Background on the Problem
In 2018, the World Health Organization (WHO) highlighted the growing incidences of healthcare-associated infections (HAIs) contracted by patients while receiving medical assistance from hospitals and other healthcare facilities. These incidences became quite alarming because instead of patients getting treatment and medical care from these institutions, they contract other secondary infections. As a result, patients end up spending more time in the hospital, which results in an increase in the cost incurred. This situation can worsen to become a lifelong disability or even lead to death (CDC, 2013).
Purpose of the Project
One of the biggest challenges facing long-term care facilities is catheter-acquired urinary tract infection (CAUTI). There are significant reports that show urinary tract infection as the fourth most prevalent form of the disease in the United States (Nicolle,2014). Approximately 12.9% of the total health care infection relates to urinary tract infection, and 67.7% of these cases involve patients with a urinary catheter (Nicolle, 2014). With 75% of CAUTI cases reported among patients in long-term care facilities, the WHO deemed it necessary to strictly implement an intervention that would help resolve this issue. The purpose of this quality improvement project is to adapt evidence for the prevention of Catheter-acquired Urinary Tract Infection in long-term care facilities for senior patients who are 65 years old and older but younger than 89 within 6 weeks. To achieve this objective, studies have revealed that using a disposable washcloth with 2% chlorhexidine gluconate daily helps reduce bacteria in the skin which causes the infection can help significantly reduce the development of catheter-acquired urinary tract infection (CAUTI), thereby ensuring the patient’s health and general wellbeing (Durant, 2017).
Significance of the Problem in Nursing and Healthcare
There are evidence-based researches that prove the efficacy of using a disposable washcloth with 2% chlorhexidine gluconate as an active cleansing agent during routine care for senior patients on Foley catheter in a long-term care facility (Shippey & Malan, 2004; Delesie, Blot, Vanacker & Vandijck, 2011; Popovich et al., 2012). The use of chlorhexidine gluconate (CHG) washcloth has significantly reduced the overall incidence of hospital-acquired infections by 1.82 incidences for every 1000 patients that are from 6.60 cases with a non-antimicrobial washcloth to 4.78 cases using CHG bathing per 1,000 patients on a daily average (Climo et al., 2013).
The benefit of the Project to Practice
One benefit of this quality improvement project is that it is likely to decrease the incidences and prevalence rate of CAUTI among senior long-term care patients. Moreover, the members of the healthcare team will be able to address the primary health issues that confront patients upon hospital consultation and hospital visits rather than being diverted from the primary health concern. This proposal shall also address the secondary impact of CAUTI identified earlier, which included more extended hospital stay, increase cost, lifelong disability, and even death (CDC, 2013).
Picot Question
For senior patients ages 65 years and above of long-term care facilities (P), how does the use of disposable washcloth with 2% chlorhexidine gluconate (I) compared to standard catheter care (C) affect the rate and prevalence of catheter-associated urinary tract infections (O) within a six-week period (T)?
Review of Literature
Theoretical Framework
Change in any environment requires assessment, planning, and evaluation. Kurt Lewin, the author of the Change Model in Nursing, identified the three-stage model for change—unfreezing, change, and refreezing (Scott, 2016). In the case of the project, the most common bathing practice for patients with indwelling Foley catheters or suprapubic Foley catheters is limited to the use of non-chlorhexidine gluconate washcloths. However, this practice has been proven ineffective in managing and controlling the spread of CAUTI (AACN Practice Alert,2016). The need to change this practice becomes necessary as the incidence of CAUTI cases increases compromising the health and general welfare of patients (unfreezing stage). It is hereby proposed that change must be realized through a thorough assessment of 2% chlorhexidine gluconate washcloths when bathing the residents with an indwelling Foley catheter or suprapubic Foley catheter to prevent the spread and development of bacteria, which causes bacteriuria (change stage). There is a need to establish that the use of traditional washcloths is less effective compared to 2% chlorhexidine gluconate washcloths. While change is relatively hard to implement in almost all circumstances, disbursing information and conducting research would be key in ensuring that CHG is implemented in spite of the additional cost to the health care facility as well as the additional task that healthcare provider will be required to engage in while implementing the intervention. However, it must be brought to everyone’s attention that institutionalizing this practice, could avoid future problems which is costlier and more tedious than mere preparation and implementation. Once accepted, this new intervention must take full effect and be made permanent (refreezing). The organization, in this case, the long-term care facility administrators, must ensure that every member of the healthcare team abides by the new procedure. Constant monitoring, follow-ups, and evaluation must be guaranteed to assure the effectiveness and efficiency of the practice.
Synthesis and Analysis of Evidence
Several studies show how effective nursing management can be especially when 2% chlorhexidine gluconate washcloths are used in caring for patients with indwelling catheters (McCoy et al., 2019; Peter, Devi & Nayak, 2018; Zurmehly, 2018). In 2018, Peter, Devi, and Nayak determined the primary culprit for the high incidences of catheter-acquired urinary tract infection (CAUTI) and this was credited to non-sterile techniques used by nurses while handling patients with indwelling Foley catheter or suprapubic Foley catheters. The same results were revealed in a study made by McCoy et al. (2019), which suggested that the nurse’s failure to properly handle the catheter, especially during bathing was just one of the reasons catheter-acquired urinary tract infection (CAUTI) occur. Literature supports the use of 2% chlorhexidine gluconate washcloths during bathing could significantly reduce the rate and prevalence of CAUTI among patients. The following are just but few articles and research literature that are in agreement with this statement.
A study done by Rhee et al. (2018) where compared three different types of CHG wipes with different strengths, such as no-rinse 2% CHG wipes compared to 4% CHG liquid and cotton washcloth moistened with sterile water. This study was done on 126 participants; 63 of these participants had one forearm cleansed with CHG 2% (Method A); 33 other participants had their contralateral arm cleansed with CHG 4% liquid (Method B); 30 participants received on one arm cotton washcloth moistened with sterile water (Method C). They concluded that participants who had their arm cleansed with CHG 2% had decreased microbial densities much lower than those who had the CHG 4%.
Sinha et al. (2015) have conducted 12 trials in this review (seven hospital-based and five community-based studies) done to observe the effect of chlorhexidine on newborn skin and cord a systematic review level I evidence with the objective to analyze the effectiveness of chlorhexidine on neonatal skin or cord of all newborns. The studies were done over a period ranging from six months to 37 months. Individuals who participated in these studies ranged from 112 to 29,790. According to Sinha et al. (2015), three trials of high-quality evidence found that chlorhexidine cord cleansing reduces neonatal mortality {RR 0.81, 95% CI 0.71 to 0.92}, and the neonatal mortality rate reduction is currently 12%.
Swan, et al. (2016) conducted a randomized level I study on 325 patients in a 24-bed surgical ICU at a quaternary academic medical center and have found that CHG bath given every other day lowered the risk of infections by 44.5%. The goal of this study was to compare daily bathing with soap and water to every other day 2% CHG wipes bathing for a period of 28 days; it was shown that CHG wipes bathing decreases the risk of HAIs (hazard ratio = 0.555; 95% Cl, 0.309-0.997; p = 0.049).
An article written by Wang et al. (2017) reported that current literature suggests very strongly that CHC baths prevent HAIs. They also revealed that CHG possesses a potent antibacterial reaction when in contact with gram-positive organisms. This randomized controlled level I article explored the effectiveness of CHG bathing (Wang, et al., 2017) These authors stated that CHG wipes bathing done every other day on 11 patients can save one HAI. These $33 baths can lead to a saving of $6,000 to $60,000 per HAI. They reported a study done by [Vernon et al., 2006] (Wang et al., 2017) that revealed CHG 2% washcloths lowered the procurement of Vancomycin-resistant. (VRE).
Afonso et al. (2015) presented 15 randomized controlled trials studies, which demonstrate reduction of bloodstream infection and a decrease of bacteremia using chlorhexidine washcloths. The goal was to measure the impact of chlorhexidine wipes in preventing the spread of pathogens. They analyzed data from three different units: the intensive care unit, a pediatric care unit, and a hospital ward with and without the use of chlorhexidine wipes. The intervention was associated with a 64% reduction of pathogen transmission. CHG wipe is worth implementing in practice
Cao et al. (2018) discussed several randomized controlled trials and quasi-experimental trials which considered varied approaches to urethral cleaning and compared them to disinfection with respect to their effectiveness in preventing CAUTIs. There were 33 studies including 6490 patients who took part in the studies. To prevent Urinary tract infection in patients with indwelling Foley catheters, different cleaning methods were used. Seven methods of urethral cleaning were deemed eligible and summarized in the network meta-analysis. 2% Chlorhexidine wipes were the most effective according to the results of the Bayesian analysis; consequently, they were recommended for preventing CAUTIs.
Carter et al. (2014) presented a literature Review done on a 28-bed general/telemetry medicine unit in an Academic Health Science Center. The indwelling catheter must be in place longer than two days on the day of the event to qualify as a CAUTI. The infection is attributed to the current unit if it has been greater than two days since transfer when all elements are met. The goals of this study included: Measuring different successful interventions, such as verification of appropriate circumstances to insert an indwelling urinary catheter, the use of appropriate insertion techniques, meticulous maintenance procedures, removal at earliest possible opportunity, appropriate competency training for all relevant staff members on the new evidence-based policies and procedures for the reduction of CAUTIs
Analyzing the implementation of the CAUTI prevention bundle, which involved in Identifying standards for the insertion of catheters and standards for keeping it inserted on a day-by-day basis, developing stringent hygienic practices for the maintenance of the catheters while in use, forming an educational campaign to teach direct-care providers, patients, and families about the proper use and hygiene of catheter? Strong evidence supports the use of chlorhexidine gluconate (CHG) bathing as a means to reduce healthcare-associated infections, including central line-associated bloodstream (CLABSI) and surgical site infections (SSI). Other studies proved that incidence rates were reduced in a high-risk patient population implementing daily bathing with CHG non-rinse cloths. These non-rinse CHG wipes application significantly reduces the risk of colonization with vancomycin-resistant enterococcus (VRE) or MRSA. It was shown by implementing an evidence-based CAUTI prevention bundle and reducing the number of CAUTIs, patient outcomes and the overall standard of patient care improved on this general medicine/telemetry unit Chlorhexidine gluconate wipe bathing is worth use in practice
Critical Care Nurse (2016) revealed that AACN Practice Alert develop guidelines for urinary catheterization. This instrument is based on already existing tools, for instance, the HOUDINI Protocol, and its primary aim is to standardize indwelling catheter-related assessment, providing the necessary guidance for nurses. The criteria include indications for indwelling urinary catheterization insertion and adherence to an aseptic technique for placement as measures that can decrease the risk factors for CAUTIs. Among other ways to prevent CAUTIs in adults, cleaning the catheter with chlorhexidine gluconate wipes was recommended as an intervention capable of decreasing CAUTI.
Strouse (2015) revealed that literature searches through multiple databases were used to find research articles on bathing and cleansing practices and CAUTI prevention. There were 22 studies included in this review. The study aimed to demonstrate that the use of 2% CHG gluconate wipes bathing is an effective method for reducing the incidence of CAUTIs. It was found that CHG is an antiseptic that has coverage against fungi, gram-positive and gram-negative bacteria, such as methicillin-resistant Staphylococcus aureus (MRSA), Vancomycin-resistant enterococci (VRE), and other multi-drug-resistant organisms (MDRO), as well as CLABSIS. Research findings suggesting up to 76% of CLABSI reduction occurred when 2% CHG wipes were utilized. The bactericidal properties of CHG have also demonstrated effectiveness in reducing the incidence of SSIs and MDROs, such as MRSA and VRE, by 23% when used for pre-operative bathing (Climo et al., 2013).
Methodology
Overview of the Approach
This quality improvement project will evaluate the efficacy of daily 2% chlorhexidine gluconate washcloths in reducing CAUTIs in long-term residents with an indwelling Foley catheter or suprapubic indwelling Foley Catheter. The methodology used for this project will adopt a quantitative approach to ascertain the effectiveness of the intervention. This effectiveness will be measured based on the actual data that would determine and report the incidence rate of CAUTI over the six-week implementation period. Specifically, urinalysis and urine culture analysis will be used.
The Site, Agency, and Participant Information
Claridge House is a 240 bed-licensed Nursing Home located in North Miami, Florida, which consists of three units (1-South, 2-South, and 1-North). The prevalence of CAUTIs on the 2-South unit with 100 beds was significantly higher than the other two units, and it is for this reason that this section of the nursing home was selected to form part of the study. Isolating the other sections prevent major disruption in nursing home daily activities and assures efficient data processing system. Armed with the knowledge of the facility’s goal, which is to increase patient safety and satisfaction, prevent money loss associated with CAUTIs, and avoid penalty imposed by Centers for Medicare and Medicaid Services (CMS) and or the Joint Commission (JCAHO), the study will be able to support this objective.
The participants of the study will include the nursing home’s staff and patients. The maximum number of the nursing home’s nurses and certified nursing assistants will be involved, as well as the patient care technician. They will be recruited to participate in a training program to ensure the appropriate use of the intervention (2% chlorhexidine gluconate washcloths). The patients will be selected based on several criteria, including age, medical condition, medication, and presence of a urinary catheter. Specifically, patients must be admitted for more than a period of eight weeks in the selected long-term care facility, aged 65 years and older (but younger than 89), not diagnosed with urinary tract infection prior to the study, not under any form of antibiotic treatment for any form of infection during the duration of the study and must have either an indwelling Foley catheter or suprapubic Foley catheter. The number of patients who can be involved is limited to 10 because of the monetary costs of using 2% chlorhexidine gluconate washcloths; potentially, the sample can be increased to 20 patients. Consent must be obtained from the patient or the patient’s immediate guardian. An extensive explanation of the purpose, the procedure, the different pros and cons of the study, and possible outcomes should be discussed with the patient or their guardian in compliance to obtaining the consent. The patient or their guardian’s voluntary participation must be obtained through a signature affixed on the consent form.
Methods
In this quality improvement project, the Walden Library Medicine, Health Sciences, and Nursing Databases will be used to search for materials and references related to the clinical question related to the effectiveness of using 2% chlorhexidine gluconate washcloths in reducing CAUTIs among patients with an indwelling urinary catheter. This paper will use the databases MEDLINE, ProQuest, and CINAHL to search for keywords including catheter-acquired urinary tract infection, 2% chlorhexidine gluconate, and urinary tract infection. The library and literature search should generate relevant resources on the topic. For the quantitative aspect of the study, a program designed to educate and train nurses and nursing assistants assigned to bathing and cleaning the senior long-term care facility residents on the proper use of 2% chlorhexidine gluconate amongst the participants of the study will be utilized. The program will take 30 minutes inclusive of a 20-minute lecture and a 10-minute hands-on demonstration. Instructional modules and printed materials will be handed out for the nurses’ and nursing assistants’ reference. The participants, in this case, the senior individuals in the long-term care facility who are eligible and have consented to the study, will also receive modules that will keep them informed about what the study is about, the objectives of the study, benefits as well as the risks that come with participating in the study. To assess the effectiveness of the informed application of % chlorhexidine washcloths, the nurses’ and nursing assistants’ understanding will be evaluated with the help of self-designed instruments. Furthermore, the effectiveness of the intervention will also be assessed based on the incidence or development of new cases of CAUTI during a six-week evaluation period as measured by urinalysis and urine culture results.
Instruments
To measure the effectiveness of the training intervention, a self-designed knowledge checklist shown in table 1 will be utilized to gauge the level of understanding of the healthcare professionals. The assessment sheet shown in table 2, which details the proper step-by-step procedure for CAUTI detection, will be used as a part of the educational materials. The patient evaluations, which will include urinalysis and urine culture analysis, will employ the site’s standard reporting procedures for such analyses.
Table 1 Self-designed assessment test
Table 2: Knowledge checklist
Data Collection
The data collection process will be divided into two segments. The first part relates to the training program involving the members of the healthcare team. A self-designed assessment sheet that details the proper step-by-step procedure will be utilized to gauge the level of understanding of the healthcare professionals. This information will be collected before the training program and after it; the scores will be compared to check if any improvements are associated with the program. This assessment will not directly respond to the PICOT question, but it will allow demonstrating that the practitioners have the knowledge necessary to use the intervention (2% chlorhexidine washcloths). In addition to that, as a part of a practice improvement project, this part of the study will offer the practitioners some additional education on CAUTI prevention. This is the reason why the maximum number of nurses, certified nursing assistants, as well as patient care technicians, are meant to be engaged in the program. The staff participants will then be involved in monitoring the patients, who will be selected for the study, during the 6-week evaluation period and ensure that records of any infection activity are noted down.
CHG’s effectiveness in the reduction of CAUTIs will be examined using a pre-post design, which means that the patient’s state measured prior to the institution of CHG baths will be compared to their condition after CHG bathing has been implemented. Thus, at the start of the evaluation period, each patient will be tested for urinary tract infection using a urinalysis and urine culture. Only patients who test negative will be eligible for the study; they will proceed to be treated as usual but with the introduction of 2% chlorhexidine gluconate washcloths. If any participant develops CAUTI over the six weeks following their recruitment, the case will be recorded to report CAUTI rates during the project, and the patient will be disenrolled. The patients who do not develop a CAUTI will be tested once again with the help of urinalysis or urine culture at the end of the six-week period. The efficacy of the intervention will be assessed by comparing the pre-and post-intervention analyses results while taking into account the number of patients who developed CAUTI within six weeks. Thus, this part of the data collection process will gather the information that will help to answer the PICOT question.
Data Analysis Plan
In this quality improvement project, descriptive statistics will be used to describe the participants taking part in the study. The demographic data will be gathered using the self-designed checklist, which includes participants’ gender, professional role, and experience. The mean, median, mode, and standard deviation will be calculated so as to get a better picture of the population. No plans for collecting the demographic data of the patients have been made, but their inclusion criteria determine certain groups that they belong to (in particular, older people).
The project contrasts the pre-and post-training scores of the professional participants, as well as the test results for patient-participants. The former scores are determined by the self-designed Likert-scale instrument, which will provide ordinal data. In order to test the pre-and post-training ordinal-scale data for statistically significant differences, Wilcoxon signed ranks test is typically used (Polit & Beck, 2017, p. 412). The present project intends to use it as well; if statistically significant differences are present for any item, it will be checked to find out if the changes are positive (more correct answers) or not (more incorrect answers). This analysis will show if the professionals involved in the project are likely to apply the intervention correctly.
The findings for the patients can be expressed through nominal data; basically, they will test either “positive” or “negative” for CAUTI, and positive tests will be an exclusion criterion. Still, urinalysis and culture analysis also produce continuous data (for bacteria, nitrite, and blood in urine), and this information will be collected for pre-and post-intervention. A common test that is used with continuous data for pre-and post-test results in a sample is paired t-test (Polit & Beck, 2017, p. 412). However, Polit and Beck (2017) point out that a t-test is best substituted for a nonparametric test if the sample is too small or the distribution is too abnormal (p. 416). Therefore, depending on the results, the Mann-Whitney U test, which is a nonparametric counterpart of the t-test (Polit & Beck, 2017, pp. 412, 416), might need to be used. The lack of a statistically significant difference between pre-and post-test results would indicate that the condition of the participants did not worsen. This part of the analysis will directly respond to the PICOT question, showing the effectiveness of the intervention at preventing CAUTI over the established period of time with the chosen population.
Regarding other data analysis plans, the procedures to be carried out are as follows. SPSS software will be used to run all the tests, which is why the collected data will be inserted into an SPSS file. The data will be checked and cleaned, and descriptive analyses will be used to describe the results and determine if the t-test can be used for the patient dataset. Then, the inferential tests will be run with the commonly used significance level of 0.05 and a confidence interval of 95 (Polit & Beck, 2017). In other words, with α <= 0.05, the changes in the scores or analyses will be viewed as statistically significant with 95% confidence. The results will be reported using SPSS-generated tables and figures.
References
AACN Practice Alert (2016). Prevention of Catheter-Associated Urinary Tract Infections in Adults. Critical Care Nurse Journal; 36(4): 9-11. Web.
Afonso, E., Blot, K., Blot, S. (2016). Prevention of hospital-acquired bloodstream infections through chlorhexidine gluconate-impregnated washcloth bathing in intensive care units: A systematic review and meta-analysis of randomized crossed trials. Euro Surveillance; 219 (46). Web.
Cao, Y., Gong, Z., Shan, J., Gao, Y. (2018). Comparison of the preventive effect of urethral cleaning versus disinfection for catheter-associated urinary tract infections in adults: A network meta-analysis. International Journal of Infectious Diseases; 76: 102-108. Web.
Centers for Disease Control and Prevention (2013). Urinary Tract Infection (UTI) Event for Long-term Care Facilities. Web.
Centers for Disease Control and Prevention (2017). Catheter-Associated Urinary Tract Infections (CAUTI). Web.
Centers for Disease Control and Prevention: Healthcare Infection Control Practices Advisory Committee. (2017). Guidelines for prevention of catheter-associated urinary tract infections 2009. Web.
Carter, N., Reitmeier, L., Goodloe, L. (2014). An evidence-based approach to the prevention of catheter-associated urinary tract infection. Urologic Nursing; 34(5): 238-245. Web.
Delesie, L., Blot, S., Vanacker, T., & Vandijck, D. (2011). Implementation of chlorhexidine gluconate in the prevention of line-related infection. American Journal Of Infection Control, 39(4), 346-347.
Durant, D.J. (2017). Nurse-driven protocols and the prevention of catheter-associated urinary tract infections: A systematic review. American Journal of Infection Control, 45(12), 1331–1341. Web.
McCoy, C., Paredes, M., Allen, S., Blackley, J., Nielsen, C., Paluzzi, A., … Radovich, P. (2017). Catheter–associated urinary tract infections: Implementing a protocol to decrease incidence in oncology populations. Clinical Journal of Oncology Nursing, 21(4), 460–465. Web.
Nicolle L. E. (2014). Catheter associated urinary tract infections. Antimicrobial Resistance and Infection Control, 3(23). Web.
Peter, S., Devi, E. S., & Nayak, S. G. (2018). Effectiveness of clinical practice guidelines on prevention of catheter-associated urinary tract infections in selected hospitals. Journal of Krishna Institute of Medical Sciences, 7(1), 55–66. Web.
Polit, D.F., & Beck, C.T. (2017). Nursing research: Generating and assessing evidence for nursing practice (10th ed.). Philadelphia, PA: Lippincott, Williams & Wilkins.
Popovich, K., Lyles, R., Hayes, R., Hota, B., Trick, W., Weinstein, R., & Hayden, M. (2012). Relationship between Chlorhexidine Gluconate Skin Concentration and Microbial Density on the Skin of Critically Ill Patients Bathed Daily with Chlorhexidine Gluconate. Infection Control & Hospital Epidemiology, 33(9), 889-896.
Scott, G. (2016). Nurse-led practice is a model for change. Nursing Standard, 30(26), 3-3.
Shippey, S., & Malan, T. (2004). Desquamating Vaginal Mucosa from Chlorhexidine Gluconate. Obstetrics & Gynecology, 103(Supplement), 1048-1050.
Strouse, A. (2015). Appraising the literature on bathing practices and catheter-associated urinary tract infection prevention. Urologic Nursing 35(1):11-17