每日使用葡萄糖酸洗必泰抗菌沐浴的意义

chlorohexidine gluconate bathingimpregnated cloths results insignificant reduction inline-associated bloodstreamM.Dixon,RN,BSN,MHA,CCRN,CIC,and Robin L.Carver,RN,BSN,CICRaleigh,North CarolinaBackground:Central line-associated bloodstream infections(CLABSI)contribute to increased morbidity,mortality,length of stay, and excessive cost of care.Methods:This study was an observational cohort study using historical controls in the setting of a9-bed surgical intensive care unit in a Level I trauma center;all patients admitted or transferred into the unit were enrolled in the study.Objectives:A quality improvement intervention protocol was instituted to reduce CLABSI incidence with a3-month effectiveness study using2%chlorhexidine gluconate-impregnated cloths for daily patient bathing;education of surgical intensive care unit staff on changes to CLABSI prevention protocol and all existing CLABSI prevention policies and bundles already in place;and com-pliance monitoring and documentation.Results:The3-month effectiveness study showed a decrease in CLABSI rates from12.07CLABSIs per1000central line-days to3.17 CLABSIs per1000central line-days(73.7%rate reduction;P5.0358).Conclusion:CLABSI incidence rates were reduced in a high-risk patient population using evidence-based prevention bundles and implementing daily bathing with2%chlorhexidine gluconate nonrinse cloths.Key Words:CLABSI;bloodstream infection;chlorhexidine;CHG bathing.Copyrightª2010by the Association for Professionals in Infection Control and Epidemiology,Inc.Published by Elsevier Inc.All rights reserved.(Am J Infect Control2010;38:817-21.)The Centers for Disease Control and Prevention de-fines a central line-associated bloodstream infection(CLABSI)as a primary bloodstream infection occurringin a patient with a central line in place within48hoursprior to onset of the infection.1In2008,the NationalHealthcare Safety Network reported a pooled meanincidence rate of CLABSIs in the trauma critical carepatient population of4.0CLABSIs per1000centralline-days.2CLABSIs contribute to patient morbidity and mortality,extended length of stay,and increased cost of care.3-8In-fectious disease and infection prevention professionalsfollow the guidance of national prevention programs toprevent CLABSIs and other hospital-acquired infec-tions.8,9One of the most frequently touted preventiontools is the Institute for Healthcare Improvement(IHI)Central Line Bundle,9which consists of5interventions:(1)hand hygiene;(2)maximal barrier precautions duringinsertion;(3)skin antisepsis with chlorhexidine gluco-nate(CHG);(4)optimal catheter site selection with avoid-ance of the femoral vein for central venous access inadult patients;and(5)daily review of line necessity,with prompt removal of unnecessary lines.The surgical intensive care unit(SICU)in a Level Itrauma center successfully implemented the IHI Cen-tralLine Bundle in2005.By January2007,compliancewith the IHI Central Line Bundle was sustained atgreater than90%,but the unit’s CLABSI rate was trend-ing above the National Healthcare Safety Networkbenchmark rate.A review of the available literatureidentified a study by Bleasdale et al(2007)10in which817a61%decrease in the CLABSI rate occurred in a medical intensive care unit after implementation of daily bathing with CHG-impregnated cloths.The organization’s Infection Prevention and Control De-partment staff decided to attempt to replicate these results in the SICU setting.We worked with the man-agement and staff of the SICU to implement a quality improvement intervention of daily bathing with CHG-impregnated cloths to reduce the incidence of CLABSIs in the SICU.METHODSDesign overviewThis was an observational cohort study that used historical controls.Setting and participantsThe study setting was a9-bed SICU in a Level I trauma center.All patients admitted or transferred into the unit were enrolled in the study.Intervention objectivesThe Institutional Review Board of this organization approved(waiver received)a quality improvement in-tervention protocol with the following objectives:Reduce CLABSI incidence rates in the SICU through an initial3-month effectiveness study of the use of 2%CHG-impregnated cloths for daily patient bathing per a standardized protocol;educate SICU staff about the CLABSI prevention pro-tocol and about all existing CLABSI prevention poli-cies and bundles in place;monitor caregiver compliance using a daily log;compare historical preintervention and postinterven-tion CLABSI rates;andextend the2%CHG bathing protocol predicated on proven effectiveness.Description of usual practicesThe following practices were in place during the ef-fectiveness study:Noncoated,nonantimicrobial central lines were rou-tinely used throughout the facility.Maximal sterile barrier precautions were utilized at time of insertion.A standardized kit is available in the facility.Ports were decontaminated with alcohol prep pads for5seconds prior to access.No securement device was in use.A dressing(Biopatch[ETHICON,INC;a Johnson& Johnson Company,Somerville,NJ]with T egaderm[3M Health Care,St.Paul,MN])was applied at the time of insertion and changed every7days and as needed utilizing aseptic technique according to the facility’s policy,which requires performance of hand hygiene and application of clean gloves prior to changing the dressing.Hand hygiene was utilized,and clean gloves were worn prior to handling any central lines.Alcohol hand gel was available for use before and after pa-tient contact if hands were not visibly soiled;other-wise,soap and water hand hygiene was required. Unit hand hygiene compliance averaged greater than80%throughout the study period.ChloraPrep(Enturia,Inc,Leawood,KS)was utilized for site cleaning at insertion and with dressing changes. Tubing was changed every72hours per Centers for Disease Control and Prevention recommendations. Necessity of lines was reviewed on the daily goals sheet and in interdisciplinary rounds.Whereas lines were usually closed systems,occa-sionally,patients who had certain surgical proce-dures arrived to the unit with a stopcock or other device attached to the line.Blood for laboratory orders was drawn from central lines per physician order.CHG interventionAll SICU patients without a known sensitivity to CHG were bathed daily with disposable2%CHG-impregnated cloths(Sage2%Chlorhexidine Gluconate Patient Preoperative Skin Preparation Cloths;Sage Pro-ducts Inc,Cary,IL).This bath replaced traditional bathing methods using soap and water in a basin.The bath was documented daily on a compliance monitoring log.The cloths were not rewarmed,rewet,rinsed,or reused and were kept in the manufacturer-provided warmer.One pack of6cloths was used for each bath, with1cloth used for each of the following areas:Neck,chest,and arms;back;right leg;left leg;perineum;andbuttocks.The CHG cloths were not used on the head,on the face,or inside the vagina;these areas were cleansed with a terry-cloth washcloth,soap(Aloe Vesta Body Wash&Shampoo;ConvaT ec,Princeton,NJ),and water. Each patient’s skin was moisturized with baby oil or skin conditioner(Lotion Soft Skin Conditioner Skin Cream;STERIS Corp,Mentor,OH).Incontinence cleanup was also performed with a terry-cloth wash-cloth,soap,and water.A pack of2CHG-impregnated818Dixon and Carver American Journal of Infection ControlDecember2010cloths was used after each incontinence cleanup to en-sure the persistent presence of CHG on the skin.Each day,the charge nurse or designee placed a sticker from each patient’s chart on the SICU CHG bath-ing log and checked the box indicating whether or not the patient received the CHG bath that day;if they did not,the reason was provided.Compliance monitoring of central line bundleCompliance with maximal sterile barrier precau-tions at insertion is evaluated through an audit per-formed by nursing staff assisting with central line insertion.Each line inserted is audited,and the audit results charted on a checklist that is not a part of the patient medical pleted central line inser-tion bundle checklists are submitted to the Infection Prevention Department,where they are entered into a database.Data are analyzed by unit,and compliance rates are reported quarterly.Audits of compliance with hand hygiene are con-ducted on a similar checklist.All hand hygiene compli-ance audits are entered into a system-wide database from which unit and system level reports can be ob-tained by unit management staff.Hand hygiene com-pliance data are presented monthly on the unit-based nursing scorecard.Staff educationAll nursing staff members receive education about infection prevention policies and practices on hireand are trained and evaluated on central line practices at the unit level by nurse educators.Clinical perfor-mance is evaluated annually by unit management staff.Documentation of adverse eventsIf a rash or other adverse reaction developed during the study period,caregivers were instructed to discon-tinue the use of the CHG cloths and to resume soap-and-water bathing.Furthermore,the principal in-vestigator for this quality improvement project was to be contacted,and sensitivity to CHG was to be recorded on the patient’s medical record.Data collectionThe CLABSI preintervention and postintervention incidence rates were calculated as follows:(number of CLABSIs/number of central line-days)31000.Statistical analysisHypothesis.We hypothesized that the CLABSI rate in the SICU would decrease at least 30%from the prein-tervention to the postintervention time periods,which were defined as follows:Initial 3-month effectiveness study:May 2008through July 2008;andextended postintervention period:May 2008through September 2009.Sample size.With data from more than 6000device-days,there was adequate statistical power todetectFig 1.CLABSI rate January 2007through September 2009. Vol.38No.10Dixon and Carver 819an absolute difference of less than 1%as statisti-cally significant with an a level of 5%and a b level of 20%.Statistical methods.A x 2test was used to assess the change in CLABSI rates over time.Counts per 1000device-days were presented as the CLABSI rates.In ad-dition,the test statistic and P values were reported,and a P value less than or equal to an a level of.05was con-sidered statistically significant.RESULTSThe initial 3-month effectiveness study included 144patients and showed a decrease in CLABSI rates from 12.07CLABSIs per 1000central line-days to 3.17CLABSIs per 1000central line-days,a 73.7%rate reduction (P 5.0358).On the basis of these results,the protocol of daily bathing with CHG-impregnated cloths was continued,and a comparison was madebetween the CLABSI rates using a preintervention pe-riod of January 2007through April 2008and postinter-vention period of May 2008through September 2009.A statistically significant relative reduction of 76%(test statistic 513.1,P ,.001)was noted,from a pre-intervention CLABSI rate of 8.6CLABSIs per 1000cen-tral line-days (27/3148)to 2.1CLABSIs per 1000central line-days (7/3346)(Fig 1;T able 1).The CHG bathing logs,composed of a simple grid with space for a patient identification sticker and a check box indicating whether or not a CHG bath was given,indicated that compliance with the quality im-provement intervention was 100%.There were no ad-verse events reported for any patient associated with this study.DISCUSSIONPrevention of CLABSIs is a key focus of infection pre-vention professionals.This intervention was imple-mented in a clinical setting where basic infection prevention measures had been successfully imple-mented with high compliance rates,but elevated CLABSI incidence rates persisted.A thorough review of the evidence-based literature indicated that additional measures could be taken to help prevent CLABSIs.The ‘‘Compendium of Strategies to Prevent Healthcare-Associated Infections’’8of the Society for Healthcare Epidemiology of America/Infectious Disease Society of America outlines guidance for preventing CLABSIs,which includes adherence to national guide-lines,such as the IHI Central Line Bundle;existence of appropriate hospital infrastructure,such as staffing,lab-oratory facilities,resources for education,and training;and practical implementation of prevention activities,including physician/nurse education,development of catheter insertion checklists,and establishment of cath-eter insertion kits (ie,all necessary items for catheter in-sertion).The guidance provided by Society for Healthcare Epidemiology of America/Infectious Disease Society of America also includes special approaches recommended for use in locations within the hospital that have unacceptably high CLABSI rates despite im-plementation of the basic CLABSI prevention strategies.One of these recommendations is as follows:‘‘Bathe ICU patients older than 2months of age with a chlorhexi-dine preparation on a daily basis (B-II).’’8In the context of the continued high rate of CLABSI in the SICU,the in-fection prevention and control staff recognized that bathing patients daily with CHG-impregnated cloths should add an additional preventive measure against development of CLABSIs.The results of this study support the findings of other researchers who have reported a decreased incidence of CLABSIs with the use of CHG-impregnated cloths forT able 1.Infection rate and confidence interval per monthMonth-year Infection rate (per 1000device-days)Lower limit of 95%confidence interval Upper limit of 95%confidence interval January-200713.333 2.758138.469February-2007 5.18130.131228.529March-20070.00000.000024.293April-2007 5.52490.139930.397May-2007 4.40530.111524.299June-20079.8522 1.195435.135July-20079.0909 1.102932.452August-2007 5.05050.127927.817September-20070.00000.000023.077October-20070.00000.000018.645November-2007 4.67290.118325.759December-200727.77810.26159.477January-200817.937 4.908445.287February-2008 5.84800.148032.150March-200810.753 1.304938.301April-200810.695 1.297938.099May-20089.7561 1.183734.796June-20080.00000.000017.834July-2008 4.52490.114624.952August-20080.00000.000017.090September-20088.6580 1.050330.924October-2008 4.44440.112524.513November-20080.00000.000019.956December-20080.00000.000017.748January-2009 4.00000.101322.084February-20090.00000.000019.533March-20090.00000.000020.511April-20090.00000.000017.495May-20090.00000.000019.030June-2009 5.84800.148032.150July-20090.00000.000023.369August-20090.00000.000024.454September-20090.00000.000022.242820Dixon and CarverAmerican Journal of Infection ControlDecember 2010daily patient bathing.10,11An estimated 248,678blood-stream infections occur in hospitals each year,12with an estimated mortality rate of 12%to 25%for each CLABSI.The financial burden on the health care system is estimated at $36,441per episode,with an annual eco-nomic expenditure of approximately $9,062,074,998.13Given these cost estimates,this quality improvement initiative resulted in cost savings during the 17-month intervention period of approximately $728,820(from $983,907preintervention [January 2007through April 2008]to $255,087postintervention [May 2008through September 2009])(Fig 2).As with any successful quality improvement initiative,support from the unit’s man-agement staff and ongoing caregiver education were es-sential to ensuring effective compliance.The clinical implications of this study are clear:daily bathing with 2%CHG-impregnated cloths can signifi-cantly reduce the incidence of CLABSIs in a SICU pa-tient population.Unlike many other interventions suggested for CLABSI reduction,CHG cloth bathing does not require additional work on the part of the pa-tient care staff because it replaces an existing bathing process.In fact,anecdotal reports from staff members indicate increased satisfaction with CHG cloth bathing over traditional basin bathing because the rinsing step is eliminated from the bathing process.In addition,re-placement of traditional soap-and-water bathing with 2%CHG cloth bathing may reduce the risk of many types of hospital-acquired infections by eliminating the need for bath basins,a known source of environ-mental microbial contamination.14In clinical areas where basic infection prevention measures have been successfully implemented withhigh compliance rates,alternative methods should be investigated to decrease infection rates.In these situa-tions,implementation of evidence-based quality im-provement initiatives improves patient outcomes.The authors thank the SICU management team and staff for their diligent and enthu-siastic implementation of this quality improvement intervention and their ongoing commitment to infection prevention.References1.Centers for Disease Control and Prevention.NHSN manual:patient safety component protocols.Available from:/nhsn/PDFs/pscManual/4PSC_CLABScurrent.pdf .Accessed December 7,2009.2.Edwards JR,Peterson KD,Andrus ML,Dudek MA,Pollock DA,Horan TC,et al,The National Healthcare Safety Network Facilities.National Healthcare Safety Network (NHSN)peport,data summary for 2006through 2007,issued November 2008.Am J Infect Control 2008;36:609-26.3.Maki DG,Kluger DM,Crnich CJ.The risk of bloodstream infection in adults with different intravascular devices:a systematic review of 200published prospective studies.Mayo Clin Proc 2006;81:1159-71.4.O’Grady NP ,Alexander M,Dellinger EP ,Gerberding JL,Heard SO,Maki DG,et al.Guidelines for the prevention of intravascular catheter-related infections.Centers for Disease Control and Preven-tion.MMWR Recomm Rep 2002;51(RR-10):1-29.5.Pittet D,T arara D,Wenzel RP .Nosocomial bloodstream infections in critically ill patients:excess length of stay,extra cost,and attributable mortality.JAMA 1994;271:1598-601.6.Hu KK,Veenstra DL,Lipsky BA,Saint e of maximal sterile bar-riers during central venous catheter insertion:clinical and economic outcomes.Clin Infect Dis 2004;39:1441-5.7.Warren DK,Quadir WW ,Hollenbeak CS,Elward AM,Cox MJ,Fraser VJ.Attributable cost of catheter-associated bloodstream infections among intensive care patients in a nonteaching hospital.Crit Care Med 2006;34:2084-9.8.Marschall J,Mermel LA,Classen D,Arias KM,Podgorny K,Anderson DJ,et al.Strategies to prevent central line-associated bloodstream infec-tions in acute care hospitals.Infect Control Hosp Epidemiol 2008;29(Suppl 1):S22-30.9.5Million Lives Campaign.Getting started kit:prevent central line in-fections how-to guide ( )Cambridge,MA:Institute for Healthcare Improvement;2008.10.Bleasdale SC,T rick WE,Gonzalez IM,Lyles RD,Hayden MK,Weinstein RA.Effectiveness of chlorhexidine bathing to reduce catheter-associated bloodstream infections in medical intensive care unit patients.Arch Intern Med 2007;167:2073-9.11.Holder C,Zellinger M.Daily bathing with chlorhexidine in the ICU toprevent central line-associated bloodstream infections.J Clin Out-comes Manage 2009;16:509-13.12.Klevens RM,Edwards JR,Richards CL Jr,Horan TC,Gaynes RP ,PollockDA,et al.Estimating health care-associated infections and deaths in US hospitals,2002.Public Health Rep 2007;122:160-6.13.Stone PW ,Braccia D,Larson E.Systematic review of economic anal-yses of health care-associated infections.Am J Infect Control 2005;33:501-9.14.Johnson D,Lineweaver L,Maze L.Patients’bath basins as potentialsources of infection:a multicenter sampling study.Am J Crit Care2009;18:31-40.Fig 2.Cost of CLABSI:preintervention andpostintervention. 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