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Daily Bathing With Antiseptic Agent Significantly Reduces Risk of Hospital-Acquired Infections in Intensive Care Unit Patients


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Snapshot

Summary

Nurses and nurse aids in intensive care units bathe patients each day using washcloths impregnated with an antiseptic agent (chlorhexidine gluconate). This practice significantly reduced hospital-acquired infections without having a negative impact on the incidence or severity of skin reactions.

Evidence Rating (What is this?)

Strong: The evidence consists primarily of a randomized study that compared infection rates on nine hospital units during a 6-month period when unit staff used chlorhexidine-impregnated washcloths with a 6-month period in which they bathed patients in the usual manner. Additional evidence comes from an earlier observational study involving six intensive care units that compared infection rates during 6-month periods before and after implementation.
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Developing Organizations

Hunter Holmes McGuire VA Medical Center
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Date First Implemented

2007
The bathing practice began on a pilot basis in the mid-2000s; a multicenter, cluster-randomized trial ran from August 2007 to February 2009.begin pp

Patient Population

Vulnerable Populations > Intensive care unit patientsend pp

Problem Addressed

Hospital-acquired infections are a growing, costly, and largely preventable problem that creates severe health risks for patients and financial and other burdens for hospitals. Traditional infection control practices can reduce the risk of infection and/or its spread once it occurs. However, adherence to these practices remains suboptimal. Daily bathing of patients with an antiseptic agent may be a more feasible, equally effective alternative, but to date many hospitals have not implemented this practice.
  • A common, growing, and largely preventable problem: The prevalence of hospital-acquired infections from multidrug-resistant organisms such as methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococci (VRE) has increased in recent years. For example, between 1990 and 1997, the prevalence of VRE in hospitalized patients increased from less than 1 percent to approximately 15 percent.1 An estimated 1.7 million hospital-acquired infections occur in the United States each year,2 and up to 70 percent of them can be prevented.3
  • Severe health risks for patients: Numerous studies show that hospital-acquired infections lead to longer lengths of stay, greater use of later-generation antibiotics, higher costs, and increased risk of death.1 Roughly 99,000 people die each year due to hospital–acquired infections.2
  • Financial and other burdens for hospitals: A growing number of third-party payers, including Medicare, are no longer willing to pay hospitals additional money to treat hospital-acquired infections.4,5 In addition, whenever an infection occurs, hospitals have to implement costly and burdensome procedures to prevent it from spreading, including isolating patients and requiring all visitors and staff to take cumbersome precautions before every patient encounter, including rigorous hand hygiene and use of protective gowns and gloves.
  • Low adherence: The precautionary measures outlined above tend to be burdensome and require the consistent cooperation of many individuals during many encounters with patients. As a result, adherence to them remains suboptimal.6,7
  • Unrealized potential of daily bathing with antiseptic agent: Daily bathing of patients with chlorhexidine gluconate has been shown to reduce various types of hospital-acquired infections, but many hospitals do not routinely use this approach.8,9,10

What They Did

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Description of the Innovative Activity

Nurses and nurse aids in intensive care units (ICUs) use washcloths impregnated with chlorhexidine gluconate to bathe patients each day. Key elements of this practice are outlined below:
  • Daily bathing, with integration of chlorhexidine based on existing practices: Nurses and/or others responsible for bathing patients incorporate the use of chlorhexidine in a manner consistent with the existing bathing practices in the ICU. In general, units use one of two options, as outlined below:
    • Prepackaged washcloths: During various trials of this practice, unit-based staff used prepackaged, chlorhexidine-impregnated washcloths to bathe patients. This approach was consistent with the previous bathing practices used on these units, which called for bathing with prepackaged washcloths moistened with soap and water (but not chlorhexidine). The chlorhexidine-impregnated washcloths are used for all areas of the body except around the face, so as to avoid getting the antiseptic agent in the mucous membrane or eyes. (Staff members use the regular prepackaged washcloths for these areas.) Since the trials ended, the majority of participating units have continued with this same approach.
    • “Homemade” washcloths: On some units, standard bathing practices entailed staff moistening a regular washcloth using a basin with soap and water. On these units, this practice can be integrated into these existing bathing practices by having staff mix in the appropriate amount of bottled, generic chlorhexidine to create a properly diluted mix for soaking the washcloth.
  • Monitoring for skin reactions: Nurses monitor patients for potential skin reactions that occur as a result of the antiseptic agent. If a serious reaction occurs, the use of chlorhexidine is discontinued for that patient. Over time, the intensity of such monitoring may diminish, as the likelihood of a reaction tends to be quite small.

Context of the Innovation

Opened in 1946, the Hunter Holmes McGuire VA Medical Center (McGuire VAMC) in Richmond, VA, serves the health care needs of more than 200,000 veterans from 52 cities and counties in central and southern Virginia and parts of northern North Carolina.

The impetus for this practice change came from Edward S. Wong, MD, and Michael W. Climo, MD, clinical researchers and infection control practitioners at the facility. These two physicians regularly work with colleagues in other academic medical centers around the country as part of the Centers for Disease Control and Prevention (CDC) Prevention Epicenters Program. Established in 1997, this program brings together staff in CDC’s Division of Healthcare Quality Promotion with academic investigators who research innovative practices to prevent and control hospital-associated infections. As part of this initiative, Dr. Wong and Dr. Climo proposed a pilot study to test the practice of daily washing with chlorhexidine-impregnated washcloths. As discussed in the Planning and Development Process section below, this initial study evolved into several additional, more rigorous studies conducted at various facilities that participate in the Prevention Epicenters Program.

Did It Work?

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Results

This practice significantly reduced hospital-acquired infections and did not have a negative impact on the incidence or severity of skin reactions.
  • Significantly fewer cases of MRSA and VRE acquisition: In a multicenter, cluster-randomized trial involving eight ICUs and a bone marrow transplant unit, the overall rate for acquiring MRSA or VRE was 23 percent lower on units when they used the chlorhexidine-impregnated washcloths than on these same units when they used regular washcloths (5.1 versus 6.6 cases per 1,000 patient days). The difference was somewhat larger for VRE (25 percent) than for MRSA (19 percent).7 In an earlier study involving six ICUs at four academic centers, MRSA infections fell by 32 percent and VRE infections fell by 50 percent during the 6-month period after implementation of the practice, as compared with the 6-month period before.10
  • Significantly fewer bloodstream infections: In the multicenter, randomized trial, the overall rate of hospital-acquired bloodstream infections was 28 percent lower on units when they used the chlorhexidine-impregnated washcloths than on these same units when they did not (4.78 versus 6.60 cases per 1,000 patient days). This difference stemmed primarily from reductions in primary bloodstream infections (31 percent) and central catheter–associated bloodstream infections (53 percent); the practice did not have an impact on the rate of secondary bloodstream infections, which is not surprising given that such infections typically stem from urinary tract or wound infections. The relative reduction in risk of primary bloodstream infections was greatest among patients who had been on the unit for longer periods of time (and hence face a higher absolute risk of infection).7
  • No impact on adverse skin reactions: In the multicenter, randomized trial, the overall incidence of skin reactions was lower among patients bathed with chlorhexidine-impregnated washcloths than those receiving usual care (2.0 versus 3.4 percent). None of the reported reactions in either group appeared to be related to bathing, and most reactions (85 percent) were considered mild or moderate in nature.7

Evidence Rating (What is this?)

Strong: The evidence consists primarily of a randomized study that compared infection rates on nine hospital units during a 6-month period when unit staff used chlorhexidine-impregnated washcloths with a 6-month period in which they bathed patients in the usual manner. Additional evidence comes from an earlier observational study involving six intensive care units that compared infection rates during 6-month periods before and after implementation.

How They Did It

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Planning and Development Process

Key steps included the following:
  • Choosing bathing product: ICUs at McGuire VAMC and most of the other academic medical centers participating in CDC's Prevention Epicenters Program already used prepackaged washcloths as part of the regular patient bathing routine. Consequently, leaders of this practice change decided that using a similar prepackaged product would be the least disruptive way to introduce the new bathing technique.
  • Training nurses: Nurses and other staff involved in bathing patients attended brief, unit-based training sessions to learn the proper technique for bathing patients with chlorhexidine-impregnated washcloths. During the trials, representatives from the company that manufactured the prepackaged washcloths led a session for each participating unit, providing hands-on teaching and reviewing educational aids related to where and how to wash. Since the trials ended, such training occurs on a periodic basis to ensure that new staff learn (and existing staff continue to use) the proper techniques.
  • Removing incompatible products: Because certain skin moisturizers inactivate chlorhexidine, adopting units eliminated these products prior to implementation. To aid in this process during the trials, the company that manufactured the chlorhexidine-impregnated washcloths provided a list of incompatible products. In practice, relatively few units had to switch moisturizers because only a few products are incompatible. On an ongoing basis, decisions to switch or add moisturizers are made after reviewing an up-to-date list of incompatible products.
  • Conducting series of tests: The practice change was evaluated through a series of tests, beginning with a small pilot test and expanding first to a larger observational study and then to a cluster-randomized trial, as described below:
    • Pilot test in one center: In the mid-2000s, Dr. Wong and Dr. Climo conducted a small pilot test in a few ICUs at the McGuire VAMC. This study yielded promising results.
    • Larger observational study: Dr. Wong and Dr. Climo approached colleagues at other academic medical centers about conducting a larger observational study. This study compared pre- and post-implementation infection rates at six ICUs in four academic medical centers, again finding the approach to be effective.
    • Cluster-randomized trial: Buoyed by the success of the observational study, Dr. Wong and Dr. Climo wanted to prove the concept worked through a more rigorous evaluation. To that end, they again worked through the CDC Prevention Epicenters Program to recruit additional medical centers. Ultimately, nine units within six hospitals agreed to participate in a trial.
  • Integrating practice into regular routine: Since conclusion of the larger trial, most units that participated in the various trials have chosen to continue the practice, making use of chlorhexidine-impregnated washcloths a standard part of bathing.

Resources Used and Skills Needed

  • Staffing: The bathing practice requires no new personnel, as existing staff both participate in the upfront training and bathe patients as part of their regular duties.
  • Costs: Data on program-related costs are not available. Such costs tend to be fairly small and will likely be more than made up for by the savings associated with preventing costly infections. As noted, hospitals do not have to use prepackaged washcloths and instead can have staff make the solution in a basin by mixing in the appropriate amount of generic chlorhexidine.
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Funding Sources

Centers for Disease Control and Prevention; Sage Products
CDC provided funding to support the initial pilot tests and the more rigorous multicenter trial through the Prevention Epicenters Program. Sage Products supplied the washcloths for these studies (both regular washcloths and those impregnated with chlorhexidine) and provided training and educational support, including participating in weekly conference calls.end fs

Adoption Considerations

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Getting Started with This Innovation

  • Evaluate severity of problem: Some hospitals and units have a significant problem with multidrug-resistant organisms and hospital-acquired infections, while others do not. Consequently, hospital and/or unit staff considering adopting this practice should first analyze the extent of the problem, including the incidence of infections and its impact on the costs and quality of care.
  • Promote benefits to senior leaders: Data documenting the magnitude of the problem should be shared with senior administrators, along with estimates of the potential cost and quality benefits of adopting this practice. As noted, hospital-acquired infections impose a significant toll on many hospitals, both from a quality and financial perspective. Administrators will likely be swayed by the simplicity and effectiveness of this approach, which prevents infections from occurring in the first place rather than reacting to them when they happen. This “universal decolonization” approach may be an appealing alternative to the traditional, costly, burdensome measures that hospitals use to prevent the spread of infection once it occurs.

Sustaining This Innovation

  • Conduct refresher training sessions: Over time, staff turnover and/or other issues may cause adherence rates to the daily washing practice to drop. To prevent this problem, conduct brief unit-based training sessions on a regular basis.
  • Monitor supply: Supply-chain problems may periodically arise that lead to shortages of available product on the units, particularly with the prepackaged washcloths. To avoid this problem, set up a standardized process and/or designate an individual to make sure that adequate supplies remain on hand.

More Information

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References/Related Articles

Climo MW, Yokoe DS, Warren DK, et al. Effect of daily chlorhexidine bathing on hospital-acquired infection. N Engl J Med. 2013;368(6):533-42. [PubMed]

Climo MW, Sepkowitz KA, Zuccotti G, et al. The effect of daily bathing with chlorhexidine on the acquisition of methicillin-resistant Staphylococcus aureus, vancomycin-resistant Enterococcus, and healthcare-associated bloodstream infections: results of a quasi-experimental multicenter trial. Crit Care Med. 2009;37(6):1858-65. [PubMed]

Footnotes

1 Siegel JD, Rhinehart E, Jackson M, et al; the Healthcare Infection Control Practices Advisory Committee. Management of multidrug-resistant organisms in healthcare settings, 2006. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention. 2009 Dec. Available at: http://www.cdc.gov/hicpac/mdro/mdro_3.html.
2 Klevens RM, Edwards JR, Richards CL Jr, et al. Estimating health care-associated infections and deaths in U.S. hospitals, 2002. Public Health Rep. 2007;122(2):160-6. [PubMed] Available at: http://www.cdc.gov/HAI/pdfs/hai/infections_deaths.pdf (If you don't have the software to open this PDF, download free Adobe Acrobat ReaderĀ® software External Web Site Policy.).
3 Scott RD. The direct medical costs of healthcare-associated infections in U.S. hospitals and the benefits of prevention. Atlanta: Centers for Disease Control and Prevention. 2009 Mar. Available at: http://www.cdc.gov/HAI/pdfs/hai/Scott_CostPaper.pdf.
4 Stone PW, Glied SA, McNair PD, et al. CMS changes in reimbursement for HAIs: setting a research agenda. Med Care. 2010;48(5):433-9. [PubMed]
5 Sipkoff M. Hospitals asked to account for errors on their watch: CMS and states may stop paying for specific hospital-acquired conditions: will health plans follow suit? Manag Care. 2007;16(7):30, 35-7. [PubMed]
6 U.S. Department of Health and Human Services. HHS action plan to prevent healthcare-associated infections: road map to elimination. Washington, DC: U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. 2013 Apr. Available at: http://www.hhs.gov/ash/initiatives/hai/actionplan/index.html.
7 Climo MW, Yokoe DS, Warren DK, et al. Effect of daily chlorhexidine bathing on hospital-acquired infection. N Engl J Med. 2013;368(6):533-42. [PubMed]
8 Vernon MO, Hayden MK, Trick WE, et al. Chlorhexidine gluconate to cleanse patients in a medical intensive care unit: the effectiveness of source control to reduce the bioburden of vancomycin-resistant enterococci. Arch Intern Med. 2006;166(3):306-12. [PubMed]
9 Bleasdale SC, Trick WE, Gonzalez IM, et al. Effectiveness of chlorhexidine bathing to reduce catheter-associated bloodstream infections in medical intensive care unit patients. Arch Intern Med. 2007;167(19):2073-9. [PubMed]
10 Climo MW, Sepkowitz KA, Zuccotti G, et al. The effect of daily bathing with chlorhexidine on the acquisition of methicillin-resistant Staphylococcus aureus, vancomycin-resistant Enterococcus, and healthcare-associated bloodstream infections: results of a quasi-experimental multicenter trial. Crit Care Med. 2009;37(6):1858-65. [PubMed]
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Original publication: April 23, 2014.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: June 04, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

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