1. Helen Jackson MSN, APRN-CNS, GCNS-BC
CHLORHEXDINE GLUCONATE BATHING ONCOLOGY PATIENTS WITH CENTRAL VENOUS ACCESS
Helen Jackson MSN, APRN-CNS, GCNS-BC

2. Nebraska Methodist Hospital – Omaha, Nebraska
423 Acute Care Hospital

3. PURPOSE
Will daily Chlorhexidine Gluconate (CHG) bathing decrease Central Line Associated Bloodstream Infections (CLABSI) for patients with ports on the Oncology Unit?

4. BACKGROUND
CLABSI is a preventable adverse event - affects quality of life, causes economic burden on patient and health care system and may even result in death.
Joint Commission National Patient Safety Goal – Use proven guidelines to prevent infection of the blood from central lines.

5. BACKGROUND
Treatments necessary for oncology patients compromise the immune system and put them at a very high risk for CLABSI.
Prevention of CLABSI front-line focus for any oncology unit.
CLABSI committee that review all CLABSI.
Determined trend was maintenance related for CLABSI.

6. BACKGROUND
Many evidence based interventions were implemented during 2013 and in the beginning of 2014 with 100% support of management
Use of alcohol permeated caps
Two person blood draw process
Neutral displaced injection caps
IV Team to access all ports and do all dressing changes

7. CLABSI ON ONCOLOGY UNIT

8. HOW DID WE GET THERE

9. Plan-Do-Study-Act Model Evidence Based Practice
FRAMEWORK
Quality Improvement
Plan-Do-Study-Act Model
Evidence Based Practice
Iowa Model

10. LITERATURE REVIEW To look at all interventions to prevent CLABSI
All interventions we found were part of our process except for CHG bathing.
What is the evidence for daily CHG bathing patients with central venous access in decreasing CLABSI?
How will oncology patients skin tolerate daily CHG bathing?

11. WHAT THE EVIDENCE SHOWED
Majority Level II
CDC Guidelines for prevention of Intravascular Catheter-Related Infections (2011)
Daily bathing of ICU patients
Meta analysis by Sievert, Armola & Halm (2011) to determine if CHG bathing decreases hospital acquired infections
No randomized controlled studies; Four quasi experimental studies and 1 cross over study
One study in long-term acute care hospital; others in ICU
O’Horo, et.al. (2014) conducted a Systematic review and meta analysis of randomized controlled trials and quasi-experimental studies to determine efficacy of daily bathing with CHG for prevention of healthcare-associated bloodstream infections.

12. WHAT THE EVIDENCE SHOWED
Effect of daily CHG bathing on hospital acquired infection by Climo, et.al. (2013)
Suggests CHG bathing reduces risk of hospital acquired blood stream infections in patients in ICU and bone marrow transplantation units - 28% lower rate
Marshall, et.al (2014) published SHEA (Society for Healthcare Epidemiology of America) Strategies to Prevent Central Line Associated Bloodstream Infections in Acute Care Hospitals
Identified CHG bathing in ICU patients as Quality of evidence: Level 1
Role of CHG bathing in non-ICU patients remains to be determined

13. WHAT WAS THE NON-ICU EVIDENCE
Kassakian, et.al. (2011) evaluated the effectiveness of daily CHG bathing in non-ICU settings using quasi-experimental design
Found 64% decrease in MRSA and VRE healthcare acquired infections in general medical population.
Rupp, et. al. (2012) conducted a quasi-experimental study to determine effect of CHG bathing on health-care associated infections.
CHG well tolerated and significant decrease in C. difficile infections in hospitalized patients.
Review of literature – Provides class IIb evidence.
No random controlled studies; quasi-experimental studies consider intervention especially in medical ICUs.

14. Implemented Daily CHG Bathing Patients with Ports and Tunneled Catheters on Oncology Unit
August 1, 2014 was go live date
Support from management on the Oncology Unit
Used TRIP as method to disseminate practice change
Recruited two nursing assistants to champion CHG bathing
Went to Oncology Unit Meetings in July 2014
Posted signs up on Oncology Unit
Met with Staff individually to discuss change

15. Translating Research into Practice (TRIP) Chlorhexidine Gluconate (CHG) Bathing for Port Patients
Why?
6 South had 7 Central Line Associated Blood Stream Infections (CLABSI) the entire year South has had 6 CLABSI from January to June 2014, all of which have been ports.
What’s been done so far?
Use of Curos caps
Two person blood draw
No longer re-infuse waste when drawing blood for lab tests – stop cock eliminated
IV team accesses all ports & changes all dressings.
What does the evidence say?
Literature supports that daily bathing with CHG in the ICU has reduced CLABSI. Now literature is starting to support daily bathing with CHG outside the ICU as a means to reduce CLABSI.
CLABSI “…often result from the ingress of skin organisms into the blood stream along vascular catheters or other breaks in skin integrity, skin decontamination could theoretically also decrease the risk of infection.”¹
Axillary & inguinal skin sites are moist & rich in apocrine glands & may be microbial niches that favor long term colonization of skin organisms.²
CHG is effective against a wide range of gram positive & gram negative bacterial, yeast & molds. Works by disrupting cytoplasmic membranes & remains active for hours after use.³
Supported by CDC as a category II recommendation for preventing CLABSI.
No adverse effects for patient with no serious skin reactions noted.
Change in practice: Daily CHG bathing on all patients with ports & tunneled catheters starting August 1, 2014
Bathe patients with CHG from jaw line to feet with one cloth used for each area: neck/shoulder/chest, upper extremities, abdomen, right lower extremity, left lower extremity, back/buttocks.
Patients may shower using a bottle of Hibiclens – educate them on properly using a washcloth to clean their bodies in the order listed above.
Soap/shampoo & water to clean face & hair rather than the CHG wipes – do first. CHG okay for use in perineal area, but Hibiclens is not.
Do not rinse CHG, allow to air dry.
Aloe Vesta & Sensi Care products may be used after CHG is dry if additional moisturizer needed.
Change linen & gown daily on all patients with ports & tunneled catheters.
Selected References
1. Climo, M. et al. (2013). Effect of daily Chlorhexidine bathing on hospital-acquired infection. New England Journal of Medicine, 368(6),
2. Lin, M. et al. (2014). The effectiveness of routine daily Chlorhexidine Gluconate bathing in reducing Klebsiella pneumonia Carbapenemase-producing enterobacteriaceae skin burden among long-term acute care hospital patients. Infection Control and Hospital Epidemiology, 35(4),
3. Medina, A., Serratt, T., Pelter, M., & Brancamp, T. (2014) Decreasing central line-associated blood stream infections in the non-ICU population. Journal of Nursing Care Quality, 29(2),
H. Jackson;

16. Evaluation of Change
Random audits and informal surveys of nurses and aides on the unit weekly
Took about three months to become imbedded into daily practice.
Continued surveillance of CLABSI.

17. OUTCOMES
After initiation of CHG bathing on patients with ports and tunneled catheters there was one more CLABSI in 2014 that was a PICC
In 2015 there were four CLABSI
One was gut epithelial disruption and translocation
One associated with possible oropharyngeal translocation
One gram + staph (PICC)
One associated with yeast/mold
NO CLABSI on the Oncology Unit for 2016 as of April 15.

18. IMPLEMENTATION ON ALL UNITS
July 2015 – CHG bathing was taken to Practice Council
August 2015 – Implemented CHG bathing on all units for all patients with central venous access
In 2015 prior to August there were 14 CLABSI in non-ICU units house wide and from August 2015 to April 2016 there have been two.

19. BARRIERS TO COMPLIANCE
How to identify patients with central venous access that need CHG bathing.
What to do when patients refuse.
Documentation of CHG bathing is inconsistent.
What to use if patient allergic to CHG.

20. MAINTAINING CHANGE
Had a station at Annual Skills Summit competencies required by all RNs and CNAs.
Added CHG bathing pre-selected to all central venous access care plans.
Continued audits of CHG bathing.
Continued surveillance of CLABSI.
Share positive impact with staff at monthly Unit Based Councils.

21. IMPLICATIONS FOR NURSING PRACTICE
Implementation of CHG bathing for non-ICU patients with central venous access has a positive impact on CLABSI.

22. FUTURE RECOMMENDATIONS
More studies on CHG bathing outside of the ICU population
Develop maintenance bundles to include CHG bathing

23. REFERENCES
APIC Implementation Guidelines: Guide to preventing central line-associated bloodstream infections (2015). Retrieved from
Grady, N. et al. (2011). CDC guidelines for prevention of intravascular catheter-related infections. Retrieved from
Climo, et al. (2013). Effect of daily chlorhexidine bathing on hospital-acquired infection. The New England Journal of Medicine. Feb; 368:
Kassakian, S. et al. (2011). Impact of chlorhexidine bathing on hospital-acquired infections among general medical patients. Infection Control and Hospital Epidemiology, 32(3), pp
Joint Commission 2016 Critical Access Hospital National Patient Safety Goals retrieved from
Marschall, J. et al. (2014). SHEA/IDSA practice recommendation; Strategies to prevent central line-associated bloodstream infections in acute care hospitals: a 2014 update. 35(7), pp Retrieved from

24. REFERENCES
Medina, A., Serratt, T., Pelter, M. & Brancamp, T. (2014)., Decreasing central line-associated bloodstream infections in the non-ICU population. Journal of Nursing Care Quality, 29(2), pp
O’Horo, J. et al. ((2012). The efficacy of daily bathing with chlorhexidine for reducing healthcare-associated bloodstream infections: A meta analysis. Infection Control and Hospital Epidemiology, 33(3), pp
Rupp, M. et al. (2012). Effect of hospital-wide chlorhexidine patient bathing on healthcare-associated infections. Infection Control and Hospital Epidemiology, 33(11), pp
Sievert, D., Armola, R. & Halm, M. (2011). Chlorhexidine gluconate bathing: Does it decrease hospital acquired infections. American Journal of Critical Care, 20(2), pp