Professional Documents
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C HLORHEXIDINE
BATHING AND MICROBIAL
CONTAMINATION IN
PATIENTS BATH BASINS
By Jan Powers, RN, PhD, Jennifer Peed, RN, BSN, Lindsey Burns, RN, BSN, and
Mary Ziemba-Davis, BA
C N E 1.0 Hour
in place of standard soap and water to wash patients.
Methods Bathing with chlorhexidine gluconate is the standard
of practice for all patients in intensive care units at St Vincent
Hospital. Specimens from 90 bath basins used for 5 days or
Notice to CNE enrollees: more were cultured for bacterial growth to assess contamina-
A closed-book, multiple-choice examination tion of basins when chlorhexidine gluconate is used.
following this article tests your understanding of Results Of the 90 basins cultured, only 4 came back positive
the following objectives: for microbial growth; all 4 showed growth of gram-positive
1. Compare the rate of bacterial contamination organisms. Three of the 4 organisms were identified as coag-
on bath basins using soap to those basins ulase-negative staphylococcus, which is frequently found on
where a standardized chlorhexidine solution is the skin. This translates into a 95.5% reduction in bacterial
used for bathing. growth when chlorhexidine gluconate is used as compared
2. List 3 common organisms found in patients with soap and water in the previous study (Fisher exact test,
bath basins. P < .001). The only factor that was related to positive cultures
3. Describe how basin, device, infection control, of samples from basins was the sex of the patient.
and isolation variables affect culture results Discussion Compared with the previous study examining
when using chlorhexidine for patient baths. microbial contamination of basins when soap and water was
used to bathe patients, bacterial growth in patients bath basins
To read this article and take the CNE test online, decreased significantly with the use of chlorhexidine gluconate,
visit www.ajcconline.org and click CNE Articles drastically reducing the risk for hospital-acquired infections.
in This Issue. No test fee for AACN members. Such reduced risk is especially important for critically ill patients
at high risk for bacterial infection. (American Journal of Critical
2012 American Association of Critical-Care Nurses Care. 2012;21:338-343)
doi: http://dx.doi.org/10.4037/ajcc2012242
338 AJCC AMERICAN JOURNAL OF CRITICAL CARE, September 2012, Volume 21, No. 5 www.ajcconline.org
Based on this and other studies of microbial basins, using a new washcloth for each body part
contamination of patients bath basins,2 a change in bathed. Initial bathing occurs within 6 hours of
practice eliminating the use of bath basins for hygiene ICU admission and daily thereafter. After completion
in hospitalized patients would be warranted. How- of bathing, basins are wiped with a paper towel to
ever, it is not yet known whether bacterial contami- eliminate standing water and then placed upside
nants are present in patients bath basins when down on a storage table to air dry. Basins are
chlorhexidine gluconate (CHG) solution is used for labeled and designated solely for CHG bathing and
bathing. It is known that bathing with CHG decreases are discarded if contamination with vomit or other
the frequency of infections with vancomycin-resistant bodily fluids occurs. An additional basin is labeled
enterococcus and methicillin-resistant Staphylococcus for the storage of bath supplies.
aureus3-8 and bloodstream infections.8-11 Research
studies showing the effectiveness of CHG bathing in Study Procedure
the reduction of hospital-acquired infections have Samples from 90 basins used to wash 90 patients
not clearly delineated which preparation of CHG in a 40-bed mixed medical surgical ICU at a large
(impregnated cloths vs CHG solution diluted in bath Midwestern tertiary care hospital (St Vincent Hospi-
water) is most effective. Based on previous studies, tal, Indianapolis, Indiana) were cultured for micro-
standard practice in our intensive care unit (ICU) is bial contamination. Study enrollment continued
bathing of all patients with 2 fl oz (60 mL) of 4% until a sample of 90 basins was
CHG solution diluted in 3 qt (2.85 L) of water. The achieved. All bath basins were Patients hospital
purpose of this study was to assess the presence of dated when the patient was admit-
bacterial contaminants in wash basins when CHG ted to the ICU, and only basins that bath basins are
solution is used in place of standard soap and water had been in use for 5 days were a known source
to wash patients. included in the sample. Approval
was obtained from the institutional of microbial
Methods review board before the start of the contamination.
Bathing Procedure study. Once enrolled, bath basins
Before the start of the study, standardized pro- were assigned a unique identification number to
cedures for patient hygiene and storage of wash basins ensure that basin duplication did not occur. A data
were in place. ICU nurses bathe patients with 2 fl tracking sheet was completed, with the data being
oz (60 mL) CHG to 3 qt (2.85 L) water in bath entered into a Microsoft Excel spreadsheet by a trained
investigator. The data collection tool recorded:
Patients demographics: sex, medical vs surgical
About the Authors
Jan Powers is director of clinical nurse specialists and a admission diagnosis, age, length of stay in the hos-
clinical nurse specialist in the trauma intensive care unit pital, and length of stay in the ICU;
at St Vincent Hospital in Indianapolis, Indiana. Jennifer Basin variables: the number of days that basins
Peed and Lindsey Burns are staff nurses in the medical
intensive care unit at St Vincent Hospital. Mary Ziemba- had been in use when the culture samples were
Davis is a research scientist on the clinical nurse specialist obtained and the number of days since the patients
team at St Vincent Hospital. last bath when the basins were sampled;
Corresponding author: Jan Powers, RN, PhD, Director of Device variables: presence of central catheters,
Clinical Nurse Specialists and Nursing Research, Trauma arterial catheters, peripherally inserted central catheters,
Intensive Care Unit Clinical Nurse Specialist, St Vincent
Hospital, 2001 West 86th Street, Indianapolis, Indiana endotracheal tubes, tracheostomy tubes, ventilators,
46260 (e-mail: jmpowers@stvincent.org). urinary catheters, and fecal containment devices;
www.ajcconline.org AJCC AMERICAN JOURNAL OF CRITICAL CARE, September 2012, Volume 21, No. 5 339
340 AJCC AMERICAN JOURNAL OF CRITICAL CARE, September 2012, Volume 21, No. 5 www.ajcconline.org
Sex .04
Female 4 (100.0) 38 (44.2)
Male 0 (0.0) 48 (55.8)
Diagnosis .55
Medical 3 (75.0) 71 (82.6)
Surgical 1 (25.0) 15 (17.4)
Age, median, y 68.0 60.5 .64c
Length of stay, median, d
In hospital 7.5 9.0 .36d
In intensive care unit 7.5 7.5 .87e
Central catheter .62
Yes 3 (75.0) 43 (50)
No 1 (25.0) 43 (50)
Arterial catheter .47
Yes 1 (25.0) 12 (14.0)
No 3 (75.0) 74 (86.0)
Peripherally inserted central catheter >.99
Yes 2 (50.0) 47 (54.7)
No 2 (50.0) 39 (45.3)
Endotracheal tube .62
Yes 3 (75.0) 45 (52.3)
No 1 (25.0) 41 (47.7)
Tracheostomy tube .57
Yes 0 (0.0) 20 (22.2)
No 4 (100.0) 70 (77.8)
Ventilator >.99
Yes 2 (50) 52 (60.5)
No 2 (50) 34 (39.5)
Foley catheter >.99
Yes 4 (100.0) 76 (88.4)
No 0 (0.0) 10 (11.6)
Fecal containment device .57
Yes 1 (25.0) 16 (18.6)
No 3 (75.0) 70 (81.4)
Infection shown by latest culture >.99
Yes 2 (50.0) 52 (60.5)
No 2 (50.0) 34 (39.5)
Antibiotics
Yes 2 (50.0) 65 (75.6) .27
No 2 (50.0) 21 (24.4)
Isolation .57
Yes 0 (0.0) 20 (23.3)
No 4 (100.0) 66 (76.7)
aUnitsfor age and length of stay are as specified in first column; all other values are No. (%) of patients.
bMost P values based on Fisher exact test, unless W value indicated in footnote.
cWilcoxon rank sum test, W = 3888.5.
dWilcoxon rank sum test, W = 3960.5.
eWilcoxon rank sum test, W = 3922.0.
Our study was limited to 90 CHG bath basins by Like Johnson et al, basins in the current study were
design to make accurate comparison to the 92 soap sampled from a medical/surgical ICU. Unlike the
and water bath basins cultured by Johnson et al.1 study by Johnson et al, our study did not include
www.ajcconline.org AJCC AMERICAN JOURNAL OF CRITICAL CARE, September 2012, Volume 21, No. 5 341
342 AJCC AMERICAN JOURNAL OF CRITICAL CARE, September 2012, Volume 21, No. 5 www.ajcconline.org
1. What was the purpose of the study described in this article? 6. How was the 95% infection reduction calculated?
a. To assess bath basins for bacterial contamination when chlorhexidine was a. The study group was compared to a group in another unit that used soap
used in place of soap instead of chlorhexidine.
b. To assess bath basins for bacterial contamination when soap was used in b. The present study group was compared to a past study group by Johnson
place of chlorhexidine et al that used soap.
c. To assess bath basins for bacterial contamination based on patient length c. The study hypothesis stated all patients with bath basins would have infections.
of stay d. The study groups infection rate was compared to the hospitals historical data.
d. To assess bath basins for bacterial contamination in all ICU patients
7. Which of the following percentages of bath basin samples grew
2. Which of the following methods was used to determine study bacteria in the previous study by Johnson et al?
eligibility? a. 32% c. 95%
a. Patients had to be admitted to the unit following a surgical procedure. b. 54% d. 98%
b. Patients had to use bath basins for at least 5 days.
c. Patients had to be bathed within 6 hours of admission. 8. Which of the following demographic characteristics was statistically
d. Patients had to have bath basins changed out every 5 days during admission. signif icant in the basins with positive cultures?
a. Age
3. Which of the following was considered part of the standardized b. Length of stay
bathing practice in the study hospital? c. Gender
a. Using the bath basin for storing patient supplies d. Diagnosis
b. Using the bath basin as an emesis basin as needed
c. Using a paper towel to dry the basin following the bath 9. Which of the following percentages of patients with a positive
d. Using a new bath basin for each bath culture was in isolation?
a. 0% c. 50%
4. Which of the following was considered a device variable in the study? b. 25% d. 100%
a. Time the culture was obtained in relation to time since last bath
b. Isolation status at the time the culture was obtained 10. Which of the following was the most common organism found on
c. Presence of a central venous catheter when the culture was obtained the study cultures?
d. Length of stay at the time the culture was obtained a. Gram-negative rods
b. Gram-positive cocci
5. How were cultures obtained from the basins in this study? c. Coagulase-positive staphylococcus
a. Culture swabs were rolled around the corners and bottom of the basin d. Clostridium difficile
when it was dry.
b. Culture swabs were rolled around the corners of the basin after wetting it 11. Which of the following factors may have affected the study results?
with tap water. a. The standardized bathing practice was implemented prior to the study
c. Culture swabs were rolled around the corners and bottom of the basin b. The study had too many control groups
prior to drying it following the bath. c. The use of tap water for the baths
d. Culture swabs were wetted with sterile saline and rolled around the corners d. The patient length of stay prior to the cultures
and bottom of the basin.
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