Running head: DECREASING BLOODSTREAM INFECTIONS

Decreasing Bloodstream Infections

Kellycha Santos
University of South Florida

DECREASING BLOODSTREAM INFECTIONS

Abstract
The clinical problem being researched is the increased rate of infection in the hospital
setting specifically in critically ill adult patients. The objective of the paper is to compare
chlorhexidine dressings with standard non-chlorhexidine dressings to see if chlorhexidine affects
the incidence of bloodstream infections. The three randomized controlled trials were found
through the databases PubMed and CINAHL (see Table 1). The keywords used were catheterrelated bloodstream infections, chlorhexidine, critically ill adults and randomized controlled
trials. In addition to the three trials, a guideline obtained from OGrady et al. (2011)
recommending prevention strategies for catheter-associated bloodstream infections was also
used. The results obtained from all three trials and the guideline supported the PICOT question
that chlorhexidine dressings significantly decreased the incidence of bloodstream infections
when used in place of standard dressings. Although the evidence found in the trials support the
project, there are still some limitations which include failure of drawing cultures on some
catheters, patients withdrawing consent, severe contact dermatitis, and absence of double
binding.

Decreasing Bloodstream Infections

DECREASING BLOODSTREAM INFECTIONS

Patients admitted to the hospital setting are more than likely to receive at least one, if not
more, type of catheter; whether it be a peripheral catheter, peripherally inserted central catheter,
midline peripheral catheter, or a urinary catheter. These devices hold a variety of purposes which
include: intravenous fluids, medications, blood products, access for hemodialysis, hemodynamic
monitoring, and parenteral nutrition (Kusek et al., 2012). With the constant use of these devices,
there is a high potential for infection which can ultimately lead to increased mortality, morbidity
and healthcare costs (Kusek et al., 2012). In the United States alone, there are an estimated 15
million patients with central venous catheters of which 80,000 acquire a catheter-related
bloodstream infection (Timsit et al., 2009). With the proposed use of chlorhexidine dressings as a
method of prevention, there will be reduced hospital readmissions, mortality and morbidity rates
and at the same time the quality of life and quantity of life for the patient will be improved.
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
In order to implement this change, there are several members of the health care team that
would need to be on board. The members to be included are registered nurses, charge nurses and
nurse managers. The role of the registered nurse would be to implement the use of the
chlorhexidine dressings, monitor for signs of impending infections, and chart any newfound
infections. The role of the charge nurse and the nurse manager would be to encourage and
educate the registered nurses. Chlorhexidine is available at most hospitals, the nurses job would
be to use a chlorhexidine based dressing as opposed to a standard dressing.
Literature Search

DECREASING BLOODSTREAM INFECTIONS

The databases used to find the three clinical trials and other pertinent evidenced based
information relevant to the PICOT question were CINAHL, PubMed and the National Guideline
Clearinghouse. The key terms used were catheter-related bloodstream infections, critically ill
adults, chlorhexidine and randomized controlled trials (see Table 1).
Literature Review
Three randomized controlled trials and one clinical practice guideline were used to
evaluate the effectiveness of chlorhexidine in reducing catheter-related bloodstream infections.
Timsit et al. (2009) conducted a study to assess the superiority of chlorhexidine impregnated
sponges as opposed to standard dressing changes for patients in the intensive care unit. The study
included 7 intensive care units in 3 universities and 2 general hospitals. All patients were above
the age of 18 and expected to receive either an arterial catheter or venous catheter for at least 48
hours. There were 2,095 eligible patients of which 1,636 were evaluated. All patients provided
informed consent prior to the start of the study.
The strengths of this particular study were that it proved that chlorhexidine impregnated
sponges decreased the rate of catheter-related bloodstream infections from 1.40 per 1,000
catheters to 0.60 per 1,000 catheters (p=.03). Other strengths of the study were: the patients were
randomly assigned, both the patients and providers were blind to the study group, and the
patients underwent follow up 48 hours after discharge from the intensive care units. Limitations
of this study were that of 1,653 patients, 17 withdrew consent, however, it does not state why. In
addition, severe contact dermatitis was reported in 8 patients.

DECREASING BLOODSTREAM INFECTIONS

Timsit et al. (2012) conducted a trial to compare chlorhexidine dressings, highly adhesive
dressings, and standard dressings in a time frame of one year. The study followed 1,879 patients
in over 12 intensive care units. Patients were required to be over the age of 18 and required to
have intravascular catheterization for at least 48 hours. Any patients with an allergy to
chlorhexidine or the other standard dressings used were excluded. The patients were randomly
assigned by a web-based random number generator. Dressings were changed every 3 to 7 days
and 24 hours after being initially inserted; dressings that were either soiled or leaking were
changed immediately.
The strengths of this study were the process for selecting the patients; they were
randomly selected by a number generator and they received one of the three dressings by random
selection. Another strength of this study was the standard assessment tool and the dates the
patients dressings were changed remained the same in all three groups. The greatest strength of
this study was the final result yielding that chlorhexidine dressings reduced the number of
catheter-related bloodstream infections by 60% (p=0.02). The limitations of this study were
differentiating catheter infection from catheter colonization. The study reports that colonization
may be mistaken for infection. Another weakness of this study was that 6.9% of catheters had no
cultures drawn. The last limitation was that due to 2% chlorhexidine dressings not being
available, the study had to be instead conducted with 0.5% alcoholic chlorhexidine; however, the
study still showed that chlorhexidine majorly decreased catheter-related bloodstream infections
in the intensive care unit.

DECREASING BLOODSTREAM INFECTIONS

Ruschulte et al. (2009) conducted a randomized controlled trial to evaluate the

effectiveness of chlorhexidine sponges in reducing catheter-related bloodstream infections in
patients receiving chemotherapy. The study included six hundred and one patients who were
randomly placed in either a control group or an experimental group. The experimental group
received the chlorhexidine impregnated dressings while the control group received a standard
sterile dressing. The patients were examined over a period of 9,731 days with the control group
having catheters in place for 15.8 days and the experimental 16.6 days. The patients in the
experimental group had a significantly lower rate of infection (6.3%) than that of the control
group (11.3%). The patients were assessed daily for swelling, pain, redness, temperature, white
blood cell count, and C-reactive protein. The results of the study revealed that chlorhexidine
dressings significantly reduced the incidence of infection in patients receiving chemotherapy
(p=0.016).
The strengths of this study are that patients were similar in respect to demographic and
clinical data. Informed consent was obtained from all patients and those who had a CVC for less
than five days were not included. The patients were randomly assigned by a computer-generated
identification system. With the exemption of infection, there were no other complications
reported. Weaknesses of this study were that double binding was not possible, however, nurses
who were not involved in the study assessed the insertion sites and microbiologists examined
cultures in order to reduce the influence of the design not being blinded. The rationale for
including this study is that patients receiving chemotherapy are immunocompromised similar to
the critically ill adults in the proposed project, therefore they have similar risks in obtaining
catheter-related bloodstream infections (see Table 1).

DECREASING BLOODSTREAM INFECTIONS

The guideline retrieved from the Centers for Disease Control and Prevention (CDC)
sought to provide recommendations for preventing catheter-related bloodstream infections. The
interventions suggested to reduce infections include educating the staff on proper aseptic
technique and hand hygiene, skin preparation with chlorhexidine or 70% alcohol, catheter site
dressing changes, cleansing with 2% chlorhexidine wash, use of antimicrobial/antisepticimpregnated catheters and scheduled replacement of catheters. The evidence given by the CDC
supports the evidence as they state suggest the use of a chlorhexidine impregnated sponge
dressing for patients older than 2 months (OGrady et al., 2011).
Synthesis
The evidence collected from the three randomized controlled trials all supported the
PICOT question comparing the use of chlorhexidine as opposed to non-chlorhexidine dressings
in reducing bloodstream infections in critically ill adult patients. The study participants differed
on the reason why they were receiving catheterization. The study conducted by Ruschulte et al.
(2009) followed patients receiving chemotherapy for hematological or oncological malignancies.
The studies conducted by Timsit et al. (2009) and Timsit et al. (2012) followed patients in
intensive care units in various different hospitals. The three studies compared chlorhexidine with
non-chlorhexidine products by placing patients in control and experimental groups. The study
conductors obtained informed consent, insured the patients did not know the group they were
placed in and catheter cultures were obtained when infection was suspected. All three trials
supported the PICOT question that chlorhexidine is superior when preventing bloodstream
infections.

DECREASING BLOODSTREAM INFECTIONS

Limitations of the studies provide aid in improving the project in order to successfully
implement this practice change. The study conducted by Timsit et al. (2009) did not provide
reasoning as to why patients withdrew consent from their study; severe contact dermatitis also
occurred in 8 patients. In the study conducted by Timsit et al. (2012) the limitations were the
inability to differentiate catheter colonization from catheter infection; other limitations included
not drawing cultures for 6.9% of catheters and 2% chlorhexidine not being available so 0.5%
alcoholic chlorhexidine was used instead. The study conducted by Ruschulte et al. (2009) failed
to provide double binding; however, nurses who were not involved in the study did catheter
assessments to reduce any biases. Overall, the three studied provided a lot of information that
allow the opportunity to improve the project and reduce the limitations while at the same time
supporting the PICOT question.
Proposed Practice Change
The research selected supports the superiority of chlorhexidine dressings in reducing
infections in the selected patient population. As a result, this practice change will be introduced
to hospital officials, physicians, nurse managers, charge nurses and registered nurses. In order to
prove the efficacy of chlorhexidine, a small study must be conducted in eligible patients who
provide consent. Patients should be placed in a control or experimental group and they will
receive non-chlorhexidine dressings or chlorhexidine dressings. While studies have proven
successful in other hospitals, it is crucial to get St. Josephs on board and this will be completed
by conducting presentations and formulating a small study.
Change Strategy

DECREASING BLOODSTREAM INFECTIONS

To promote staff engagement the data that was previously collected, which includes prior
studies indicating the strengths and weaknesses, will be presented. The weaknesses found in the
studies will be targeted in order to get team members on board. Any questions or concerns the
staff have will be addressed to reduce uncertainties. The staff will be provided with the
expectations for change and the need for improvement and infection reduction in the facility. To
implement this change at St. Josephs hospital, the IOWA model will be used as it is currently in
place at this facility.
Roll Out Plan

DECREASING BLOODSTREAM INFECTIONS

Step 1

Step 2

Step 3

Step 4

Identify triggers
Identify clinical problem
o Bloodstream infections
acquired due to the use of
central venous catheters
are rising.
o To promote change at St.
Josephs hospital,
chlorhexidine dressings
are proposed instead of
non-chlorhexidine
dressings; the incidence of
infection will be recorded
after 6 months.
Form a team
Registered Nurse
Nurse Managers
Healthcare Providers
Dermatologist
EBP team
Assemble relevant research and
related literature
Meet with Shimberg
Reference Librarian at USF to
ensure valid research results.
Select three randomized
control trials and one National
Clearinghouse guideline.
Critique/ Synthesize research for use
in practice
The research collected will be
synthesized in order to utilize
the best data in the proposed
project.
Piloting a Practice Change
The registered nurses will
receive either a control or
experimental group of patients
with one receiving
chlorhexidine dressings and
the other receiving nonchlorhexidine dressings.
The registered nurses will
then document their

10

January, 2015

January, 2015

February, 2015

March-June, 2015

DECREASING BLOODSTREAM INFECTIONS

Step 4

Step 5

assessments and any

incidence of infection.
Evaluate the Pilot
The EBP team will collect the
results and identify if
chlorhexidine was superior in
reducing the incidence of
infection.
The EBP team will also
review the data for the
strengths, weaknesses and the
need for improvement.
If any modifications need to
be made, they will be done
before the project is
disseminated.
Disseminate Results
The project will be
disseminated first to local
hospitals by presenting to
hospital officials and nurse
managers.
The project will be
disseminated regionally by
presenting at national research
conferences and by publishing
the project in a nursing
journal.

11

March-June, 2015

Implement July, 2015

DECREASING BLOODSTREAM INFECTIONS

12

Iowa Model of Evidence-Based Practice (Melnyk & Fineout-Overholt, 2015, p.282).

Project Evaluation
Beginning in April, a select number of patients similar in demographic and baseline
clinical data will be receiving chlorhexidine dressing changes as opposed to standard nonchlorhexidine dressings. The specific data that will be collected are current incidences of
catheter-related bloodstream infections in the six months prior to the start of the study and
compare those results with the incidence of infection with the use of chlorhexidine dressings.
Success is indicated if by the end of the six months the incidence of bloodstream infections has
decreased in the patients through the use of chlorhexidine. In order for the project to be
successful, incidences must be lower by at least 5% than the prior six months of data indicates.
The data will be collected by the documentation obtained by the registered nurses, nurse
managers and infection control.
Dissemination of EBP
In order to disseminate this change in practice, various steps should be taken. First and
foremost, the project proposed must be presented to the institutional review board (IRB) at St.
Josephs Hospital and it must be approved. The change must then be introduced to the nurses at
St. Josephs since they will be the ones implementing the chlorhexidine dressings. To get the
nurses involved, presentations will be made and given to the critical care floors and any
questions or uncertainties can be addressed. After getting St. Josephs on board, the project can
then be introduced locally to other hospitals by having team members involved in the project
present to the nurse managers and hospital officials in the selected hospitals. Any improvements
or revisions will be made and lastly, the change can be introduced regionally. To introduce the
project regionally, the research collected can be presented to different hospitals by having
presentations, presenting at national conferences and meetings, and lastly by having the research
published in a nursing journal.

DECREASING BLOODSTREAM INFECTIONS

13

References
Kusek, L., Soule, B. M., Kupka, N., Williams, S., Koss, R., Loeb, J., . . . Wyllie, C. (2012).
Preventing central line-associated bloodstream infections. Retrieved from
http://www.jointcommission.org/topics/hai_clabsi.aspx
Melnyk, B. M., & Fineout-Overholt, E. (2015).Evidenced-Based Practice in Nursing &
Healthcare (3rded.). Philadelphia, PA: Wolters Kluwer Health.
OGrady, N. P., Alexander, M., Burns, L. A., Dellinger, E. P., Garland, J., Heard, S., . . . Saint, S.
(2011). Guidelines for the prevention of intravascular catheter-related infections.
Retrieved from http://www.cdc.gov/hicpac/pdf/guidelines/bsi-guidelines-2011.pdf
Ruschulte, H., Franke, M., Gastmeier, P., Zenz, S., Mahr, K. H., Buchholz, S., . . .Piepenbrock, S.
(2009). Prevention of central venous catheter related infections with chlorhexidine
gluconate impregnated wound dressings: A randomized controlled trial. Annals of
Hematology, 88(3), 267-272.doi: 10.1007/s00277-008-0568-7
Timsit, J. F., Schwebel, C., Bouadma, L., Geffroy, A., Garrouste-Orgeas, M., Pease, S., . . .Lucet
J. C. (2009). Chlorhexidine-impregnated sponges and less frequent dressing changes for
prevention of catheter-related infections in critically ill adults: A randomized controlled
trial. The Journal of the American Medical Association, 301(12), 1231-1241. doi:
10.1001/jama.2009.376
Timsit, J. F., Mimoz, O., Mourvillier, B., Souweine, B., Garrouste-Orgeas, M., Alfandari,
S., . . .Lucet, J. C. (2012). Randomized controlled trial of chlorhexidine dressing and
highly adhesive dressing for preventing catheter-related infections in critically ill adults.
American Journal of Respiratory and Critical Care Medicine, 186(12), 1272-1278. doi:
10.1164/rccm.201206-1038OC
Table 1

DECREASING BLOODSTREAM INFECTIONS

Literature Review

14

DECREASING BLOODSTREAM INFECTIONS

Reference

Aims

15

Design and

Sample

Measures
Randomized,
prospective, open,
controlled, clinical
study.

statistics
601 patients
Patients in the
from 2 high
experimental
dependency
group had
units
significantly
undergoing
lower rates of
chemotherapy
infection (6.3%)
were studied.
than the control
The patients
group (11.3%).
were examined Results yielded
from January
that chlorhexidine
2004- January
dressings did, in
2006.
fact, reduce the
incidence of
infection
(p=0.016).
1,636 patients
Use of
from 7 intensive chlorhexidine
care units in 3
dressings with
universities
intravascular
were studied.
catheters reduced
The patients
the incidence and
were examined risk of infection
from December as opposed to
2006- June
those receiving
2008.
non-chlorhexidine
(p=.03).

Ruschulte, H., Franke, M.,

Gastmeier, P., Zenz, S.,
Mahr, K. H., Buchholz, S., . .
.Piepenbrock, S. (2009).
Prevention of central venous
catheter-related infections
with chlorhexidine gluconate
impregnated wound
dressings: A randomized
controlled trial. Annals of
Hematology, 88(3), 267272.doi: 10.1007/s00277008-0568-7

To evaluate the
effectiveness
of
chlorhexidine
dressings for
reducing
catheter-related
bloodstream
infections of
catheters
inserted for
chemotherapy.

Timsit, J. F., Schwebel, C.,

Bouadma, L., Geffroy, A.,
Garrouste-Orgeas, M.,
Pease, S., . . .Lucet J. C.
(2009). Chlorhexidineimpregnated sponges and
less frequent dressing
changes for prevention of
catheter-related infections
in critically ill adults: A
randomized controlled
trial. The Journal of the
American Medical
Association, 301(12),
1231-1241. doi:
10.1001/jama.2009.376.

To assess the
superiority of
chlorhexidine
dressings
regarding the
rate catheterrelated
bloodstream
infections.

Randomized, 2x2
factorial, assessorblind study.

Timsit, J.F., Mimoz, O.,

Mourvillier, B., Souweine,
B., Garrouste-Orgeas, M.,
Alfandari, S., . . .Lucet, J.
C. (2012). Randomized
controlled trial of
chlorhexidine dressing and
highly adhesive dressing
for preventing catheterrelated infections in
critically ill
adults.American Journal

To determine if
chlorhexidine
dressings
decreased
catheter
colonization
and catheterrelated
bloodstream
infections.

Randomized,
assessor masked,
clinical study.

Measures:
Infection was
confirmed with
blood cultures via
the catheter
lumina and
peripheral blood
cultures according
to time positivity.

Measures:
Colonization rate
for comparison of
3- vs every 7- day
dressing changes.

Measures:
Catheter tips were
cultured using a
simplified
quantitative broth
dilution technique
with vortexing and
sonication.

1,879 patients
in over 12
intensive care
units were
studied. The
patients were
examined from
May 2010 to
July 2011.

Outcomes /

The results
yielded that with
chlorhexidine the
rate of catheter
related infections
was 67% lower
than with nonchlorhexidine
dressing (p=0.02)

DECREASING BLOODSTREAM INFECTIONS

of Respiratory and Critical
Care Medicine, 186(12),
1272-1278. doi:
10.1164/rccm.2012061038OC

16