Chlorhexidine Gluconate Bathing

Hospital-acquired infections (HAIs) are the leading cause of life-threateningcomplications in the United States (Reagan et al., 2019). HAIs includes central line-associated bloodstream infection (CLABI), catheter-associated urinary tract infection (CAUTI), select surgical site infections (SSI), hospital-onset Clostridium difficile (C-diff), and hospital-onset Methicillin-resistant Staphylococcus aureus (MRSA) (Regan et al., 2019). CLABIs and CAUTIs are the most common HAIs found among oncology and hematology patients due to the complications of diagnoses and treatments making these patients immunocompromised. CLABIs and CAUTIs can delay treatments, extend length of stay, and increase the cost of care for patients (Dixon & Carver, 2010). According to the World Health Organization (WHO), any patient that have devices or wound serves as an entry port for bacteria has an increased risk of a patient acquiring HAIs (Reagan et al., 2019). Most, if not all oncology and hematology patients have either an implanted venous assisted device (IVAD) or a peripheral inserted central catheter (PICC) line to receive their treatments making them at high risk to acquire HAIs. On a Medical/Oncology Unit from August to September 2019, there were multiple CLABIs and CAUTIs cases found back to back among the gerontology oncology and hematology patients. After auditing each CLABI and CAUTI the trend that was found was a lack of daily hygiene and linen changes. Using chlorhexidine gluconate (CHG) to bathe patients is listed as one of the prevention interventions for HAI CLABIs and CAUTIs (Dixon & Carver, 2010). CHG is an antiseptic solution that resides on the skin longer than regular soap, therefore it continues to protect the patient from infection long after they bathe (Reagan et al., 2019). To study the effects of CHG Bathing on HAIs such as CLABIs and CAUTIs, all patients 60 years of age or older who also have central line or Foley catheter admitted onto the Medical/Oncology Unit will be using CHG Bath wipes daily. The goal of this project is to evaluate staff and patients adherence to daily CHG bathing to estimate the effect on preventing HAI CLABIs and CAUTIs.

CHLORHEXIDINE GLUCONATE BATHING Chlorhexidine Gluconate Bathing Mai See Xiong, BSN, RN University of Utah April 22, 2020 In partial fulfillment of a Master of Science degree College of Nursing Major: Nursing Specialty: Nursing Education 1 CHLORHEXIDINE GLUCONATE BATHING 2 Chlorhexidine Gluconate Bathing Hospital-acquired infections (HAIs) are the leading cause of life-threatening complications in the United States (Reagan et al., 2019). HAIs includes central line-associated bloodstream infection (CLABI), catheter-associated urinary tract infection (CAUTI), select surgical site infections (SSI), hospital-onset Clostridium difficile (C-diff), and hospital-onset Methicillin-resistant Staphylococcus aureus (MRSA) (Regan et al., 2019). CLABIs and CAUTIs are the most common HAIs found among oncology and hematology patients due to the complications of diagnoses and treatments making these patients immunocompromised. CLABIs and CAUTIs can delay treatments, extend length of stay, and increase the cost of care for patients (Dixon & Carver, 2010). According to the World Health Organization (WHO), any patient that have devices or wound serves as an entry port for bacteria has an increased risk of a patient acquiring HAIs (Reagan et al., 2019). Most, if not all oncology and hematology patients have either an implanted venous assisted device (IVAD) or a peripheral inserted central catheter (PICC) line to receive their treatments making them at high risk to acquire HAIs. On a Medical/Oncology Unit from August to September 2019, there were multiple CLABIs and CAUTIs cases found back to back among the gerontology oncology and hematology patients. After auditing each CLABI and CAUTI the trend that was found was a lack of daily hygiene and linen changes. Using chlorhexidine gluconate (CHG) to bathe patients is listed as one of the prevention interventions for HAI CLABIs and CAUTIs (Dixon & Carver, 2010). CHG is an antiseptic solution that resides on the skin longer than regular soap, therefore it continues to protect the patient from infection long after they bathe (Reagan et al., 2019). To study the effects of CHG Bathing on HAIs such as CLABIs and CAUTIs, all patients 60 years of age or older who also have central line or Foley catheter admitted onto the Medical/Oncology CHLORHEXIDINE GLUCONATE BATHING 3 Unit will be using CHG Bath wipes daily. The goal of this project is to evaluate staff and patients adherence to daily CHG bathing to estimate the effect on preventing HAI CLABIs and CAUTIs. Method This study was a quality improvement project on reducing Central Line Blood Stream Infection (CLABSI) and Catheter-Associated Urinary Tract Infection (CAUTI) with the intervention of Chlorhexidine Gluconate (CHG) Bath on a Medical/Oncology Unit. Patients included in this project were 60 years and older with a central line and/or a Foley catheter who were admitted for treatment. Patients that were excluded from the project were comfort care patients. All patients included in the CHG Bath were admitted for treatment of the original diagnose or treatment of complications related to their diagnose. All patients had their central line access and placed or a Foley catheter placed either in the clinics or on the unit using the protocol of the facility. The care that nurses and nursing aids provided for central lines and Foley catheters remained the same according to facility and unit protocol. This quality improvement project was conducted for 3 months from January to March 2020. Pre-Implementation Phase The decision on doing this CHG Bath quality improvement project was based on the current findings of the CLABSIs and CAUTIs cases identified on the Medical/Oncology Unit. The CLABSIs and CAUTIs cases were to occur in patients who were 60 years or old, and according to documentation had not bathe, washed their hands, and or had their bed linen changed for 2 days or more. Discussion among the leaderships of the Medical/Oncology Unit decided to go forth with the implementation of daily CHG Bath all patients who are 60 years and older who had a central line and/or a Foley Catheter. CHLORHEXIDINE GLUCONATE BATHING 4 During the time between collecting baseline data and implementation, interprofessional meetings were initiated before the implementation of the project to address all possible gap analysis and planning of the intervention. All registered nurses and nursing aides were trained on identifying appropriate patients and how to perform CHG Bath to ensure that all patients received the same quality of care and treatment protocol upon the implementation of CHG Bath. The leadership of the Medical/Oncology Unit which included the nurse manager, clinical nurse coordinator (CNC), nurse educator, and infection control coordinator were brought together to understand the CHG Bath quality improvement project and the professional role and responsibilities of each staff member. Implementation Phase Once CHG Bath was implemented on the unit from January to March 2020. Every morning the charge nurse identified which patients qualify for CHG Bath based on the criteria. Each patient who qualified for the protocol was identified daily on a tracking sheet and all necessary bathing supplies were labeled individually for them. Once the task was done, the staff will charted on the patient's electronic file and highlight the patient's room number on the tracking sheet as an identification that the task was performed. Daily audits were done on each qualified patient to identify whether or not a CHG Bath was given. If it was not, it was documented if it was due to staff or patient's non-compliance. During shift change report, nurses and aids were responsible to pass off in report if the patient was a CHG Bath patient and either or if the bath was completed during the shift. Data Collection The CHG bathing tracking sheet included a simple grid with space to write down the patient's room number as a reminder that they are qualified for CHG Bath for the day. If a CHG CHLORHEXIDINE GLUCONATE BATHING 5 bath was performed, the room number on the grid was highlighted, indicating that compliance with the quality improvement interventions was 100%. To help with compliance, CHG Bath wipes supplies were set out and labeled with the patient's room number, the primary RN, and the primary nursing aid of the patient, as a reminder that the patient needs to get a CHG bath. This was mentioned by many staff members that it was very helpful in making sure that they were 100% compliant with the quality improvement project. Evaluation The Infection Control Champion Nurse and CNC conducted daily audits on all patients who qualified for CHG Bath. The audit includes compliance rate of staff performing CHG Bath, compliance of patients receiving a CHG Bath, barriers to performing CHG Bath. The nurse manager, CNC, and the unit's clinical practice council (CPC) received monthly reports on compliance rates and barriers. Solutions to barriers were brought up by staff, CPC, CNC, and nurse infection control champion to be able to further the project. All project data were presented monthly to encourage the achievement of goals. The project data compared the rates of CLABSI and CAUTI in the 3-months of using CHG Bath with the previous months of no CHG Bath usage on the unit. Surveys and meetings were conducted to assist nurses and nursing aids in working together to identify gaps and barriers and brainstorm successful solutions to overcome these identified barriers. The Infection Prevention Coordinator, Nurse Educator, and CNC assisted in giving CHG Baths and evaluated staff when performing CHG Bath to ensure that the task was being performed correctly and provide any additional education if needed. They rotated around different shifts to be able to answer all questions and concerns about possible problems of CHG Bath throughout the 3 months. CHLORHEXIDINE GLUCONATE BATHING 6 Ethics of Methodology An ethical situation that was discussed was why would CHG Bath not be performed on other patients with a central line or Foley catheter just because they are not 60 years or older. Regardless, if a patient is younger or older than 60, having a central line and/or a Foley catheter puts them at risk for an infection. This could be seen as not all patients are getting equal care and treatment. The argument for this decision is that majority of CLABSIs and CAUTIs cases were among patients who are 60 years or older. Being at an older age, these patients are often more fatigued and less likely to care for themselves appropriately, leaving them to be at a higher risk. The quality improvement project is focused on the gerontology patient population; however, if a benefit is realized, the plan is to extend this to include all patients. Results During the initial 3-month study from January 2020 to March 2020, the average compliance level was 79% for daily CHG Bath. The study included a total of 528 patients who had the opportunity to receive CHG Bath. Out of the 528 patients, 421 patients received daily CHG Bath. 35 of the 528 patients refused the CHG Bath at least once during their admission, which resulted in having 93% of patient compliance. Fatigue and inconvenience were some of the reasons why the patient refused. Patients were interviewed throughout the project about their understanding of CHG Bath and their compliance level with getting a CHG Bath. 72 of the 528 patients did not get a CHG Bath due to poor communication among staff or the staff simply did not get to the task, which results in having 86% of staff compliance. In January 2020, there was an 80% compliance level. In February 2020, there was a 78% compliance level. Lastly, in March 2020, there was an 80% compliance level (Table 1). Table 1. Compliance Rate for CHG Bath per month. CHLORHEXIDINE GLUCONATE BATHING Months January 2020 February 2020 March 2020 CHG Performed 174 142 105 CHG Not Performed 43 39 25 7 Total # of Patients 217 181 130 Percentage of Compliance 80% 78% 80% Since the implementation of CHG Bath in January on the Medical/Oncology Unit, there have been no new cases of CLABSIs or CAUTIs reported. September 24, 2019, was the last reported CLABSI and CAUTI on unit, therefore, 3 months before the implementation there were no cases and no new cases since the implementation. Altogether it has been a total of six months with no CLABSIs or CAUTIs cases on the unit. Based on these results, the protocol of daily bathing with CHG Bath wipes will be continued on the unit with minor changes as extending CHG Bath to all patients with central lines and/or Foley Catheters. The ongoing staff compliance will be monitored through monthly audits. The unit has set a goal to have an 82% compliance level for the daily CHG Bath protocol. Barriers and Solutions to Staff's Compliance A survey was sent out allowing staff members to report barriers, problems, failures, success, solutions that they came up with in giving CHG Baths. Some the barriers or problems to non-compliance is patient feeling too fatigued, coordinating the time to do the CHG Bath when the patient also has other appointments such as PT, OT, and visitors, and identifying and passing on in report to the next shift if the patient is a CHG Bath patient or not. These barriers were addressed with solutions such as performing CHG Bath for the patient while they rest in bed taking less than 10 mins. Also working as a team if the patient is available for a CHG Bath and the primary nursing aid is not available either the primary RN or any available staff step in to assist with the CHG Bath. Another solution was making it a priority and requirement for RN to report to nursing aid if the patient is a CHG Bath patient. CHLORHEXIDINE GLUCONATE BATHING 8 Patient's Level of Compliance The majority of patients were very compliant with receiving CHG Bath regardless if they have a full understanding of how it is beneficial to them or not. In one of the interviews, the patient mentioned "I know that they say it will help but I don't remember how. It's ok. I trust my nursing aid and RN that they are just doing it to protect me" (B. Laree, personal communication, January 31, 2020). One incident, when the charge nurse had to provide additional education when the patient refused the CHG Bath, after the patient was given the CHG Bath, charge nurse reported patient saying, "it actually felt pretty good" (W. Anastasia, personal communication, February 18, 2020). Limitations A potential study limitation was the usage of CUROS caps during the time the CHG Bath went live. CUROS caps are alcohol-containing caps that are twisted onto ports of IV tubing lines and central lines for disinfection and protection (3M, 2020, para. 2). According to 3M (2020), the consistent use of CUROS disinfecting caps on an IV needleless connector has been associated with decreasing CLABSIs. (para. 2). 3M (2020) claim, that CUROS caps can protect ports up to 7 days if it is not removed (para. 1) The usage of CUROS caps and CHG Bath at the same time made it difficult to measure and determine the amount of benefit from each intervention. Although, one can state that it is probably the use of CUROS caps and not CHG Bath that is preventing CLABSIs and CAUTIs. However, CUROS caps can explain central line infections but not urinary tract infection. It can be argued that even if CHG Bath is not the main contributor to reducing CLABSIs or CAUTIs, it does provide additional protection to the patient on top of the use of CUROS caps in preventing and reducing CLABSIs and CAUTIs. CHLORHEXIDINE GLUCONATE BATHING 9 Discussion CHG Bath has been known to be used the majority in critical care units due to the highest risk of complications patients can develop while on ventilators, have multiple access lines, and are at a completely vulnerable stage. With the same idea that oncology and hematology patients are very vulnerable to infection, daily CHG Bath was implemented on an acute care unit, Medical/Oncology Unit. CLABSIs and CAUTIs are most commonly HAIs found among oncology and hematology patients due to the high demand use of IVAD, PICC, and Foley catheters. The use of daily CHG Bath on the Medical/Oncology Unit which includes oncology, hematology, and BMT patients, has significantly reduced the rate of CLABSIs and CAUTIs cases. The result of this quality improvement study supports the findings of other researchers that there is a decrease incidence of CLABSIs and CAUTIs with the use of CHG Bath wipes for daily patient bathing. According to the CDC (2019), the estimated cost for a CLABSI is about $46,000. In August 2019 the Medical/Oncology Unit had 2 CLABSIs incidents and according to CDC's estimated cost, it would have resulted in $92,000. Given these cost estimates, the CHG Bath used in this quality improvement project cost approximately $40,500 for the 3-month time period which is still less than one CLABSI occurrence alone. The clinical implication of this quality project is clear: daily bathing with CHG Bath wipes can significantly decrease the rates of CLABSIs and CAUTIs. CHG Bath does not require additional work on the part of the nursing staff because it replaces the existing bathing process. For hospitals, there is no change in the budget because CHG Bath wipes cost the same amount as the regular bath wipes only that CHG Bath wipes will be more effective and beneficial to CHLORHEXIDINE GLUCONATE BATHING 10 patients. Preventing patients from developing HAIs, hospital facilities will be saving more and spending less. Nursing staff may think that they don't have much control over the infections that patients develop, but they possess more power than any other medical staff when it comes to protecting patients from developing infections during their hospital stay. HAIs usually develop in patients when staff forgets or neglect to follow patient care protocols due to a variety of reasons. Washing hands, changing bed linen, scrubbing caps of access lines before and after medications, etc. are all the little and simple things but yet have a significant impact on patient care. Providing daily CHG Bath can help prevent and reduce the amount of CLABSIs and CAUTIs is a great reminder to nursing staff that simple task can make a huge impact on patient care. Nursing staffs are advocates for the patient during vulnerable times, therefore, it must be our priority and responsibility to do everything we can to protect our patients from getting harm regardless it if is from people or infections. In all acute care units, not only basic infection prevention should be taken into measures, but the implementation of evidence based daily CHG Bath should be an alternative method to decrease the infection rate and improving patient outcomes. Conclusion Prevention of HAIs such as CLABSIs and CAUTIs are the key focus of medical professionals. CLABIs and CAUTIs are common complications in immunocompromise patients with devices. The Medical/Oncology Unit has a good compliance rate of infection prevention but CLABSIs and CAUTIs incidences persisted. After reviewing much evidence-based literature it was decided to implement the daily use of CHG Bath on the Medical/Oncology Unit. The unit will be performing daily CHG Bath to prevent and reduce HAIs such as CLABSIs and CAUTIs. CHLORHEXIDINE GLUCONATE BATHING 11 After implementing CHG Bath on the unit for a 3-month time period it was found that there were no occurrences of CLABSIs and CAUTIs. It has been a total of six months since the last CLABSI and CAUTI occurrence. Including CHG Bath in the daily routine care for patients has increased patient's cleanliness and decrease the rates of CLABSIs and CAUTIs. It has been noted that there has also been an increase in daily bathing for patients and daily bed linen change which contributes to reducing HAIs. The continued use of CHG Bath wipes will only improve rates of CLABSIs and CAUTIs in this Medical/Oncology Unit. One year prior to the implementation of this project, an acute care unit (Hematology/BMT Unit) in the same facility, who had been doing daily CHG Baths had similar results of a decrease in the rate of CLABSIs and CAUTIs. From the result of these two acute care units, it demonstrates that CHG Bathing can be successfully implemented and beneficial to any acute care unit with patients that have a high use of central lines and/or Foley catheters across the nation. The initial CHG Bath quality improvement project was done on patients of 60 years or older with a central line and/or a Foley catheter. The next implementation is to include all patients with a central line and/or Foley catheter regardless of age. It is important to include all patients regardless of age because according to WHO, all patients that have devices are at a risk for HAIs (Reagan et al., 2019). Daily CHG Bath on this Medical/Oncology Unit will continue to be implemented into their daily routine care for all patients admitted unto the unit. CHLORHEXIDINE GLUCONATE BATHING 12 References Centers for Disease Control and Prevention. (2019). Staphylococcus aureus in healthcare settings. Retrieved from https://www.cdc.gov/hai/organism/staph.html Dixon, J.M., & Carver, R.L. (2010). Daily chlorhexidine gluconate bathing with impregnated cloths results in statistically significant reduction in central line-associated bloodstream infections. American Journal of Infection Control, 38 (10),817-821. doi:10.1016/j.ajic.2010.06.005 Reagan, K.A., Chan, D.M., Vanhoozer, G., Stevens, M.P., Doll, M., Godbout, E.J., … Bearman, G. (2019, August 7). You get back with you give: Decreased hospital infections with improvement in CHG bathing, a mathematical modeling and cost analysis. American Journal of Infection Control, 47, 1471-1473. Retrieved from https://www.sciencedirect.com/science/article/piiS0196655319306832 Vanhoozer, G., Lovern, I., Masroor, N., Abbas, S., Doll, M., Cooper, K., … Bearman, G. (2018, October 12). Chlorhexidine gluconate bathing: Patient perceptions, practices, and barriers at a tertiary care center. American Journal of Infection Control, 47. Retrieved from https://www.sciencedirect.com/science/article/pii/S0196655318308265 3M. (2020). 3M curos disinfecting cap for needleless connectors. 3M Science Applied to Life. https://www.3m.com/3M/en_US/company-us/all-3m-products/~/3M-Curos-DisinfectingCap-for-Needless-Connectors/?N=5002385+3292659417&rt=rud