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Impact of Chlorhexidine Bathing on MRSACasey Stevens, UDUniversity of South FloridaNUR 4169AbstractClinical problem: Methicillin-resistant Staphylococcus aureus (MRSA) is a bacterium that is resistant to many antibiotics. In medical facilities, MRSA causes life-threatening bloodstream infections, pneumonia and surgical site infections (CDC, 2013). This infection is spread by contact and is passed onto people who have weak immune systems such as patients in the hospital. There needs to be more nursing interventions along with washing your hands, and isolation precautions, to help decrease the MRSA cases diagnosed in the hospital. Objective: To determine if the daily use of chlorhexidine wipes decreases the MRSA cases within the hospital compared to using the general use of soap and water. Data Sources: Using Pubmed, three randomized control trials were found to support the nursing care intervention. Specific words and phrases were used to narrow down the search. Those words included: chlorhexidine bathing techniques, bathing techniques to decrease MRSA cases, chlorhexidine bathing, and effect of daily chlorhexidine bathing on hospital acquired infections. Results: Climo et al.’s (2013) research showed that the overall rate of MRSA acquisition was 23% lower during the intervention period. Climo et al. (2009) was a study conducted by the same researchers but in a different year. The results showed that within this study 32% of MRSA cases were decreased following the introduction of chlorhexidine bathing. The last study done by Kassakian et al. (2011) presented with a 64% reduced risk of developing the primary outcome of MRSA within four general medicine units.Conclusion: Through a synthesis of selected literature, it has been concluded that the effectiveness of daily chlorhexidine wipes compared to the general use of soap and water to decrease MRSA cases is highly significant. Impact of Chlorhexidine Bathing on MRSAAccording to the Center of Disease Control and Prevention (CDC), Methicillin-resistant Staphylococcus aureus (MRSA) is a bacteria that is resistant to many antibiotics (2013). In medical facilities, MRSA causes life-threatening bloodstream infections, pneumonia and surgical site infections (CDC, 2013). This infection can prolong the length of stay and can increase costs of care and patient morbidity and mortality (Climo et al., 2009). MRSA can be prevented with the proper nursing care and interventions. This is a major problem within our health care facilities and needs to be addressed nationwide. According to current research a specific nursing intervention being done to reduce MRSA cases on general medical hospital floors is the daily use of chlorhexidine wipes. “Chlorhexidine gluconate is an antiseptic agent that has broad-spectrum activity against many organisms, including S. aureus and enterococcus species. Unlike many other antiseptics, chlorhexidine has residual antibacterial activity, which may decrease the microbial burden on patients' skin and prevent secondary environmental contamination.” (Climo et al., 2013, p.4) In order to evaluate the effectiveness of chlorhexidine bathing techniques a PICOT question was formulated. In adult patients placed on the complex medicine floor, how does using chlorhexidine wipes compared to the general use of soap and water affect the prevention of hospital acquired infections like MRSA within the patients stay at the hospital?Literature SearchHinks and Elaine Shimberg Health Sciences Library’s online resource PubMed was used to search for current articles with relevant information that could support the PICOT question being asked. Specific words and phrases were used to narrow down the search. Those words included: chlorhexidine bathing techniques, bathing techniques to decrease MRSA cases, chlorhexidine bathing, and effect of daily chlorhexidine bathing on hospital acquired infections. Literature Review Three randomized control led trial (RCT) articles and one clinical guideline were found regarding the effects that chlorhexidine wipes have on preventing hospital acquired infections such as MRSA (Table 1). The guideline used was retrieved from the Agency for Healthcare Research and Quality (AHRQ). It discussed that recent research has shown that the daily use of chlorhexidine wipes may decrease the incidence of MRSA cases within the patients stay at the hospital. The guideline used different randomized studies to compare the results and make a standard regulation that hospitals should follow. The instructions given were to bathe the patients with chlorhexidine wipes rather than soap and water and to strictly avoid the patient’s eyes and middle ear when bathing. Climo and colleagues (2013) completed a cluster-randomized study on the effects of the use of chlorhexidine wipes on patient’s daily and if it helped prevent hospital acquired infections. For this study, 7,727 patients agreed to participate from August 2007 to February 2009. The strengths of the article were the clearly defined meaning of chlorhexidine gluconate and it articulated in detail what hospital-acquired infections are. It made the reader understand the study because of the distinct definitions given in the introduction. The only weaknesses observed of this source was it had to have a correction published four months following the original article due to incorrect information in one of the tables. The corrected report was republished in June 2013. The relevance of the source to the project being done is the study evaluated whether the use of chlorhexidine wipes could actually prevent MRSA. Having the randomized controlled study results gave the reader the essential information needed to support the intervention. The experimental groups of patients were bathed daily with chlorhexidine wipes and the control group of patients received a bath with the general use of soap and water. The data results showed that overall there was a 23 percent decrease of MRSA and VRA infections within the experimental group of patients compared to the control group (P=0.05).Climo and colleagues (2009) article was about how daily bathing with chlorhexidine wipes can prevent MRSA, VRE, and other blood stream infections. It states that because patients already have a daily bathing routine in their orders, it is an easy change to switch to chlorhexidine wipes instead of the general use of soap and water. This study was over a six-month period where all admitted patients to six specific intensive care units received the intervention and over another six-month period the patients received only bathing with soap and water. The strength of this article was that it contained extensive information about the results found from the study. This is easily the most crucial aspect for the project because it completely supports my PICOT proposal. The results showed that there was a 32 percent decrease of MRSA cases within the study following the introduction of this new intervention (P=0.046). The only weakness found was that the study was based mostly on Intensive Care Units (ICU) instead of a step down unit that I will be doing my project for. This article will serve to be beneficial as a resource because it provides useful information and relevant data showing the importance of the reduction in hospital acquired infections and how using chlorhexidine wipes can make that happen. The third and final study used was from Kassakian and colleagues (2011) quasi-experimental study design. Their article was about the effect that chlorhexidine wipes have on hospital acquired infections. The results showed that the daily use of chlorhexidine wipes will prevent MRSA, VRE, and C-Diff. There were a total of 7,102 patients in the control group of this study and 7,699 adult patients placed in the intervention group. Within the experimental group the patients were bathed with chlorhexidine wipes versus the control group who were bathed with just soap and water. This article had the largest reduction of hospital-acquired infections due to the use of chlorhexidine wipes. Having a 64% reduction rate shows that the intervention was significant. An important strength of this article was that the study was actually based on general medical patients rather than intensive care patients. It showed that all patients in the hospital could benefit from bathing with chlorhexidine wipes to prevent a hospital-acquired infection not just those in the ICU. Although the report supplied numerous tables to view, it was difficult to understand the values that were given. The article was interesting and was based on current research. Synthesis Current research has provided enough evidence to prove that using daily chlorhexidine wipes can prevent hospital-acquired infections such as MRSA. In all three randomized control led trials examined the results show that the intervention rate of success was highly significant. Climo et al.’s (2013) research showed that the overall rate of MRSA acquisition was 23% lower during the intervention period. Climo et al. (2009) was a study conducted by the same researchers but in a different year. The results showed that within this study 32% of MRSA cases were decreased following the introduction of chlorhexidine bathing. As stated within this study, daily bathing is a hospital policy, therefore it is an easy change to start using the chlorhexidine wipes versus the general use of soap and water (Climo et al., 2009). The last study done by Kassakian and colleagues, presented a 64% reduced risk of developing the primary outcome of MRSA within four general medicine units. In all three studies the controlled variables of the study were the patients that received daily bathing with soap and water. The experimental group of the studies was the patients that received their daily baths with chlorhexidine wipes. Current research shows that the nursing care intervention of using chlorhexidine wipes instead of general soap and water can be effective for preventing MRSA. However, there is a gap in the research that does not completely support the PICOT question. My PICOT question is based on improving the incidences of MRSA hospital wide but the majority of the research along with the clinical guideline supports only using chlorhexidine wipes in the intensive care unit only. The randomized control led trials need to be broadened so the intervention can be effective for all patients admitted to the hospital. Clinical Recommendations Patient hygiene is highly promoted nationwide within hospital facilities. A patients bathing routine should be done at least once a day. Bathing could mean helping the patient while in the shower, or simply assisting the patient with a bed bath. Because this is not a new or foreign policy to nursing care, it would not be difficult to change the policy from a daily bath to a daily bath using chlorhexidine wipes. It would be an opportunity to improve hospital care because the evidence based research proves that using these wipes can significantly lower the number of MRSA cases for a specific floor and hospital wide. Many members of the health care field would need to be involved in making this intervention happen. The help of the nurse educator is very valuable making this intervention a reality because they are very willing to share information they have on the topic with their fellow nurses on the floor as well as what the protocol is on current practices. The nurse manager would also need to be involved to track statistics, and provide information to the nurses. It is essential to involve the infection control nurse in the intervention because of their invaluable expertise on the topic and their knowledge of policies that are implemented hospital wide. If the hospital has all these people on board supporting this new nursing care intervention, then it could be followed through and ultimately have a positive effective intervention implemented hospital wide. ReferencesCalfee, D.P., Salgado, C.D., Classen, D., Arias, K.M., Podgorny, K., Anderson, D.J. . . . Yokoe, D.S. (2008). Strategies to prevent transmission of methicillin-resistant staphylococcus aureus in acute care hospitals. The Society for Healthcare Epidemiology of America, 29(S1), S62-S80. doi: 10.1086/591061.Centers for Disease Control and Prevention (2013). Methicillin-resistant staphylococcus aureus (MRSA) infections. Retrieved from , M.W., Yoioe, D. S., Warren, D. K., Perl, T. M., Bolon, M., Herwaldt, L. A.,…Wong, E.S. (2013, February 7). Effect of daily chlorhexidine bathing on hospital-acquired infection. New England Journal of Medicine, 368, 533-542. doi: 1056/NEJMoa1113849. Climo, M. W., Sepkowitz, K. A., Succotti, G., Fraser, V. J., Warren, D. K., Perl, T. M., …Wong, E. S. (2009, June). The effect of daily bathing with chlorhexidine on the acquisition of methicillin-resistant Staphylococcus aureus, vancomycin-resistant enterococcus, and healthcare-associated bloodstream infections: results of a quasi-experimental multicenter trial. Critical Care Medicine 37, 1858-1865. doi:10.1097/CCM.0b013e31819ffe6d.Kassakian, S. Z., Mermel, L. A., Jefferson, J.A., Parenteau, S. L., & Machan, J. T. (2011, February 10). Impact of chlorhexidine bathing on hospital-acquired infections among general medical patients. Chicago Journals, 32 (3), 238-243. doi:10.1086/658334.Table 1Literature Review ReferenceAimsDesign and MeasuresSampleOutcomes / statisticsClimo, M. W., Yoioe, D. S., Warren, D. K., Perl, T. M., Bolon, M., Herwaldt, L. A.,…Wong, E. S. (2013, February 7). Effect of daily chlorhexidine bathing on hospital-acquired infection. New England Journal of Medicine, 368, 533-542. doi: 1056/NEJMoa1113849. To provide a nursing care intervention that can prevent multidrug resistant organisms (MDRO’s)Multicenter randomized control trial Study involved six ICU’s that had a control group of patients that bathed with soap and water and the experimental group of patients that bathed with chlorhexidine wipes. The overall rate of MRSA or VRE acquisition was 23% lower during the intervention period (5.10 vs. 6.60 cases per 1000 patient-days, P=0.03)Climo, M. W., Sepkowitz, K. A., Succotti, G., Fraser, V. J., Warren, D. K., Perl, T. M., …Wong, E. S. (2009, June). The effect of daily bathing with chlorhexidine on the acquisition of methicillin-resistant Staphylococcus aureus, vancomycin-resistant enterococcus, and healthcare-associated bloodstream infections: results of a quasi-experimental multicenter trial. Critical Care Medicine 37, 1858-1865. doi:10.1097/CCM.0b013e31819ffe6d.To determine if the use of daily chlorhexidine bathing would decrease the incidence of MRSA, VRE, and among ICU patients. Multicenter RCTSix ICU’s measured the incidence of MRSA, and VRE during a six month period of only bathing with soap and water and a six month period of only bathing with chlorhexidine wipes. Acquisition of MRSA decreased 32% (5.04 vs. 3.44 cases/1000 patient days, p = 0.046Kassakian, S. Z., Mermel, L. A., Jefferson, J.A., Parenteau, S. L., Machan, J. T. (2011, February 10). Impact of chlorhexidine bathing on hospital-acquired infections among general medical patients. Chicago Journals, 32 (3), 238-243. doi:10.1086/658334.To evaluate the effectiveness of daily CHG bathing in a non-ICU setting to reduce MRSA ompared with daily bathing with soap and water.Quasi-experimental study designRCTA total of 7,102 and 7,699 adult patients were admitted to the medical service in the control and intervention groups, respectively. Patients admitted from January 1 through December 31, 2008, were bathed daily with soap and water (control group), and those admitted from February 1, 2009, through March 31, 2010, were bathed daily with CHG-impregnated cloths (intervention group).Daily bathing with CHG was associated with a 64% reduced risk of developing the primary outcome ................
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