Potential for contamination of tourniquets during peripheral venipuncture: a scoping review protocol

Background : The tourniquet should be placed above the venipuncture site, thus promoting venous distension. Given its characteristics and use in clinical practice, tourniquets can be a source of microbial contamination. However, the results of scientific studies on this topic are scattered in the literature. Objective : To map the available evidence on the microbial contamination of tourniquets used in peripheral venipuncture, as well as identify health professionals’ practices in handling these devices. Review method : Methodology proposed by the Joanna Briggs Institute. A scoping review protocol was established, which is appropriate to each database/repository, with the purpose of identifying relevant studies that meet the criteria outlined. Two independent reviewers will assess all articles for relevance, as well as perform data extraction and synthesis. Presentation and interpretation of results: The mapping of the potential for contamination of tourniquets and profes- sionals’ practices will contribute to the dissemination of the available evidence. Conclusion: This scoping review is expected to contribute to the critical analysis of the clinical practices in this area, given their potential impact on the safety of care delivery.


Introduction
Peripheral venipuncture for obtaining venous access or collecting blood is one of the most common invasive procedures in clinical settings (Marsh, Webster, Mihala, & Rickard, 2017;Rickard et al., 2012;Wallis et al., 2014). In order to interrupt venous blood flow in the distal area of the limb to be cannulated and, consequently, promote venous distension, tourniquets should be in place no longer than 60 seconds (Gorski et al., 2016). For this purpose, the tourniquet should be applied 5 to 10 centimeters above the puncture site (Veiga et al., 2011). With regard to the clinical equipment used during care delivery, the Portuguese Directorate-General of Health (Direção-Geral da Saúde, 2013) highlighted the infection control precautions for each clinical procedure and the associated risks. In several healthcare units, clinical equipment is still inconsistently and sometimes inadequately managed, which, together with economic constraints, leads to the increasingly inappropriate reuse of materials (e.g., tourniquets) and a non-compliance with specific guidelines (World Health Organization, 2016). However, recent studies point to a large gap between nurses' knowledge and practices in this domain (Aftab, Zia, Zahid, Raheem, & Beg, 2015). Tourniquets used in peripheral venipuncture can be a source of microbial dissemination when inadequately decontaminated; hence, health organizations should ensure that they are disinfected between uses following the manufacturer's instructions (Costa, 2017;World Health Organization, 2010). The latest guidelines recommend that tourniquets should be single-patient use (Gorski et al., 2016) and manufactured using a material with a low risk for microbial contamination, thus discouraging the use of fabric tourniquets (World Health Organization, 2010; Royal College of Nursing, 2016). A preliminary search conducted in the JBI Database of Systematic Reviews and Implementation Reports, the Cochrane Database of Systematic Reviews, CINAHL (via EB-SCO), and MEDLINE (via PubMed) found no literature reviews (published or underway) on this topic. Therefore, the authors decid-ed to conduct a scoping review, based on the methodology proposed by the Joanna Briggs Institute for Scoping Reviews (Peters et al., 2017), with the purpose of mapping the available evidence on the microbial contamination of tourniquets during peripheral venipuncture, while identifying health professionals' practices during this procedure. More specifically, this review aims to answer the following questions: What is the most common microbial contamination found in tourniquets used in peripheral venipuncture (based on contamination rate, counts of microorganisms, their status as species or subspecies, and their resistance profiles)? What are the characteristics of the tourniquets used in peripheral venipuncture (material and design)? What are the health professionals' practices related to handling these devices (hand hygiene, glove use, tourniquet disinfection, sharing tourniquet with other professionals, storage and transport conditions)?

Systematic review method
A scoping review was chosen because its main purpose is to map the evidence available on a given research focus and identify gaps as a preliminary effort to justify the development of a systematic literature review (Peters et al., 2017). In addition, it can be an information tool to assist health professionals in decision-making and clinical practice.

Search strategy and study identification
The scoping review will use the participants, concept, and context strategy (PCC). With regard to participants, the review will include studies which only include health professionals with the appropriate skills to perform peripheral venipuncture (nurses, physicians, phlebotomists, etc.). As regards the concept, it will include studies focused on the potential microbial contamination of tourniquets during peripheral venipuncture and professionals' practices related to handling these devices. Microbial contamination is defined as the soiling of inanimate objects with potentially infectious microorganisms (World Health Organization, 2016). As regards the context, all clinical settings and geographical regions will be included. With regard to study design, this review will consid-ANABELA DE SOUSA SALGUEIRO OLIVEIRA et al. er experimental and epidemiological designs, including randomized controlled studies, quasi-experimental studies, before-and-after studies, and case studies. In addition, it will also consider literature reviews, observational studies, cross-sectional and longitudinal descriptive designs, dissertations, and gray literature. Other texts will also be considered such as opinion documents and reports. In relation to the search strategy and study identification, the following online databases will be searched: JBI Database of Systematic Reviews and Implementation Reports, CINAHL Complete (via EBSCO), MEDLINE (via PubMed), SciELO, Scopus, and Cochrane Central Register of Controlled Trials. The search for unpublished studies will be performed in the Scientific Open Access Repository of Portugal, Banco de Teses CAPES, and OpenGrey.

Data extraction
Data will be extracted by two independent reviewers, using the extraction tool which was developed by the researchers in line with the review objective and questions (Figure 1). During the data extraction process, this instrument can be revised and changed depending on the researchers' needs. Potential for contamination of tourniquets during peripheral venipuncture: a scoping review protocol Extracted data will provide specific details about the population, study designs, and relevant outcomes for the research question and specific objectives. The authors of the studies will be contacted to clarify any doubts or request further information during this process. Any disagreements that may arise between the reviewers will be resolved through discussion, or with a third reviewer.

Data synthesis
Data will be presented in narrative form, using tables, in line with the objective and focus of the scoping review. This process will be achieved through consensus between two reviewers. Any disagreement will be resolved with a third reviewer. In the review question "What is the most common microbial contamination found in tourniquets used in peripheral venipuncture?", the tables and charts can include data indicated in Figure 2.
Data will be presented in narrative form, using tables, in line with the objective and focus of the scoping review. This process will be achieved through consensus between two reviewers. Any disagreement will be resolved with a third reviewer.
In the review question "What is the most common microbial contamination found in tourniquets used in peripheral venipuncture?", the tables and charts can include data indicated in Figure 2.  In the review question "What are the health professionals' practices related to handling these devices?", the tables and charts can include data indicated in Figure 4.   Data will be presented in narrative form, using tables, in line with the objective and focus of the scoping review. This process will be achieved through consensus between two reviewers. Any disagreement will be resolved with a third reviewer.
In the review question "What is the most common microbial contamination found in tourniquets used in peripheral venipuncture?", the tables and charts can include data indicated in Figure  In the review question "What are the health professionals' practices related to handling these devices?", the tables and charts can include data indicated in Figure 4.
In the review question "What are the characteristics of the tourniquets used in peripheral venipuncture?", the tables and charts can include data indicated in Figure 3.
In the review question "What are the health professionals' practices related to handling these devices?", the tables and charts can include data indicated in Figure 4.

Presentation and interpretation of results
Data will be presented in narrative form, using tables, in line with the objective and focus of the scoping review. This process will be achieved through consensus between two reviewers. Any disagreement will be resolved with a third reviewer.
In the review question "What is the most common microbial contamination found in tourniquets used in peripheral venipuncture?", the tables and charts can include data indicated in Figure 2.  Figure 2. Data synthesis grid for the first review question.
In the review question "What are the characteristics of the tourniquets used in peripheral venipuncture?", the tables and charts can include data indicated in Figure 3.  In the review question "What are the health professionals' practices related to handling these devices?", the tables and charts can include data indicated in

Presentation and interpretation of results
The mapping of the potential for tourniquet contamination, as well as the description of the tourniquets' characteristics and the health professionals' practices in handling them, will contribute to the dissemination of the available evidence on this topic.

Conclusion
The analysis of specific domains related to the use of tourniquets during peripheral venipuncture, which are intrinsically associated with health professionals' practices, is essential to ensure quality care, enhance patient and professionals' safety, and reduce the costs associated with this procedure. As contributions to clinical practice, the mapping of the available evidence on the potential for contamination of these devices is expected to inform the analysis of the current practices in this area, as well as to promote the redesign of these practices and the implementation of quality assurance systems in health institutions. In addition, as a research implication, this scoping review is expected to be a preliminary exercise to justify the formulation of specific questions and the development of systematic reviews on the effectiveness of some practices in reducing the potential for contamination of tourniquets during peripheral venipuncture.