The preoperative procedure of using with chlorhexidine-alcohol (CHG) before surgery has been proven to be more effective to reduce the number of surgical site infections (SSI) than the use of povidone iodine. By reducing the number of infections post surgery, it can lower patient morbidity and can reduce hospital stay time and eliminate further unnecessary costs.
A2a. Basis for Practice (who determined )
The basis for changing the method of using chlorhexidine-alcohol bath before all surgeries and not just the open heart patients. In HCA facility, the infectious disease nurse (ID), wound care nurse and the operating room (OR) manager have collaborated to find an effort to reduce the rate of surgical site infections. In an interview with the infectious disease nurse, the wound care nurse and the OR manager, it was discussed if infections may have been caused before the operation or post operatively. The patient is prepped on before taken into surgery. This may consist of hair clipping and an antiseptic bath. The patient is then wheeled into the surgery room where they are further prepped on the operating table. At this point, the infection risk should be low. It was concluded that there was a lower risk of surgical site infections if the patient had been pre-operatively prepared with an antiseptic bath.
A2b. Rationale (why did they look into it/physiologic)
The patient’s skin is usually the pathogen source, along with the mucous membrane. Once the skin has been surgically cut open, the underlying tissue is then exposed to the overlying flora. The skin’s normal flora, such as Staphylococcus, E. Coli, Bacillus fragilis, can serve as risk contaminants. The purpose of bathing/showering with antiseptic before surgery is to remove any dirt and reduce microorganisms from the skin temporarily. There are several patient characteristics that can contribute to SSIs such as the patients age, nutritional status, diabetes, obesity, and nicotine use. Out of control glucose level (higher than 200mg/dl) can interfere with wound healing. Obesity, separate from diabetes, can cause high wound healing risks factors. Smoking constricts blood vessels which can cause tissue hypoxia and hypovolemia. With the proper skin preparation, the rate of infection at and/or near the incision can be controlled.
A2c. Explanation (why did they implement it)
It was found that SSIs is one of the primary causes for approximately one-third of all nosocomial infections. Post surgical infections can lead to longer length of stay, additional increase expenses, possible hospital readmission, and endanger future health outcomes. First step in treatment of SSIs is the prevention. SSIs can raise hospital costs by to prolonging hospital stays and with that incurring additional expenses such as more diagnostic tests, therapeutic antibiotics, and rarely added surgery. In 2009, it was estimated that SSI extended length of stay on average of 9.7 days and increased costs by $20,842 per admission with hospital readmissions due to SSI accounting for additional millions in health care spending. (Reichman 2009) Obviously, the deeper the infection, the more it tends to cost more than that of a superficial one. The Centers for Medicare and Medicaid Services (CMS) no longer reimburse hospitals for certain SSIs, including mediastinitis.
A3. Recommend a practice change
Before all procedures and/or surgeries, regardless if it is an open heart or something not as complicated, all patients should be pre-operatively bathed/showered with antiseptic to help reduce the risk of post surgical site infections.
A3a. Reference List (2015- 2010)
1. Darouiche RO, et al. (2010) Chlorhexidine-Alcohol versus Povidone-Iodine for Surgical Site Antisepsis. N Engl Med. 2010;362(1):18-26
2. Ehrlich, A. (2010) Chlorhexidine-Alcohol Scrub May Prevent Surgical Site Infections Better Than Povidone-Iodine. The Clinical Advisor. 107-108
3. Kamel C., et al (2012) Preoperative Skin Antiseptic Preparations for Preventing Surgical Site Infections: A Systematic Review. Infect Control Hosp Epidemol. 2012, 33(6): 608-617
4. Magalini, S., et al (2013) Observational Study on Pre-Operative Surgical Field Disinfection: Povidone- Iodine and Chlorhexidine- Alcohol. European Review for Medical and Pharmacological Sciences. (17): 3367-3375
5. Poulin,P., et al.(2014) Preoperative Skin Antiseptics for preventing surgical site infections: What to do? ORNA Journal Sept 2014:14-29
A4. Clinical Implications on patients
If all patients were bathed/showered preoperatively with an antiseptic, it would reduce the risk of SSIs. This would benefit the patient with shorter time spent on a critical care unit, would reduce the mortality rate and can reduce the readmission rate . Bathing/showering would mean an extra step for the patient and the nurse with added cost for the antiseptic chlorhexidine wash but it serves as added protection in the prevention of post surgical infection. Before bathing/showering with soap and water prior to a procedure/surgery was accepted. It has been proven that antiseptic showering decreases skin microorganism count. Chlorhexidine gluconate products necessitate the need for several applications for the maximum antimicrobial benefit. Thus, each patient receives two preoperative antiseptic showers. Patient will be instructed to shower/bathe at home and educated not to use any perfume and/or lotion after. .
A5. Changes on practice setting
By implementing CHG antiseptic wash, all regular soap must be eliminated. It has been proven that the more CHG is applied, the better protection the patient has against infections With less infections, the less costs the hospital will incur. However, the areas of the hospital impacted would be those that do the order purchasing. There must be adequate storage and continuous supply of the CHG wipes and/or solution. The purchasing staff must understand the importance of continuity in order for the patient to achieve maximum benefit and that there should be adequate floor stock at all times. There must be nursing and patient education, which should include the operating room and surgical staff..
Drying time of antiseptic, avoid pooling of skin prep solutions, avoid alcohol-base skin prep products should be taught and explained to the OR staff. Safety issues regarding CHG solutions should be taught as well, that however rare, it is still possible that it can start an OR fire. There should be printed educational literature to be given to the patient for pre-operative teaching as to why such a procedure is in place. All other pre-operative procedures should be included as well such as prophylactic antibiotics, the removal/clipping of hair, the importance of maintenance of glucose control. Staff, such as nurses and aides, must understand and accept the change and help patients understand their surgical care
A6. Involve stakeholders to change/comply with change
Once the recommended change has been approved by administration, all department managers must be notified and educated of the reasoning behind the change. Medical staff director will provide education and buy-in from physicians and surgeons ID nurses play an influential part by providing updated statistics of SSIs with graphs and posters strategically located so show the trend of lowering SSI rates will make the change easier to accept.
B1. Barriers encountered applying research
Of course there are some barriers that are expected to be encountered such as noncompliance and/or hesitance of staff and maybe the allergies of patient may include ingredients of an chlorhexidine gluconate bath. There is also the rare possibility of lack of stock of antiseptic wash during certain periods of purchasing supplies.
B2. TWO strategies to overcome barriers
Communications between ID nurses and staff to help understand that their efforts are for the patients. People, staff and patients, might not understand why antiseptic wash is necessary; and if so, why two applications? Education is a key part in getting compliance. Continuous monitoring of inventory is necessary to keep the supply adequate. Scanning and weekly count would be able to detect low stock.
B3. Research findings
SSIs are responsible for most nosocomial infections. Patients stay longer, incur more charges from diagnostic testing and/or antibiotics. Patients have a higher risk for readmission, sometimes they might need another surgery. The best treatment for SSI is prevention . Antiseptic wash with CHG reduces the SSI rate before patients go to surgery.
Darouiche RO, et al. (2010) Chlorhexidine-Alcohol versus Povidone-Iodine for Surgical Site Antisepsis. N Engl Med. 2010;362(1):18-26
Ehrlich, A. (2010). Chlorhexidine-Alcohol Scrub May Prevent Surgical Site Infections Better then Povidone-Iodine. The Clinical Advisor, 107-108. Retrieved March 16, 2015, from www.clinicaladvisor.com
Guideline for Prevention of Surgical Site Infection, 1999. Center for Disease Control and Prevention (1999). Retrieved March 16, 2015.
Kamel C., et al (2012) Preoperative Skin Antiseptic Preparations for Preventing Surgical Site Infections: A Systematic Review. Infect Control Hosp Epidemol. 2012, 33(6): 608-617
Magalini, S., et al (2013) Observational Study on Pre-Operative Surgical Field Disinfection: Povidone- Iodine and Chlorhexidine- Alcohol. European Review for Medical and Pharmacological Sciences. (17): 3367-3375
Poulin,P., et al.(2014) Preoperative Skin Antiseptics for preventing surgical site infections: What to do? ORNA Journal Sept 2014:14-29
Preoperative Care. (2012, January 1). Retrieved March 16, 2015, from http://www.sageproducts.com
Reichman, D., & Greenberg, J. (2009). Reducing Surgical Site Infections: A Review. Obstetrics & Gynecology, 212-221.