Chlorhexidine Gluconate Dressings

Chlorhexidine
Gluconate
Dressings
S. Oakley RN, T. Pienkos, RN,
and
J. Rodgers, RN
Northeastern State University
Application
of CHG
Dressing on invasive
access and prevention
of Central Line
Associated
Bloodstream Infections
(CLABSI)
Problem
•
CLABSIs increase morbidity and mortality
•
CLABSIs lengthen hospital stay and
complicate illness and increase hospital costs
•
Management of CVCs is a multidisciplinary
problem, but routine management is a
nursing responsibility.
•
CLASBIs can be caused by normal flora on
the skin (Staphylococcus aureus)
PICO Question
 Among
patients in the acute
care setting with a central line,
does the use of a dressing with a
chlorhexidine-impregnated
sponge (compared to a dressing
without a chlorhexidine
impregnated sponge) reduce
the risk of acquiring a central line
associated blood stream
infection?
Literature Review
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Understand infection rates and
prevalence with CVC after using CHG
dressings
Observation and implementation of
CHG in ICU settings
Both children and adults
Benefits to use of CHG dressings
Many search engines used including:
• EBSCHO Host, Ovid, Medline,
ProQuest, and CINAHL Plus
• Key words: Central lines, central
lines ICU, infection prevention,
dressings, and CLABSIs.
• Articles used between the years
2007-2013
CLABSIs in the United States
•
Approximately 48% of ICU patients have central venous
catheters, accounting for 15 million central catheter days
per year in the United States ICUs
•
CLABSIs have reported mortality rates of 12-25%
•
CLABSIs cost from $21,300 and $35,000 to treat so avoiding
infections can save an institution hundreds of thousands of
dollars annually (O'Grady et al., 2011)
•
1.14 CLABSIs per 1,000 central-line days in 2009 (CDC, 2011)
Centers
for Disease Control and Prevention (2011). Vital signs: Central line-associated bloodstream
infections—United States, 2001, 2008, and 2009. Morbidity and Mortality Weekly Report, 60(8), 243-248.
Retrieved from: http://cdc.gov/mmwr
Chlorhexidine Dressing for Prevention
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Randomized controlled study on 71 pediatric patients
in a controlled group(standard dressing) , and 74
pediatric patients in the study group (CHG dressing) in
the ICU
Significant reduction in colonization and catheterrelated bloodstream infections with the patients who
utilized the chlorhexidine dressings compared to the
standard polyurethane dressings
Chlorhexidine dressings would also reduce costs,
especially hospitalization stays
Protection against infection through the use of
antimicrobial agent in dressing
Reduction in hospital costs due to reduced rate of
infection, and decrease in patient mortality
Levy, I., Katz, J., Solter, E., Samra, Z., Vidne, B., Birk, E., Ashkenazi, S., & Dagan, O. (2005). Chlorhexidineimpregnated dressing for prevention of colonization of central venous catheters in infants and children.
The Pediatric Infectious Disease Journal, 24, 676-679. doi:10.1097/01.inf.0000172934.988865.14
Risk Factors for Central Line Infections
 Having
a Central Line
 Comorbidities (DM, Liver Failure,
immunosuppression)
 Improper sterile technique upon insertion
 Lack of use of bundling
 961 critically ill patients in a prognostic
study over a 2-year period
 Selected patients had a minimum stay of 4
days
 Out of 961 patients 59 CLASBIs were noted
Lissauer, M., Leekha, S., Preas, M., Thom, K., & Johnson, S. (2012). Risk factors for central line-associated bloodstream infections
in the era of best practice. J Trauma, 72, 1174-1180. doi:10.1097/TA.0b013e31824d1085
Prevention Using CHG Dressings
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Randomized trial of 1,879 patients in
12 French ICUs over 14 month period
67% lower when using the dressing
that contained CHG
Contact Dermatitis noted in 1.1% of
patients
“CHGs decrease the 3% catheter
related infections with standard
dressings by 61% (1.87% total)” (Timsit
et al., 2012)
Timsit, J., Mimoz, O., Mourvillier, B., Souweine, B., Garrouste-Orgeas, M., Alfandari, S., Plantefeve, G., … & Lucet, J. (2012).
Randomized controlled trial of chlorhexidine dressing and highly adhesive dressing for preventing catheter-related infections
in critically ill adults. American Journal of Respiratory and Critical Care Medicine, 186, 1272-1278. doi:10.1164/rccm.20120610380C
Chlorhexidine-Impregnated Sponges
Use
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of CHG sponges:
Randomized trial of 1636 clients
over 18 months
Decrease the rate of infection
Decrease the needed frequency of dressing
changes from 3 days to 7 days
Timsit,
J., Schwebel, C., Bouadma, L., Geffroy, A., Garrouste-Orgeas, M., Pease, S. & Lucet, J. (2009).
Chlorhexidine-impregnated sponges and less frequent dressing changes for prevention of catheter-related
infections in critically ill adults. Journal of the American Medical Association, 301(12), 1231-1241.
doi:10.1001/jama.2009.376
Chlorhexidine Gluconate Dressings (CHG)
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Quantitative and qualitative observational study
MSICU patients with CVC dressings using CHG
Improvement care bundle:
• Application of TSD
• Visual inspection every shift
Advantages:
• Insertion site visualized easily
• Less step than previous dressings
• Cheaper cost
• Nurse satisfaction
• Decrease in infection rates
Disadvantages:
• Difficult to remove dressing
Pfaff, B., Heithaus, T., & Emanuelsen, M. (2012). Use of a 1-piece chlorhexidine gluconate
transparent dressing on critically ill patients. Critical Care Nurse, 32(4), 35-40.
doi:10.4037/ccn2012956
Reduction of CLASBIs
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Quantitative Observational study
1,298 ICU patients from two different floors
From November 2010 to May 2012
Observed patients using newly initiated CVC
dressings and patients who central lines used
Standard dressings used from 1999 to
November 2010 were used in the data.
Infection control interventions preformed before study
• Use of Insertion bundles
• Standardize operating procedures when
administering IV meds
• Use of subclavian site instead of groin
• Education to healthcare personal regarding
insertion procedures and maintenance
Advantages
• Decrease in CLABSI
• Less time admitted to hospital
Scheithauer, S., Lewalter, K., Schroder, J., Koch, A., Hafner, H., Krizanovic, V., & Nowicki, K. (2013). Reduction of
central venous line-associated bloodstream infection rates by using a chlorhexidine-containing dressing.
Berlin, Heidelberg: Springer-Verlag. doi:10.1007/s15010-013-0519-7
Economic Impact
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Ye,
By implementing CHG dressings in a facility that
averages 3,078 CVCs on an annual basis will :
Decrease CLABSIs by 35 incidences
Decrease in 145 local infections
Save clients 281 ICU days
Prevent 4 deaths
Save $895,000 a year
X., Rupnow, M., Bastide, P., Lafuma, A., Ovington, L., Jarvis, W. (2011). Economic impact of
use of chlorhexidine-impregnated sponge dressing for prevention of central line-associated
infections in the united states. American Journal of Infection Control, 39, 647-654.
doi:10.1016/j.ajic.2010.11.008
Clinical Performance
 63
patients , 33 with CHG dressing
30 patients without
 5-point scale used to question
patients and nurses
 CHG dressing outscored tegaderm
in nearly every category
 Overall satisfaction score was 94% for
CHG and 69% for standard tegaderm
dressings
Olson, C. & Heilman, J. (2008). Clinical performance of a new transparent chlorhexidine gluconate
central venous catheter dressing. Journal of the Association for Vascular Access, 13(1), 13-19.
doi:10.2309/java.13-1-4
Nursing Satisfaction
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Convenience sampling 107 with
CHG and a control group of 110
with standard dressing
24 nurses surveyed using 5-point
rating system for a total of 122
dressing applications/changes
85% favorable to changing to the
CHG dressing from standard
dressing
Ability to visualize site
Ability to absorb fluid
Overall performance of dressing
Maryniak, K. (2009). Clinical performance and nursing satisfaction of a transparent chlorhexidine gluconate iv
securement dressing with peripherally inserted central catheters. Journal of the Association for Vascular Access, 14,
200-205. doi:10.2309/java.14-4-5
Dermatitis & CHG dressings
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Study done in 7 pediatric patients
Dermatitis as a complication to
using chlorhexidine dressings
Immunosuppression from organ
transplant and CVC placement in
femoral site
Dermatitis resolved after removal of
chlorhexidine
Limitations:
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Limited patients in study
No relocation of CVC sites
information provided
Weitz, N., Lauren, C., Weiser, J., LeBoeuf, N., Grossman, M., Biagas, K., & Garzon, M.
(2013). Chlorhexidine gluconate-impregnated central access catheter dressings
as a cause of erosive contact dermatitis. JAMA Dermatology, 149, 195-199.
doi:10.1001/jamadermatol.2013.903
Dermatitis
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Systematic review, focused on CHG
as topical antiseptic
Evaluated 8 RCT
One showed skin changes from
antiseptic use
Patients treated with CHG were
45% more likely to develop redness
at the site than those treated with
alcohol-based solutions
Contact dermatitis is often mistaken
for infection and the central line is
removed; however dermatitis can
be treated with the central line in
place.
Kutzscher, L. (2012). Management of irritant contact dermatitis and peripherally inserted central catheters.
Clinical Journal of Oncology Nursing, 16(2), 48-55. doi:10.1188/12.CJON.E48-E55
Recommended Strategies
 Utilize
CHG dressings with
all patients except those
with burns
 Decreases occurrences of
CLABSIs
 Cost effective
 Minor risk factors
involved
Plan Implementation
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Approval obtained from Chief
Executive Officer, Chief Financial
Officer, Medical Director, and Chief
Nursing Officer
Introduce dressing to nursing
educator and clinical leads to train
nursing staff
Set roving in-service dates with samples of product
Once approved product may be used
No more than 3 months needed to approve policy,
train staff, and order product.
Budget needs minimal
Suggestions for Further Study
Obtain
data from several
ICUs in the region
 Use of bundling included
in the study
 Education and training of
staff and physicians
 Use subclavian site for
insertion of CVC
CONCLUSION
 CLABSI
remain a serious complication in the acute
care
 Have high morbidity and mortality
 Increase healthcare costs
 Lengthen hospital stays
 Use of 1-piece CHG dressings most favorable
intervention to prevent CLABSIs
 Can save approx.
$895,000 annually for an
acute care facility
 ICU stays decreased by
281 incidences and 4 deaths
annually can be prevented
QUESTIONS??

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