Chlorhexidine wipe bathing might help reduce the risk of deadly central line-associated bloodstream infections (CLABSIs) among cancer inpatients, but barriers can complicate implementation efforts, a speaker reported at the Oncology Nursing Society (ONS) 42nd Annual Congress, held May 4–7 in Denver.
Barriers include workflow challenges, confusion about roles or “ownership” of such initiatives among nurses and other providers, and patient noncompliance, said Laura Johnson, MSN, RN, BMTCN, of the University of Chicago Medicine.
An estimated 250,000 CLABSIs occur each year in the United States. On average, each case leads to 24 additional days of hospitalization, at a cost of up to $29,000—and more than a third of patients die, Johnson pointed out.
The US Centers for Medicare & Medicaid Services has reduced reimbursement of hospital-acquired conditions like CLABSIs, and the Joint Commission has emphasized the importance of reducing these infections, Johnson noted.
The University of Chicago conducted an evidence-based practice (EBP) audit of patient bathing with chlorhexidine wipes after an increase in hospital-wide CLABSIs in 2014. Oncology unit CLABSI rates were higher than other departments.
Oncology staff nurses, clinical nurses, and nurse educators discussed chlorhexidine gluconate bathing wipes and learned that some nurses were concerned about the possibility that chlorhexidine could cause skin irritation in the oncology patient population. Consultations with other hospitals and a literature search, however, suggested that the chlorhexidine wipes likely do not increase skin irritation risk for cancer patients.
The researchers developed a staff protocol and patient-education plan, and in-service training, before starting a push for chlorhexidine bathing in the oncology units in October 2015. Laminated information sheets were posted in patient rooms and a one-page staff protocol sheet was distributed. Patients were encouraged to ask nurses for a package of warm wipes and were instructed on their proper use.
The audit revealed that in the hematology/oncology and stem cell transplantation units, chlorhexidine bathing increased from under 50% in November 2015 to 80% in February 2016. In the head & neck and solid tumors units, rates climbed from 60% to more than 80% over the same period. There were no reported adverse reactions to the wipes, Johnson noted.
In the 4 months prior to implementation, the CLABSI rates for the hematology/oncology unit and solid tumor unit were 2.72 cases per 1,000 central-line days (7 cases of CLABSI) and 0.44 per 1,000 central-line days (1 case), respectively. During the 4 months following implementation, CLABSI rates dropped to 1.90 cases per 1,000 central-line days (5 cases) in the hematology/oncology unit; there were no CLABSI cases in the solid tumors unit during the intervention audit period.
“As a result of the findings of this EBP project, daily chlorhexidine gluconate bathing was determined to be safe and likely contributed to CLABSI reduction,” Johnson reported.
After CLABSI rates in the hematology/oncology unit dropped in December and January, however, they began to rise again by February 2016.
“So there was a reduction,” Johnson said. More-immunocompromised patients, lower compliance rates, more complex patient-management challenges, and unspecified additional risk factors for infection might have been responsible for the uneven improvement, she suggested. Port-a-caths were more common in the solid tumor unit, she added.
Patients in the solid tumor unit more consistently asked nurses for chlorhexidine wipes as well, said Johnson. “Patients began taking ownership.”