LET’S GET BACK

TO THE BASICS:
PREVENTION OF CLABSI
Halle Venechuk, Karissa Rossow, Mckenna Miling
University of Mary
27 April 2023
 Introduction

https://www.bactiguard.com/wp-content/uploads/2020/03/bip-central-venous-catheter-low.png https://www.myamericannurse.com/wp-content/uploads/2019/06/Screen-Shot-2019-06-19-at-3.52.09-AM-e1560930813940.png

https://www.vascularwellness.com/wp-content/uploads/2021/09/Small-Bore-Internal-Jugular-Central-Venous-Catheter-Lines-2.jpg
CURRENT CDC Current Recommendations

PRACTICE • Bathe ICU patients with CHG daily

• Immediately replace dressings that are
wet, soiled, or dislodged.
• Scrub the access port immediately prior
to each use with antiseptic
(CHG, povidone iodine, an iodophor,
or 70% alcohol) (CDC, 2011).

Current Practice in Bismarck,

ND
• Daily CHG bath introduced to a
Bismarck hospital around 2017
https://www.walmart.com/ip/Hibiclens-Antibacterial-Hand-Soap-Antiseptic-Skin-Cleanser-8-oz-Wound-4-CHG-For-Surgery-
Antimicrobial-Home-Hospital/2148077428
 History and Evolution
Central Lines
Stephen Hales Werner Frossman
Inserted a glass tube into the Catheterized own heart Gained widespread
jugular vein of a horse through cephalic vein clinical standard practice

1733 1891 1929 1953 1960s

Rudolph Matas Sven Seldinger

Used to treat shock Central venous
associated with surgery catheterization became a
standard therapeutic option
 History and Evolution
CLASBI Prevention and CHG
Infection Control
was introduced to Small number of CHG and
hospitals hospitals began to alcohol skin
recognize preparation
CHG was discovered CLASBI combo CHG sponge 2% CHG cloth

1950 1954 1960s 1970 1988 1992 1993 2002 2005

United Kingdom Hand washing with Impregnated CDC officially

chlorhexidine is CHG catheter recommends
CHG is used as a shown to reduce skin using CHG
disinfectant and flora by 86% - 92% for CVC
topical antiseptic
CHG introduced into
the United States
 CLABSI's shown to be deadly

Organisms (CLABSI)

History •
•
Gram-positive organisms are the most common (60%)

and
Gram Negatives (17.7%)
• Candida species (11.8%)
• Others (10.5%)

Evolution Cause of infection

CLABSI prevention
 Clinical Significance

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Prolonged Hospital Stay https://encrypted-tbn0.gstatic.com/images?q=tbn:ANd9GcQ96tV8b02h15nmiyti8zh53cT0LzuktMWUGqlbyFVw0nUJ4-
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Nurses can do something about it!

Clinical Question
Is chlorohexidine gluconate (CHG)
bathing the most effective way to
prevent central line associated
bloodstream infections (CLABSI)
compared to alternative methods
during the hospital stay of the
patient?
 PICOT
Population • Patients with Central Lines

Intervention • Chlorohexidine Gluconate Bathing

Comparison • Alternatives to a CHG bath

• Preventing Central Line Associated

Outcome Bloodstream Infections

Time • During the length of the patient’s hospital stay

 ■ Quantitative
– Prospective, uncontrolled before and after study
■ Aim
Implementation of Daily – Assess CHG bathing on CLABSI incidence
Chlorhexidine Bathing across all ICU subunits in a tertiary care center
that already had a CLABSI prevention bundle
in Intensive Care Units and continuous surveillance system.
for Reduction of ■ Findings

Central Line-Associated – Before intervention CLABSI rate: 2.45/1000

catheter days
Bloodstream Infections – After intervention CLABSI rate: 1.00/1000
catheter days (P < 0.001)
■ Conclusions
– Introduction of daily bathing with 2% CHG
cloths in ICUs was statistically significant
in reduction in the incidence of CLABSI
Scheier, T., Saleschus, D., Dunic, M., Frohlich, M. R., Schupbach, R., Falk, C., Sax,

H., Kuster, S. P., Schreiber, P. W.

Central-line Associated
Bloodstream Infections  Quantitative
in Intensive Care Units - CLIP-ID study

Before and After  Aim

- To compare the effects of 2% CHG cloths,
Implementation of 0.08% octenidine wash mitts, and soap and water

Daily Antiseptic Bathing 

on CLABSI rates.
Findings
- CHG: 0.80 CLABSI/1000 CL days (p =0.0172)

with Chlorhexidine -
-
Octenidine: 1.47 CLABSI/1000 CL days
Soap and Water: 1.17 CLABSI/ 1000 CL days
or Octenidine –  Conclusions
A Post-hoc Analysis of a - 0.08% octenidine and soap and water groups
were NOT statistically significant for reducing
CLABSI

Cluster-Randomized - 2% CHG cloths are statistically significant for

reducing CLABSI
Controlled Trial
Denkel, L. A., Schwab, F., Clausmeyer, J., Behnke, M., Golembus, J., Wolke, S.,

Gastmeier, P., Geffers, C.

 ■ Quantitative Study
– Randomized Control Trial
Chlorhexidine Gluconate
■ Aim
Bathing in Children – The objective was to determine whether CHG
with Cancer or those reduces the rate of CLABSI in children with cancer
or those undergoing allogenic hematopoietic cell
Undergoing transplantation (HCT). The study used 2% CHG-
impregnated cloths compared with cloths
Hematopoietic Stem Cell impregnated with mild cleansers.
Transplantation: A ■ Findings
Double-Blinded – CLABSI rate difference of 2 per 1000 central line
days
Randomized Controlled – The estimated cumulative 90-day incidence of
Trial From the Children’s CLABSI occurring was 34.6% in the CHG group
and 24.1% in the control group with mild cleansers
Oncology Group – P-value proves significance if less than 0.017
– P- value = .049
Zerr, D. M., Milstone, A. M., Dvorak, C. C., Adler, A. L., Chen, L., Villaluna, D.,
■ Conclusions
Dang, H., Qin, X., Addetia, A., Yu, L. C.,

Conway Keller, M., Esbenshade, A. J., August, K. J.,

– Daily CHG bathing did not reduce the risk of
 ■ Quantitative Study
– Cluster randomized trial

Chlorhexidine Gluconate ■ Aim

– Evaluate the impact of daily CHG solution bathing
Bathing of Adult on the incidence of hospital-associated infections
(HAI), including CLABSI’s, among adult ICU
Patients in the Intensive patients at a tertiary-care teaching hospital in
Care Units in São Paulo, Brazil. The study used pH neutral soap and water
compared with daily bathing with 2% CHG
Brazil: solution

Impact on the Incidence ■ Findings

– CLABSI incidences significantly reduced in
of Healthcare- intervention patients (9.2 VS 22.6 infections/ 1000
Associated Infection patients-days)
– P-value of CLABSI incidence rate = 0.125
■ Conclusions
– Daily CHG bathing is not statistically significant
Reis, M. A. O., de Almeida, M. C. S., Escudero, D., & Medeiros, E. A.
in ICU patients over two months of age to prevent
CLABSIs
 ■ Quantitative Study
– Randomized Control Trial
■ Aim
Daily Bathing with – Daily bathing with a 4% CHG scrub followed by
4% Chlorhexidine water rinsing compared to bathing with water
and standard soap followed by water rinsing.
Gluconate (CHG) ■ Findings
in Intensive – p-value proves significance if less than 0.05.
Care Settings: – 4% CHG daily scrub p-value equaling 0.204.

A Randomized – Bloodstream infections (BSI) plus CLABSI in the

control arm p-value equal 0.027.
Control Trial ■ Conclusions
– Daily bathing with 4% CHG scrub was not
statistically significantly in reducing CLABSI’s.
Pallotto, C., Fiorio, M., De Angelis, V., Ripoli, A., Franciosini, E., Quondam – Daily bathing with soap and water was
Girolamo, L., Volpi, F., Iorio, P., statistically significant in reducing
Francisci, D., Tascini, C., & Baldelli, F. BSI plus CLABSI’s.
 ■ Quantitative Study
– Quasi-Experimental

The use of ■ Aim

– Evaluate the effectiveness of 3.15% CHG with
3.15% Chlorhexidine 70% Alcohol swabs compared with 70%
Gluconate/70% Alcohol regular alcohol scrubs in decreasing the CLABSI
rates in dialysis patients.
Hub Disinfection to ■ Findings
Prevent Central Line- – Pre-implementation: 11 CLABSI events
Associated Bloodstream – 6-month trial period: No CLABSI events
– Post-implementation: 5 CLABSI events.
Infections in – P-value = 0.0493
Dialysis Patients ■ Conclusions
– Using CHG with Alcohol for hub disinfection
was statistically significant in decreasing
Cooney, R. M., Manickam, N., Becherer, P., Harmon, L. S., Gregg, L., Farkas, Z., Shea, L. CLABSI events.
M., Parekh, P., Murphy, J., & Shade, W.
 Synthesis
2% CHG cloths was significant in decreasing CLABSI (Scheier, 2021; Denkel, 2022).
in contrast to 2% CHG cloth was not significant in decreasing CLABSI
(Zerr et al., 2022).

• Inconclusive

2% CHG bathing (Reis et al., 2022) and 4% CHG bathing (Pallotto et al., 2019)
were not significant in decreasing CLABSI.

3.15% CHG/ 70% alcohol hub disinfectant was significant in decreasing

CLABSI (Cooney et al., 2020).
• More Research Needed
 Recommendations
3.15% Chlorhexidine Gluconate with
70% Alcohol For Hub Disinfection

https://www.google.com/url?sa=i&url=https%3A%2F%2Fpdihc.com%2Fproducts%2Finterventional-care%2Fprevantics-device-
swab-strip
https://www.google.com/url?sa=i&url=https%3A%2F%2Fpdihc.com%2Fproducts%2Finterventional-care%2Fprevantics- %2F&psig=AOvVaw30nNBrPv_BQ1OGdrHFTEXV&ust=1682014649089000&source=images&cd=vfe&ved=0CBAQjRxqFwo
device-swab-strip TCJjktf_Gtv4CFQAAAAAdAAAAABAi
%2F&psig=AOvVaw30nNBrPv_BQ1OGdrHFTEXV&ust=1682014649089000&source=images&cd=vfe&ved=0CBAQjRxqF
woTCJjktf_Gtv4CFQAAAAAdAAAAABBB

(Cooney, R. M., 2018)

Kotter’s 8 Step Change Method

■ Detailed
■ Clear Plan
■ The employees have a voice in the change
■ Sense of urgency in the method

https://getlucidity.com/strategy-resources/guide-to-kotters-8-step-change-model/

(Schmidt, & Brown, 2022)

 Establish Urgency
■ Infections reported in 2021: 27,021 (Centers for Disease Control and Prevention, 2021)
– Standardized Infection Ratio for the national average is 0.92
– North Dakota and Hawaii are the states with the lowest rates at 0.57
■ 8% decrease since 2015 (Centers for Disease Control and Prevention, 2021)
■ ~ 250,000 people truly get CLABSI, reported or not reported according to the Joint
Commission.
■ 12-15% mortality rate (Centers for Disease Control and Prevention, 2021)
■ Burden the healthcare system ~ $46,000 per case (Toor et al., 2022)

https://arpsp.cdc.gov/profile/nhsn/clabsi#:~:text=HAI%20Profile&text=The%20Standardized%20Infection%20Ratio%20for,acute%20care%20hospitals%20in%202021.
 Create a Coalition
■ Unit Nurses that work directly with central lines
■ Managers on units that have reoccurring central lines on units
■ Physicians who insert lines, and continue care on the patients
■ Ask each group/people…
– Common practice
– Thoughts about the change proposal per unit
– How they like to get their information
– How they like to be educated on the information

This Photo by Unknown Author is licensed under

CC BY-SA
Create & Communicate
Vision Statement
• Ensuring safe central line use by decreasing rate of
CLABSI in patients
Posters
• Bathrooms
• Breakrooms
• Emails
• Nursing stations
Education
• Nurses
• Onboarding experience for new hires
• Physicians
https://www.connectedcare.sickkids.ca/quick-hits/cvadscrub
 Change leaders

Empower Feedback from staff

the
Action Show appreciation to the staff

Removing the barriers

 • Pilot study on the ICU for 6 months
• Week 2, 100% implemented in the ICU
Short-term
Goals

• After pilot study, in the 6th month

• Week 2, 50% implementation
Long-term • Week 4, 100% implementation
Goals
 Anchor Approaches

CONTINUATION ANALYZE CONTINUATION OF

OF REPORTING DATA EDUCATION FOR STAFF
DATA TO STAFF PER UNIT
EDUCATION DURING
THE ONBOARDING
PROCESS
 Conclusion
Update evidence-base practice

Implementing CHG/alcohol hub disinfectant

Less Shorter hospital Decreased

Lower cost
patient days stays mortality rates

** REMINDER **
More research is needed
 X X
https://www.walmart.com/ip/Hibiclens-Antibacterial-Hand-Soap-Antiseptic-Skin-Cleanser-8-oz-Wound-4-CHG-For-Surgery-
Antimicrobial-Home-Hospital/2148077428
https://www.roswellpark.org/cancertalk/202203/preparing-surgery-chg-cloths

https://www.google.com/url?sa=i&url=https%3A%2F%2Fpdihc.com%2Fproducts%2Finterventional-care%2Fprevantics-device-swab-strip%2F&psig=AOvVaw30nNBrPv_BQ1OGdrHFTEXV&ust=1682014649089000&source=images&cd=vfe&ved=0CBAQjRxqFwoTCJjktf_Gtv4CFQAAAAAdAAAAABBB
 References
Bell, T., & O'Grady, N. P. (2017). Prevention of central line-associated bloodstream infections. Infectious disease clinics of North America, 31(3),

551–559. https://doi.org/10.1016/j.idc.2017.05.007

Centers for Disease Control and Prevention (CDC). (2011). Central line-associated bloodstream infections: Resources for patients and healthcare

providers. https://www.cdc.gov/hai/bsi/clabsi-resources.html

Centers for Disease Control and Prevention (CDC). (2021). 2020 national and state healthcare-associated infections (HAI) progress report.

https://arpsp.cdc.gov/profile/national-progress/united-states

Chlorhexidine Facts: History of Chlorhexidine. (n.d.). https://www.chlorhexidinefacts.com/history-of-chlorhexidine.html

Cooney, R. M., (2018). “The effectiveness of 3.15% chlorhexidine gluconate/70% alcohol disinfection to prevent central line-associated blood

stream infections.” Presented at 2018 Associated of Vascular Conference in Columbus, OH.

Cooney, R. M., Manickam, N., Becherer, P., Harmon, L. S., Gregg, L., Farkas, Z., Shea, L. M., Parekh, P., Murphy, J., & Shade, W. (2020). The

use of 3.15% chlorhexidine gluconate/70% alcohol hub disinfection to prevent central line-associated bloodstream infections in dialysis

patients. British journal of nursing (Mark Allen Publishing), 29(2), S24–S26. https://doi.org/10.12968/bjon.2020.29.2.S24
 References
Denkel, L. A., Schwab, F., Clausmeyer, J., Behnke, M., Golembus, J., Wolke, S., Gastmeier, P., & Geffers, C. (2022, November 1). Central-line associated

bloodstream infections in intensive care units before and after implementation of daily antiseptic bathing with chlorhexidine or octanedione-A post-hoc

analysis of a cluster-randomized controlled trial. Research Square. https://doi.org/10.21203/rs.3.rs-1644513/v1.

Habboush, Y., Yarrarapu, S. N. S., & Guzman, N. (2022). Infection control. StatPearls [Internet]. https://www.ncbi.nlm.nih.gov/books/NBK519017/

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I., Randolph, A., & Weinstein, R. A. (2002) Guidelines for the prevention of intravascular catheter-related infections. Recommendations and Reports, 51(10),

1-26. https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5110a1.htm.

Lavelle, J., & Costarino, A. (2016). Central venous cannulation. Obgyn Key. https://obgynkey.com/central-venous-cannulation/

McPheeters, R., & Catoera, I. (2023). Central venous access via external jugular vein. Medscape. https://emedicine.medscape.com/article/2116323-

overview#:~:text=Central%20venous%20catheterization%2C%20or%20central,heart%20through%20his%20cephalic%20vein.

Pallotto, C., Fiorio, M., De Angelis, V., Ripoli, A., Franciosini, E., Quondam Girolamo, L., Volpi, F., Iorio, P., Francisci, D., Tascini, C., & Baldelli, F. (2019). Daily

bathing with 4% chlorhexidine gluconate in intensive care settings: A randomized controlled trial. Clinical microbiology and infection: The official

publication of the European Society of Clinical Microbiology and Infectious Diseases, 25(6), 705–710. https://doi.org/10.1016/j.cmi.2018.09.012
 References
Reis, M. A. O., de Almeida, M. C. S., Escudero, D., & Medeiros, E. A. (2022). Chlorhexidine gluconate bathing of adult patients in intensive care

units in São Paulo, Brazil: Impact on the incidence of healthcare-associated infection. The Brazilian journal of infectious diseases: An

official publication of the Brazilian Society of Infectious Diseases, 26(1), 101666. https://doi.org/10.1016/j.bjid.2021.101666

Scheier, T., Saleschus, D., Dunic, M., Fröhlich, M. R., Schüpbach, R., Falk, C., Sax, H., Kuster, S. P., & Schreiber, P. W. (2021). Implementation

of daily chlorhexidine bathing in intensive care units for reduction of central line-associated bloodstream infections. The Journal of

Hospital Infection, 110, 26–32. https://doi.org/10.1016/j.jhin.2021.01.007

Schmidt, N. A. & Brown, J. M. (2022). Evidence-based practice for nurses: Appraisal and application of research (5th ed.). Burlington, MA:

Jones & Bartlett Learning. ISBN: 978-1-284-22632-4

 References
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ctions-toolkit-and-monograph/variability-of-surveillance-practices-for-central-lineassociated-bloodstream-infections-and-its-impl/#:~:text=

Central%20line%2Dassociated%20bloodstream%20infections%20(CLABSIs)%20are%20health%20care,to%20%242.3%20billion%20a%

20year

Toor, H., Farr, S., Savla, P., Kashyap, S., Wang, S., & Miulli, D. E. (2022). Prevalence of central line-associated bloodstream infections

(CLABSI) in intensive care and medical-surgical units. Cureus, 14(3), e22809. https://doi.org/10.7759/cureus.22809

Zerr, D. M., Milstone, A. M., Dvorak, C. C., Adler, A. L., Chen, L., Villaluna, D., Dang, H., Qin, X., Addetia, A., Yu, L. C., Conway Keller, M.,

Esbenshade, A. J., August, K. J., Fisher, B. T., & Sung, L. (2021). Chlorhexidine gluconate bathing in children with cancer or those

undergoing hematopoietic stem cell transplantation: A double-blinded randomized controlled trial from the Children's Oncology

Group. Cancer, 127(1), 56–66. https://doi.org/10.1002/cncr.33271