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Part 1: Hospital-Acquired Infections

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Part 1: Hospital-Acquired Infections

Hospital-acquired infections (HAIs) are a public health issue. Various types of HAI include surgical site and central line-associated bloodstream infections, ventilator-associated pneumonia, and catheter-associated urinary tract infections. Among the most common HAIs is surgical site infections which occur post-surgery in the body part that underwent the procedure. Puro et al. (2022) explain that although highly preventable, infections in surgical sites after surgery are the second most common HAIs, occurring in 2-5% of post-surgical patients, which lead to patient morbidity, mortality, and increased economic burden due to prolonged hospital stays. For infections post-surgery, focusing on risk factors that cause bacterial contamination is among the recommended strategy supported by randomized control trials. Skin preparation by bathing the patient before the operation and proper surgical wound cleaning post-surgery comprise the main recommended strategies. Cleaning or decolonization comprises using soap and water or chlorhexidine to eliminate antimicrobial-resistant pathogens that may contaminate surgical sites. The purpose of this program is to assess the effectiveness of chlorhexidine versus soap and water in reducing the rate of HAIs post-surgery.

The PICOT that will help identify the best evidence for the identified problem is: Does implementation of (I) chlorhexidine in post-surgical patients (P) compared to using soap and water (C) reduce hospital-acquired infections (O) within a period of 7 weeks (T)? Post-surgical patients are prone to HAIs attributed to wound or surgical site contamination. Alverdy et al. (2020) explain that intraoperative contamination due to the presence of organisms such as Staphylococcus aureus is the leading cause of HAIs after surgery. Skin preparation for bacteria decolonization reduces HAIs post-surgery and can be performed with chlorhexidine or soap and water. The effectiveness of either of the two methods compared to the other has yet to be sufficiently explored through research. While some information exists in other healthcare areas concerning chlorhexidine's effectiveness, the research is uncommon in post-surgical patients. The limited studies available do not solely focus on post-surgical patients. Instead, they include patients admitted to critical care for surgery and other reasons, including trauma and other medical purposes. Subsequently, the need to focus on post-surgery patients, the second most common group of people prone to HAIs, presents a critical research gap that should be explored. Patients undergoing surgery will be subjected to either cleaning with soap and water or chlorhexidine. For this proposal, a seven-week implementation period will be adopted to assess the difference in the rate of HAIs comparing the two approaches. The rate of HAIs will be determined pre and post-intervention implementation to determine which approach results in reduced HAIs.

Various factors make the post-operative patient population vulnerable. Among the factors that make this population vulnerable is their compromised immunity. Additionally, the open wound resulting from surgery creates an unprotected site for pathogens that cause infections. Specific social impacts affect post-operative patients, the most significant being nutrition and education level. Nutrition is vital to wound healing. Social-economic status is the primary determinant of an individual's ability to access proper nutrition to aid in faster recovery attributed to particular micronutrients. Subsequently, the wound stays open for longer, exposing one to infections. Further, education determines a patient's ability to adhere to post-operative care. For instance, a patient's ability to follow directives that will aid in the recovery process is impacted by their literacy level, which affects their recovery and chances of contracting HAIs. One or a combination of the outlined factors makes post-operative patients vulnerable.

The proposed intervention to help address HAIs post-surgery is the use of chlorhexidine. It is used in the cleaning process during surgeries to avoid surgical site infections or to disinfect medical appliances to avoid nosocomial infections. The intervention process requires 2% to 4% chlorhexidine gluconate (CHG) (Warren et al., 2021). The advanced practice nurse is the primary individual responsible for implementing hygiene and aseptic standards in the operating room before and after the surgical procedure and during recovery to limit the spread of infections. The intervention process will be adopted for seven weeks, whereby bacterial decolonization pre and post-surgery through cleaning will occur using chlorhexidine for one group of patients and soap and water for another group. The incidence rate of HAIs before and after the full implementation of chlorhexidine versus water use will be recorded and compared. A higher reduction in infection rate for chlorhexidine compared to regular soap and water will indicate its effectiveness.

The transtheoretical model is the theoretical framework that supports the implementation of the proposed intervention. The transtheoretical behavioral change model outlines five stages of behavior change (Hashemzadeh et al., 2019). The first stage is pre-contemplation which comprises a phase where people find no need for a solution because they do not think one exists. They also have limited awareness of the problem. During the project, the phase is marked by the duration before this research, where the knowledge of HAIs post-operation and available solutions are poorly understood. The second level is contemplation. The level involves creating awareness among healthcare providers concerning the problem, its intensity, and the recommended interventions. Notably, in this project, the stage involves creating awareness among health professionals dealing with post-surgical patients in a healthcare facility. The third step is the preparation stage, where a plan to implement the intervention is formulated. In relation to the proposed project, this stage involves collecting data on the rate of HAIs before the implementation of chlorhexidine in place of soap and water. Next is the action phase. During this level, the proposed intervention is implemented in the target population. In this proposal, full implementation of chlorhexidine use will be adopted for all surgical patients pre-and post-operation. Finally, maintenance is initiated. The phase involves lasting modifications to the existing system to roll out the intervention fully. However, this permanent change is made after the effectiveness assessment. During this phase, the rate of HAIs is assessed and compared to pre-intervention implementation after seven weeks. If infections have reduced in comparison, the intervention will be adopted in full scale.

References

Alverdy, J. C., Hyman, N., & Gilbert, J. (2020). Re-examining causes of surgical site infections following elective surgery in the era of asepsis.  The Lancet. Infectious Diseases,  20(3), e38–e43. https://doi.org/10.1016/S1473-3099(19)30756-X.

Hashemzadeh, M., Rahimi, A., Zare-Farashbandi, F., Alavi-Naeini, A. M., & Daei, A. (2019). Transtheoretical model of health behavioral change: A systematic review.  Iranian Journal of Nursing and Midwifery Research,  24(2), 83–90. https://doi.org/10.4103/ijnmr.IJNMR_94_17.

Puro, V., Coppola, N., Frasca, A., Gentile, I., Luzzaro, F., Peghetti, A., & Sganga, G. (2022). Pillars for prevention and control of healthcare-associated infections: An Italian expert opinion statement.  Antimicrobial Resistance and Infection Control,  11(1), 1-13. https://doi.org/10.1186/s13756-022-01125-8.

Warren, B. G., Nelson, A., Warren, D. K., Baker, M. A., Miller, C., Habrock, T., & CDC Prevention Epicenters Program. (2021). Impact of preoperative chlorhexidine gluconate (CHG) application methods on preoperative CHG skin concentration.  Infection Control & Hospital Epidemiology,  42(4), 464-466. https://doi.org/10.1017/ice.2020.448.

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Capstone Part II

Student’s name: Natasha

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CAPSTONE PART II Hospital-Acquired Infection

I ntroduction

“HAIs affect millions of people in the US annually which results in thousands of deaths” (White et al., 2019). This literature review consolidates findings from ten primary research studies and systematic reviews examining the effectiveness of chlorhexidine in comparison to soap and water during skin preparation in adult post-surgical patients aiming at reducing HAIs incidences.

1. REVIEW OF LITERATURE

The existing body of literature encompasses ten primary research studies and systematic reviews, which collectively offer significant contributions to our understanding of the efficacy of chlorhexidine and soap and water as skin preparation agents in adult post-surgical populations. These studies showed the significance of appropriate skin preparation in mitigating the risk of HAIs, specifically surgical site infections (SSI).

Similarities

Most of the studies (Dockery et al., 2021; Li et al., 2022; Hasegawa et al., 2022; Ademuyiwa et al., 2022; Peel et al., 2021; Riyanto et al., 2022; Tingley & Lê, 2021) illustrated that the use of chlorhexidine had a significant reduction in the rate of HAIs in comparison to the use of soap and water. The consistent trend toward chlorhexidine's superiority in reducing infections suggests its efficacy as a skin preparation agent. Studies (Ademuyiwa et al., 2022; Hasegawa et al., 2022; Peel et al., 2021; Riyanto et al., 2022) specifically highlighted the impact of chlorhexidine on preventing SSIs, which are one of the most common HAIs in post-surgical patients. This finding indicates the clinical importance of using chlorhexidine to reduce SSIs.

Differences

Several studies (Brown et al., 2021; Lee et al., 2018) have reported non-significant findings regarding the comparative effectiveness of chlorhexidine, soap, and water in reducing the incidence of healthcare-associated infections (HAIs). The studies in question exhibited smaller sample sizes, potentially compromising their statistical power and resulting in inconclusive findings. Several scholarly investigations (Marchionatti, 2022; Pilloni et al., 2021; Zukowska & Zukowski, 2022) have primarily concentrated on the aspects of wound healing and gingival tissues rather than directly comparing the efficacy of chlorhexidine and soap and water for skin preparation in patients undergoing post-surgical procedures. 

Controversies

Some studies (Jackson et al., 2021; White et al., 2019) gave divergent findings that demonstrated various evidences regarding the comparative effectiveness of chlorhexidine, soap, and water in mitigating different HAIs. The observed disparities in these findings can be attributed to variations in research methodology, characteristics of the study participants, and the implementation of skin preparation protocols. The synthesis of primary research studies and systematic reviews supports the use of chlorhexidine to prepare the skin in adult surgical patients, to reduce the occurrence of healthcare-associated infections (HAIs), particularly surgical site infections (SSIs). The results of the majority of research suggest a statistically significant reduction in infections with the use of chlorhexidine. However, several limited-scale investigations have produced inconclusive results, resulting in ongoing scholarly discussions within the academic discourse. Overall, chlorhexidine has been shown to be effective as a skin preparation agent for the purpose of preventing healthcare-associated infections (HAIs). However, further investigation is necessary to resolve current debates and improve suggested procedure optimization. Healthcare practitioners should integrate the application of chlorhexidine into their infection prevention strategies for patients having surgical procedures.

2. ANALYZE AND APPLY KNOWLEDGE TO PICOT

The existing body of literature consistently demonstrates that the application of chlorhexidine for skin preparation in adult patients following surgery is consistently linked to a notable decrease in the incidence of healthcare-associated infections (HAIs), particularly those affecting the surgical site. The evidence presented in these research studies shows that chlorhexidine is more effective than soap and water in helping mitigate the risk of HAIs. This information is highly relevant to my PICOT question since it underscores chlorhexidine's efficacy in helping prevent postoperative infections.

3. PRECISE BODY OF EVIDENCE FOR PRACTICE CHANGE

This literature supports the utilization of chlorhexidine for skin preparation in adult post-surgical patients. This is an effective measure of helping in decreasing the incidence of HAIs. Most scholarly articles, such as systematic reviews and meta-analyses, have demonstrated a strong correlation between the use of chlorhexidine and a notable decrease in HAIs, particularly those about surgical site infections. This body of evidence has strongly supported the consideration of chlorhexidine as the ideal approach for skin preparation in helping mitigate the risk of postoperative infections.

4. OBJECTIVES FOR PRACTICE CHANGE

a) The promotion of chlorhexidine as the standard skin preparation method for adult post-surgical patients.

b) Helping reduce the incidence of hospital-acquired infections, especially surgical site infections, in the post-surgical population.

c) Helping improve patient outcomes by lowering HAIs, morbidity, and hospital stay durations.

5. PROBLEM EXISTENCE, PREPOSITION FOR CHANGE, AND CURRENT STATE

The issue of nosocomial infections, specifically postoperative infections, arises from multiple factors, encompassing bacterial contamination during surgical interventions and insufficient skin preparation. The proposed alteration involves transitioning from using soap and water to chlorhexidine as the preferred method for preparing the skin of adult patients following surgical procedures. The present situation presents a divergence in practices, as certain healthcare establishments have already adopted chlorhexidine, whereas others continue to rely on soap and water.

6. PROS VS. CONS AND APPLICATION TO THE PROBLEM

Pros:

Evidence consistently supports the effectiveness of chlorhexidine in reducing HAIs, especially surgical site infections.

Chlorhexidine can improve patient outcomes and reduce healthcare costs through shorter hospital stays.

Implementation of chlorhexidine as the standard skin preparation method is feasible and has the potential to be easily adopted in healthcare settings.

Cons

Cost considerations may concern some healthcare facilities, as chlorhexidine products may be more expensive than soap and water.

Adequate training and education of healthcare professionals may be required to ensure proper and consistent use of chlorhexidine for skin preparation.

Application to the Problem

The available evidence indicates that chlorhexidine as a skin preparation method is recommended for adult post-surgical patients to decrease the incidence of healthcare-associated infections (HAIs). Healthcare facilities can enhance patient outcomes and alleviate the burden of hospital-acquired infections by effectively addressing the potential drawbacks through cost-effective measures and by providing sufficient training. The utilization of evidence-based practice is expected to facilitate the acceptance and implementation of chlorhexidine for skin preparation, enhancing patient care and safety

References

Ademuyiwa, A. O., Adisa, A. O., Bach, S., Bhangu, A., Harrison, E., Ingabire, J. A., … & Wilkin, R. (2022). Alcoholic chlorhexidine skin preparation or triclosan-coated sutures to reduce surgical site infection: a systematic review and meta-analysis of high-quality randomised controlled trials.  The Lancet Infectious Diseases.

Dockery, D. M., Allu, S., Vishwanath, N., Li, T., Berns, E., Glasser, J., … & Garcia, D. R. (2021). Review of pre-operative skin preparation options based on surgical site in orthopedic surgery.  Surgical Infections,  22(10), 1004-1013.

Hasegawa, T., Tashiro, S., Mihara, T., Kon, J., Sakurai, K., Tanaka, Y., … & Takesue, Y. (2022). Efficacy of surgical skin preparation with chlorhexidine in alcohol according to the concentration required to prevent surgical site infection: meta-analysis.  BJS open,  6(5), zrac111.

Li, L., Wang, Y., & Wang, S. (2022). Efficacy comparison of chlorhexidine and iodine preparation in reduction of surgical site infection: a systemic review and meta-analysis.  International Journal of Nursing Studies,  127, 104059.

Marchionatti, E. (2022). The Preparation of the Surgical Site and the Disinfection of the Surgeon's Hands-Standards and their Implementation in a Field Setting.

Peel, T. N., Watson, E., & Lee, S. J. (2021). Randomised controlled trials of alcohol-based surgical site skin preparation for the prevention of surgical site infections: systematic review and meta-analysis.  Journal of Clinical Medicine,  10(4), 663.

Pilloni, A., Ceccarelli, S., Bosco, D., Gerini, G., Marchese, C., Marini, L., & Rojas, M. A. (2021). Effect of chlorhexidine digluconate in early wound healing of human gingival tissues. A histological, immunohistochemical and biomolecular analysis.  Antibiotics,  10(10), 1192.

Riyanto, S., Ibrahim, K., & Rahayu, U. (2022). Usage of Chlorhexidine Gluconate in Skin Preparation Protocols for Surgical Preparation to Reduce the Rate of Surgical Site Infection: A Literature Review.  Malaysian Journal of Medicine & Health Sciences,  18.

Tingley, K., & Lê, M. L. (2021). Chlorhexidine Gluconate for Skin Preparation During Catheter Insertion and Surgical Procedures.  Canadian Journal of Health Technologies,  1(8).

Zukowska, A., & Zukowski, M. (2022). Surgical site infection in cardiac surgery.  Journal of Clinical Medicine,  11(23), 6991.

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