IMPLICATIONS FOR PRACTICE PAPER 1

Implications for Practice Paper

Stacy D. Dunham

University of South Florida

IMPLICATIONS FOR PRACTICE PAPER 2

Implications for Practice Paper

Healthcare-associated infections are a widespread problem throughout hospitals and pose

a lethal threat to a patients health. According to the World Health Organization (2002), HAIs

are An infection acquired in hospital by a patient who was admitted for a reason other than that

infection. This includes infections acquired in the hospital but appearing after discharge (p.9).

The Centers for Disease Control and Prevention (CDC) report one in twenty-five hospitalized

patients will have a HAI during hospitalization (2016). While statistics show the overall rate of

incidence of HAIs down nationwide, in the state of Florida MRSA bacteremia is up by 4%

compared to the national average (CDC, 2016). According to the Agency for Healthcare

Research and Quality (2014), In 2012, there were 36.5 million hospital stays in the United

States, with an average length of stay of 4.5 day (p.1). If there are 36.5 million hospitalized

patients and one in twenty-five of them acquire a nosocomial infection, it equates to 1,460,000

HAIs annually. With numbers like this it emphasizes the importance of implementing and

enforcing policies to reduce infection. The use of antiseptic agents like chlorhexidine can provide

patients a safeguard in preventing transmission of disease, reduce nosocomial infections, and

have better outcomes in the hospitalized patient. This paper assesses the efficacy of daily CHX

baths in ICU patients to reduce HAIs. Among ICU patients with a length of stay greater than two

days, how does receiving daily CHX baths, compared to nonantimicrobial baths, decrease the

frequency of nosocomial infections throughout their hospital admission?

Synthesized Literature Review

IMPLICATIONS FOR PRACTICE PAPER 3

PubMed, Oxford Journals, American Journal of Infection Control, Elsevier, and the

National Guideline Clearinghouse were all used to research various clinical trials, nursing

practices, and hospital guidelines to reduce infection. The key search terms used were hospital

acquired infections, nosocomial infections, MRSA, VRE, bacteremia, risks to ICU patients,

chlorhexidine baths, bathing practices, and infection control practices.

Climo et al. (2013) reported the overall rate of HAIs with the use of CHX compared to

nonantimicrobial agents were significantly reduced (P=0.007), and the number of MRSA or VRE

infections also saw a reduction (P=0.03). In addition, Milestone et al. (2013) reported children

bathed with CHX had a 36% decreased possibility of bacteremia then children bathed using

standard practices (aIRR 064, 95% CI 042098). Viray et al. (2014) reported a decrease in

MRSA infections in the surgical ICU population who were receiving daily CHX baths (P=.001),

as well as a decrease in S. aureus in the surgical ICU (P=0.012). Lastly, the CDC published

guidelines (2010) recommending decolonization of MRSA patients with CHX baths, as well as

universal daily chlorhexidine bathing in high risk patient populations, such as ICU patients.

Research shows by administering CHX baths, either with washcloths or in the liquid

form, to ICU patients it will result in an overall decrease of HAIs, such as Staphylococcus

aureus, bacteremia, VRE, and MRSA. Significant progress has been made in the reduction of

HAIs, risks, morbidity, and cost; however, there are no significant data to support a notable

reduction in length of hospital stays or deaths. Additional studies will need to be performed to

assess if incorporating daily CHX bathing as a standardized practice in ICUs will have any

impact on those.

Proposed Practice Change

IMPLICATIONS FOR PRACTICE PAPER 4

Current research supports a change in daily bathing practices of ICU patients with a

length of stay greater than two days by implementing the use of antiseptic agents like

chlorhexidine to safeguard patients and prevent the transmission of disease, reduce nosocomial

infections, and have better outcomes.

Implications for Practice

Sarasota Memorial Hospital (SMH) currently uses the revised Iowa Model (Melnyk &

Fineout-Overholt, 2015). This model examines the health care system in its entirety from the

physicians to the patients in order to pinpoint problems and come up with solutions to promote

better patient outcomes. The first step is to identify a problem plaguing SMH. In this case it

could be the frequency of nosocomial infections in ICU patients. Once the problem is identified

SMH would need to determine whether or not this is a relevant problem at their facility and if

change is necessary. The second step is to amass a team to evaluate the problem, review current

practices, and assess credible research on the problem and associated practices. If there is

evidence to support the need for change the final step of the model will be implemented, which is

to develop a new policy and integrate it into daily practice, and lastly to evaluate the efficacy of

the new policy. Current research substantiates HAIs in ICU patients are a prevalent problem.

However, by implementing daily CHX baths, an evidence based practice, it has shown to reduce

the rate of HAIs, risks, length of stay, and cost to the patients, insurance companies, and

hospitals.

Nurses are at the frontline of patient care and have the ability to positively affect change.

By nurses staying current on the latest research and evidence based practices related to

nosocomial infections they will have the knowledge and ability to provide the safest environment
IMPLICATIONS FOR PRACTICE PAPER 5

for ICU patients. In addition, they will have the ability to effectively control the spread of many

resistant organisms.

Ethical Considerations

There are six ethical principles which are relevant to the proposed practice change. The

first is whether the newly revised bathing protocol will improve patient outcome and is worth

implementing (Melnyk & Fineout-Overholt, 2015). The second is if this EBP project is able to

produce credible and verifiable results, which in this case would be a reduction in HAIs (Melnyk

& Fineout-Overholt, 2015). The third is whether or not all ICU patients partaking in the new

protocol were treated fairly and equally with no exceptions being made for any one person

(Melnyk & Fineout-Overholt, 2015). The new protocol would dictate every patient in the ICU

would receive daily CHX baths. Next is whether the benefits of the new bathing protocol

outweigh the potential risks (Melnyk & Fineout-Overholt, 2015). Research has already shown

patients who receive daily CHX baths are exposed to fewer risks, have better outcomes, and

decreased HAIs, length of stay, and cost. However, if the protocol isnt implemented then HAIs

would remain a prevalent problem in ICU patients. A review of the EBP project should also be

performed to ensure ethical standards are being maintained (Melnyk & Fineout-Overholt, 2015).

Lastly, respect for the patient should be upheld by preserving their privacy, keeping them

informed, and being mindful of their health while implementing the new protocol (Melnyk &

Fineout-Overholt, 2015).

The educational needs of all personnel would need to be determined prior to the

implementation of practice changes. However, after implementing the new bathing protocol into

the standards of care it will be sustained by offering educational programs to meet the learning
IMPLICATIONS FOR PRACTICE PAPER 6

needs of the providers. This will include in-service education, continuing nursing education, and

ongoing evaluation of the CHX bathing protocol to determine if it remains beneficial to the

patient or if it is time for a revision in practices (Melnyk & Fineout-Overholt, 2015).

Conclusion

The data showed ICU patients who received daily CHX baths have shown to have a lower

rate of various HAIs which cuts down cost, risk, and morbidity. The CDC published guidelines

(2010) recommending decolonization of MRSA patients with CHX baths, as well as universal

daily chlorhexidine bathing in high risk patient populations, such as ICU patients, to reduce

HAIs.
IMPLICATIONS FOR PRACTICE PAPER 7

References

Agencies for Healthcare and Research (2014). Healthcare cost and utilization project, statistical

brief #180. Retrieved from http://www.hcup-us.ahrq.gov/reports/statbriefs/sb180-

Hospitalizations-United-States-2012.pdf

Centers for Disease Control and Prevention (2010). Methicillin-resistant Staphylococcus aureus

(MRSA) infections. Retrieved from

http://www.cdc.gov/hai/pdfs/toolkits/MRSA_toolkit_white_020910_v2.pdf

Centers for Disease Control and Prevention (2016). HAI data and statistics. Retrieved from

http://www.cdc.gov/HAI/surveillance/

Centers for Disease Control and Prevention (2016). National and state healthcare associated

infections progress report. Retrieved from http://www.cdc.gov/HAI/pdfs/progress-

report/hai-progress-report.pdf

Climo, M. W., Yokoe, D. S., Perl, T. M., Bolon, M., Herwaldt, L. A., Weinstein, R. A., . .

.Wong, E. S. (2013). Effect of daily chlorhexidine bathing on hospital-acquired

infection. The New England Journal of Medicine, 368(6), 533542. doi:

10.1056/NEJMoa1113849

Melnyk, B., Fineout-Overholt, E. (2015). Evidence-based practice in nursing & healthcare: a

guide to the best practice (3rd ed.). Philadelphia, PA: Lippincott, Williams & Wilkins.

Milstone, A. M., Elward, A., Song, X., Zerr, D. M., Orscheln, R., Speck, K., . . . Perl, T. M.

(2013). Daily chlorhexidine bathing to reduce bacteraemia in critically ill children: A

IMPLICATIONS FOR PRACTICE PAPER 8

multicentre, cluster-randomised, crossover trial. The Lancet, 381(9872), 1099-1106.

doi:10.1016/S0140-6736(12)61687-0

Viray, M., Morley, J., Coopersmith, C., Kollef, M., Fraser, V., Warren, D. (2014). Daily bathing

with chlorhexidine-based soap and the prevention of staphylococcus aureus transmission

and infection. Infection Control and Hospital Epidemiology, 35(3), 243-250. Retrieved

from http://ovidsp.tx.ovid.com.ezproxy.hsc.usf.edu/sp-

3.18.0b/ovidweb.cgi?&S=PEELFPEHOKDDICLFNCJKLGJCKMPOAA00&Abstract=S

.sh.34|1|1

World Health Organization. (2002). Prevention of hospital-acquired infections. Retrieved from

http://www.who.int/csr/resources/publications/drugresist/en/whocdscsreph200212.pdf?ua

=1