CAPSTONE PART 2 NATA

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Part 1: Hospital-Acquired Infections

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Part 1: Hospital-Acquired Infections

Hospital-acquired infections (HAIs) are a public health issue. Different types of HAI

include surgical site and central line-associated bloodstream infections, ventilator-associated

pneumonia, and catheter-associated urinary tract infections. Among the most common HAIs is

surgical site infections which occur post-surgery in the body part that underwent the procedure.

Puro et al. (2022) explain that infections in surgical sites after surgery are the second most

common HAIs, occurring in 2-5% of the patients undergoing operation. HAIs lead to patient

morbidity, mortality, and increased economic burden due to prolonged hospital stays. Seventy

percent of HAIs are preventable (Puro et al., 2022). For infections post-surgery, focusing on risk

factors that cause bacterial contamination is among the recommended strategy. Strategies

supported by randomized control trials include skin preparation by bathing the patient before

surgery, avoiding hair removal using razors, perioperative glycemic control, and maintaining

normothermia. Skin preparation through bathing or decolonization is a process where healthcare

professionals use soap and water or chlorhexidine to eliminate antimicrobial-resistant pathogens.

The purpose of this program is to assess the effectiveness of chlorhexidine versus soap and water

in reducing the rate of HAIs post-surgery.

The PICOT that will help identify the best evidence for the identified problem is: Does

implementation of (I) chlorhexidine in post-surgical patients (P) compared to using soap and

water (C) reduce hospital-acquired infections (O) within a period of 7 weeks (T)? Post-surgical

patients are prone to HAIs attributed to wound or surgical site contamination. Alverdy et al.

(2020) explain that intraoperative contamination due to the presence of organisms such as

Staphylococcus aureus is the leading cause of HAIs after surgery. Skin preparation for bacteria

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decolonization reduces HAIs post-surgery and can be performed with chlorhexidine or soap and

water. The two methods are associated with varying rates of post-surgical infections. For some

authors, such as Ammanuel et al. (2021), the two options in skin preparation and hand hygiene

before the operation do not differ when the rate of HAIs post-surgery is compared. However,

Lewis et al. (2019) note that some studies have revealed inconclusive evidence while comparing

the two, while others support chlorhexidine as a more effective method in reducing the rate of

HAIs post-surgery. A seven-week implementation period is adopted for this proposal to assess

the difference in the rate of HAIs comparing the two approaches. The rate of HAIs will be

determined pre and post-intervention implementation to determine which approach results in

reduced HAIs.

Various factors make the post-operative patient population vulnerable. Among the factors

that make this population vulnerable is their compromised immunity. Additionally, the open

wound resulting from surgery creates an unprotected site for pathogens that cause infections.

Specific social impacts affect post-operative patients. The most significant ones include nutrition,

glycemic control, and education level. Nutrition is vital to wound healing. Social-economic

status is the primary determinant of an individual’s access to proper nutrition. A lack of good

nutrition denies patients the micronutrients necessary for wound healing post-surgery.

Subsequently, the wound stays open for longer, exposing one to infections. Further, social-

economic status is associated with better glycemic control. Notably, perioperative glycemic

control is one factor that determines the incidence rate of HAIs after surgery (Seidelman et al.,

2023). Finally, education determines a patient’s ability to adhere to post-operative care. For

instance, a patient’s ability to adhere to directives that will aid in the recovery process is

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impacted by their literacy level, which affects their recovery and chances of contracting HAIs.

One or a combination of the outlined factors makes post-operative patients vulnerable.

The proposed intervention to help address HAIs post-surgery is the use of chlorhexidine.

Chlorhexidine is an antiseptic agent used in the cleaning process during surgeries to avoid

surgical site infection or in the disinfection of medical appliances to avoid nosocomial infections.

The intervention process requires 2% to 4% chlorhexidine gluconate (CHG) (Warren et al.,

2021). CHG no-rinse 2% CHG-impregnated cloths are more effective in reducing microbial

density post-surgery. However, the 4% CHG liquid formula is often used because it is more cost-

effective (Warren et al., 2021). The advanced practice nurse is the primary individual responsible

for implementing hygiene and aseptic standards in the operating room before the surgical

procedure and during recovery to limit the spread of infections. The intervention process will be

adopted for seven weeks, whereby bacterial decolonization pre and post-operation via cleaning

will occur using chlorhexidine. The incidence rate of HAIs before and after the full

implementation of chlorhexidine use will be recorded and compared. A reduction in infection

rate will indicate the effectiveness of chlorhexidine compared to using soap and water.

The transtheoretical model is the theoretical framework that supports the implementation

of the proposed intervention. The transtheoretical behavioral change model outlines five stages

of behavior change (Hashemzadeh et al., 2019). The first stage is pre-contemplation which

comprises a phase where people find no need for a solution because they do not think one exists.

They also have limited awareness of the problem. During the project, the phase is marked by the

duration before this research, where the knowledge of HAIs post-operation and available

solutions are poorly understood. The second level is contemplation, where awareness of the

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problem and the intervention are created. Notably, in this project, the stage involves creating

awareness among health professionals dealing with surgery in a healthcare facility. The third step

is the preparation stage, where an action plan is developed. In relation to the proposed project,

this stage involves collecting data on the rate of HAIs before the implementation of

chlorhexidine in place of soap and water. The fourth stage is the action phase, where the

intervention is implemented. In this stage, full implementation of chlorhexidine use will be

adopted for all surgical patients pre-and post-operation. The final stage is maintenance, where a

permanent change is made to embrace the intervention fully. However, this permanent change is

made after the effectiveness assessment. During this phase, the rate of HAIs after the seven

weeks is assessed and compared to pre-intervention implementation. If infections have reduced

in comparison, the intervention will be adopted in full scale.

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References

Alverdy, J. C., Hyman, N., & Gilbert, J. (2020). Re-examining causes of surgical site infections

following elective surgery in the era of asepsis. The Lancet. Infectious Diseases, 20(3),

e38–e43. h"ps://doi.org/10.1016/S1473-3099(19)30756-X.

Ammanuel, S. G., Edwards, C. S., Chan, A. K., Mummaneni, P. V., Kidane, J., Vargas, E.,

D’Souza, S., Nichols, A. D., Sankaran, S., Abla, A. A., Aghi, M. K., Chang, E. F., Hervey-

Jumper, S. L., Kunwar, S., Larson, P. S., Lawton, M. T., Starr, P. A., Theodosopoulos, P. V.,

Berger, M. S., & McDermott, M. W. (2021). Are preoperative chlorhexidine gluconate

showers associated with a reduction in surgical site infection following craniotomy? A

retrospective cohort analysis of 3126 surgical procedures. Journal of Neurosurgery, 135(6),

1889–1897. h"ps://doi.org/10.3171/2020.10.JNS201255.

Hashemzadeh, M., Rahimi, A., Zare-Farashbandi, F., Alavi-Naeini, A. M., & Daei, A. (2019).

Transtheoretical model of health behavioral change: A systematic review. Iranian Journal

of Nursing and Midwifery Research, 24(2), 83–90. h"ps://doi.org/10.4103/

ijnmr.IJNMR_94_17.

Lewis, S. R., Schofield-Robinson, O. J., Rhodes, S., & Smith, A. F. (2019). Chlorhexidine

bathing of the critically ill for the prevention of hospital-acquired infection. The Cochrane

Database of Systematic Reviews, 8(8), 1-52. DOI: 10.1002/14651858.CD012248.pub2.

Puro, V., Coppola, N., Frasca, A., Gentile, I., Luzzaro, F., Peghetti, A., & Sganga, G. (2022).

Pillars for prevention and control of healthcare-associated infections: An Italian expert

opinion statement. Antimicrobial Resistance and Infection Control, 11(1), 1-13. h"ps://

doi.org/10.1186/s13756-022-01125-8.

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Seidelman, J. L., Mantyh, C. R., & Anderson, D. J. (2023). Surgical site infection prevention: A

review. JAMA, 329(3), 244-252. h"ps://doi.org/10.1001/jama.2022.24075.

Warren, B. G., Nelson, A., Warren, D. K., Baker, M. A., Miller, C., Habrock, T., & CDC

Prevention Epicenters Program. (2021). Impact of preoperative chlorhexidine gluconate

(CHG) application methods on preoperative CHG skin concentration. Infection Control &

Hospital Epidemiology, 42(4), 464-466. h"ps://doi.org/10.1017/ice.2020.448.