Chlorhexidine for Daily Bathing for Patients in Hospitals

Should traditional soap and water be replaced with chlorhexidine for daily bathing for patients in ICU?

Abstract

Title: Association between chlorhexidine and soap and water for baths for patients in ICUs for prevention of HAIs. The purpose of this paper is to determine if traditional soap and water should be replaced with chlorhexidine for daily bathing purposes for hospitalized patients to prevent spread of HAIs. Literature regarding history of chlorhexidine in bathing patients will be reviewed. Chlorhexidine has been used for over 25 years in clinical settings and continues to be used for skin cleansing and hand washing to prevent spread of HAIs in hospitalized patients. Positive effects of chlorhexidine have been documented with most of them supporting effective prevention of HAIs in patients.

Most HAIs are spread by health professionals from patient to patients and thus hand washing with chlorhexidine helps reduce spread of the same. This research will also highlight some evidence of effectiveness of chlorhexidine as a way of prevention of spread of various HAIs including CAUTIs. Most studies have not found any adverse effects in patients who use chlorhexidine for bathing apart from hearing loss and hypersensitivity for some patients. In nursing research, it is important that methods used provide data that can be applied within the context. Use of case study in this case will help come up with real experiences of nurses and patients in real time in the real world.

Qualitative methods will also be useful because they provide real insights to the issues affecting the stipulated population. The research will utilize qualitative research methods and case study as the tradition of choice. Interviews as well as observation will be used to collect data and triangulation will be used triangulation to ensure rigor in the research results. Keywords: HAIs, CAUTI, Chlorhexidine, qualitative study, case study.IntroductionInfections acquired in hospitals have been associated with extended stay in hospital, increased healthcare costs and fatalities (Noto et al., 2015).

Most patients with compromised immune systems are at a great risk of acquisition of healthcare-associated infections (HAI). Patients in intensive care unit are at the highest risk of infections and thus will be the basis of this research. There are many ways that have been utilized to help reduce HAI such as hand hygiene and bundles for insertion.HAI has been defined as any infection acquired in a hospital or a health setting (Noto et al., 2015). The infections can be spread by health care professionals who are in constant contact with different patients or through equipment used in hospitals everyday (Noto et al., 2015).

Among infections that can be spread include hospital-acquired pneumonia, urinary tract infections and puerperal fever. These infections have been prevented in many ways among then use of traditional soap and water and through use chlorhexidine cleansing of bath water. Chlorhexidine has been used to reduce bacterial burden on skin and thus reducing infections (Noto et al., 2015).

This research aims at determining if use of chlorhexidine in cleansing daily baths reduces the number of infections in HAI and CAUTI patients. Most researchers have emphasized the need to use chlorhexidine in bathing water as compared to water and soap. Patients’ bath basins in hospitals have been found to be reservoirs of bacteria which play a part in development of HAIs. To reach conclusive results the research will utilize qualitative methods with case study as the preferred tradition. Qualitative research is important in healthcare because researchers are able to get information about why patients and healthcare professionals behave the way they do. In this case, utilization of case study methods will allow usage of a wide variety of approaches such as intrinsic, collective and instrumental (Anderson, 2010).

This will generally ensure that the results of the research are valid and reliable. Research questionsRQ1: Should traditional soap and water be replaced with chlorhexidine for daily baths for HAI and CAUTI patients?

Tradition

There are many ways used to conduct qualitative research. This research will utilize case study tradition of qualitative research. Case study method has undergone substantial development over the years (Anderson, 2010). They have the capability of helping readers understand a complex issue and sometimes add strength to what is already known about the subject. They also give a researcher an opportunity to explain contextual analysis of different events and their relationships (Anderson, 2010).

There has been a lot of documentation of an increase in the number of infections in the ICU (O’Horo et al., 2012). Numerous studies have also credited use of chlorhexidine in baths as way of reducing HAIs including CAUTIs. Case studies will help me gain insight as to why chlorhexidine is preferred over traditional soap and water in bathing patients in ICU (O’Horo et al., 2012). Given the expansive nature of this method, it will be possible to know causes of infections and thus have the ability gauge whether use of chlorhexidine is the best method of preventing infections among hospitalized patients. Literature reviewIntroduction to chlorhexidineChlorhexidine is a topical antiseptic that has been utilized globally for some decades. It has generally been used in children and adults as hand wash, vaginal antisepsis and body washes among others (Weinstein et al., 2008).

Chlorhexidine is water soluble that connects to the negatively charged bacterial cell wall which in turn changes the bacterial cell osmotic balance (Weinstein et al., 2008). When used in low concentrations, chlorhexidine affects the cell integrity but when used in high concentrations it leads to death of the cells. Effects of daily chlorhexidine bathing on infection with pathogensOne of the main effects of using chlorhexidine is that it significantly reduces HAIs. Climo et al. (2013) found that use of chlorhexidine reduces hospital acquired bloodstream infections. Noto et al. (2015) conducted a research with an aim of determining if daily bathing of critically ill patients with chlorhexidine could reduce incidences of HAI.

The researchers found out that using chlorhexidine in daily baths did not reduce HAIs among central line-associated bloodstream infections or catheter-associated urinary tract infections patients. According to the conclusion of this study, there is no difference in using traditional soap and water and chlorhexidine in bathing patients in preventing cases of HAIs. Chlorhexidine has the capability of reducing infections because it reduces vancomycin-resistant enterococci on patients’ skin and healthcare professionals’ hands (Climo et al., 2013  Huang et al., 2016).Huang et al. (2016) noted that daily bathing with chlorhexidine is known to reduce mortality in hospitalized patients.

CAUTI patients also showed less infections and spread of MRSA was also lower when patients were bathed daily with chlorhexidine. Huang et al. (2016) from their study concluded that bathing patients daily with chlorhexidine will significantly reduce HAIs in ICU and thus recommended this. Most of literature reviewed shows that there is a positive correlation between infections and use of chlorhexidine in baths rather than use of soap and water for patients in hospital and especially in ICU where infections are prevalent (O’Horo et al., 2012).

Evidence supporting effectiveness of chlorhexidine for infection control

The most important interventions in hospitals today in prevention of pathogens are hand washing and skin antisepsis. Chlorhexidine has been used for over 25 years in the clinical settings and has been shown to decrease skin flora and transient bacteria (Weinstein et al., 2008). Chlorhexidine has also been said to have residual skin activity which prevents any rapid regrowth of skin organisms thus enhancing the duration of skin antisepsis. This means when chlorhexidine is used in hand scrubs, there is a reduction in the numbers of bacteria on the skin as compared to soap and water (Weinstein et al., 2008). Apart from hand scrubs chlorhexidine can be used in insertion and maintenance of devices like catheters. Before insertion of devices, skin preparation is done using chlorhexidine to ensure that skin is decolonized against microorganisms which in turn reduces infections.

According to Weinstein et al. (2008) methicillin-resistant staphylococcus aureus (MRSA) is one cause of HAIs in hospitals. About 8%-44% of patients admitted in ICU are affected by MRSA that colonize their skin (Weinstein et al., 2008). Chlorhexidine has been known to decolonize the skin of patients in the ICU that is mostly transmitted by health professionals from patient to patient (Weinstein et al., 2008). In this case decolonization of the skin using chlorhexidine is more effective than using soap and water. Health professionals will also have less MRSA on the skin and thus cannot transmit the same to their patients. Soap and water cannot decolonize the skin which in turn provides an opportunity for the organisms to regrow and thus encouraging infections. Adverse effectsOne of the most common reactions to chlorhexidine is contact dermatitis (Weinstein et al., 2008).

Other cases include hypersensitivity and anaphylaxis. There are no known negative effects for wiping or bathing neonates with chlorhexidine and thus this continues to be encouraged (O’Horo et al., 2012). Huang et al. (2016) documented cases which patients in study developed rashes during experiments. However, the rashes were not as result of chlorhexidine but other causes. Many studies developed have not experienced any adverse effects due to use of chlorhexidine apart from those documented by Weinstein et al. (2008) such as hearing loss and hypersensitivity. More research therefore needs to be undertaken to ensure that chlorhexidine is safe for bathing patients to completely replace it with soap and water (O’Horo et al., 2012).

Methods

While some researchers have concluded that chlorhexidine leads to reduced rates of HAIs acquisition (Climo et al., 2013) others feel that there is no difference whether soap and water are used instead (Noto et al., 2015). This research therefore aims at establishing whether soap and water should be replaced with chlorhexidine with the target population being intensive care unit patients. The rate of intensive care unit infections high and always lead to extended hospital stay (Huang et al., 2016). Replacing normal soap and water bath with chlorhexidine may result in reduced infections in ICU which is the main aim of this research. Methodology used in this research will be mostly observational of patients at certain intervals.

Use of case study methods of qualitative research will be equally important to the study because data collected will be analyzed within the context in which it was collected. The data collected will also be large and thus will provide extra information that may be useful to the entire research. A good example is information regarding chlorhexidine baths collected from nurses will help in understanding the situations when it is necessary and when the alternative is the best option. SampleCurtis et al. (2000) noted that sampling is one of the fundamental areas in qualitative researches. Sample used in the research should always be relevant to research questions presented in the paper and should always have the capability of providing rich information on the subject of study (Curtis et al., 2000).

The sample in the research will be hospitalized patients in intensive care unit (ICU) setting. ICU patients are most susceptible to infections and thus will be perfect for the research. The sample will include 100 participants who have been admitted for various reasons and are deemed to be susceptible to acquire HAIs. From the time of admission, half of the participants will bath daily with water cleansed with chlorhexidine (group 1) while the other half will use soap and water (group 2). After two weeks, the groups will exchange with group 1 bathing using soap and water while group 2 using chlorhexidine for their baths. The experiment will go on for one month when the results will be analyzed.

Data Collection

Participant observation will be one main method of data collection. Observation will ensure that participants follow instructions carefully. Participant observation will also help in analyzing any other outside factors that might affects results of the research. Data to be recorded include primary reason for admission, presence of infectionsand length of hospital stay. Data previously collected in documents such as interviews and direct observations by health observations will also be utilized. Data collected from the research will be compared to data from other studies. This will help either dispute or agree with earlier versions of studies that researched the same topic.

Health professionals will also be involved in interviews to get their point of view on use of water and soap versus the use of chlorhexidine for daily bathing of patients. Data collection using qualitative research has come under scrutiny and many researchers are concerned with how to maintain rigor. To ensure rigor in the research, a checklist of design methods and analysis will be introduced. This will act as a way of reducing biasness of the researcher and maintaining objectivity of the results. Triangulation of data is also another method that will be used to ensure validity if data collected.

Limitations

Use of qualitative methods in research has concerns on a researcher’s subjectivity and external validity of the results. The researcher is the primary instrument of data collection and analysis.

This can lead to biasness in the results of the study. This is because during the research, a researcher is left to make decisions and come to conclusions about the subjects and case being investigated. A researcher could decide to use data that only agrees with what he expected while conducting the research and thus undermining the real results of the study. On external validity, it becomes hard to compare the results of the single case study to the entire population. Researchers feel it is impossible to apply the results of one case study to an entire population. A final limitation is the amount of data collected might cause a challenge in analyzing. Data collected using qualitative method is usually huge and thus takes time to collect and analyze it.

References

Anderson, C. (2010). Presenting and evaluating qualitative research. American Journal of Pharmaceutical Education, 74(8):141.Climo, M.W et al. (2013). Effects of daily chlorhexidine bathing on hospital acquired infection. The New England Journal of Medicine, 368(6), 533-542. Curtis, S., Gesler, W., Smith, G. and Washburn, S. (2000). Approaches to sampling and case selection in qualitative research: Examples in the geography of health. Social Science & Medicine, 50, 1001-1014. Huang, H-P, Chen, B., Wang, H-Y. and He, M. (2016). The efficacy of daily chlorhexidine bathing for preventing healthcare-associated infections in adults in intensive care units. The Korean Journal of Internal Medicine, 31(6), 1159-1170. Noto, M.J. et al. (2015). Chlorhexidine bathing and healthcare-associated infections: A randomized clinical trial. Journal of American Medicine Association, 313(4), 369-378. O’Horo, J.C., Silva, G.L.M., Monoz-Price, S. and Safdar, N. (2012). The efficacy of daily bathing with chlorhexidine for reducing healthcare-associated bloodstream infections: A meta-analysis. Infection Control and Hospital Epidemiology, 33(3), 257-267.Weinstein, R.A., Milstone, A.M., Passaretti, C.L and Perl, T.M. (2008). Chlorhexidine: Expanding the armamentarium for infection control and prevention. Clinical Infectious Diseases Journal, 46(2), 274-281. [bookmark: _GoBack]`

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