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.
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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