1. To CHG or Not to CHG? The Role of Bathing Practices in Reducing
Healthcare Associated Infections in
Critically-Ill Adults
Hello. My name is Michelle Stimson. On behalf of my teammate Jon Rospierski, I would like to welcome you to our presentation. As many of you know, healthcare associated infections continue to challenge us as clinicians. This is especially true in the critically-ill adult. Despite many established infection control measures such as proper hand washing and contact precautions, healthcare associated infections remain prevalent. Evidence is beginning to emerge regarding bathing practices and their ability to decrease the acquisition and transmission of healthcare associated infections. During our time together, we will explore the use of non-traditional bathing practices as an infection control measure for reducing healthcare associated infections in the critically-ill adult.
By: Jon Rospierski & Michelle Stimson
Ferris State University
Nursing 531

2. Meet Our Team Michelle Stimson Jon Rospierski
Healthcare Associated Infections (HAIs) in the critically-ill adult
Chlorhexidine Gluconate (CHG) as an anti-bacterial agent
Evidence on CHG bathing practices
Jon Rospierski
Emerging challenges with daily CHG use
Evidence on non-CHG bathing practices
Final recommendations and closing remarks
Jon and I are both nursing educators and we have been asked to take a look at the evidence on both sides of this issue. Therefore, this presentation will take place in 2 parts. I will be presenting Part 1. Part 1 will focus on healthcare associated infections in the critically-ill adult and the use of daily chlorhexidine bathing as an infection control measure for reducing the transmission and acquisition of healthcare associated infections. Jon will be joining us for Part 2. Jon will discuss some of the challenges associated with chg bathing and will present information other alternatives. After he is finished, Jon will wrap up our time together with some final recommendations and closing remarks. Now that I have introduced today's presenters and the outline for our presentation, let's get started with Part 1.

3. Healthcare Associated Infections
Healthcare Associated Infections
HAI Estimates Occurring in US Acute Care Hospitals, 2011
Major Site of Infection
Estimated No.
Pneumonia
157,500
Gastrointestinal Illness
123,100
Urinary Tract Infections
93,300
Primary Bloodstream Infections
71,900
Surgical site infections from any inpatient surgery
Other types of infections
118,500
Estimated total number of infections in hospitals
721,800
Healthcare Associated Infections continue to threaten patient safety and quality outcomes. According to the Centers for Disease Control and Prevention (CDC, 2016), in 2011, 721,000 acute care patients acquired a healthcare associated infection. Healthcare associated infections lead to increased costs, prolonged lengths of stay, and increased morbidity and mortality. (Rubin, Wessels, & Downer, 2013). On average, healthcare associated infections increase length of stay by 7 days and can cost approximately $40,000 per patient to treat (Rubin, Wessels, & Downer, 2013).
Retrieved from
CDC, 2016
Rubin, Wessels & Downer, 2013

4. The Critically-Ill Adult
Approximately 20% of critically-ill patients acquire healthcare associated infections
High risk population due to invasive lines and immunocompromised status
Most common causative agents: multi-drug resistant organisms (MRSA & VRE)
In the acute care setting, the critically-ill adult is particularly at risk for acquiring a healthcare associated infection. In fact, approximately 20% of critically-ill adults will acquire one. Critically-ill adults are more likely to undergo invasive procedures and obtain multiple invasive lines over the course of their care. Often, they are immunocompromised and have longer lengths of stay. The most common causative agents of healthcare associated infections are multi-drug resistant organisms such as methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin resistant Enterococcus (VRE). (Climo et al., 2009)
Climo et al., 2009

5. MRSA & VRE Chen et al., 2013 Climo et al., 2009 TJC, 2011
In intensive care units, the prevalence of MRSA & VRE colonization is approximately 60 and 30% respectively (Chen et al., 2013). In the inpatient setting, MRSA and VRE infections continue to rise despite hand washing practices, contact barrier precautions, and rapid identification of colonized patients. (Climo et al., 2009)
Multi-drug resistant infections are difficult to treat and many are considered preventable. Therefore in 2011, The Joint Commission generated a National Patient Safety Goal challenging healthcare providers to implement evidence-based practices proven to prevent healthcare associated infections due to multi-drug resistant organisms (TJC, 2011). Colonization with MRSA or VRE bacteria is a risk factor for acquiring a healthcare associated infection. Therefore, changing the way critically-ill adults are bathed may be a way to decrease bacteria colonization on the body. (Chen et al., 2013)
Retrieved from
j ac.1.64.img FnKyz5d9PUw#imgrc= BWSLDCx17xVMCM%3A
Chen et al., 2013
Climo et al., 2009
TJC, 2011

6. Chlorhexidine Gluconate (CHG)
Is an anti-bacterial agent
First introduced in 1970
Can reduce MRSA & VRE bioload on the skin
Bactericidal to many gram-positive and gram-negative bacteria
Used in hand sanitizers, surgical scrubs, mouth rinses & bathing cloths
CDC recommends CHG for preventing central line blood stream infections (CLABSI)
Chlorhexidine gluconate (CHG) is an anti-bacterial agent and is effective against gram-positive and gram-negative bacteria (Kim et al., 2016; Rubin, Wessels, & Downer, 2013). Chlorhexidine was first introduced in It can now be found in various hand sanitizers, surgical scrubs, mouth rinses, and disposable bathing cloths (Rubin, Wessels, & Downer, 2013). Chlorhexidine has been shown to decrease the bioload of MRSA and VRE on the skin (Climo et al., 2009; Kim et al., 2016). Based on previous research findings, the CDC recommends the use of chlorhexidine impregnated dressings and daily chlorhexidine bathing to prevent incidences of central line blood stream infections CLABSI (CDC, 2012). Interest is growing in the use of daily chlorhexidine bathing for reducing other healthcare associated infections in critically-ill adults (Kim et al., 2016). We have seen other healthcare organizations turn to CHG as a means for giving daily baths to critically ill patients. I too think our organization should incorporate this process. I have found several research articles supporting the use of chg bathing for reducing healthcare associated infections in the critically-ill adult and would like to review some of them with you now.
CDC, 2012
Climo et al., 2009; Kim et al., 2016
Rubin, Wessels, & Downer, 2013

7. Climo et al. (2013) 7727 Adult Patients Results Climo et al., 2013
Prospective, multicenter, non-blinded crossover study
Intervention: bathing with CHG impregnated washcloths for 6 months
Control: bathing with non-antimicrobial washcloths for 6 months
Eight ICUs: Medical, Coronary & Surgical plus 1 BMT Unit
7727 Adult Patients
9 units were divided into 2 groups: control vs intervention—switched after 6 months
Results
19% reduction in MRSA
1.89 (I) vs 2.32 (C) cases/1000 PD (P=.29)
25% reduction in VRE
3.21(I) vs 4.28 (C) cases/1000 PD (P=.05)
The first study I would like to discuss was completed by Climo et al in The study was a prospective, multi-center, non-blinded crossover study involving 7727 adult patients in 8 ICUs and 1 bone marrow transplant unit within six healthcare systems. The goal of the study was to evaluate the difference in healthcare associated infection rates between patients bathed with chg impregnated wipes verses nonantimicrobial washcloths. I chose this study because it was recently published, is a high level of evidence, had a large sample size, is multi-centered, and builds off of several notable studies published beforehand. There is one caveat however, Sage Products, the manufacture of the chg impregnated wipes, provided some grant funding for this study. The study was set up in the following manner. Units were randomly assigned to one of 2 arms; either 6 months of daily chg bathing (which was the treatment arm) or 6 months of traditional bathing (the control arm). After the 6 months were completed, the units then completed the alternative bathing method for the following 6 months. CHG baths were completed per manufacture recommendations. No washout period between the transition occurred. Patient nares were swabbed for MRSA on admission and discharge from the unit and perirectal areas were swabbed for VRE in the same fashion. A regression analysis was performed on the data and the authors found the following results: A 19% reduction in MRSA related infections (1.89 (I) vs 2.32 (C) cases/1000 PD (P=.29)) and a 25% reduction in VRE related infections (3.21(I) vs 4.28 (C) cases/1000 PD (P=.05)). The overall rate of MRSA or VRE acquisition was 23% lower during the intervention period (5.10 vs cases per 1000 patient-days, P = 0.03). The authors also noted no serious skin reactions as a result of daily bathing with chg. The results of this study support the use of daily bathing with chg as a method for reducing the transmission of multi-drug resistant organisms in critically-ill adults.
Climo et al., 2013

8. For patients bathed daily with CHG:
Chen et al. (2013)
For patients bathed daily with CHG:
44% decrease in MRSA
(IRR =0.58, 95% CI: )
Decrease in MRSA-VAP
(IRR =0.22, 95% CI: )
Decrease in VRE colonization
(IRR =0.51, 95% CI: )
Decrease in VRE infection
(IRR =0.57, 95% CI: )
Methods & Design
Meta-analysis
Level 1 evidence
Goal of the study: Review the relationship between CHG bathing and the acquisition of MRSA & VRE related infections
12 articles were included
Over 250,000 patient days
This next article I would like to discuss is a meta-analysis performed by Chen et al in The authors reviewed the relationship between daily CHG bathing and the acquisition of MRSA & VRE related infections. I included this article because it was published in 2013 and meta-analyses are the highest level of evidence available (Melnyk & Fineout-Overholt, 2015). The authors looked at 12 studies totaling over 250,000 patient days. Ten of the studies were interrupted time series in design and 2 were cluster-randomized controlled trials. The studies compared daily bathing with chg to traditional soap and water baths or nonantimicrobial wipes in critically-ill adults. After pooling the data, here is what the authors found: The risk for acquiring a MRSA related infection decreased by 44% if the patient was bathed with chg. Also, VRE colonization dropped from 247 events in the control group to 140 events in the experimental group and VRE related infections dropped from 37 events in the control group to 20 in the experimental group. There was also a decrease in MRSA related ventilator associated pneumonia events for patients bathed with chg. The findings of this study support the daily use of CHG bathing in the critically-ill adult for reducing both MRSA & VRE related infections.
Recommendation: Daily bathing with CHG in critically-ill adults
Chen et al., 2013
Melnyk & Fineout-Overholt, 2015

9. Kim et al. (2016)
Meta-analysis: compare CHG bathing to traditional soap & water & the acquisition of HAIs in the critically-ill adult
18 studies were included: 6 RCTs and 12 ITSs
MRSA Infection
Intervention: 3.28 /1000 PD
Control: 4.97 /1000 PD
(95% CI: ; P b.001)
VRE Infection
Intervention: 3.00/1000 PD
Control: 4.86/1000 PD
(95% CI: ; P= .004)
Heterogeneity was assessed (Cochrane Q test)
Recommendation: Daily bathing with CHG compared to traditional methods decreases the acquisition of HAIs caused by MRSA & VRE
Another meta-analysis was performed by Kim et al to compare rates of healthcare associated infections in critically-ill adults bathed on a daily basis with CHG compared to other traditional methods such as soap and water. I included this article because it was published quite recently, includes a large number of studies, and since it is a meta-analysis, it provides us with high-level data. Eighteen studies were included in this meta-analysis. Six were randomized control trials and 12 were interrupted time series studies. Only studies that followed the CDC's definitions and diagnostic criteria for healthcare associated infections were included. All studies reported their data in cases per 1000 patient days. After looking at almost 200,000 patient days, the authors found a reduction in MRSA related infections in the intervention group verses the control group cases/1000 patient days in the intervention group and 4.97 cases per 1000 patient days in the control group. There was also a reduction in VRE related infections in the intervention group cases per 1000 patient days were found in the intervention group vs 4.86 cases/1000 patient days in the control group. The results of this study verify daily bathing with chg in the critically-ill adult does reduce the acquisition of healthcare associated infections compared to bathing with conventional methods such as soap and water. Both of these meta-analyses provide us with strong and reliable evidence supporting the use of chg bathing in critically-ill adults.
Next, I would like to introduce Jon Rospierski. He will be discussing some of the challenges associated with chg and present alternative bathing practices for reducing the transmission of healthcare associated infections.
Kim et al., 2016
Melnyk & Fineout-Overholt, 2015

10. Issues with CHG Skin Rashes Allergic contact dermatitis Meta-analysis
Reactions to CHG:
Skin Rashes
Allergic contact dermatitis
Photosensitivity
Fixed drug eruptions
Urticaria
Anaphylactic shock
Meta-analysis
4 RCTs
92 in CHG over 132,678 patient-days
136 events control over 119,600 patient-days
We have heard of many organizations changing bathing practices to CHG in the critically-ill adult, however, I feel like other alternatives should be considered. The studies that Michelle has described link specifically to CHG and its positives. I would like to point out some flaws that have been found throughout different articles, and I would also like to consider a couple of alternatives that we could use to incorporate into our practice and teach our staff.
For example, CHG is not 100% free form problems. A level 5 systematic review from Hong and colleagues noted that health-care workers (HCW) are exposed to increasing chlorhexidine usage due to its increased use in the last few years. Adverse reactions to chlorhexidine range from allergic contact dermatitis, photosensitivity, fixed drug eruptions, urticaria and anaphylactic shock have been reported. Most have been isolated case reports on adverse reactions occurring in healthy individuals or HCW (Hong et al., 2015). To focus on skin rashes, Choi and colleagues used a meta-analysis of 5 RCTs that included results of the adverse effects of chlorhexidine in four of those 5 studies. In total, 92 events in the chlorhexidine group developed over 132,678 patient-days compared to 136 events in the control arm over 119,600 patient-days (Choi et al., 2015). Risk exists, which brings upon the study by Milstone and colleagues.
Choi et al., 2015

11. Milstone et al. (2013) Cluster-randomized, two-period crossover
10 pediatric ICUs at 5 hospitals
2% CHG-impregnated cloth vs. Standard bathing
To assess whether daily CHG bathing compared with standard bathing practices would reduce bacteremia in critically ill children
2,525 in control and 2,422 CHG
Skin reactions in 1.7% of admissions intervention > control units
28% related to CHG
Skin irritation
Did not like the smell or feel
Allergic reaction
Concern about a chemical reaction
Lotion that not compatible with CHG
In a cluster-randomized, two-period crossover trial by Milstone and colleagues, 10 pediatric intensive care units (ICUs) at 5 hospitals were randomly assigned to bathe patients > 2 months of age daily with a 2% CHG-impregnated cloth or with standard bathing practices for a six-month period. Units switched to the alternative bathing method during the second six-month period. The goal of the study was to assess whether daily CHG bathing compared with standard bathing practices would reduce bacteremia in critically ill children. This study was chosen because the strength of the level of evidence as a randomized control trial, which is a level 2, helped to reinforce the findings as being useful toward consideration for practice. 4,947 pediatric admissions were used and an almost equal number of control to treatment units were used –( 2,525 in control and 2,422). Each hospital had one control and one intervention unit, randomized by hospital and ICU type, and it used a random number generator to select assignments. Findings from the study included no serious adverse events, but skin reactions occurred in 1.7% of admissions where a greater proportion of admissions to intervention than to control units, and 28% of those were related to CHG. Of the 2.6% of the patients that withdrew from the study, 12 were due to skin irritation from CHG, 8 did not like the smell or feel of it, 2 had an allergic reaction, 1 had a concern about a chemical reaction, and 1 used a lotion that was not compatible with CHG-citing another possible problem. While these were not the purpose for the study, these findings from it have to be considered for patient use. (Milstone et al., 2013).

12. Bath basin with CHG soap: $3.18
Back to Bath Basins?
Wound care supplies
Patient food
STORAGE
Incontinence care
Catching emesis
Returning washcloths
Cross-contamination
Bath basin with CHG soap: $3.18
2% CHG washcloths: $5.52
One-time use only
Many hospitals provide overnight patients with a bath basin which is commonly used as catch all containers during patients’ stays. Other uses include: storage of patient food, storage of wound care supplies, catching emesis, and incontinence care (Danielson, Williamson, & Johnson, 2013). Bath basins have been cited as a reservoir for bacteria and is a source for transmission of HAIs from cross-contamination from one person to another and from returning washcloths back into the basin. When only one washcloth is in contact with one body part there is a reduction in cross infections from wash basins (Veje & Larson, 2014). In using the bath basin with CHG soap, it costs approximately $3.18 for one bath. It costs 6 of the washcloths impregnated with 2% CHG, enough for 1 bath, about $5.52. A bath basin costs approximately $0.35. (Petlin et al., 2014). Instead of spending the money on the baths, exclusively using bath basins for one-time use only can be found to be contaminated as well (Marchaim et al., 2012). This takes us to the next article as an alternative.
Danielson, Williamson, & Johnson (2013)
Veje & Larson (2014)
Petlin et al. (2014)
Marchaim et al. (2012)

13. Noddeskou, Hemmingsen, & Hørdam (2015)
Randomized controlled trial
Crossover design
Larson et al. (2004)
Traditional basin with soap and water vs. Disposable bath
Eliminates transfer of microorganisms
No difference in cost of supplies
Less nursing time with disposable baths
A study by Noddeskou and colleagues was conducted as a randomized controlled trial, using a crossover design that replicated a similar study completed by Larson and colleagues in The traditional basin used with soap and water was compared to a disposable bath, which was prepacked in single-use units and heated before use. The method included both observations and questionnaires. This level 2 of evidence design is being discussed because it used prepacked single unit baths, where no basin is included and of transfer of micro-organisms is eliminated. The previous study that was it was mimicked from, obtained specimens from the skin of each patient for each method of bathing for microbiological cultures from the groin and the area around the umbilicus. The disposable bath offered fewer opportunities for recontamination of the skin (Larson et al., 2004). Some items that Noddeskou and colleagues found from their study was that there was no difference in the cost of supplies using the 2 methods, and less nursing time was used with disposable baths, saving costs in that manner. It helped with the challenges of keeping basins clean and free of micro-organisms, and thereby protecting patients from potential infections. This method is an alternative that has to be taken into consideration.
(Noddeskou, Hemmingsen, & Hørdam, 2015)

14. Alternative Antiseptic
Increased Resistance
5-10%
Increased Sensitivity
Octenidine
There is increasing resistance to chlorhexidine in MRSA. Clorhexidine resistance genes have now been reported with varying incidence, around 5–10% in the UK and higher internationally (Edgeworth, 2010). As you recall earlier, side effects have been shown to result from CHG. Should a patient have skin sensitivity to CHG (contact dermatitis or anaphylaxis) the alternative antiseptic agent Octenidine is used instead for daily bathing (Willis et al., 2015). Also noted earlier was that CHG was refused by patients. In a prospective cluster crossover study, there were no reports of patients refusing to use octenidine during the project. (Harris et al., 2015). So this brings us to another possibility for our patients.
Willis et al. (2015)
Harris et al. (2015)

15. Danilevicius et al. (2015)
Quasi-experimental
Efficacy & tolerability of octenidine-based products
MRSA-positive patients
36 hospitalised patients
14 females, 22 males
1 or 2 cycles of 7 days
Specific parts and whole body
Decontamination 67% of patients
No side-effects or secondary symptoms
86% very well tolerated
5.6%) or failed decontamination (27.8%)
Catheterized
Drains Nasogastric tubes
Bacteria were isolated
Danilevicius and colleagues used a quasi-experimental study to assess the efficacy and tolerability of octenidine-based products in decontaminating MRSA-positive patients. In 36 hospitalised patients (14 females, 22 males) who were isolated to prevent cross infection, octenidine (OCT)-based products were used in one or two cycles of 7 days each that comprised of a consistent and simultaneous implementation of cleaning to specific and whole body parts. The study found complete decontamination was achieved in 67% of the patients following treatment with the octenidine-based products. None of the patients experienced side-effects or secondary symptoms such as skin irritation or allergic reactions during the course of the study. In addition, octenidine was very well tolerated in 86% of patients. Nearly all of the patients who experienced incomplete (5.6%) or failed decontamination (27.8%) were catheterized, had drains and/or nasogastric tubes, from which bacteria were isolated subsequently. These additional medical devices complicate a thorough decontamination and thus may have hindered complete MRSA decontamination. The results demonstrate that octenidine-based products are highly efficient and a good choice in multifaceted MRSA decontamination regimes, which are necessary to curb the increasing problem of severe infections (Danilevicius et al., 2015). From these articles, alternatives are out there and must be considered.

16. Where Do We Go from Here? Limited octenidine research
Quasi-experimental research not strong enough evidence
Consider it as an alternative
Insignificant amount of patients affected by CHG
Need more evidence from alternative methods
However…The amount of research behind octenidine is very limited, and no matter how you look at, water and soap are no match for any of the antiseptics mentioned. Not too much research has been performed on octenidine, so the evidence is not strong. We can, however, consider it as an alternative for the very few patients that could be affected by the use of CHG. Such a minute percentage of people have adverse effects from the use of CHG, so the evidence is not sufficient enough to not consider CHG. It must also be noted that quasi-experimental research is not strong enough evidence to guide a change to our daily bathing methods. Randomized-controlled trials must be considered as additional knowledge, but there is also not enough information from that level of evidence to overcome the overwhelming evidence found with using CHG

17. Change of Practice Chlorhexadine For Critically Ill Patients
Meta-Analysis in
Research
Chen et al. (2013) Kim et al. (2016)
Reduce both MRSA & VRE colonization
Choi et al. (2015)
5 RCTs
Daily bathing with CHG reduced the development of HAIs
Continuous Research and Education
Emergence of chg resistance
Chlorhexadine
For Critically Ill Patients
After careful deliberation and consideration, the evidence is clear that changing our bathing practices for critically-ill adult patients from the previous soap and water method to CHG for preventing healthcare associated infections is warranted. Meta-analysis are the strongest level of evidence for which practice change is made. The article by Chen and colleagues (2013) and then again by Kim and colleagues (2016) are 2 such meta-analyses. The authors from both articles recommend the use of daily CHG bathing in the critically-ill adult in place of conventional methods such as soap and water reduce both MRSA & VRE colonization and related infections. Another meta-analysis by Choi and colleagues considered five randomized controlled trials, and they also found that daily bathing with chlorhexidine reduced the development of hospital-acquired blood stream infections. Another finding consistent with other articles previously described was the emergence of chg resistance from daily use. So continued research will always be always needed even after we implement this new process at our facility. As educators, it is our job now to educate not only the methods that we have found in this research, but just as importantly, the reasons for this change.
On behalf of Michelle, we would like to thank you for your time.

18. References
Centers for Disease Control & Prevention [CDC]. (2012). Top CDC recommendations to prevent healthcare-associated infections. Retrieved from HAI/prevent/top-cdc-recs- prevent-hai.html
Centers for Disease Control & Prevention [CDC]. (2016). HAI data and statistics. Retrieved from hai/surveillance/index.html
Chen, W., Li, S., Li, L., Wu, X., & Zhang, W. (2013). Effects of daily bathing with chlorhexidine and acquired infection of methicillin-resistant Staphylococcus aureus and vancomycin-resistant Enterococcus: A meta-analysis. Journal of Thoracic Disease, 5(4),
Choi, E. Y., Park, D. A., Kim, H. J., & Park, J. (2015). Efficacy of chlorhexidine bathing for reducing healthcare associated bloodstream infections: a meta-analysis. Annals of Intensive Care, 5(1), 1-9.
Climo, M .C., Sepkowitz, K. A., Zuccotti, G., Fraser, V. J., Warren, D. K., Perl, T. M., ...& Wong, E. S. (2009). The effect of daily bathing with chlorhexidine on the acquisition of methicillin-resistant Staphylococcus aureus, vancomycin-resistant Enterococcus, and healthcare-associated bloodstream infections: Results of a quasi-experimental multicenter trial. Critical Care Medicine, 37(6),

19. References
Climo, M. W., Yokoe, D. S., Warren D. K., Perl, T. M., Bolon, M., Herwaldt, L. A., …& Wong, E. S. (2013). Effect of daily chlorhexidine bathing on hospital-acquired infection. New England Journal of Medicine, 368(6),
Danilevicius, M., Juzéniené, A., Juzénaité-Karneckiené, I., & Veršinina, A. (2015). MRSA decontamination using octenidine-based products. British Journal of Nursing, 24.
Edgeworth, J. D. (2010). Has decolonization played a central role in the decline in UK methicillin- resistant Staphylococcus aureus transmission? A focus on evidence from intensive care. Journal of Antimicrobial Chemotherapy, 66, ii41–ii47.
Harris, P. N., Le, B. D., Tambyah, P., Hsu, L. Y., Pada, S., Archuleta, S., ... & Fisher, D. A. (2015). Antiseptic body washes for reducing the transmission of methicillin-resistant staphylococcus aureus: A cluster crossover study. In Open Forum Infectious Diseases, 2(2), 51. New York, NY: Oxford University Press.
Hong, C. C., Wang, S. M., Nather, A., Tan, J. H., Tay, S. H., & Poon, K. H. (2015). Chlorhexidine anaphylaxis masquerading as septic shock. International Archives of Allergy and Immunology, 167(1),

20. References
Kim, H. A., Lee, W. K., Na, S., Roh, Y. H., Shin, C. S., & Kim, J. (2016). The effects of chlorhexidine gluconate bathing on health care–associated infection in intensive care units: A meta-analysis. Journal of Critical Care, 32(1),
Larson, E. L., Ciliberti, T., Chantler, C., Abraham, J., Lazaro, E. M., Venturanza, M., & Pancholi, P. (2004). Comparison of traditional and disposable bed baths in critically ill patients. American Journal of Critical Care, 13(3),
Marchaim, D., Taylor, A. R., Hayakawa, K., Bheemreddy, S., Sunkara, B., Moshos, J., ... & Lephart, P. R. (2012). Hospital bath basins are frequently contaminated with multidrug-resistant human pathogens. American Journal of Infection Control, 40(6),
Melnyk, B., & Fineout-Overholt, E. (2015). Evidence-based practice in nursing and healthcare: A guide to best practice (3rd ed.). Philadelphia, PA: Wolters Kluwer Health.
Milstone, A. M., Elward, A., Song, X., Zerr, D. M., Orscheln, R., Speck, K., ... & Pediatric SCRUB Trial Study Group. (2013). Daily chlorhexidine bathing to reduce bacteraemia in critically ill children: A multicentre, cluster-randomised, crossover trial. The Lancet, 381(9872),

21. References
Nøddeskou, L. H., Hemmingsen, L. E., & Hørdam, B. (2015). Elderly patients' and nurses' assessment of traditional bed bath compared to prepacked single units–randomised controlled trial. Scandinavian Journal of Caring Sciences, 29(2),
Petlin, A., Schallom, M., Prentice, D., Sona, C., Mantia, P., McMullen, K., & Landholt, C. (2014). Chlorhexidine gluconate bathing to reduce methicillin-resistant Staphylococcus aureus acquisition. Critical Care Nurse, 34(5),
Rubin, C., Wessels, E., & Downer, S. (2013). Chlorhexidine gluconate: To bathe or not to bathe? Critical Care Nurse Quarterly, 36(2),
Spencer, C., Orr, D., Hallam, S., & Tillmanns, E. (2013). Daily bathing with octenidine on an intensive care unit is associated with a lower carriage rate of meticillin-resistant Staphylococcus aureus. Journal of Hospital Infection, 83(2),
The Joint Commission [TJC]. (2011). Hospital national patient safety goals. Oakbrook Terrace, IL: The Joint Commission.

22. References
Veje, P. L., & Larsen, P. (2014). The effectiveness of bed bathing practices on skin integrity and hospital-acquired infections among adult patients: a systematic review protocol. The JBI Database of Systematic Reviews and Implementation Reports, 12(2),
Willis, G. C., Ooi, S. T., Foo, M. L., Ong, P. L., Tan, B. B. C., Li, D., ... & Chng, F. L. (2015). The effect of daily chlorhexidine baths on nosocomial meticillin-resistant Staphylococcus aureus infection in MRSA-colonized patients admitted to general wards. International Journal of Infection Control,11(4).