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- 1. Evidence Based Practice Self-learningPacket Ashley Epprecht, Alexis Reed, Kate Shaner, Chelsea Undheim (http://shopsageproducts.com/store/p/62- Fragrance-Free-Essential-Bath-Cleansing- Washcloths.aspx)
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- 3. CURRENT PRACTICE • AtSaint Joseph Medical Center on 2 North, a progressive care unit, the current practice for bathing patients, with or without central lines, is the use of soap and water in a bath basin. • The care providers use warm water, soap, clean washcloths, and a standard six quart basin to bathe patients daily. (http://www.medscape.com/viewarticle/586213_4)
- 4. THE PROBLEM • Soapand water bath basins have been found to be sites for colonization of bacteria. • These basins serve as reservoirs that could lead to patient contamination by hospital acquired infections. (Powers, Peed, Burns, & Ziemba-Davis, 2012)
- 5. WHAT IS AHAI? • A hospital-associated infection (HAI) is a type of infection that occurs due to contact with a contaminated healthcare provider, or their interventions. (Pennsylvania Department of Health, 2012) • For example, a health worker’s contaminated hands (Derde, Dautzenberg, & Bonten, 2012) • Infections can range from surgical wounds to pneumonia. • HAIs are considered to be one of the leading causes of death. • They can cost the health care system billions of dollars annually. (Pennsylvania Department of Health, 2012) • The most common bacteria are: • Methicillin-resistant Staphylococcus aureus (MRSA) • Vancomycin-resistant Enterococcus (VRE) (Powers et al., 2012)
- 6. WHAT IS CHG? •Chlorhexidine gluconate (CHG) is a topical antiseptic solution. • It is effective against gram positive and gram negative bacteria. • When diluted with water, such as in a bath basin or in wipes, CHG alters the bacterial cell wall. (Petlin, Schallom, Prentice, Sona, Mantia, McMullen, & Landholt, 2014) (http://ep.yimg.com/ca/I/yhst- 87084252606611_2267_2066974344)
- 7. PICO QUESTION • Population:progressive care unit (PCU) patients • Intervention: chlorhexidine gluconate (CHG) bath • Comparison: soap and water basin bath • Outcome: decrease in rate of HAI’s • For PCU patients, does the use of CHG baths reduce the risk of nosocomial infections compared with basin baths?
- 8. LEARNING OBJECTIVES • Knowthe most common HAIs • Understand which patients are most at risk for acquiring HAIs • Recognize the barriers to patients receiving CHG baths • Know the benefit of using CHG for bathing patients daily
- 9. SIGNIFICANCE: PREVALENCE OFHAI’S • In one study, 132 patients of 34,333 patient days acquired MRSA (3.84 is the acquisition rate). • The acquisition rate of MRSA was 3.84 per 1,000 patients days with soap and water. (Petlin et al., 2014) • It is estimated that more than 125,000 patients are hospitalized with infections because of MRSA each year. (Chen, Li, Li, Wu, & Zhang, 2013) • Patients who are suffering profound illnesses, such as those in ICU and PCU, are most at risk for acquiring HAIs. • In 2012, St. Joseph Medical Center had a 1.88 infection rate per 1,000 patient days. • This facility had a total of 70 infections that year (2012). • In the previous year, 2011, they only had 61 infections and in 2010 they had 45 infections. • This shows that St. Joseph Medical Center had a rising infection rate. (Pennsylvania Department of Health, 2012)
- 10. SIGNIFICANCE: COST OFHAI’S VS. CHG • Cost of bath basin - $0.35 • Estimated cost of linen • Washcloths – $0.04 (estimated 6 per bath – $0.24) • Bath towels – $0.21 (estimated 4 per bath -$0.84 • Cost of 4oz bottle of CHG $1.75 • Total cost of CHG bath with basin - $3.18 • Cost of CHG impregnated wipes- $5.52 • Difference of difference of $2.34 (Petlin et al., 2014) • HAIs are associated with increased cost of care and longer length of stay. (Karki, & Cheng, 2012) • HAIs are associated with considerable morbidity and mortality rates and extra costs that are no longer reimbursed by third party providers. (Septimus, Hayden, Kleinman, Avery, Moody, Weinstein, Hickok, Lankiewicz, Gombosev, Haffenreffer, Kaganov, Jernigan, Perlin, Platt, & Huang, 2014) • The estimated cost of contaminated blood cultures is $4,500-$10,000 per patient. • This cost comes from the unnecessary use of antibiotics, additional lab tests, and increased length of stay. • The contamination comes from the introduction of organisms from the skin into the blood cultures and from inadequate preparation of the skin. (Septimus et al., 2014)
- 11. LITERATURE REVIEWED • ArticlesReviewed: 16 • Articles Appraised: 9 • Data Bases Searched: Pubmed, Ebsco, Google Scholar, Cochrane, Alvernia Interlibrary Loan, JSTOR • Keywords Used: CHG, chlorhexidine gluconate, basin baths, soap and water baths, CHG versus soap and water • Search Limits: peer-reviewed, systematic reviewed, years 2010-2015
- 12. SUMMARY OF EVIDENCE •Soap and water bath basins are found to be reservoirs for bacteria and potential development for HAIs. • When swabbing bath basins, 90% of basins grew bacteria. • The most common bacteria found were Enterococci and gram-negative organisms. • The only basins with positive growth were ones from female patients. • Researchers found that hospital tap water is a large source of bacterial contamination. (Powers et al., 2012) • CHG bathing reduces the acquisition of VRE, C.Diff, and MRSA by hospitalized ICU patients. • 132 patients hospitalized during 34,333 patient days acquired MRSA (3.84) using bath basins. When using 4oz of 4% CHG with warm water and a 6 quart basin, 109 patients acquired MRSA in 41,376 patient days (2.63). • CHG bathing is “easy to implement, cost-effective, and led to decreased unit- acquired MRSA rate in a variety of adult intensive care units.” (Petlin et al., 2014)
- 13. SUMMARY OF EVIDENCE •Daily bathing with CHG washcloths significantly reduced the risks of acquisition of multidrug resistant organisms and hospital acquired infections. • The CDC has a variety of strategies to prevent HAIs, including hand hygiene and implementing isolation precautions, but these strategies require consistent adherence by a large numbers of healthcare providers. • HAIs are associated with considerable morbidity and mortality rates and extra costs that are no longer reimbursed by third party providers. (Climo, Yokoe, Warren, Perl, Bolon, Herwaldt, Weinstein, Sepkowitz, Jernigan, Sanogo, & Wong, 2013) • Patients with central lines who received daily CHG baths were associated with lower colony counts of cultivable cutaneous bacteria. • With no CHG exposure, the colony count of 4 swabs was 5,145. • With heavy exposure to CHG (>14 CHG baths), there were 0 colony counts. (Soma, Qin, Zhou, Adler, Berry, & Zerr, 2012)
- 14. SUMMARY OF EVIDENCE •The no rinse impregnated cloths have been shown to deliver CHG (500mg) more effectively, leading to a greater and rapid reduction in bacterial load on skin. • The analysis showed a greater than 50% reduction in risk of VRE or MRSA colonization. (Karki & Cheng, 2012) • CHG has been proposed as a measure to limit the spread of antimicrobial resistant bacteria. • CHG is best used when applied to all patients in a unit simultaneously. (Derde et al., 2012) • The overall ICU blood culture contamination rate range from 4%-5.5%. • CHG usasge can lead to unnecessary removal of central lines, unnecessary testing, decreased length of stay, and decreased cost. (Septimus et al., 2014)
- 15. SUMMARY OF EVIDENCE •Colonization with MRSA or VRE is a crucial risk factor for HAIs acquisition. • The bacteria can be colonized in multiple sites of the body such as axillae, anterior nares, inguinal area, and perineum. • CHG cleansing is significantly associated with a decline in the density of VRE on patients skin. • CHG usage can also lead to a decrease in he rate of healthcare workers hands and the environment. (Chen et al., 2013) • Up to 20% of patients admitted to ICUs will develop a HAI during their stay. (Climo, Sepkowitz, Zuccotti, Fraser, Warren, Perl, Speck, Jernigan, Robles, & Wong, 2009)
- 16. NURSING IMPLICATIONS • DailyCHG bathing is a simple but effective way of decreasing MRSA acquisition. • Both basin bathing with 4% CHG in water and 2% impregnated cloths reduce HAIs. • The cost of impregnated cloths are higher, so each unit may choose which method based on preference and cost. (Petlin et al., 2014) • Using these cost-effective and safe strategies is essential in preventing HAIs. • This strategy does not require much change from previous patient bathing practice with the exception of using CHG. (Climo et al., 2013)
- 17. BARRIERS • Skin • Somenurses may think that CHG chemicals will irritate their patients’ skin. • No serious adverse effects of daily use of CHG wipes have been identified. • Serious allergic reactions have been reported, but these are very rare. (Climo et al., 2013) • Nursing perception • Some nurses may not want to change their current practice. • This process is easy to implement and also time saving with the use of CHG impregnated cloths. (Petlin et al., 2014) • Cost • CHG wash is more expensive than soap and water, but preventing HAIs can save the health care system billions of dollars annually. (Petlin et al, 2014) • PPE • The CDC states that without proper adherence to hand hygiene and isolation precautions HAIs will not be prevented. (Climo et al., 2013)
- 18. RECOMMENDATIONS • Prompt identificationof patients requiring isolation precautions is most important. • Skin decontamination will reduce the risk infection for patients during their hospital stay. (Chen et al., 2013) • CHG bathing is acceptable and useful for the reduction of central catheter associated blood stream infections, the decolonization of multi drug resistant organisms, and surgical site infections. • A protocol should be put in place where CHG bathing is standard of care for all patients. (Powers et al., 2012) • CHG bathing with a basin and water would cost $3.18, whereas bathing with CHG impregnated wipes would cost $5.52. • The wipes have 74% higher cost. • It is recommended that CHG with water and a basin is used for the most effective and cost efficient way. (Petlin et al., 2014)
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- 20. REFERENCES CHEN, W., LI,S., LI, L., WU, X., & ZHANG, W. (2013). EFFECTS OF DAILY BATHING WITH CHLORHEXIDINE AND ACQUIRED INFECTION OF METHICILLIN- RESISANT STAPHYLOCOCCUS AUREUS AND VANCOMYCIN-RESISTANT : A META-ANALYSIS. JOURNAL OF THORACIC DISEASE, 5(4), 518-523. DOI: 10.3978/J.JSSN.2072-1439.2013.08.30 CLIMO, M.W., SEPKOWITZ, K.A., ZUCCOTTI, G., FRASER, V.J., WARREN, D.K., PERL, T.M., SPECK, K., JERNIGAN, J.A., ROBLES, J.R., & WONG, E.S. (2009). THE EFFECT OF DAILY BATHING WITH CHLORHEXIDINE ON THE ACQUISITION OF METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS, VANCOMYCIN- RESISANT ENTEROCOCCUS, AND HEALTHCARE-ASSOCIATED BLOODSTREAM INFECTIONS: RESULTS OF A QUASI-EXPERIMENTAL MULTICENTER TRIAL. CRITICAL CARE MED, 37(6), 1858-1865. DOI: 10.1097/CCM.0B013E31819FFE6D CLIMO, M.W., YOKOE, D.S., WARREN, D.K., PERL, T.M., BOLON, M., HERWALDT, L.A., WEINSTEIN, R.A. SEPKOWITZ, K.A., JERNIGAN, J.A., SANOGO, K., & WONG, E.S. (2013). EFFECT OF DAILY CHLORHEXIDINE BATHING ON HOSPITAL-ACQUIRED INFECTION. THE NEW ENGLAND JOURNAL OF MEDICINE, 368(6), 533-542. DOI: 10.1056/NEJMOA1113849
- 21. REFERENCES (CONTINUED) DERDE, L.P.G.,DAUTZENBERG, M.J.D., & BONTEN, M.J.M. (2012). CHLORHEXIDINE BODY WASHING TO CONTROL ANTIMICROBIAL-RESISTANT BACTERIA IN INTENSIVE CARE UNITS: A SYSTEMATIC REVIEW. INTENSIVE CARE MED, 38, 931-939. DOI: 10.1007/S00134-012-2542-Z KARKI, S. & CHENG, A.C. (2012). IMPACT OF NON-RINSE SKIN CLEANSING WITH CHLORHEXIDINE GLUCONATE ON PREVENTION OF HEALTHCARE-ASSOCIATED INFECTIONS AND COLONIZATION WITH MULTI-RESISTANT ORGANISMS: A SYSTEMATIC REVIEW. JOURNAL OF HOSPITAL INFECTION, 82, 71-84 . HTTP:// DX.DOI.ORG/10.1016/J.JHIN.2012.07.005 PENNSYLVANIA DEPARTMENT OF HEALTH. (2012). HEALTHCARE ASSOCIATED INFECTIONS (HAI) IN PENNSYLVNIA HTTP://WWW.PORTAL.STATE.PA.US/PORTAL/SERVER.PT/ COMMUNITY/HEALTHCARE_ASSOCIATED_INFECTIONS/14234/ HAI_ANNUAL_REPORTS/1403644 PETLIN, A., SCHALLOM, M., PRENTICE, D., SONA, C., MANTIA, P., MCMULLEN, K., & LANDHOLT,C. (2014). CHLORHEXIDINE GLUCONATE BATHING TO REDUCE METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS ACQUISITION. CRITICAL CARE NURSE, 34(5), 17-25. HTTP://DX.DOI.ORG/10.4037/CCN2014943
- 22. REFERENCES (CONTINUED) POWERS, J.,PEED, J., BURNS, L., & ZIEMBA-DAVIS, M. (2012). CHLORHEXIDINE BATHING AND MICROBIAL CONTAMINATION IN PATIENTS' BATH BASINS. AMERICAN JOURNAL OF CRITICAL CARE, 21(5), 338-343. DOI:10.4037/ AJCC2012242 SEPTIMUS, E.J., HAYDEN, M.K., KLEINMAN, K., AVERY, T.R., MOODY, J., WEINSTEIN, R.A., HICKOK, J., LANKIEWICZ, J., GOMBOSEV, A., HAFFENREFFER, K., KAGANOV, R.E., JERNIGAN, J.A., PERLIN, J.B., PLATT, R., & HUANG, S.S. (2014). DOES CHLORHEXIDINE BATHING IN ADULT INTENSIVE CARE UNITS REDUCE BLOOD CULTURE CONTAMINATION? A PRAGMATIC CLUSTER- RANDOMIZED TRIAL. INFECTION CONTROL AND HOSPITAL EPIDEMIOLOGY, 35(3), 17-22. DOI: 10.1086/677822 SOMA, V.L., QIN, X., ZHOU, C., ADLER, A., BERRY, J.E., & ZERR, D.M. (2012). THE EFFECTS OF DAILY CHLORHEXIDINE BATHING ON CUTANEOUS BACTERIAL ISOLATES: A PILOT STUDY. INFECTION AND DRUG RESISTANCE, 5, 75-78. HTTP://DX.DOI.ORG/10.2147/IDR.930662