Improving Urinary Catheterization Reducing Catheter-Related In
finalEBP
1. Evidence Based Practice
Self-learning Packet
Ashley Epprecht, Alexis Reed, Kate
Shaner, Chelsea Undheim
(http://shopsageproducts.com/store/p/62-
Fragrance-Free-Essential-Bath-Cleansing-
Washcloths.aspx)
3. CURRENT PRACTICE
• At Saint 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
• Soap and 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 A HAI?
• 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
• Know the 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 OF HAI’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 OF HAI’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
• Articles Reviewed: 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
• Daily CHG 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
• Some nurses 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 identification of 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)
19. Every day, every patient
(http://ep.yimg.com/ca/I/yhst-
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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
