Running head: UNIVERSAL CHLORHEXIDINE

Universal Chlorhexidine Bathing Implementation Plan Kimberly Cremerius University of South Florida

UNIVERSAL CHLORHEXIDINE Universal Chlorhexidine Bathing Implementation Plan

Methicillin-resistant Staphlococcus aureus (MRSA) is a type of bacteria that does not respond to antibiotics that physicians use to treat most staph infections (Mayo Clinic, 2013). According to the Centers for Disease Control and Prevention (2013), although the incidence of hospital associated MRSA infections has decreased significantly in the last several years MRSA continues to be one of the leading causes of hospital associated infections. The estimated number of overall MRSA infections out of a population of 100,000 people is 80,461cases. The medical community still encourages improvement in the prevention and treatment of MRSA to continue decreasing the incidence rates in the hospital setting (Centers for Disease Control and Prevention [CDC], 2013). PICOT Question Do patients in a hospital setting benefit more from universal decolonization with chlorhexidine baths compared to targeted screening and decolonization to decrease the spread of nosocomial MRSA infections throughout their stay in the hospital? Infrastructure to Support Practice Change Florida Hospital of Tampa (FHT) is an Adventist hospital whose mission is to extend the healing ministry of Christ by focusing on healing the whole person: mind, body, and spirit (Florida Hospital, n.d.). All staff members focus on helping the patients any way possible and respond encouragingly to newly implemented practices to improve care for the patients. The quality improvement team for each floor initiates the practice change. After initiation, the nurses are responsible for implementation and compliance with the new practice. During the daily huddle with the patients physicians and weekly floor meetings the nurses can articulate any questions or concerns with the new practice.

UNIVERSAL CHLORHEXIDINE Synthesized Literature Review Literature Search The articles included in this synthesis were found using PubMed database. The key words used to search for the articles included MRSA, chlorhexidine baths, infection control, and prevention. Synthesis

In Huang et al.s (2013) randomized control trial, the results supported the use of universal decolonization practices because the group that tested those interventions had a notably decreased amount of MRSA-positive blood cultures compared to the screening and isolation group (p= 0.01). The universal decolonization practices in this trial included application of intranasal mupirocin twice a day for five days in addition to using chlorhexidine-impregnated cloths for the daily bath throughout the patients stays in the ICU (Huang et al., 2013). Kassakian, Mermel, Jefferson, Parenteau, and Machan (2011) validated the use of 2% chlorhexidine-impregnated cloths to decrease the incidence rate of MRSA and vancomycin-resistant enterococci (VRE) hospital associated infections. The results showed that the rate of hospital associated infection with MRSA and VRE in the intervention group was 64 percent less than the control group (p = 0.06) (Kassakian et al., 2011). In Harbarth et al.s (2008) study, the researchers nullified the necessity of rapid screening to decrease the incidence of nosocomial MRSA infection. The data revealed that there was no significant decrease in the amount of nosocomial MRSA infections in the intervention group compared to the control group (p = 0.29) (Harbarth et al., 2008). Finally, Robicsek, Neaumont, Thomson, Govindarajan, and Petersons (2009) study

UNIVERSAL CHLORHEXIDINE analyzed the effect of differing amounts of nasal mupirocin treatments on the possibility

of the MRSA colonization persisting and how the treatments affected the risk of infection from colonized MRSA. The decolonization with the nasal mupirocin eliminated the colonization of MRSA (p = 0.076), but did not protect against future colonization and did not decrease the risk of becoming infected (Robicsek et al., 2009). This last study invalidates the necessity for universal application of mupirocin, which Huang et al. (2013) also tested alongside the chlorhexidine baths. Proposed Practice Change Based on the evidence chlorhexidine baths decrease the rate of hospital associated MRSA infections. Current practices should change to coincide with the evidence-based research and implement daily chlorhexidine baths for all patients regardless of screening results to prevent the spread of MRSA in the hospital. Currently, at FHT, the staff gives the patients in the ICU chlorhexidine baths once a day, but on general floors the patients receive soap and water baths once a day. The practice of daily chlorhexidine bathing should be implemented on general floors along with ICU and progressive care floors to decrease the spread of nosocomial MRSA infections. Change Strategy It is important to promote enthusiasm with the staff for the new proposal to gain support and make the implementation of the proposed practice change easier. According to the Kotter and Cohens Model of Change, appropriate communication that connects with the emotions of the staff will facilitate the transition to the new procedure while emphasizing the beneficial impact the proposed practice will have on the patient population (Melnyk & Fineout-Overholt, 2011). Also, it is important to remove obstacles

UNIVERSAL CHLORHEXIDINE such as lack of adequate skill or proper materials to or the staff will be annoyed with the change in practice and will become less compliant (Melnyk & Fineout-Overholt, 2011).

Providing information sessions to explain how the new procedure should be implemented will empower the staff to change their current practice and will resolve any uncertainty about the change. Roll Out Plan Steps Step 1 Definition Assess the need for change in Practice Include stakeholders Collect internal data about current practice Compare external and internal data Identify problem Link problem interventions, and outcomes Locate the best evidence Identify types and sources Review research concepts Plan the search Conduct the search Critically analyze the evidence Appraise and weigh the evidence Synthesize the best evidence Assess feasibility, benefits, and risks of new practice Design practice change Define proposed change Identify needed resources Design the evaluation of the pilot Design the implementation plan Implement and evaluate change in practice Implement pilot study Evaluate processes, outcomes, and costs Develop conclusions and recommendations Integrate and maintain change in practice Communicate recommended change Timeframe For Rollout Completed September 2013

Step 2

Completed October 2013

Step 3

Completed October 2013

Step 4

November 2013

Step 5

Implement: January 2014 Evaluate: July 2014

Step 6

August 2014

UNIVERSAL CHLORHEXIDINE to stakeholders Integrate into standards of practice Monitor process and outcomes periodically Celebrate and disseminate results of project Model of evidence-based practice change (Melnyk & Fineout-Overholt, 2011, p. 255). Project Evaluation In January 2014, the quality improvement team will implement the use of

universal chlorhexidine baths to every floor of the hospital. The team will collect data on how many patients came to the hospital with positive MRSA test results and compare that data to the number of new MRSA infections after initiating the new practice. The results will be reviewed once a month to evaluate the impact of the new practice. If the results show a decrease in MRSA infections by 20% or greater, then the implemented practice is considered a success and the quality improvement team will continue to encourage its use. However, if the results of MRSA infection have decreased less than 20%, then the new practice does not have a large enough impact on the rate of infection to continue implementing it throughout the hospital. Dissemination of EBP There are many ways to disseminate the plan to other areas locally and regionally. According to Melnyk and Fineout-Overholt (2011), panel presentations are one way to circulate new practices. This strategy gathers personnel from other hospitals in the regional area to discuss and ask questions about the new evidence-based practice implemented at FHT. Another way to distribute the new practice is by publishing a journal article, which could open the information to the public to be seen nationally through the Internet (Melnyk & Fineout-Overhold, 2011).

UNIVERSAL CHLORHEXIDINE References

Centers for Disease Control and Prevention. (2013). Methicillin-resistant staphylococcus aureus (mrsa) infections. Retrieved from http://www.cdc.gov/mrsa/tracking/index.html Florida Hospital. (n.d.). Our mission: Extending the healing ministry of Christ. Retrieved from https://www.floridahospital.com/about/mission Harbarth, S., Fankhauser, C., Schrenzel, J., Christenson, J., Gervaz, P., Bandiera-Clerc, C., Pittet, D. (2008). Universal screening for methicillin-resistant staphylococcus aureus at hospital admission and nosocomial infection in surgical patients. The Journal of the American Medical Association, 299(10). doi: 10.1001/jama.299.10.1149 Huang, S., Septimus, E., Kleinman, K., Moody, J., Hickok, J., Avery, T., Platt, R. (2013). Targeted versus universal decolonization to prevent icu infection. The New England Journal of Medicine, 368(24). doi: 10.1056/NEJMoa1207290 Kassakian, S. Z., Mermel, L. A., Jefferson, J. A., Parenteau, S. L., & Machan, J. T. (2011). Impact of chlorhexidine bathing on hospital-acquired infections among general medical patients. Infection Control and Hospital Epidemiology, 32(3). doi: 10.1086/658334 Mayo Clinic. (2013). MRSA infection. Retrieved from http://www.mayoclinic.org/mrsa/index.html Melnyk, B. M., & Fineout-Overholt, E. (2011). Evidence-Based Practice in Nursing & Healthcare (2nd ed.). Philadelphia, PA: Wolters Kluwer Lippincott Williams & Williams.

UNIVERSAL CHLORHEXIDINE Robicsek, A., Beaumont, J. L., Thomson, R. B. Jr., Govindarajan, G., & Peterson, L. R. (2009). Topical therapy for methicillin-resistant staphylococcus aureus colonization: Impact on infection risk. Infection Control and Hospital Epidemiology, 30(7). doi: 10.1086/597550