Lauren Turner RN, MS, CCRN, CCNS The UVA Professional Nursing Staff Organization’s 12th Annual Evidence-Based Practice Symposium Chlorhexidine bathing for all? A quality improvement initiative for CLABSI reduction in the PICU Lauren Turner RN, MS, CCRN, CCNS

Nosocomial infections contribute to morbidity and mortality Background Nosocomial infections contribute to morbidity and mortality 12 Month UVA PICU CLABSI Rate: 3.7 CLABSI/1,000 line days National PICU CLABSI Rate: 1.2 CLABSI/1,000 line days Investigation for improvement in infection prevention

Magnet Query Discussed CVL interventions with 15 PICUs Policies, equipment/devices, nursing practices, bathing, blood culture practices… Common practice was chlorhexidine (CHG) bathing regardless of age and weight for infection prevention

A group of PICU patients (less than 60 days corrected gestational age) was getting infected- it was identified that bathing practices were different in this patient group due to our hospital bathing guidelines

Changes to FDA regulations in 2012 % Chlorhexidine Gluconate (CHG) Cloth Detailed View: Safety Labeling Changes Approved By FDA Center for Drug Evaluation and Research (CDER) – May 2012   Summary View1 Drug Facts Box Directions for Use in Infants added.......use with care in premature infants or infants under 2 months of age. These products may cause irritation or chemical burns. http://www.fda.gov/Safety/MedWatch/SafetyInformation/Safety-RelatedDrugLabelingChanges/ucm307387.htm Changed from “do not use” to “use with care”…

How CHG works Cationic bisbiguanide: works by destroying the bacterial cell membrane and precipitating cell contents within the first layer of skin. “Cross hatch" technique uses friction to destroy any bioburden within the first layer of skin CHG provides immediate, cumulative and residual antibacterial activity Caution in premature neonates due to top epidermis layer not being fully formed- the friction created with CHG can cause burns and skin breakdown.

Literature Review of CHG safety in neonates CHG in neonatal population documented for use with daily skin cleansing, disinfection prior to invasive procedure, umbilical cord cleansing, vaginal washing, CHG impregnated dressings Limited available evidence Literature review (3), Quasi-experimental, Randomized Control Trial & Case Study Adverse effects No documented adverse events in full term neonates Use with caution in premature and low birth weight infants Questions of absorption in bloodstream- little evidence

PICU Patient population No preterm or low birth weight patients “Our gut feeling”: We would not see any adverse effects of CHG bathing in PICU patients

Objective Decrease CLABSI rates in the PICU Monitor for adverse effects of CHG in infants less than 60 days corrected gestational age

Methodology August-November 2015 All PICU patients with an invasive device received daily and PRN CHG baths Infection rates were monitored Patients examined daily for adverse effects rash, erythema, burn or skin erosions

Results 77 patients with invasive devices received CHG baths 12 patients > 60 days corrected gestational age. Infection rates decreased from 3.7 to 3.1 CABSI/1,000 CVC line days No adverse skin conditions observed in patients > 60 days corrected gestational age.

Clinical Implications Daily CHG bathing was implemented as a standard of care for all PICU patients with invasive devices CHG bathing is now considered a preventive measure for CLABSI prevention in the PICU with minimal risk factors and associated adverse effects.

Other considerations Unit priority Weekly discussion of line management Need for central access Line entries with medications and blood sampling Use of antibiotic coated PICC catheters Unit nurse champions CVL Standard Work: Dressing change & scrub the hub Information sharing with acute care pediatrics in process!

References Da Cunha, M., Procianoy, R., Franceschini, T., De Oliveira, L., & Cunha, M. (2008). Effect of the first bath with chlorhexidine on skin colonization with staphylococcus areus in normal healthy term newborns . Journal of Scandanivan Infectious Disease, 40(8), 215-220. doi:10.1080/00365540801932447 Imdad, A., Bautista, R., Senen, K., Uy, M., Mantaring, J., & Bhutta, Z. (2013). Umbilical cord antisepsis for preventing sepsis and death among newborns . Cocharine Database Systematic Review, 31(5) doi:10.1002/14651858.CD008635.pub2 Kutsch, J. O., D. (2014). Neonatal skin and chlorhexidine: A burning experience. Neonatal Network, 33(1), 19-23. doi:10.1891/0730-0832.33.1.19 Mullany, l., Darmstadt, G., & Tielsch, J. (2006). Safety and impact of chlorhexidine antisepsis interventions for improving neonatal health in developing countries. Journal of Pediatric Infectious Disease, 25(8), 665-675. Quch, C., Milstone, A., perpete, C., Bonefant, M., Moore, D., & Perreault, L. (2014). Chlorhexidine bathing in a tertiary care neonatal intensive care unit:  impact on central line-associated bloodstream infections. Infection Control and Hospital Epidemiology, 35(2), 158-163. Sankar, M., & Paul, V. (2013). Efficacy and safety of whole body skin cleansing with chlorhexidine in neonates- A systemic review. Journal of Pediatric Infectious Disease, 32(6), 227-234. doi:10.1097/INF.0b013e31828693f6