 for eligible studies.
Concepts: To compare the use of Chlorhexidine with the use of
iodine for preoperative skin antisepsis and cost.
Independent Variable: Skin preparation solution, Cost analysis
model
Dependent Variable:
Type of surgery, Skin Culture results
Preoperative skin antisepsis with Chlorhexidine is more
effective than preoperative skin antisepsis with iodine for

preventing surgical site infections and results in a cost savings
of $16-$26 per surgical case and $349,904 - $568,594 per year
for the Hospital of the University of Pennsylvania.
Level 1
Running head: TRANSLATING EVIDENCE INTO PRACTICE
1
TRANSLATING EVIDENCE INTO PRACTICE 5
Translating evidence into practice
Ese Nosakhare
Nurs-6052N Essentials of Evidence-Based Practice
June 13, 2015
Translating evidence into practice

It is vital to state that the identification of a research
problem leads to the formulation of a research question, which
is key to investigating a particular phenomenon (Maidl, Leske &
Garcia, 2014). Although it is difficult to identify a clinical
research question, this paper has developed one regarding the
Neurotrauma ICU patients. The research question is: Does the
enforcement of scheduled hours of time to rest decrease the
multiple of incidences of delirium in adult critical care patients
in the ICU? In fact, Delirium has been directly associated with
higher medical costs, increased risk of death, and extended
stays. However, a lack of sleep and delirium has not been
proven. This is despite the fact that some knowledge exists,
which indicates that deprivation of sleep has adverse effects on
cognitive functioning. Moreover, stays for more days in
hospitals increased medical costs, and high mortality rates are
linked to delirium.
The significance of the research question to the nursing
practice is to help nurse practitioners to develop changes that
increase the level of sleep. In fact, this question guides the
nurses in preventing and managing sleep deprivation in ICU
patients. As a result, incidences of delirium in ICU patients will
reduce.
From the literature reviews, it is clear that the studies
conducted are consistent. Most of the studies have concentrated
on the incidences of derilium and the ICU quite a time. The
conclusions that were drawn were similar, and both indicated
that the ICU patients value ICU quite time. This is for the
reason that quiet time is associated with a decreased level of
delirium. According to the scholars, the visitors, and the nurses
also play significant roles because they are also stakeholders.
They also have influence in the production of noise, implying
that it is crucial to establishing patients' perception concerning
the matter. Notably, some researchers have noted that noise is
not the only sleep disruptor. According to Xie, Kang, and Mills
(2009), other factors other than noise cause the same effects.
The writers have established noise masking as the best approach

for improving the sleep of the ICU patients (Weinhouse et al.,
2009: Xie et al., 2009). It is essential to state that the fact that
Xie and colleagues (2009) found that noise is not the only cause
of delirium implies that there is a need to conduct further
studies to investigate other stresses.
Noise masking is a nursing evidence-based practice that can be
done using the modern technology. This is where a soothing
background sound is introduced by the networked sound
masking technology. The soothing background has been
engineered to hide conversations and noise while the patient
remains comfortable and unobtrusive. This networking system
improves the sleeping conditions because of its ability to
decrease the amount of change between the background sound
levels and peaks.
Evidently, there are no major effects that are associated with
noise masking. What should be noted is that failure to
disseminate the practice may result in negative outcomes for
ICU patients and staff. Concerning the patients, it affects the
patients' recovery time. This is because exposure to noise raises
the heart rates. Additionally, high levels of sound increase
blood pressure levels, which may lead to higher risks of cardiac
problems. Studies have shown that chronic noise increases the
risk of cardiac attack by fifty percent for men and seventy-five
percent for women. Concerning the staff, noise increases stress,
which can hinder the effective performance of the staff
members. Moreover, noise disruption and distraction may lead
to medication errors.
The first strategy that will be used is to increase reach to many
audiences. This will be achieved through the utilization of
social media platforms. Another strategy that the nurse will use
is to increase the motivation to utilize and apply noise masking.
In fact, it is expected that the healthcare service providers will
increase interest in the use of noise masking through
championing, asking for patients; opinions and social network.
It is important to increase the ability to use and apply noise
masking. It is crucial to state that nurses should combine many

dissemination strategies to address noise as a cause of delirium.
I would communicate this message to my colleagues
utilizing many ways. The first method I will use is the media.
The information regarding noise masking will be accessed
through social media platforms, although, it will also be
broadcasted. Accessible forums, such as online and open access
will be used.
After disseminating the information, then, I will start by
asking the management to provide the relevant materials and
equipment that are necessary for the implementation of noise
masking practice. After the materials and equipment, I will call
the staff members to assist me in distributing the masks to the
patients and encourage them to use. This will be done after the
patients’ consent has been sought.
Regarding the opposition I may face, I will neither fear nor
hesitate to continue implementing noise masking. I will be stern
with my actions and explain to the opposers the significant role
played by the practice and the adverse effects that are
associated withafailure to implement the evidence-based
practice. If the concerns raised would be difficult to be
addressed orally, then, I will refer the concerned to read the
article reviewed regarding the significant role played by noise
masking. Thus, it is hoped that the practice will be successful
and useful in many hospitals and will be critical to reducing
delirium.
References
Maidl, C. A., Leske, J. S., & Garcia, A. E. (2014). The
influence of “quiet time” for patients in
Critical care. Clinical nursing research, 23(5), 544-559.
Weinhouse, G. L., Schwab, R. J., Watson, P. L., Patil, N.,
Vaccaro, B., Pandharipande, P., & Ely, E. W (2009). Bench-to-
bedside review: Delirium in ICU patients - the importance of
sleep deprivation. Critical Care, 13(6), 234-241.
Xie, H., Kang, J., & Mills, G. H. (2009). Clinical review: The
impact of noise on patients’ sleep and the effectiveness of noise

reduction strategies in intensive care units. Critical Care, 13(2),
208-215.
Running head: LITERATURE REVIEW 1
LITERATURE REVIEW 7
Literature Review: ICU Quiet Time
Name
Institution
Literature Review
Introduction
Literature review represents very integral aspects of the
research process. It is aimed at deriving out the current
knowledge on the selected topic including the common patterns,
contradictions, and gaps and, as a result, aid in determining
what needs to be done by future researchers. In the present
paper, the aim is to analyze and synthesize studies that have

been conducted focusing on ICU Quiet time and more
particularly, the effects of strict enforcement of scheduled hours
of rest time on multiple incidences of delirium in adult critical-
care patients in the ICU.
History
The onset of ICU Quiet time has been reported as dating back in
the 1960s. It originated in the North America and, in particular,
Quebec, Canada. It took place as a result of the natural
continuation of creativity and innovations that occurred in
Quebec. The period saw the introduction of the Hospital
Insurance and Diagnostic Services Act, which brought rise to
the concept and practice of public health insurance. This
triggered the implementation of varied infrastructural projects
in the health care. It is in the course of these changes that quiet
time in ICUs was introduced with the aim of speeding up the
healing of the patients. This practice prevails even in the
modern day times.
Current Evidence
For a considerable period, research on ICU Quiet time has been
rampant. Most of the frequent cited studies include Gardner,
Collins, Osborne, Henderson, and Eastwood (2008), Maidl,
Leske, and Garcia (2013), Olson, Borel, Laskowitz, Moore, and
McConnell (2001), Richardson, Thompson, Coghill, Chambers,
and Turnock (2009), Taylor (2008) and Weinhouse et al. (2009).
In their study, Gardner, Collins, Osborne, Henderson, and
Eastwood (2008) used a sample of 299 participants. The sample
received a scheduled quiet time intervention. In the process, the
researchers evaluated the levels of noise, the rest of the
inpatients, their sleep behaviors, and their well-being. It was
concluded that the majority of the ICU patients are not usually
concerned with noise. However, they often prefer a period in
which they are not exposed to noise. The researchers also
identified that nurses also see a great value in ICU Quiet time.
In another study by Maidl, Leske, and Garcia (2013), the
researchers carried out a set of non-randomized, uncontrolled
quiet time trials in ICUs. The intervention involved a reduction

of the environmental stressors and enhanced patient rest prior to
the onset of the trials. It was determined that ICU patients often
prefer quiet time. Also, according to the researchers, the
nursing practitioners that work in the ICUs also value quiet time
as they are allowed to chart and, as a result, reduce their levels
of stress. In the process, better care is facilitated.
In another study by Olson, Borel, Laskowitz, Moore, and
McConnell (2001), a sample of 239 ICU patients were subjected
to a number of observations. As such, they were observed at
least eight times each day prior and after the implementation of
quiet time protocol. It was identified that the implementation of
quiet time is of central importance as it reduces not only sound
but also the levels of light. In addition to this, it was determined
that the patients are more likely to fall asleep during quiet time
as opposed to those who are exposed to noise and light.
Richardson, Thompson, Coghill, Chambers, and Turnock (2009)
also conducted a study on quiet time in ICUs. The aim was to
decrease the levels of noise. The researchers came up with a
primary clinical guideline that was constituted of pre-
assessment, education, as well as, the implementation of the
intervention. It was identified that noise reduction programs are
very effective in reducing the levels of noise in an ICU. It was
also concluded that patients often recover at a faster rate in
ICUs where the levels of noise have been reduced. This is
especially due to the notion that they tend to fall asleep more.
This, according to the researchers, should be the case for the
ICU patients.
A similar study was conducted by Taylor (2008). The aim was
to investigate the best visiting practices. To do this, the
researcher implemented a naturalistic intervention involving
visitors, ICU patients, and the nurses. From the results of the
study, the researchers concluded that all the participants valued
visiting times. However, each of them saw quiet time as an
essential intervention in ICUs. Weinhouse et al. (2009), on their
part, conducted a review of literature in which the intention was
to investigate the clinical and neurobiological effects of the

deprivation of sleep. The researchers also investigated the
potential association that prevails between the deprivation of
sleep and delirium in ICU patients. It was identified that,
experimentally and clinically, the deprivation of sleep compares
closely with delirium. The researchers also named some of the
similarities where they defined them as deficits in memory and
attention, poor processing of thoughts, along with alterations in
the mental status of the ICU patients. The researchers concluded
that delirium had negative effects on patient sleep in ICU.
Clearly, the current body of research is consistent. As it can be
seen, each of the study that has focused on the incidences of
delirium and ICU Quiet time seem to come to a similar
conclusion; that ICU patients value ICU Quiet time and reduced
delirium. Most of the researchers, however, focus on the ICU
patients. It must be understood that visitors and nurses are also
important stakeholders. Thus, it is imperative to determine their
perceptions regarding the issue. From the review, the only
studies that focus on visitors and nurses are that by Weinhouse
et al. (2009) and Maidl, Leske, and Garcia (2013). There is
indeed consistency with the findings of the two studies given
that they report the same findings. While this is the case, there
is a need for further research, not only to increase the
knowledge of the same but also to confirm the validity and the
reliability of such findings.
Another notable thing about the present studies is the idea that
they all focus on noise alone as the source of delirium. In a
study by Xie, Kang, and Mills (2009), the researchers identified
that noise is not the sole factor that disrupts sleep. As such,
there are a series of other influences that cause the same effect.
The researchers also identified that sound masking is the most
appropriate approach for improving the sleep of ICU patients.
This study clearly suggest that a discrepancy with the current
research exists. It shows that the current knowledge is limited
and construed. There is a need to expand the scope by covering
other types of stressors. On top of this, the current body of
research clearly fails to acknowledge on what interventions

should be implemented in order to improve on ICU Quiet time.
This is also an area that should be considered in future research.
Conclusion
Although there is consistency in findings, ICU quiet time needs
further review given the limited nature of comparative research.
There are several gaps that can be attributed to the present body
of research. The larger part of the research has focused on the
ICU patients. They have utterly failed to consider the
perceptions of other interested groups and these include visitors
and staff. In addition to this, there is a gap in that current
studies see noise as the sole stressor. Besides, most studies do
look at the possible interventions to guarantee ICU Quiet Time.
In order to expand the body of knowledge, there is a need to
focus on other environmental stressors.
Summary
A review of literature was carried out with the aim of assessing
the current evidence to aid in investigating the effects of strict
enforcement of scheduled hours of rest time on multiple
incidences of delirium in adult critical-care patients in the ICU.
The studies reviewed clearly evidenced that ICU patients
usually value quiet time. However, they seem not to focus on
the perceptions of other stakeholders such as the staff and the
visitors. Also, they do not focus on other stressors aside from
noise. Besides, not one the studies focused on the appropriate
interventions. These gaps call for further research.

References
Gardner, G., Collins, C., Osborne, S., Henderson, A., &
Eastwood, M. (2009). Creating a therapeutic environment: A
non-randomised controlled trial of a quiet time intervention for
patients in acute care. International journal of nursing studies,
46(6), 778-786.
Maidl, C. A., Leske, J. S., & Garcia, A. E. (2014). The
influence of “quiet time” for patients in critical care. Clinical
nursing research, 23(5), 544-559.
Olson, D. M., Borel, C. O., Laskowitz, D. T., Moore, D. T., &
McConnell, E. S. (2001). Quiet time: A nursing intervention to
promote sleep in neurocritical care units. American Journal of
Critical Care, 10(2), 74-78.
Richardson, A., Thompson, A., Coghill, E., Chambers, I., &
Turnock, C. (2009). Development and implementation of a noise
reduction intervention programme: a pre‐and postaudit of three
hospital wards. Journal of clinical nursing, 18(23), 3316-3324.
Taylor, A. (2008). Exploring patient, visitor and staff views on
open visiting. Nursing Times, 104(40), 30-33.
Vaccaro, B., Pandharipande, P., & Ely, E. W (2009). Bench-to-
bedside review: Delirium in ICU patients - importance of sleep
deprivation. Critical Care, 13(6), 234-241.
Xie, H., Kang, J., & Mills, G. H. (2009). Clinical review: The
impact of noise on patients’ sleep and the effectiveness of noise
reduction strategies in intensive care units. Critical Care, 13(2),
208-215.
Running head: ICU QUIET TIME
1

ICU QUIET TIME
5
Researchable Topic: ICU Quiet Time
Ese Nosakhare
Nurs-6052N Essentials of Evidence-Based Practice
June 13, 2015
The identification of the research problem is the first and
foremost step that every researcher has to undertake. The
hardest thing for a nurse in evidence-based practice (EBP) is
coming up with a clinical question that can be answered with
research-based evidence (Polit and Beck, 2012). Knowing this,
a clinical question that is focused on patients and significant to
nursing can help obtain the knowledge needed to address the
needs of certain patient populations (Thibane, Thomas & Ye,
2009). A nurse making a clinical question that can be answered
requires a game plan that can identify pertinent nursing issues.
Furthermore, the nurse must put that nursing issue into an easy
format for research. Doing so will allow the best evidence to
achieve EBP (Richardson, 2009). Analyzing present issues in

nursing connected to evidence based practices for ICU delirium,
a nurse should have the capability to identify certain steps in
making a well rounded clinical question that is structured and
focused on the key features to help complete evidence-based
practice. Therefore, this discussion is aimed at deriving the
correct clinical question to assist in research. The study is
primarily concerned with how to reduce incidences of
disorientation in ICU patients using the PICO format.
Developing a research problem is a creative process (Polit
and Beck, 2012, p. 76). Neurotrauma ICU patients typically
have an increased need for sleep. However, the ICU setting
predisposes ICU patients to sleep deprivation due to exposure to
bright lights, high noise levels, the regular intrusion of staff and
visitors, and patient care activities. Current evidence suggests
that a relationship exists between sleep, delirium, and mortality
(Gardner & Henderson, 2009). Delirium is commonly linked to
higher medical costs, increased risk of death and extended
hospital stays. There has not been a direct between lack of
sleep and restlessness. Current knowledge that sleep deprivation
affects cognitive function point to a very direct connection
between the two.
Extended hospital stays, increased medical costs and high
risk for mortality have been directly associated with fever
(Weinhouse & Watson, 2009). Nurses can assist with decreasing
the incident delirium in ICU patients by implementing simple
methods and hence help improve health outcomes. Some of
these methods include turning off lights or even dimming them,
reducing noise levels, reducing the number of visits/intrusions,
proper positioning of patients and adequate pain control, etc.
All these interventions aim at helping patients have some quiet
time (Gardner & Henderson, 2009).
According to Thabane in his book, “Exploring patient,
visitor and staff views on open visiting.” He states that the
practicality of carrying out any study venture is based on the
study question and should be well thought-out early in the
procedure in order to steer clear of waste of useful power and

intellectual vigor (Thabane, Thomas and Paul, 2006). Once one
has identified a topic of interest, you can ask wide-range
questions that can lead you to a researchable problem (Polit &
Beck, 2012). These questions can assist one place emphasis on
the research problem and give the focus better clarity. The
questions to add to the background are listed below:
1. What are the current practices regarding delirium
management in the Neuro ICU?
2. What are the main influencing factors for the implementation
of the ICU delirium guidelines in the Neuro ICU as reported by
the doctors, RN’s and administration?
3. What should be the specific information to improve delirium
guidelines based on the answers to the first questions?
4. What are other alternative methods to cope with the current
problem in Neuro-trauma ICU?
5. What is the expected outcome of applied interventions?
6. What time frame is required? (If applicable).
These PICOT questions will enable asking of well
structured, clear, focused and answerable questions. Key
concepts and words derived from the question are then used in
medical literature and nursing research for the most excellent
evidence today.
The principle for generating an answerable query is
followed the PICO format; Population at risk, Intervention,
Comparison, Outcome. PICO is a systematic and consistent
method used to identify the components of a clinical matter.
The use of the PICO format to formulate a clinical question aids
in the clarification of certain aspects of the clinical subject.
This clarification will help guide the study of the evidence.
When a PICO question is properly defined, the probability of
finding the best evidence to guide clinical practice in a quick
and efficient manner increases. In this case the PICO question
would be; In the ICU patients, does reducing intrusion and noise
result in proper sleep and reduced delirium?
A literature search was conducted using Pub MED,
CINAHL and EBSCOhost databases. The keywords used for the

searches were; ICU, delirium, quiet time, enforced visitations,
rest periods, patient outcomes and sleep. The inclusion criteria
were only articles from the past decades, inpatient, adult
critical-care patients. The initial search yielded 70 articles.
Using these terms in database search engines mentioned above
will help find research evidence to answer this specific PICO
question.
Conclusion
The objective of this research is to investigate if
strict enforcement of scheduled hours of rest time would
decrease the multiple incidences of delirium in adult critical-
care patients in the ICU. ICU patients have a very high risk for
lack of sleep, which leads to a source of concern for multi-
disciplinary teams in health care. Nurses have a vital role to
play in executing and leading change to improve patient’s sleep.
Prevention and adequate management of sleep deprivation in
ICU patients may help reduce the incidence of delirium and its
negative effects. Studies have correlated sleep deprivation with
incidences of delirium in ICU patients, which lead to impaired
cognitive function and longer hospital stays. With this specific
topic and PICO question, I fully commit to answering my
background questions and sharing the findings.

References
Gardner, G., Collins, C., Osborne, S., Henderson, A., &
Eastwood, M. (2009). Creating a therapeutic environment: A
non-randomised controlled trial of a quiet time intervention for
patients in acute care. International Journal of Nursing Studies,
778-786.
Richardson, A., Thompson, A., Coghill, E., Chambers, I., &
Turnock, C. (2009) Development and implementation of a noise
reduction intervention program: A pre- and post-audit of three
hospital wards. Journal of Clinical Nursing, 3316-3324.
Thabane L, Thomas T, Ye C, Paul J (2006).. Posing the research
question: Not so simple. Exploring patient, visitor and staff
views on open visiting. Nursing Times.
Vaccaro, B. & Ely, E. W (2009). Bench-to-bedside review:
Delirium in ICU patients - importance of sleep
deprivation. Critical Care, 234-241.

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