2% chlorhexidine gluconate (CHG) cloths

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2% chlorhexidine gluconate (CHG) cloths reduce surgical site infections.:

2% chlorhexidine gluconate (CHG) cloths reduce surgical site infections . Jennifer Hayes Franklin Pierce University NR 560 Sherry Greifzu February 9,2016

Project need:

Project need Research supports the use of 2% chlorhexidine gluconate (CHG) cloths to reduce surgical site infections (Diaz & Newman, 2015; Eiselt , 2009). However, patients who are admitted to the two inpatient medical-surgical acute care units are not being prepped with the cloths prior to surgery. This increases the likelihood of developing surgical site infections. This quality improvement project is to assess gaps between guidelines and practices of CHG cloths on the medical/surgical units, and to provide interventions to assess these gaps.

Specific Aim :

Specific Aim The specific aim of this project is to increase the use of CHG cloths among inpatient floors by 50% by the end of May 2016.

Global Aim:

Global Aim The global aim is to improve the use of CHG cloths on inpatient units. The process will lead to inpatients being prepped with CHG cloths to their surgical site to reduce chances of developing surgical site infections. By working on this process we expect to: 1 ) Review medical records associated with surgical site infections to obtain baseline data regarding documented use of CHG cloths in the two medical-surgical inpatient acute care hospital units 2 ) Through observation, survey, and discussion identify reasons and barriers nurses are not using CHG cloths 3 ) compare rates of compliance between the two medical surgical units 4 ) develop and provide educational offerings for nurses which includes the rationale for standardized process for use of the CHG cloths 5)conduct medical record reviews for a selected period of time after the educational offerings to obtain data regarding the documented use of CHG cloths by nurses in the two medical surgical units, and associated surgical site infections . It is important to work on this now because we have identified the need to improve (1) the standardized process of using CHG clothes, and (2) decrease cost related to surgical site infections.

Literature Review:

Literature Review Surgical site infections are the second most common healthcare-associated infection. The Center for Disease and Prevention and the National Nosocomial Infection System have established criteria for defining surgical site infections (Diaz & Newman, 2015). The financial burden to treat surgical site infections is huge. According to Diaz and Newman (2015) “lengths of hospital stay postoperatively extend 7 to 10 days, whole hospital charges range from $3,000 to $29,000 per patient with a surgical site diagnosis”. There is literature that estimates nearly 60% of surgical site infections are preventable.

Literature Review cont.:

Literature Review cont. Eiselt (2009) conducted a comparison study that examined the use of 2% chlorhexidine cloths (CHG) no rinse (N= 736) with betadine skin antiseptic (N= 727) in reducing surgical site infections. Patients bathed the night before and used the cloth and then the nurses would use again in the holding area. The results showed the average rate of surgical site infection prior to the use of CHG cloths were 3.19% and post intervention results were 1.59% and a year later was 0.6%. The cost to treat surgical site infections is astronomical. In a more recent study, Graling and Vasaly (2013) examined the effectiveness of CHG cloths in reducing surgical site infections. The CHG group (N= 335) were compared with a control group (N= 284). Results indicated an overall reduction in infections in the CHG group compared with the control group.

Barriers to Implementing Change:

Barriers to Implementing C hange Micro- Barriers to medical/surgical nurses is lack of knowledge and unwillingness to change current practice and frequent turnover of staff . Mesmo - Surgeons do not want to be responsible for placing an order to use CHG cloths, they believe it is a basic nursing procedure that should be completed as part of prepping the patient for surgery. Unit managers want orders written for CHG cloths Macro-Senior leaders’ barriers to implementing this change is that it’s not a top priority, with the use of prophylactic antibiotic use, surgical site infections rates are decreased.

The need for systems thinking with the meso and macro systems. :

T he need for systems thinking with the meso and macro systems. All information on surgical site infections are inputted into a data system and report cards are generated. Reducing surgical site infection rates is important when benchmarking. It would behoove mesmo and macro systems to be a part of implementing and enforcing current procedures and policies to reduce inpatients risk of developing surgical site infections.

PDSA:

PDSA Plan: Since the use of CHG clothes is a current practice that is followed by outpatients, my focus will be on inpatient use. I will create a survey for the nurses who work on the two inpatient surgical floors asking about their knowledge, reasons and barriers to why nurses are not using CHG clothes. I will provide the data I have collected on chart reviews on how many inpatients had a preventative cloth used. Written material on prevention of surgical site infections will be provided . Do: I will provide educational offerings for nurses which includes the rationale for standardized process for use of the CHG cloths.

PDSA cont.:

PDSA cont. Study: I will provide the data I have collected on chart reviews on how many inpatients had a preventative cloth used. Act: Conduct medical record reviews for a selected period of time after the educational offerings to obtain data regarding the documented use of CHG cloths by nurses in the two medical surgical units, and associated surgical site infections.

Fishbone Diagram:

Fishbone Diagram

Objectives:

O bjectives To increase the use of CHG cloths among inpatient floors by 50%. To decrease surgical site infections among inpatients Aim: The specific aim is to increase the use of CHG cloths among inpatient floors by 50% May 2016. Using a balanced scorecard, I will measure pre and post data on the documented use of CHG cloths. A follow up action plan will be determined based on data findings.

Plan for Data:

Plan for Data C hart reviews and working with the surgical quality improvement coordinator who also tracks surgical site infections. Checklist tracks the use of CHG cloth (e.g. the night before surgery and the morning of). I have reviewed every patients chart (inpatient and outpatient), from June 2015-October 2015. There have been 20 patients during this time who were admitted prior to surgery and only 1 patient was prepped with the CHG cloth prior to surgery. There was two documented surgical site infections from this group. To note, CHG cloths are not used on genitals, above the shoulders, or on open wounds.

Plan for Data cont.:

Plan for Data cont. I am going to develop a survey to give to the medical/surgical nurses. The questions are intended to assess: the nurses’ knowledge about CHG cloths t o help me determine how I can improve compliance .

Run Chart Use of CHG Cloths:

Run Chart Use of CHG Cloths The Run Chart would monitor the use of CHG cloths. The chart would include: the date of surgery the unit the patient was on (1 South and 1 West) whether the CHG cloth was used did the patient develop a surgical site infection

Quality Improvement Team :

Quality Improvement Team The quality improvement team would consists of myself, the surgical quality improvement coordinator, and infection prevention nurse. I would review the data quarterly and report it to the surgical quality improvement coordinator and the infection prevention nurse. By reviewing the data, I will know if my current interventions are effective and whether I need to re-evaluate my plan.

Information Technology:

Information Technology At the VA, all medical charts are electronic. All information needed for this project is in electronic form which makes it easier to track and monitor the use of CHG cloths. I can also access the chart to assess surgical site infections. I am also organizing the data in an excel spreadsheet. With all the data in electronic form and already there, it makes it easy to sustain this project. The data is there for anyone to look at as well.

References :

References Diaz, V., & Newman, J. (2015). Surgical Site Infection and Prevention Guidelines : A Primer for Certified Registered Nurse Anesthetists. AANA Journal , 83 (1), 63-68 6p Eiselt , D. (2009). Presurgical skin preparation with a novel 2% chlorhexidine gluconate cloth reduces rates of surgical site infection in orthopaedic surgical patients. Orthopaedic Nursing , 28 (3), 141-145 5p. doi:10.1097/NOR.0b013e3181a469db Graling , P, R. & Vasaly , F. W. (2013). Effectiveness of 2% CHG Cloth Bathing for Reducing Surgical Site Infections.  AORN Journal . 97 , 5, 547-551  Nelson, E.C., Batalden , P. B., & Godfrey, M. M. (2007). Quality by design: A clinical microsystems approach . Jossey -Bass.

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