Chlorhexidine Gluconate Guidelines for Preventing Surgical Infections

Introduction to Clinical Practice Guidelines and Infection Prevention

In the U.S. healthcare environment, clinical practice guidelines are effective healthcare protocols for enhancing patient safety and achieving evidence-based practice. These guidelines provide recommendations on the best available practices to assist clinicians and other healthcare professionals in delivering high-quality care. More importantly, clinical practice guidelines are designed to optimize patient care through systematic assessment and evidence-based review, weighing the pros and cons of alternative care options. The guidelines serve as the strongest resources to assist healthcare professionals in making clinical decisions and incorporating evidence gained through practice and scientific investigation into patient care. Healthcare organizations develop guidelines in the form of policies, which are endorsed across the organization to create a platform that employees will follow, holding them accountable to a defined standard of care.

The hospital described in this paper is one of the better-performing healthcare organizations in the United States and adheres to practice guidelines in implementing antimicrobial administration during surgery to prevent surgical site infections (SSIs) and healthcare-associated infections (HAIs). Working as a nursing professional in the general surgery unit, years of experience in that setting have made clear that the surgery unit places the highest emphasis on HAI prevention during surgical operations. As part of the team participating in the HAI prevention program, the unit adheres to health quality standards. The organization has also obtained certifications in infection prevention and control — for example, participating in the "Certification in Infection Prevention and Control" program offered by the Certification Board of Infection Control and Epidemiology (CBIC, 2016, p. 1).

"The certification provides a standardized measurement of current basic knowledge needed for physicians to practice infection prevention and control. The certification also encourages clinicians to grow, thereby promoting their professionalism among infection prevention and control professionals." (CBIC, 2016, p. 1).

This confirms that the organization places the highest emphasis on infection prevention and control during surgery, assisting it in adhering to healthcare quality standards.

The hospital promotes training and teaching programs to ensure that all employees adhere to the policy of preventing HAIs in the surgery unit. Clinicians are obliged to use chlorhexidine gluconate (CHG) before surgery is carried out to prevent healthcare-associated infections. Evidence-based research confirms that chlorhexidine is a topical antiseptic agent that can reduce bacterial colonization of the skin and is effective against different multidrug-resistant organisms. The unit therefore emphasizes using CHG at both pre- and post-operative stages, since chlorhexidine is effective in preventing various types of health-related infections (HRIs) and SSIs (Rauber et al., 2013).

Franco et al. (2017) identify SSIs as a common phenomenon within the healthcare environment. In the United States, between 2% and 5% of patients who undergo surgery are affected, despite the fact that 55% of SSIs are preventable with the aid of evidence-based clinical approaches. The annual total costs of SSIs in the United States are estimated at between $166 million and $345 million. While many recommendations have been proposed to prevent HAIs or SSIs — including hair removal, use of prophylactic antibiotics, and management of comorbidities — the main source of infection remains the microorganisms introduced during surgical procedures. The surgical unit therefore takes every measure to prevent the spread of SSIs using the chlorhexidine agent.

Use of Chlorhexidine to Prevent HAIs

HAIs are a major safety concern for both patients and healthcare providers. Given the increase in mortality, morbidity, and length of hospital stay associated with SSIs and HAIs in the U.S. healthcare environment, the healthcare organization has taken measures to prevent the spread of HAIs during clinical surgery in order to enhance the safety of both patients and providers. To this end, the use of chlorhexidine bathing is enlisted in the clinical guidelines that clinicians must follow when performing patient surgery. The unit places emphasis on patient hygiene before surgery and implements CHG bathing to prevent contamination during surgical operations.

Emphasis is placed on preventing HAIs because they involve multidrug-resistant bacteria that increase morbidity, mortality, and length of hospital stay, and lead to higher costs of care (Karki & Cheng, 2012). Bacterial resistance colonization often increases the risk of infection among inpatients. Whole-body bathing with CHG-soaked water is an effective approach to reducing bacterial density on patient skin and helps reduce the risk of bacterial transmission from one patient to another. Typically, CHG is effective for "regular cleansing of patient's skin in intensive care units, hematology-oncology units, or prior to high-risk surgical procedures instead of, or after, the normal soap-and-water bathing" (Karki & Cheng, 2012, p. 72). CHG contains an antimicrobial agent that is effective against bacteria and has been a successful skin antiseptic since the 1970s. Physicians are therefore required to follow guidelines using CHG to remove HAIs from patients during operations.

The Centers for Disease Control and Prevention (CDC) identifies healthcare-associated infections as the kind of infections that patients acquire while receiving medical treatment in healthcare settings, noting that they are often preventable. Although the United States healthcare system has made significant progress in preventing HAIs, there is still much work to be done: at least one HAI is recorded for every 25 inpatients. Data presented by the CDC reveal that there was no change in catheter-associated urinary tract infections (CAUTI) between 2009 and 2014 (CDC, 2016, p. 1). In 2011, an estimated 722,000 HAIs occurred in U.S. hospitals, and 75,000 patients died as a result of HAIs in the same year. At the global level, hundreds of millions of patients are affected by HAIs each year. Of every 100 hospitals evaluated, 10 in developing countries and 7 in developed countries are estimated to acquire HAIs annually. Steps can be taken to prevent HAIs by up to 70%, but this requires the participation of all healthcare professionals. Chlorhexidine showering has been identified as an effective preoperative measure to prevent HAIs.

The CDC guidelines for the prevention of HAIs include the following:

Professional Roles in Infection Prevention

• Mandating healthcare organizations to implement effective infection prevention practices to enhance quality improvement.
• Using antimicrobial agents before and after surgery to prevent the spread of HAIs and SSIs.

Accordingly, clinicians in the unit use a proactive method to enhance clinical practice by applying the chlorhexidine solution to clean patients before surgery. This guideline is followed because chlorhexidine is a topical antiseptic agent that is effective in reducing bacterial colonization of the skin and is effective against different multidrug-resistant organisms. Chlorhexidine is also effective in preventing various types of HRIs in addition to SSIs. A pre-surgery shower with chlorhexidine will help prevent nosocomial bloodstream infections that occur within intensive care units.

Before the team of clinicians begins a surgery operation, they follow the evidence-based guideline to ensure the prevention of HAIs or SSIs within the healthcare unit. At the pre-operative stage, the surgical team uses chlorhexidine gluconate (CHG) to clean the patient and disrupt the bacterial cell membrane present on the body. CHG has gained popularity because of its effectiveness as a showering antiseptic and for hand scrubbing prior to surgery. Before touching the patient, clinicians use the chlorhexidine solution to wash their hands to protect against harmful germs. The physicians use the same solution to clean patients to protect them against germs as well. The team also uses the fluid agent to protect themselves from contacting harmful patient-borne germs.

The procedure involves using water containing chlorhexidine to wash hands that are visibly dirty with blood or body fluids. The team washes their hands vigorously for 15 seconds, rinses hands and fingers with water, and dries them with a disposable towel. The next precaution employed by the team is to use 0.5% chlorhexidine combined with 70% w/v ethanol to wipe their hands if they are not visibly dirty. A combination of alcohol and chlorhexidine is critical for coverage against Gram-negative and Gram-positive bacteria, mycobacteria, viruses, and fungi. When preparing for surgical operations, the team implements hand preparation by removing all jewelry such as watches, rings, and bracelets. They also follow the guidelines by trimming their fingernails to less than 0.5 cm and wearing no artificial nails or nail polish (Mehta, Gupta, Todi, et al., 2014).

Conclusion

Franco, L. M., Cota, G. F., Pinto, T. S., & Ercole, F. F. (2017). Preoperative bathing of the surgical site with chlorhexidine for infection prevention: Systematic review with meta-analysis. American Journal of Infection Control, 45(4), 343–349. doi:10.1016/j.ajic.2016.12.003

Karki, S., & Cheng, A. (2012). Impact of non-rinse skin cleansing with chlorhexidine gluconate on prevention of healthcare-associated infections and colonization with multi-resistant organisms: A systematic review. Journal of Hospital Infection, 82(2), 71–84.

Mehta, Y., Gupta, A., Todi, S., et al. (2014). Guidelines for prevention of hospital acquired infections. Indian Journal of Critical Care Medicine, 18(3), 149. doi:10.4103/0972-5229.128705

Rauber, J. D., Carneiro, M., Krummenauer, E. C., Machado, J. A., & Valim, A. R. (2013). Preoperative chlorhexidine baths/showers: For or against? American Journal of Infection Control, 41(12), 1301. doi:10.1016/j.ajic.2013.05.007