1. 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

2. 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

3. 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

4. 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

5. 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.
Changed from “do not use” to “use with care”…

6. 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.

7. 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

8. 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

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

10. 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

11. 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.

12. 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.

13. 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!

14. 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), doi: /
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: / CD pub2
Kutsch, J. O., D. (2014). Neonatal skin and chlorhexidine: A burning experience. Neonatal Network, 33(1), doi: /
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),
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),
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), doi: /INF.0b013e f6