1. Performance Improvement Model Implications for Practice
Routine Chlorhexidine Bathing to Prevent
Central Line Infections in a Level IV NICU
Crista Latimer, BSN, RN, RNC-NIC, NNP Intern, Chelsey Phalen, BSN, RN, RNC-NIC, NNP Intern
Creighton University College of Nursing
Omaha, NE
Background/Problem
Methods
Outcomes
The performance improvement project team for this research study was formed consisting of the unit director, chief neonatologist, infectious disease physician and physician assistant, infection control physician, clinical educator, and nurse practitioner interns.
We researched evidenced-based practice for routine CHG baths on CLABSI rates in the NICU population and made recommendations for a performance improvement project.
All infants > 28 weeks gestation and all infants at least 14 days old if < 28 weeks gestation with an indwelling central catheter were routinely cleansed with CHG bathing wipes.
Routine baths took place every Monday, Wednesday, and Friday.
Documentation of the baths was charted by the nursing staff in the facility’s computer system.
Daily skin assessments were documented by the nursing staff using either the Neonatal Skin Risk Assessment Scale (NSRAS) or the Braden Q skin assessment scale according to the infant’s gestational age.
Weekly reports on CHG bathing and compliance were assessed by the primary investigator on the study.
We educated staff and implemented a new trial of practice into routine bathing care, central line care and unit culture.
We measured outcomes as ongoing support and education to maintain practice standards were provided.
Data reports were assessed at 90 days, and will continue to be assessed at 180 days, 270 days and 365 days.
Reported data was compared with data collected in 2013 regarding total number overall and per month of CLABSI rate, device days and rate of infections per 1,000 central line device days
Overall CLABSI rate was decreased by 28.6% when comparing October-December 2013 to October-December 2014
No evidence of skin breakdown was reported by the nursing staff as evidence by documentation of skin scores.
Staff compliance with completing and documenting the routine CHG bathing was >90% when assessed weekly by the primary investigator.
After 3 months into the study, staff compliance of knowing that chlorhexidine is a topical antiseptic that has broad activity against Gram-positive and Gram-negative bacteria, yeast and some viruses increased from 85% to 93%.
After 3 months, now only 4% thought that it must still be rinsed off the patient after use, compared with the 57% before.
Central line-associated bloodstream infection (CLABSI) rates remain a morbidity and mortality issue in neonatal intensive care units (NICU).
CLABSIs can result in 11% neonatal mortality and life-long adverse neurodevelopmental morbidity, such as risk for cerebral palsy, developmental delay and lower IQ, and is recognized as a preventable, unfavorable event.
Infants who obtain such infections are spending more time on mechanical ventilation, have an increased length of hospital stay, increased health care costs and a mortality rate that is significantly higher than those who remain free of infection during their hospital course.
Performance Improvement Model
October
Graph 1
Graph 2
The Plan-Do-Check-Act (PDCA) process was used with this performance improvement project.
Number of CLABSI
Goals
Weight in grams
Graph 3
Staff education
Educate staff on the importance of eliminating CLABSI in the NICU.
Improve staff knowledge on how to correctly use the CHG bathing wipes.
Staff Compliance
Perform routine baths with CHG bathing wipes every Monday, Wednesday and Friday on eligible infants with 100% compliance rate.
All eligible infants with a central line will receive routine CHG baths.
Eliminate/decrease CLABSI in the NICU
The occurrence of central line-associated bloodstream infections documented will be zero or significantly decrease in the NICU.
There will be no adverse skin reactions documented with proper use of the CHG bathing wipes.
Number of CLABSI
Implications for Practice
As the NICU population continues to get more fragile and delicate, routine CHG bathing can help NICUs get closer to a goal of “getting to zero” central line infections.
When maintaining a focus on our patient’s overall health risks when an indwelling central catheter is present, utilizing evidence-based practice is key to meeting these needs and eliminating CLABSI’s in the NICU.
Poster developed April 2015