This assignment is about providing recommendations on how to prevent central line associated blood-stream infections.
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Kimberly Huppert, DNP, RN, CNOR, is Perioperative Clinical Nurse Educator, Enterprise, AL.
Stacey Jones, DNP, FNP-BC, is Associate Professor, Troy University, Troy, AL.
Kelly Johnson, DNP, RN, is Associate Professor, Troy University, Troy, AL.
The Effect of Initiating Chlorhexidine Gluconate Dressings at
Insertion on Central Line Infection Rates in Surgical Patients Requiring
Access
Kimberly Huppert Stacey Jones
Kelly Johnson
A ccording to the Centers for Disease Control and Preven -tion (CDC, 2016), central line-associated bloodstream infec- tion (CLABSI) results in thousands of deaths each year and billions of dol- lars in added costs to the U.S. health- care system. Central venous cathe - ters are used routinely in the care of chronic and acute illness (Ullman et al., 2015). An estimated five million patients in the United States require short-term or prolonged central venous access each year (Safdar et al., 2014). Scheithauer and coauthors (2014) found almost 60% of hospi- tal-acquired bloodstream infections originate from some form of vascular access. Even though this access is vital to care, it also increases pat - ients’ likelihood of developing CLABSI. CLABSI is a major source of morbidity and mortality despite often being preventable (Scheithauer et al., 2014). For this reason, the Centers for Medicare & Medicaid Services (CMS) will not reimburse institutions for catheter-related infections or complications associat- ed with the acquired infection (Medicaid.gov, 2018).
According to the CLABSI toolkit, educating staff and allowing feed- back on central line infection rates can result in fewer infections. Adherence to hand hygiene, daily
Research for Practice
Central line infections are a preventable condition that have serious implications. In this study, the central line infection rate decreased after simulated training sessions for nursing staff and implementa- tion of chlorhexidine gluconate (CHG) dressings at line insertion.
surveillance of the central line site, use of aseptic technique for care of the central line, and timely removal or replacement of the central line also were included (The Joint Commission, 2017). Suggestions are nurse-focused tasks and can be enforced by nursing staff. Add - itionally, nurses should be able to recognize signs and symptoms (e.g., temperature greater than 100.4° F, chills, hypotension) of a catheter- related infection and implement appropriate treatment per protocol.
Purpose The purpose of the study was to
determine the impact of using a chlorhexidine gluconate (CHG) dressing placed at the time of cen- tral line insertion on central line infection rates by comparing infec-
tion rates before and after imple- mentation in a surgical unit. The dressing for the pre-intervention group consisted of a CHG protec- tive disc and transparent film dress- ing. Consistent with the American Association of Critical Care Nurses (AACN) Synergy Model for Patient Care (Hardin & Kaplow, 2017), out- comes involved the patient (central line infection), nursing (proper placement of CHG dressing), and system (organization resources, pro- tocol).
Bearing the burden of costs and poor patient outcomes associated with hospital-acquired infection (HAI) has led to increased awareness of central line infection rates. After CMS (2019) regulations made the cost of treating HAI the responsibil- ity of the healthcare facility, identi- fication of the most effective inter-
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ventions has become a primary focus for healthcare leaders. This serves a dual purpose: addressing a facility’s financial implications and creating the best outcome for patients.
Review of the Literature A search of the literature for
2013-2018 was conducted using PubMed, CINAHL Complete, Evi - dence-Based Nursing, ProQuest, and the Cochrane Library. Key words used during the search included CHG, chlorhexidine gluco nate, CLABSI, CRBSI, CHG dressing, central line
infection interventions, CLABSI inter- ventions, CRBSI interventions, CHG and central line infections, and best practice to treat central line infections.
Conclusive evidence was found to support use of CHG dressings for central line catheter care. Evidence showed a reduction in central line infection rates when CHG dressings were implemented. Apata and col- leagues (2017) conducted a two- phase study on the effectiveness of CHG dressings. In phase one, the CHG dressing was introduced in a hemodialysis unit (A); two other units served as control units (B and C) and maintained adhesive dress-
ings. In phase two, the adhesive dressings used on the control units were replaced with CHG dressings. The catheter infection rate was compared 12 months retrospective- ly in addition to study period. Phase one resulted in a 52% decrease in infection in group A, 12% increase in group B, and 35% increase in group C. Phase two results showed an 86% decrease in group B, 53% decrease in group C, and 20% de - crease in the intervention group A.
Kerwat and associates (2015) found use of CHG dressings resulted in decreased colonization rates of catheter insertion sites as well as catheter tips. Other researchers incorporated a silver-coated needle- less connector to inhibit microor- ganism entry into the lumen and found infections decreased (Ozden et al., 2015). This intervention was compared to use of a sterile gauze pad dressing, which yielded two infections, and a CHG dressing, which resulted in one infection. No infections were reported in the group using a CHG dressing and a silver-coated needleless connector.
Webster and coauthors (2017) compared use of a CHG disc to a polyhexamethylene biguanide disc. One CLABSI was reported in each group and one disc-related adverse effect was reported in the CHG group. An earlier study also showed significant reduction in microbial counts on removal of catheters in CHG dressing groups compared to nonantimicrobial groups (Karpanen et al., 2016). Ergul and colleagues (2018) compared infection rates at the jugular site with use of a CHG dressing (n=63) and a standard dressing (n=68). Occurrence of infection was lower in the CHG group but the difference was not statistically significant.
However, adverse integumentary conditions and bleeding disorders have been associated with CHG dressing use (Thokala et al., 2016). Local reactions include possibly severe redness and irritation. Although many reactions will self- heal, development of eschar at the dressing site has been reported (Jenks et al., 2016). A study by Ishigami and coauthors (2018)
Research for Practice
Background
Central venous access increases a patient’s likelihood of acquiring a bloodstream infection. Almost 60% of hospital-acquired bloodstream infections originate from some form of vascular access.
Aim
Examine the effect of applying a chlorhexidine gluconate (CHG) dressing at the time of central line insertion on central line-associated blood- stream infection (CLABSI) rates.
Method
A retrospective pre-post intervention design was used to compare CLABSI rates of 30 patients not receiving and 30 patients receiving the CHG dressing at the time of central line insertion in the surgical unit. Surgical nursing staff responsible for placing the CHG dressing attended a simu- lated training session on dressing application.
Results
Although no statistical significance was found, fewer CLASBI were diag- nosed in patients receiving the CHG dressing at insertion. All pre- and post-intervention cases of CLABSI were associated with pre-existing kid- ney disease. A statistically significant difference was found between infec- tion confirmed and reason inserted associated with kidney disease (t(14)=2.385 p<0.05, 95% CI=0.087-1.646). Nurse attendees agreed the sim- ulation training was valuable.
Limitations and Implications
Limitations included a small sample and implementation of the inter- vention in one department, which affected the ability to generalize study results.
Conclusion
Central line infections are preventable. The central line infection rate decreased after simulated training sessions for nursing staff and imple- mentation of CHG dressings at line insertion. Future studies should include a larger sample and multiple departments, and investigate meth- ods for identifying and managing patients at high risk for infection.
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The Effect of Initiating Chlorhexidine Gluconate Dressings at Insertion on Central Line Infection Rates in Surgical Patients Requiring Access
focused on the link between kidney disease and HAI following surgery, identifying kidney disease as the leading factor for HAI among surgi- cal patients (followed by cancer, heart failure, stroke). No research was identified addressing the effica- cy of using the CHG dressing at the time of central line insertion.
Theory The AACN Synergy Model was
chosen as the middle range theory for the study. The model delineates outcomes from the perspective of the patient, nurse, and healthcare system (Hardin & Kaplow, 2017). Patient characteristics include func- tional or behavioral changes that impact quality of life (e.g., no cen- tral line infection). Nurse character- istics include monitoring changes to match nurse competencies with patient needs (e.g., ensuring nurses are trained on the proper placement of CHG dressing). Healthcare sys- tem characteristics include having appropriate resources available and avoiding the return to bad habits (having the CHG dressing available for use).
Ethics Electronic medical records (EMRs)
were identified by performing a search for central line insertion pro- cedures for extraction of data. The principal investigator (PI) main- tained a list using patients’ medical record numbers as identifiers. This list remained at the hospital in a locked filing cabinet in the PI’s locked office. Each EMR was assign - ed a unique identifier (UI) to safe- guard personal health information. No reference was made in collected data to medical record number, name, date of birth, dates of service, or any other identifying data.
Informed consent was obtained from registered nurses (RNs) for par- ticipation in the simulation training session CHG dressing application. Participation was voluntary and par- ticipants could opt out at any point without risks to professional or per- sonal relationships with coworkers or employment at the hospital. No
information with identifying charac- teristics was collected; data were maintained on a password-protected computer accessed only by the PI.
Sample Selection
Target Population The intended sample consisted
of 60 patients who had central line access as part of treatment. To eval- uate the effectiveness of the inter- vention delivery further, researchers provided pre-intervention training on proper dressing application to nurses who were responsible for applying the CHG dressing intraop- eratively. The day-long training occurred in a classroom setting 2 days before implementation of the CHG dressing.
Study Setting The setting was the surgical
department of a 400-bed Level 2 trauma center in the southeastern United States. The facility served patients of all ages with varied health conditions. The setting was chosen due to accessibility of the population of interest.
Design and Method
Tools A retrospective pre-intervention,
post-intervention design was used. To gather information about central line infection rates, the PI created a data collection form to address UI, age, gender identity, insertion site, infection acquired (if applicable), name of the infectious organism (if applicable), and indication for cen- tral line insertion. The tool was used for retrospective and post-imple- mentation EMR reviews.
Intervention training for nurses included proper application of the CHG dressing and effects of a cen- tral line infection on the body (e.g., fever, hypotension, presence of blood stream organism [CDC, 2018]), treatment, assessment for CHG allergies, and communication of CHG allergies to the healthcare provider. Training concluded with administration of the Program for
Nursing Curriculum Integration (PNCI®) Simulation Effectiveness tool. The PNCI was developed to evaluate efficacy of simulated clini- cal experiences (SCE) and measure learning and confidence (Elfrink- Cordi et al., 2012). Ensuring surgical nurses were trained to apply the dressing properly contributed to overall fidelity of the intervention.
Reliability and Validity The researcher-created tool was
reviewed and endorsed by the PI’s Doctoral Synthesis Project commit- tee and the university’s Insti tutional Review Board (IRB) for EMR review data retrieval. The PNCI survey had a 3-point ordinal scale with con- firmed face validity (Elfrink-Cordi et al., 2012). The 13-item survey had a Cronbach’s alpha for the overall sur- vey of 0.92 with a standard error of measurement of 2.84.
Data Collection After IRB approval was received
from the facility and the university, a pre-intervention retrospective review of 30 EMRs was performed for patients who did not receive the CHG dressing at the time of central line insertion. In addition, a post- intervention retrospective review of 30 EMRs was conducted 30 days after each central line insertion pro- cedure for patients who received a CHG dressing at the time of central line insertion. All patients were over age 18. The PNCI was administered via SurveyMonkey® to nurses com- pleting the simulation training ses- sion. Invitations were sent to nurs- es’ email addresses and results were retrieved after the survey was closed.
Findings Data were analyzed using IBM®
SPSS® (v.24) (see Table 1). All nurse participants strongly agreed “com- pleting the SCE helped them under- stand classroom information bet- ter” and allowed them to feel more confident in what to tell the health- care provider. See Table 2 for responses on the PNCI survey.
Results concerning the pre-inter- vention sample (N=30) and the post-
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Research for Practice
intervention sample (N=30) were analyzed to determine the impact of use of a CHG dressing placed at the time of central line insertion on cen- tral line infection rates. The pre-inter- vention group was formed through a retrospective EMR review of patients who met inclusion criteria (e.g., required central line access as part of treatment and reported no CHG allergy) but did not receive the CHG dressing at the time of central line insertion. The post-intervention sam- ple was patients who received the CHG dressing when they required central line access as part of treat- ment (see Table 3). Results indicated no statistical difference in ages of the study group.
A chi-square test was conducted to examine differences between patient gender identity and con- firmed infection, central line inser- tion site and confirmed infection, and reason for central line insertion
and confirmed infection before and after intervention. No significant differences were found in the pre- intervention sample for any of these comparisons. Following the intervention, no significant differ- ences were found between patient gender identity and confirmed infection as well as between central line insertion site and confirmed infection. However, a statistically significant difference was found between reason for central line insertion and confirmed infection (χ2(10)=30.000, p<0.01).
Independent samples t-tests also were conducted to examine the dif- ference between gender identity and confirmed infection, and be - tween confirmed infection and rea- son inserted before and after inter- vention. No significant difference was found between gender identity and confirmed infection before or after intervention. However, a sta-
tistically significant difference was found between confirmed infection and reason inserted associated with a patient diagnosis of kidney disease (t(14)= 2.385, p<0.05, 95% CI=0.087- 1.646).
Discussion Results of the PNCI indicated all
nurses agreed the SCE helped them to understand classroom informa- tion better in regard to CHG dress- ing application and improved their assessment skills. All participants also agreed they were more com- fortable in communicating with the healthcare provider as a result of the SCE. The skills taught during the SCE led to efficient implementation of the CHG dressings and continue to contribute to a decrease in CLAB- SI. Although the results were not statistically significant, the CLABSI rate decreased from three infections in the pre-intervention sample to one infection in the post-interven- tion sample. Significant differences were found between the reason for the central line insertion and infec- tion confirmation. The identified reason was patient kidney disease, which was present in all pre-inter- vention infections and was an iden- tified co-morbidity in post-imple- mentation infection. Of 60 patients whose records were reviewed for this study, 45 (75%) had a diagnosis of kidney disease. The occurrence of kidney disease supports the findings of Ishigami and colleagues (2018), who also found kidney disease was a leading factor in patients diag- nosed with HAI.
Limitations Limitations for this study includ-
ed a small sample of 60 participants. Although inferential statistics were used, the small sample limited gen- eralizability of the study. The use of one department within one facility also restricted ability to generalize study results. No training sessions were scheduled with weekend nurs- es due to conflicting schedules, lim- iting study participation to weekday nurses.
TABLE 1. Description of Surgical Nurse Participants
(N=5)
Characteristics n %
Age (Years)
18-24 0 0
25-34 1 20.0
35-44 3 60.0
45-54 1 20.0
55-64 0 0
Gender Identity
Male 1 20.0
Female 4 80.0
Experience (Years)
0-5 0 0
6-10 2 40.0
11-15 3 60.0
16-20 0 0
≥25 0 0
Entry Level Preparation
ADN 2 40.0
BSN 3 60.0
ADN = associate degree in nursing, BSN = bachelor of science in nursing
May-June 2020 • Vol. 29/No. 3 155
Recommendations for Future Research
Future studies should include multiple departments within the facility to increase generalizability of results. The recognition of comorbidities associated with cen- tral line infections also warrants fur- ther investigation within the study location. This includes investiga- tion methods for identifying high- risk patients as well as targeted infection prevention approaches for implementation into practice.
Nursing Implications The impact of this study centers
on the importance of proper train- ing when implementing new patient interventions. The AACN Synergy Model provided the struc- ture for the project and the belief all patients should expect a progres- sion of events (absence of infection) (Peterson & Bredow, 2013). By com- pleting training, nurses become more knowledgeable, confident, and better prepared to care for patients. Use of the PNCI demon- strated increased nursing percep-
tion of competence and allowed time for hands-on training with the CHG dressing in a simulated envi- ronment.
Training contributed to success- ful implementation of the practice change by familiarizing RNs with the proposed dressing protocol. Preparing RNs before implementa- tion alleviated concerns related to dressing application in the intraop- erative setting. Facility leaders should consider offering staff edu- cation on proper dressing applica- tion to lessen concern over a prac- tice change in the clinical setting.
The Effect of Initiating Chlorhexidine Gluconate Dressings at Insertion on Central Line Infection Rates in Surgical Patients Requiring Access
TABLE 2. Description of Program for Nursing Curriculum Integration (PNCI®)
(N=5)
Variables
Do Not Agree Somewhat Agree Strongly Agree Skipped
n % n % n % n %
The instructor’s questions helped me to critically think.
0 0 2 40 3 60 0 0
I feel better prepared to care for real patients.
0 0 0 0 4 80 1 20
I developed a better understanding of the pathophysiology of the conditions in the SCE.
0 0 2 40 3 60 0 0
I developed a better understanding of the medications that were in the SCE.
0 0 2 40 3 60 0 0
I feel more confident in my decision- making skills.
0 0 1 20 3 60 1 0
I am more confident in determining what to tell the healthcare provider.
0 0 0 0 5 100 0 0
My assessment skills improved. 0 0 0 0 5 100 0 0
I feel confident that I will be able to recognize changes in my real patient’s condition.
0 0 1 20 4 80 0 0
I am able to better predict what changes may occur with my real patients.
0 0 1 20 4 80 0 0
Completing the SCE helped me understand classroom information better.
0 0 0 0 5 100 0 0
I was challenged in my thinking and decision-making skills.
0 0 1 20 4 80 0 0
I learned as much from observing my peers as I did when I was actively involved in caring for the simulated patient.
0 0 1 20 4 80 0 0
Debriefing and group discussion were valuable.
0 0 2 40 3 60 0 0
SCE = simulated clinical experiences
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Research for Practice
TABLE 3. Characteristics and Statistical Results of Pre- and Post-Intervention Patient Samples
Characteristics
Pre-Intervention Sample (N= 30)
Post-Intervention Sample (N= 30)
n % n %
Gender Identity
Male 15 50 19 63.3
Female 15 50 11 36.7
Age (Years)
20-39 0 0 3 9.9
40-50 8 26.6 3 9.9
51-60 5 16.6 7 23.3
61-70 3 19.9 6 20
71-80 6 26.7 7 23.3
81-90 5 10 3 10
≥91 0 0 1 3.3
Infection
Yes 3 10 1 3.3
No 27 90 29 66.7
Infectious Organism
None 0 90 0 96.7
E. faecalis 1 3.3 0 0
S. pseudintermedius 1 3.3 0 0
S. aureus 1 3.3 1 3.3
Site for Central Line
Left subclavian 6 20 1 3.3
Left internal jugular 3 10 5 16.7
Right internal jugular 21 70 23 76.7
Femoral 0 0 1 3.3
Reason for Central Line Insertion
Colon cancer 3 10 1 3.3
Acute renal failure 9 30 5 16.7
Sepsis 1 3.3 0 0
Chronic kidney disease 2 6.7 2 6.7
Rectal cancer 2 6.7 1 3.3
Lymphoma 1 3.3 0 0
Thrombosed fistula 1 3.3 0 0
End-stage renal disease 10 33.3 15 50
Guillain Barré 1 3.3 0 0
Colon resection 0 0 1 3.3
Increasing weakness 0 0 1 3.3
Heart failure 0 0 1 3.3
Severe weakness 0 0 1 3.3
Chronic renal failure 0 0 1 3.3
Health status 0 0 1 3.3
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Conclusion CLABSI is a preventable condi-
tion with serious implications. The central line infection rate at the study site decreased through imple- mentation of CHG dressings at the time of central line insertion. The PNCI provided a structured evalua- tion of the simulated clinical train- ing. Survey results indicated the training session before the interven- tion was a successful step in the implementation process.
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The Effect of Initiating Chlorhexidine Gluconate Dressings at Insertion on Central Line Infection Rates in Surgical Patients Requiring Access
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