Running Head: USE OF CHG ON THE INCIDENCE OF BLOODSTREAM INFECTIONS

Bloodstream Infections
Vivarian N. Moulton, RN student
University of South Florida

USE OF CHG ON THE INCIDENCE BLOODSTREAM INFECTIONS

Abstract
Clinical Problem: It is shown that patients who have catheters inserted have increased rates of
colonization and ultimately bloodstream infections resulting from the flora residing on the skin
which in turn increases the length of their hospital stay and complicates their admitting diagnosis
(Bashir, Olson, & Waters, 2012).
Objective: To determine if a standardized order of chlorhexidine (CHG) dressings will decrease
the incidence of catheter related bloodstream infections (CRBSI) for elderly critically ill patients.
Results: Research by O Grady et al. (2011) recommends usage of CHG sponge dressings in
patients older than two months, in addition to education and training and antimicrobial/ antiseptic
skin cleanser for short term usage. In addition, CHG impregnated catheters are suggested for
catheters that will remain in place over five days (OGrady et al., 2011). A study by Bashir et al.
(2012) sshowed that CHG gel dressings made a more significant reduction in reducing
colonization (p< 0.001). Scheithauer et al. (2014) conducted a study that showed that compared
to standard dressings, CHG dressings were superior in decreasing the incidence of central venous
line associated bloodstream infections (p< 0.0001). The study by Timsit et al. (2012) proved that
CHG dressings significantly decreases (p= 0.0006) the rates of catheter related infections and
CRBSI (p= 0.02).
Conclusion: Using CHG dressings decreases the incidence of colonization and CRBSI which
eliminates a comorbidity that can contribute to increased length of stay.

USE OF CHG ON THE INCIDENCE BLOODSTREAM INFECTIONS

Bloodstream Infections
In the United States, a total of 250,000 cases of CRBSIs have been estimated to occur
annually (OGrady et al., 2011). Bloodstream infections complicate a patients hospital stay. This
infection endangers the patient and lengthens their visit. By implementing standard usage of
CHG dressings on patients with catheters, the incidence of bloodstream infections declines,
hospital stays are shortened, patient outcomes are improved, and further complications to the
patients health are prevented. There are multiple studies which address the prevention of
CRBSI. This paper discusses the need for a standardized order of CHG products, namely
dressings, for all patients with catheter insertions. Three randomized controlled trials, as well as
guidelines from the Center of Disease Control and Prevention, have been assessed for the
effectiveness of this practice.

PICOT Question
In critically ill adult patients with venous catheters, how does the use of chlorhexidine
dressings compared to the use of non-chlorhexidine dressings, affect the incidence of
bloodstream infections over a period of six months?

Infrastructure
An entire interdisciplinary team is needed to design, implement and execute this evidence
based practice (EBP). Patient care technicians change dressings and report acute changes in the
appearance of a patients catheter to the nurse. An infection control specialist educates the entire
floor on this infection process. The floor nurses advocates for patients to ensure there is an order

USE OF CHG ON THE INCIDENCE BLOODSTREAM INFECTIONS

for CHG dressings and also change the dressings. Also, physicians should be a part of this
practice, and are needed to place orders for CHG dressings on all patients with catheters.

Literature Search
PubMed, CINAHL and NGC were used to search for randomized clinical trials. The key
search terms used included bloodstream infections, BSI, BSI prevention, chlorhexidine, and
catheter related bloodstream infections.
Literature Review
Three RCTs and one guideline were used to evaluate the effectiveness of CHG dressings
in reducing the incidents of CRBSI (Table 1). A study by Bashir et al. (2012) showed that even
after skin antisepsis, bacterial flora regrows on the skin. Two different microbial CHG dressings,
and a nonmicrobial dressing were used to suppress regrowth, and to compare the performance of
the CHG dressings against each other. The backs of 32 male and female volunteers were divided
into four quadrants, and each quadrant contained four treatment (post sepsis, CHG gel, CHG disk
dressing, and control) sites. Dressings were removed one test quadrant at a time on days one,
four, and seven, and regrowth suppression compared. The p value between CHG gel and control
samples was < 0.001. CHG disk and control p value was < 0.001 on days one and four and P=
0.01 on day seven. The P value between CHG gel and CHG disk samples was p= 0.01. This
study showed that the CHG gel and disk had a lower average log count on days one, four, and
seven than the control. The study also showed that the CHG gel dressings log count was lower
than CHG disk at the seventh day.
The strengths of this study were that it was randomized, reasons were given why subjects
did not complete the study, enough time was given to study the full effect of the interventions,

USE OF CHG ON THE INCIDENCE BLOODSTREAM INFECTIONS

and subjects were analyzed. In addition, the control group was appropriate, instruments used to
measure outcomes were valid and reliable, and the participants were similar in demographic and
baseline clinical variables. The main weakness was that it was not double blinded. This study
was included in the proposal because although it did not involve catheters it supported the notion
that using CHG dressings help to reduce catheter related bloodstream infections (CRBSI) by
suppressing the regrowth of flora that are responsible for the CRBSI.
In addition, a study by Scheithauer et al. (2014) was conducted to show that using CHG
dressings versus standard dressings decreases the occurrence of central line associated infections.
The study consisted of 1, 298 patients who received central lines on intensive care units. These
patients received CHG dressings versus the control which was a comparison of a similar time in
the past when standard dressings were used. The rates were documented from November 2010 to
May 2012. Out of 1000 central venous lines (CVL), there were only 1.51 related infections
which occurred with CHG dressings versus 5.87/1000 with standard dressings; in the past this
rate was 6.2/1000. A difference of p< 0.0001 was observed.
The strengths of this study are that reasons were given why subjects did not complete the
study, follow up assessments were conducted long enough to study the effects of the
intervention, the control group and instruments used to measure were appropriate, and the
participants were of similar demographic background. Weaknesses of this study was that there
were no randomization, and it was not a blinded study. This study was included in this proposal
because it upholds the notion that usage of CHG dressings versus standard dressings help to
reduce bloodstream infections.
Moreover, a RCT by Timsit et al. (2012) was completed to assess the Tegaderm CHG
dressing in decreasing the rate of major catheter related infections (CRI) and the ability of highly

USE OF CHG ON THE INCIDENCE BLOODSTREAM INFECTIONS

adhesive non-CHG dressings to decrease dressing loosening that contributes to catheter

colonization. A total of 1879 patients who had a total 4, 163 catheters were randomly assigned
one of the dressings (Tegaderm CHG, Tegaderm HP Transparent Film Dressing and Tegaderm
transparent film dressing). Using CHG dressings lowered the major CRI rate by 67% with a 95%
confidence interval [CI], 0.1740.619 and P = 0.0006. The CRBSI rates were 60% lower with a
95% CI, 0.1860.868 and P = 0.02 than with non-CHG dressings. CLABSI rates showed a
confidence interval of 0.25-0.656 with a p <0.001 in the CHG group.
Early dressing changes were less in the adhesive group (p< 0.001), and the median
dressings changes per catheter day was also lower in the adhesive group (p< 0.0001) than in the
standard group. However, the colonization rate was higher in the adhesive group than the
standard group (P= 0.0016). CLABSI rates were P= 0.45. Highly adhesive dressings decreased
the detachment rate to 64.3% versus 71.9% (P < 0.0001) but increased skin colonization (P <
0.0001) and catheter colonization (CI, 1.212.26; P = 0.0016) although it did not contribute to
the CRI and CRBSI rates. The study concluded that CHG dressings decreased CRI rates and
highly adhesive dressings decreased the dressing loosening but increased colonization.
The strengths of this study included that it was a double blinded, concealed randomized
study. The reasons participants, who were of similar demographics, did not complete the study
were provided, follow-up assessments were long enough, the control group and the instruments
used were appropriate. The weakness of this study was that it did not go into depth on the
analysis of the groups the participants were assigned to. This trial will be included in the
proposal, since it provides evidence to support that the use of CHG dressings reduces the
incidences of catheter colonization, which further helps to prevent BSI.

USE OF CHG ON THE INCIDENCE BLOODSTREAM INFECTIONS

Finally, a guideline retrieved from the CDC by O Grady et al. (2011) provided an
abundance of evidenced base practices used to help decrease the incidence of CRBSI. The
recommendation is usage of antimicrobial impregnated catheters and cuffs in addition to
educating persons who insert and maintain catheters, aseptic barrier precautions and using CHG
skin prep during the insertions. Using a CHG sponge dressing on temporary short term catheters
in patients older than 2 months of age is another recommendation of the CDC (OGrady et al.,
2011).
Synthesis
The study by Bashir et al. (2012) showed that skin flora is not completely cleansed after
being prepped with antimicrobials. The difference between CHG gel and control samples was p
< 0.001; p< 0.001 between CHG disk and control and p= 0.01 between CHG gel and CHG disk.
CHG gel dressings helped to control the bacterial regrowth more significantly than the control
and even CHG disk. Scheithauer et al. (2014) conducted a study comparing the effective of CHG
and standard dressings to a comparable time in the past. This study once again proved that with a
p < 0.0001, CHG dressings are superior in reducing the rates of CRBSI. Timsit et al. (2012)
coordinated a study which showed that Tegaderm CHG dressings were more significant (p=
0.0016) in reducing the rate of catheter related infections than Tegaderm HP transparent Film
dressing and Tegaderm transparent film dressing. The guidelines written in the study by OGrady
et al. (2011) support these findings.
The similarities of all three studies include a significant p value. This significance
supports the hypothesis that CHG dressings are superior to non CHG dressings in the prevention
of CRBSI, colonization, and in decreasing the rates of CRBSI. All three studies used CHG
dressings and non CHG dressings in their studies, were randomized, and had comparable control

USE OF CHG ON THE INCIDENCE BLOODSTREAM INFECTIONS

groups. However, not all of the studies were blinded but this did not affect the integrity of the
studies.
Extensive research has been conducted on the effectiveness of CHG dressings and has
shown a connection which proves that CHG decreases the incidence of CRBSI and colonization
in patients. However, this research does not follow through enough to supply a direct link
between this finding and a decreased length of stay or even mortality, it is just assumed.
Additional updated research should be conducted to find this link and to also provide a
comparison of a CHG bundle versus singular CHG products.
Proposed Practice Change
Clinical recommendations that emerge for Baycare health based on the three RCT and the
guidelines by OGrady et al. (2011) requires a joint team effort. The journal suggests that skin is
cleaned with an antiseptic/ antimicrobial before central venous catheter (CVC) insertion,
replacing CHG dressings when adherence isnt as effective and not replacing the catheters
routinely. Before and after these guidelines are implemented, all staff on the specified floor needs
to be educated on the infection process, on catheter care, proper dressing changes and ways to
report suggestions of improvement. After the initial educational sessions, bundles should be
implemented for all patients with catheters. These bundles should be ordered by the physician
and carried out by the floor and charge nurses should supervise the execution of the bundles in a
timely manner. The bundle would include CHG baths, dressings, and strict aseptic technique on
patients. This suggestion is based on the fact that CHG does decrease the rate of CRBSI,
therefore, if more skin flora is eradicated, the more rates will remain decreased.
Change Strategy

USE OF CHG ON THE INCIDENCE BLOODSTREAM INFECTIONS

It is one thing to theorize the implementation of a new plan. However, for it to be carried
out requires the input of all involved. Hence, the nurses, the PCTs, infection control specialist,
physicians and other members of the interdisciplinary team must be open to methods of
improving patient outcomes and reducing the chance of patients acquiring an infection while in
the hospital. This team should be able to make suggestions they know will be seriously
implemented or should feel free to voice concerns or factors inhibiting their adherence to the
new plan.

Evidence Based Practice (EBP) Model Utilized

The infrastructure involved in implementing this change must be aware and acknowledge
that CRBSI is a serious condition that can lead to complications which contributes to a patients
death. However, with proper EBP interventions the incidence of this infection can be reduced if
guidelines are followed consistently. St. Josephs Hospital currently utilizes the Iowa model to
implement EBP into the clinical setting.
Roll Out Plan

Steps
One: Identify Triggers

Process
Timeframe
a. Baycare desires to be January 2015
one of the leading
healthcare systems in
the nation.
b. The current average
for hospital acquired
BSI compared against
statewide and national
data is insignificant.
c. The problem was
identified that catheter
related bloodstream
infections increase a

USE OF CHG ON THE INCIDENCE BLOODSTREAM INFECTIONS

d.

Two: Clinical Applications

A.

B.
C.

Three: Organizational
Priorities

A.

Four: Forming a Team

A.
B.
C.

Five: Piloting a Practice

Change

D.
E.
A.
B.

patients length of
stay and morbidity.
The current practice
was questioned based
on the fact that the
current rates can be
decreased.
Leaders and
administrators
encourage a culture of
inquiry, ownership,
and evidenced based
delivery
Decreased CRBSI
improves patient
outcomes.
Nurses pose relevant
clinical practice
questions
What are risk factors
of bloodstream
infections?
What are the
complications/
consequences of
bloodstream
infections?
The need to surpass
the regions average
makes this EBP
change a top priority
for the organization.
Patient care
technicians
Infection control
specialist
Floor and charge
nurses
Unit managers
Physicians
Outcomes include a
decrease in CRBSI
Current CRBSI
unremarkable being at
the same level as
Floridas average.

January 2015

January 2015

February 2015

February 2015 August 2015

10

USE OF CHG ON THE INCIDENCE BLOODSTREAM INFECTIONS

Six: Evaluating the Pilot

Seven: Evaluating Practice
Changes and Dissemination
of Results

C. Three research and

national guidelines
collected to construct
guideline
D. EBP of CHG
dressings on all
patients with catheters
implemented on the
pilot floor
E. Implementation and
outcomes evaluated
F. Assess need for
modification
A. It is determined that
adoption of pilot is
appropriate.
A. Other regional
hospitals whose
CRBSI rates are
above average are
collaborated with.
B. Evaluate physician
orders for patients
with catheters
C. Evaluate occurrence
of CRBSI compared
to 4 months before
D. Gather feedback from
the team
E. Share findings with
other floor managers.

11

August 2015
September 2015

The Iowa Model of Evidence Based Practice (Melnyk & Fineout-Overholt, 2015, p. 283- 287)
Project Evaluation
Beginning January, all adults receiving catheter insertions will follow a guideline that
includes CHG dressings. Data will be collected from all of these patients. An evaluation can be
made to compare the occurrence of CRBSI before implementation and after. The rates will be
monitored to continually evaluate the impact on the overall incidence of CRBSI. The project will

USE OF CHG ON THE INCIDENCE BLOODSTREAM INFECTIONS

12

be considered successful if the p value is at or below 0.05 and the national average decreases to
and remains under 0.50%.

Dissemination of Evidence Based Practice

The methods to spread this EBP change throughout the hospital, other Baycare hospitals,
regional Florida hospitals, and nationwide hospitals are diverse. Constant emails, interactive
sessions, and awareness of the change in guidelines should be available in the policy and
procedures. A power point presentation may also be used as a presentation aid in educating the
staff in this and other hospitals. Assigned teams to monitor this change, acquire feedback and
report back to the leaderships should be implemented.
Methods of disseminating this practice to other hospitals include creating awareness
through posters describing research, guidelines created and the goal achieved. This poster could
be displayed at nursing conferences and team meetings. A scholarly written article can also
spread this new found EBP.

USE OF CHG ON THE INCIDENCE BLOODSTREAM INFECTIONS

13

References
Bashir, M., Olson, L., & Walters, SA. (2012). Suppression of regrowth of normal skin flora
under chlorhexidine gluconate dressings applied to chlorhexidine gluconate-prepped skin.
American Journal of Infection Control, 40(4), 344-348.
DOI: 10.1016/j.ajic.2011.03.030
Melnyk, B. M., & Fineout-Overholt, E. (2015). Evidence-based practice in nursing & healthcare
(3rd ed.). Philadelphia, PA: Wolters Kluwer Lippincott Williams & Williams.
O'Grady, N. P., Alexander, M., Burns, L. A., Dellinger, E. P., Garland, J., Heard, S. O., & ...
Saint, S. (2011). Guidelines for the prevention of intravascular catheter-related infections.
American Journal of Infection Control, 39(4), S1-34. doi:10.1016/j.ajic.2011.01.003
Scheithauer, S., Lewalter, K., Schrder, J., Koch, A., Hfner, H., Krizanovic, V... Lemmen, S.
(2014). Reduction of central venous line-associated bloodstream infection rates by using
a chlorhexidine-containing dressing. Infection, 42(1), 155-159. doi:10.1007/s15010-0130519-7
Timsit, J., Mimoz, O., Mourvillier, B., Souweine, B., Garrouste-Orgeas, M., Alfandari, S ...
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 & Critical Care Medicine, 186(12), 1272-1278.
doi:10.1164/rccm.201206-1038OC

USE OF CHG ON THE INCIDENCE BLOODSTREAM INFECTIONS

14

Table 1
Literature Table
Reference
Bashir, M., Olson, L.,
Walters, SA. (2012).
Suppression of regrowth
of normal skin flora under
chlorhexidine gluconate
dressings applied to
chlorhexidine gluconateprepped skin.
American Journal of
Infection Control, 40(4),
344-348.
DOI:
10.1016/j.ajic.2011.03.030

Scheithauer, S., Lewalter,

K., Schrder, J., Koch, A.,
Hfner, H., Krizanovic,
V... Lemmen, S. (2014).
Reduction of central
venous line-associated
bloodstream infection
rates by using a
chlorhexidine-containing
dressing. Infection, 42(1),
155-159.
doi:10.1007/s15010-0130519-7

Aims
to show that
even after skin
antisepsis,
bacterial flora
regrows on the
skin and using
2 different
microbial
chlorhexidine
gluconate
(CHG)
dressings
versus a
nonmicrobial
dressing to
suppress
regrowth, and
to compare the
performance of
the CHG
dressings
against each
other
to show that
using CHG
dressings
versus
standard
dressings
decreases the
occurrence of
central line
associated
infections

Designs and
Measures
Designs:
Randomized
Control Trial
Measures:
Dressings
were removed
1 test quadrant
at a time on
days 1, 4, and
7 and
regrowth
suppression
compared

Design:
randomized
control trial
Method:
These patients
received CHG
dressings
versus the
control which
was a
comparison of
a similar time
in the past
when standard

Samples

Outcomes/

The backs of
32 male and
female
volunteers
divided into
4 quadrants
and each
quadrant
contained 4
treatment
(post sepsis,
CHG gel,
CHG disk
dressing and
control) sites

Statistics
CHG gel was
superior to
control
samples on
days 1, 4 and
7. CHG gel
and disk had
lower average
regrowth on
days 1, 4, and
7. CHG gel
dressing was
superior to
CHG disk at
day 7.

The study
consisted of
1, 298
patients who
received
central lines
on intensive
care units.

1.51/ 1000
related
infections
occurred with
CHG dressing
and 5.87/
1000 with
standard
dressings in
this study, in
the past, this
rate was 6.2/
1000 with
standard

USE OF CHG ON THE INCIDENCE BLOODSTREAM INFECTIONS

Timsit, J., Mimoz, O.,

Mourvillier, B., Souweine,
B., Garrouste-Orgeas, M.,
Alfandari, S ... 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 & Critical
Care Medicine, 186(12),
1272-1278.
doi:10.1164/rccm.2012061038OC

to assess the
Tegaderm
CHG dressing
in decreasing
the rate of
major catheter
related
infections
(CRI) and the
ability of
highly
adhesive nonCHG dressings
to decrease
dressing
loosening that
contributes to
catheter
colonization.

dressings were
used. The
rates were
documented
from
November
2010 to May
2012.
Method:
randomized
control trial
Design:
Patients were
randomly
assigned one
of the
dressings,
frequency and
time of
dressing
changes,
colonization
and
detachment
rates were
assessed

15

dressings.
Significant
difference of
P< 0.0001

A total of
1879 patients
who had a
total 4, 163
catheters
were
assigned one
on the
dressings.

CHG
dressings
lowered major
CRI by 67%
and p =
0.0006.
CRBSI rates
with 60%
lower with p=
0.02 with
CHG versus
non CHG
dressings.
CLABSI rates
CI of 0.250.656 in CHG
group.
CHG
dressings
decreased CRI
rates and
highly
adhesive
dressings
decreased the
dressing
loosening but
increased
colonization