Implementing daily chlorhexidine gluconate (CHG) bathing in VA settings: The human factors engineering to prevent resistant organisms (HERO) project

Best products for skin antisepsis

BACKGROUND

Skin antiseptics are used for several purposes before surgical procedures, for bathing high-risk patients as a means of reducing central line-associated infections and other health care associated infections.

METHODS

A PubMed search was performed to update the evidence on skin antiseptic products and practices.

RESULTS

Current guidelines for prevention of surgical site infections (SSIs) recommend preoperative baths or showers with a plain or antimicrobial soap prior to surgery, but do not make recommendations on the timing of baths, the total number of baths needed, or about the use of chlorhexidine gluconate (CGH)-impregnated cloths. Randomized controlled trials have demonstrated that pre-operative surgical hand antisepsis using an antimicrobial soap or alcohol-based hand rub yields similar SSI rates. Other studies have reported that using an alcohol-based hand rub caused less skin irritation, was easier to use, and required shorter scrub times than using antimicrobial soap. Current SSI prevention guidelines recommend using an alcohol-containing antiseptic for surgical site infection. Commonly used products contain isopropanol combined with either CHG or with povidone-iodine. Surgical site preparation protocols for shoulder surgery in men may need to include coverage for anaerobes. Several studies suggest the need to monitor and improve surgical site preparation techniques. Daily bathing of intensive care unit (ICU) patients with a CHG-containing soap reduces the incidence of central line-associated bloodstream infections (CLABSIs). Evidence for a similar effect in non-ICU patients is mixed. Despite widespread CHG bathing of ICU patients, numerous barriers to its effective implementation exist. Measuring CHG levels on the skin is useful for identifying gaps in coverage and suboptimal skin concentrations. Using alcohol-based products with at least 2% CHG for skin preparation prior to central line insertion reduces CLABSIs.

CONCLUSIONS

Progress has been made on skin antisepsis products and protocols, but improvements in technique are still needed.

Horizontal approaches to infection prevention: daily chlorhexidine gluconate bathing

Healthcare-associated infections (HAIs) pose a significant challenge in hospitals. Infection control strategies have been widely employed to mitigate their incidence. In hospitals, chlorhexidine gluconate (CHG) solutions are commonly used as antiseptic skin cleansers as part of comprehensive infection prevention bundles, with daily CHG bathing being highly effective in reducing HAIs and lowering skin micro-organism density. This evidence review addresses the challenges of risk stratification in implementing CHG bathing protocols in hospitals. It highlights the benefits of a horizontal approach, where CHG bathing is implemented across the entire facility rather than being limited to specific patient populations. Evidence from systematic reviews and studies suggests that CHG bathing consistently reduces HAI rates in both intensive care unit (ICU) and non-ICU settings, supporting the adoption of a hospital-wide approach. The findings emphasise the significance of incorporating CHG bathing as part of a comprehensive approach to infection prevention in hospitals and highlight the potential for cost savings.

Program Evaluation of Implementation Science Outcomes From an Intervention to Improve Compliance With Chlorhexidine Gluconate Bathing: A Qualitative Study

BACKGROUND AND OBJECTIVES

Evaluation of implementation science research is warranted to better understand and determine the success of translating evidence-based infection prevention practices at the bedside. The purpose of this program evaluation was to evaluate implementation outcomes from the perspectives of nurses and nursing leaders regarding a previously conducted chlorhexidine gluconate (CHG) bathing implementation science study among 14 critical care units.

METHODS

Focus groups and interviews, using semistructured interview questions, were conducted to examine the perceptions of nurses who participated in a CHG bathing implementation science study. A deductive qualitative analysis using Proctor and colleagues' implementation outcomes framework was used. Transcripts were analyzed and categorized using the framework as a predetermined code list to structure the implementation outcomes of acceptability, appropriateness, adoption, feasibility, and sustainability.

FINDINGS

A total of 19 nurses and nurse leaders participated in a focus group or interview. Participants noted that both implementation strategies used in the initial study (educational outreach and audit and feedback) were acceptable and appropriate and expressed that the evidence-based CHG bathing practice was feasible to integrate into practice and was being adopted.

DISCUSSION

The program evaluation identified strengths and opportunities for improvement related to the implementation strategies and evidence-based CHG bathing protocol. Findings can inform future studies that seek to implement CHG bathing protocols in the critical care setting using audit and feedback and educational outreach strategies.