Enturia

• ChloraPrep Helps Aultman Hospital Curb Surgical Site Infections for 22 Months
• Adopting Chlorhexidine-based Skin Prep Procedures Sparks Patient and Financial Benefits
• Chlorhexidine-based Solutions Create a 20% Reduction in C-section SSIs

ChloraPrep Helps Aultman Hospital Curb Surgical Site Infections for 22 Months¹

An Ohio hospital started using ChloraPrep in place of povidone-iodine (Betadine^®), along with instituting other preoperative and surgical protocols and saw dramatic success in reducing infection rates.

“Although Betadine® is clinically acceptable, ChloraPrep has been proven to be much more effective,” said Beth Taylor, patient-care specialist in the invasive heart lab at Aultman Hospital in Canton, Ohio. “I compiled packets about the advantages of ChloraPrep and proper antibiotic dosing and distributed them to the cardiac catheterization lab and the cardiovascular surgeons.” Taylor was quoted in the March issue of Nursing 2006.

Taylor did her research and convinced surgeons to switch from Betadine to ChloraPrep. The result of her efforts: A 0% surgical site infection (SSI) rate for 22 months straight.

“At the end of 2005, we had two infections out of 632 pacemaker/ICD surgeries performed,” Taylor was quoted as saying.

While Taylor attributes the reduced infection rate to many of the improvements the hospital made, she said she believes that by following evidence-based standards and protocols, the hospital is protecting its patients from avoidable infections.

The story behind the success

In 2003, Aultman hospital performed 477 permanent pacemaker and implantable cardioverter-defibrillator (ICD) operations. Of those 477, six resulted in SSIs.

Taylor’s supervisor requested that she look into why the SSIs likely occurred and asked her to formulate a plan to curb future infections. Taylor examined the latest research and developed a comprehensive, evidence-based system that included using ChloraPrep in patient preoperative skin prep procedures.

Formulating a plan

Taylor started by reviewing each SSI case. She compared Aultman Hospital’s infection control protocols with those of two other facilities. She also studied recommendations by the Centers for Disease Control and Prevention (CDC) and the Association of periOperative Nurses (AORN). She compared the hospital’s policies against these best-practice recommendations.

“By reviewing the literature, I learned that perhaps 40% to 60% of surgical-site infections are preventable,” Taylor was quoted as saying.

The plan’s results: zero SSIs for 22 months

Taylor’s final step was to brainstorm ideas for possible SSI prevention improvements with Aultman’s specialists, including two infection-disease specialists. She then formulated a plan to combat SSIs in Aultman Hospital’s invasive heart lab:

• Switching from povidone-iodine to ChloraPrep – Both the CDC and AORN advise using a chlorhexidine gluconate-based solution like ChloraPrep in their evidence-based guidelines. And after examining current research, Aultman’s surgeons and catheterization staff agreed to make the switch.
• Improving the timing of antibiotic administration – Taylor learned that ideally, patients should receive an antibiotic infusion less than one hour prior to incision. Taylor and her colleagues now meet this deadline by giving antibiotics in their preparation area, versus having the unit nurse start the antibiotic when the patient is called to surgery.
• Avoiding shaving patients – The AORN’s guidelines explain that shaving can create microscopic abrasions that increase the risk of infection. Now, Aultman’s staff doesn’t shave patients anymore and only clips hair as close to the time of surgery as possible.

Taylor reinforced her recommendations by making presentations to committees and by distributing learning packets to all nursing units caring for pacemaker/ICD patients. She was quoted as saying, “Preventing surgical infections is an ongoing team effort.”

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Betadine is a registered trademark of Purdue Pharma, L.P.

Adopting Chlorhexidine-based Skin Prep Procedures Sparks Patient and Financial Benefits²

Three medical professionals, including a physician, conducted a systems-based intervention to reduce the rate of blood stream infections (BSIs) at the University of Indiana’s Wishard Memorial Hospital.

It worked. The hospital replaced a small, sterile drape and a 10% povidone-iodine solution with a large, sterile drape and a 2% chlorhexidine gluconate and 70% isopropyl alcohol solution. The hospital saw immediate, positive results.

Change in protocol led to dramatic reduction in BSIs

According to their before-after trial, “the mean quarterly CVC-associated BSI rate decreased from a baseline of 11.3 per 1,000 CVC days before the intervention to 3.7 per 1,000 CVC days after the intervention.” The difference was highly statistically significant (P<.01).

Not only were infection rates reduced, but the hospital saved approximately $350,000 annually (assuming direct costs of at least $10,000 per CVC-associated BSI).

Systems-based intervention is the best approach

The healthcare professionals conducting the trial concluded that a systems-based intervention is much more effective than relying on voluntary changes in human behavior when it comes to consistently decreasing the CVC-associated BSI rate.

“Prior to the intervention, despite making large, sterile drapes and chlorhexidine readily available and educating the house staff as to their benefits, the strong tendency was for individuals to choose the small drape and povidone-iodine; both of which were packaged in the standard CVC kit,” healthcare professionals were quoted as saying. “During the intervention period, these choices were simply removed. This led to a statistically and clinically significant reduction in the CVC-associated BSI rate.”

The facts behind the story

Sometimes, when faced with a choice between adapting to new procedures and sticking to standard protocol, people tend to choose what’s comfortable.

That’s what happened at the University of Indiana’s Wishard Memorial Hospital’s combined medical-surgical intensive care unit (ICU), which houses 22 beds. According to the trial, “There were 68 CVC-associated BSIs in 15 months before the intervention.”

New protocol resulted in significant cost savings

Those infections totaled approximately $680,000 in direct costs for the hospital. Following the intervention, when the hospital removed the previous solution and drape and required exclusive use of a 2% chlorhexidine and 70% isopropyl alcohol solution for skin antisepsis and a larger drape, the number of BSIs fell from 68 to 22 in 15 months, improving patient outcomes.

Those 22 BSIs totaled $220,000 in direct hospital costs. The significant reduction in BSIs resulted in a savings of $460,000 in costs.

Improving patient preoperative skin preparation leads to better patient outcomes and reduced hospital costs.

According to the healthcare professionals conducting the trial, the tools for improving BSI rates over the years has been education, feedback, or a combination of the two.

“All of these are probably important; however, they all rely on individuals making the right choice,” the researchers were quoted as saying. “In contrast, systems-based interventions, if designed effectively, can gently force individuals to do the right thing.”

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Chlorhexidine-based Solutions Create a 20% Reduction in C-section SSIs³

Sometimes even a simple change of a facility’s surgical site infection (SSI) prevention, strategies can make all the difference.

That’s what Brookdale University Medical Center assistant director of infection control, Robert Garcia, BS, MT, CIC, found when he created a plan to reduce SSI related to Cesarean-sections (C-sections) performed at the hospital.

He put in place a multi-step procedure for decolonizing the skin of patients in the labor and delivery department, recommending a wipe-down of the skin with a 2% chlorhexidine gluconate (CHG)-soaked cloth.

CHG considered best antiseptic on the market

“The decision-makers in labor and delivery came to the conclusion that there was significant information in the literature — so the practice is all evidence-based — that CHG was the best antiseptic on the market,” Garcia was quoted as saying. “Second, there was very good information that CHG was much more effective when used in a repeated fashion.”

Garcia’s recommendation of the repeated use of CHG-soaked cloths helped reduce complications among C-section patients by 20% during the eight months following the use of the cloths. He did note that his hospital is still looking into the exact cause of improvement, but that this was the one major step in protocol that was revised.

The facts behind the story

Garcia researched Brookdale’s current infection control procedures and found that staff members were using swabs of povidone-iodine designed for C-sections. The swabs’ packaging did not include instructions for use.

In addition, there was no established protocol for antiseptic preparation of surgical patients.

“No policy and no set instruction was really a poor combination,” he was quoted as saying.

Creating new protocols

Garcia recommended that all labor and delivery patients should undergo a scrub procedure targeted to the area where a C-section incision would be performed. That procedure continues every six hours during the patient’s labor. Then, if a C-section becomes necessary, the 2% chlorhexidine and 70% isopropyl alcohol would be used to further decolonize the patient’s skin for surgery.

Extending the protocol

Because the new protocol was so successful, Brookdale is considering rolling the program out to the medical center’s ambulatory surgical centers. In this case, the hospitals would recommend that a patient apply 2% chlorhexidine cloths after his or her shower the night before the procedure, and again on the morning of the procedure.

Garcia emphasized that no matter what the procedure is, it’s critical to apply and leave an antiseptic on the skin versus rinsing or washing it off.

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