by Rhonda Lemmo, RN, CNOR

Everyday nearly 60,000 people are patients in Intensive Care Units (ICUs) in hospitals in the United States.¹ This typically encompasses the very sick, who are experiencing major invasive surgery, accidents and/or traumas or organ failure. ICUs account for more than 10 percent of all hospital beds and more than four million individual patient admissions, equaling more than 18 million days of care. ² The related healthcare costs are estimated to be almost one percent of the U.S. gross domestic product. ³

In the medical and surgical ICUs, specialized staff members provide around-the-clock care and treatment. Critical care physicians, more recently deemed “intensivists,” and critical care nurses work together to ensure that acutely and critically ill patients and their families receive the best care possible. ^4,5 Because most patients are medically unstable, constant monitoring and continual adjustment to medications and support systems, such as ventilators, are the priority. Unfortunately, the overall mortality rate in ICUs is between 12 percent and 17 percent, much greater than the overall hospital average of about 1.5 percent. ⁶

It has been shown that up to 20 percent of ICU patients develop a healthcare-associated infection (HAI) during their stay⁷ including infections caused by multidrug-resistant organisms, such as methicillin-resistant <I>Staphylococcus aureus<$> (MRSA) and vancomycin-resistant <I>Enterococcus<$> (VRE). However, the leading cause of morbidity among ICU patients is hospital-acquired bloodstream infections (BSIs) most often associated with central venous catheters. ⁸

These HAIs prolong the patients’ lengths of stay, increase costs of care and increase morbidity and mortality. Today, with HAIs being more prevalent, new, innovative, easy-to-use and time-efficient methods to decrease HAI incidence have become critical.

Proven Protection

For catheter-associated BSIs, the best prevention method is adherence to proper sterile technique, including patient site preparation. ^9,10 In fact, the use of chlorhexidine gluconate (CHG) in skin preparation reduced catheter-associated BSIs more effectively in comparison to other skin disinfectant products such as povidone and iodine.^11,12,13,14 And, the Centers for Disease Control and Prevention (CDC) recommends the use of CHG-containing skin disinfectants for site preparation before insertion. ¹⁵

When it comes to multidrug-resistant organisms, CHG solutions reduce skin colonization of pathogens including MRSA and VRE, lowering the risk for transmission between healthcare workers and patients. Additionally, it has been shown that bathing patients with CHG has controlled outbreaks related to MRSA and VRE in the ICU and in community-acquired MRSA outside of the hospital. ¹⁶ Two smaller studies performed at single institutions, limiting the generalizability of the findings, showed that bathing ICU patients daily with CHG impregnated washcloths reduced the rate of VRE acquisition by 65 percent. ^17,18

A Simple Act, a Large Impact

While given the dire health circumstances in most critical care units, the primary attention of the healthcare workers is to provide necessary life-saving care and treatment. However, another important component of care is providing the patient with respect and support.

For a sick person in a critical care setting, bathing does more than just cleanse the skin. It stimulates circulation, improves the patient’s self-image, reduces body odor and promotes range of motion exercises. ¹⁹ It also provides healthcare workers with an opportunity to investigate wounds and skin to ensure healing. Patients may be bathed every day in the hospital, unless skin is dry or cracked when bathing may be limited to once or twice a week. ²⁰

To that end, patient bathing is an important part of the healing and care process. Often, a patient’s skin is broken due to abrasions, surgery sites or burns, leaving him or her more vulnerable to infection. Cleansing and nurturing the already broken or open skin, but avoiding injuring the skin further especially if it’s overly dry or cracked, remains imperative. And while nutrition, circulation and lotions help, bathing provides the best means for skin healing. ²¹

Lather with CHG

Armed with this knowledge and the previously-mentioned CHG research, Michael W. Climo, MD and his colleagues from Commonwealth University Medical Center, Memorial Sloan-Kettering Cancer Center, Washington University School of Medicine and The Johns Hopkins Hospital, with funding from the CDC, tracked the use of daily bathing in the ICU with CHG from December 2004 and January 2006. Using CHG as a neck-down bathing solution, they monitored the bathing of 2,650 ICU patients at six different U.S. hospitals. They found 32 percent fewer patients colonized with MRSA and 50 percent fewer cases of VRE. The CHG bathing also cut down, by as much as 73 percent, the number of patients who developed bloodstream infections.

Published in Critical Care Medicine in late 2009, the article “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,” demonstrated that “implementation of a relatively simple procedure, daily bathing with chlorhexidine, significantly reduced acquisition of VRE and MRSA and healthcare-associated bacteremias across several large university-affiliated ICUs.”

The study also found that “universal bathing with chlorhexidine, a skin disinfectant with excellent activity against MRSA, VRE, and other staphylococci, also had the advantage that many patients who were colonized with these organisms could begin treatment to eradicate skin carriage before results of ASC being available.”

And while the authors of the study encourage additional studies of the potential use of CHG in daily bathing to continue to determine long-term impact, it remains that providing critically ill patients’ and their providers with easy-to-use, cost-effective ways to ward off bloodstream infections or halt the spread of dangerous multidrug-resistant organisms is of critical importance. 

As one of the co-investigators Trish Perl, MD, director of hospital epidemiology and infection control at Johns Hopkins and a professor of medicine and pathology at the Johns Hopkins University School of Medicine, said “it’s just as important to find the right soap to prevent infection as it is to find the right drug to treat patients who develop an infection.” She also summed up the study by concluding that “our results show that using chlorhexidine [gluconate] as a daily washing agent is a simple, effective and relatively cheap way to protect the health of our most vulnerable patients.” ²²

References

1. U.S. Department of Health and Human Services, Health Resources and Services Administration, The Critical Care Workforce: A Study of the Supply And Demand for Critical Care Physicians, Report to Congress, Senate Report 109-103 and House Report 109-143, retrieved February 22, 2010 at http://Bhpr.Hrsa.Gov/Healthworkforce/Reports/Criticalcare/Default.Htm.
2. Rothschild JM. “Making Health Care Safer: A Critical Analysis of Patient Safety Practices” Agency for Healthcare Research and Quality Evidence Report/Technology Assessment Number 43. 1999; 38:p. 413.
3. Green TP. What is best for patients is best for the intensive care unit. Critical Care Medicine. 2001; 29(10): 2038-39.
4. U.S. Department of Health and Human Services, Health Resources and Services Administration, The Critical Care Workforce: A Study of the Supply And Demand for Critical Care Physicians, Report to Congress, Senate Report 109-103 and House Report 109-143, retrieved February 22, 2010 at http://Bhpr.Hrsa.Gov/Healthworkforce/Reports/Criticalcare/Default.Htm.
5. American Association of Critical-Care Nurses. (n.d.). About Critical Care Nurses. Retrieved Feburary 22, 2010, from http://www.aacn.org/WD/PressRoom/Content/AboutCriticalCareNursing.pcms?pid=1&&menu=.
6. Al-Asadi L. et al. Clinical Impact of Closed Versus Open Provider Care in a Medical Intensive Care Unit. <I>American Journal of Respiratory & Crit Care Med<$>. 1996; 153:A360.
7. Legras A, Malvy D, Quinioux AI, et al: Healthcare associated infections: Prospective survey of incidence in five French intensive care units. Intensive Care Med 1998; 24:1040–1046.
8. Climo MW, Sepkowitz KA, Zuccotti G, et al. 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. Crit Care Med. 2009; 37(6):1858-1865.
9. Raad II, Hohn DC, Gilbreath BJ, et al: Prevention of central venous catheter-related infections by using maximal sterile barrier precautions during insertion. Infect Control Hosp Epidemiol 1994; 15:231–238.
10. Climo MW, Sepkowitz KA, Zuccotti G, et al. 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. Crit Care Med. 2009;37(6):1858-1865.
11. Guideline for prevention of intravascular device-related infections. Part II. Recommendations for the prevention of healthcare associated intravascular device-related infections. Hospital Infection Control Practices Advisory Committee. Am J Infect Control 1996; 24:277–293.
12. Chaiyakunapruk N, Veenstra DL, Lipsky BA, et al: Vascular catheter site care: The clinical and economic benefits of chlorhexidine gluconate compared with povidone iodine. Clin Infect Dis 2003; 37:764–771.
13. Chaiyakunapruk N, Veenstra DL, Lipsky BA, et al: Chlorhexidine compared with povidone-iodine solution for vascular catheter-site care: A meta-analysis. Ann Intern Med 2002; 136:792–801.
14. Crnich CJ, Maki DG: The promise of novel technology for the prevention of intravascular device-related bloodstream infection. I. Pathogenesis and short-term devices. Review. Clin Infect Dis 2002; 34:1232–1242.
15. Guideline for prevention of intravascular device-related infections. Part II. Recommendations for the prevention of healthcare associated intravascular device-related infections. Hospital Infection Control Practices Advisory Committee. Am J Infect Control 1996; 24:277–293.
16. Climo MW, Sepkowitz KA, Zuccotti G, et al. 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. Crit Care Med. 2009;37(6):1858-1865.
17. Vernon MO, Hayden MK, Trick WE, et al: Chlorhexidine gluconate to cleanse patients in a medical intensive care unit: The effectiveness of source control to reduce the bioburden of vancomycin-resistant enterococci. Arch Intern Med 2006; 166:306–312.
18. Bleasdale SC, Trick WE, Gonzalez IM, et al: Effectiveness of chlorhexidine bathing to reduce catheter-associated bloodstream infections in medical intensive care unit patients. Arch Intern Med 2007; 167:2073–2079.
19. HealthNetCafe. (n.d.). Personal Hygiene: Bathing the Patient. Retrieved February 22, 2010, from http://www.healthnetcafe.com/content/day-to-day_care/personal_hygiene/bathing_the_patient.html.
20. World Health Organization. (1997). Nursing Care of the Sick. Retrieved February 22, 2010, from World Health Organization: http://www.wpro.who.int/internet/files/pub/85/33-49.pdf.
21. World Health Organization. (1997). Nursing Care of the Sick. Retrieved February 22, 2010, from World Health Organization: http://www.wpro.who.int/internet/files/pub/85/33-49.pdf.
22. Surgical Scrub Solution: Chlorhexidine Bathing Is Cheap And Effective Means Of Protecting Patients From Superbugs. (2009, September 8). Retrieved February 22, 2010, from Science Daily: http://www.sciencedaily.com/releases/2009/09/090904103351.htm.

Rhonda Lemmo is a manager at Mölnlycke Health Care in Norcross, Ga. and a Registered Nurse (RN) and Certified Nurse Operating Room (CNOR).