An Assessment of Daily Bathing Protocols in the ICU: A Comparison of Chlorhexidine Solution and Chlorhexidine Impregnated Cloths

Background: Central Line Associated Bacteremias (CLABs) cause increased patient morbidity, mortality and cost. Despite evidence-based measures including implementation of CLABs bundles, “scrub the hub” campaigns and education to reduce CLABs infections, rates remained elevated within the intensive care units (ICUs) of a large urban academic medical center. Chlorhexidine Gluconate (CHG) is a broad spectrum antiseptic agent with low toxicity, prolonged residual effects and has proven effective to prevent hospital acquired infections such as CLABs. Therefore, a study of systematic daily application of 2% CHG solution versus 2% CHG impregnated cloths was initiated. 

Objective: To determine nursing staff preference, ease of use and perceptions of effectiveness for two methods of daily patient bathing with 2% CHG. Secondary objectives included staff compliance with both methods, cost comparison of each method and overall impact of 2% CHG on CLAB rates compared with historical controls.

Methods: An IRB approved 24 week cross over study was conducted. All eligible patients admitted to the medical intensive care unit (MICU), surgical intensive care unit (SICU), pediatric intensive care unit (PICU) and cardiovascular surgical care unit (CVSCU) were provided systematic daily application of 2% CHG baths. Two ICUs in the first 12-week time period were randomly assigned to use CHG impregnated cloths while the other two ICUs simultaneously used CHG solution to bathe patients. Bathing protocols were crossed over during the second 12-week time period to control for confounders. Anonymous Likert-scale questionnaires measuring staff preference, ease of use and perceptions of effectiveness were distributed four times throughout the study; analysis of variance was used to compare mean scores. CLABs were measured using Centers for Disease Control and Prevention case definitions. Unit consumption of materials was reviewed to determine compliance and cost.

Results: Analysis revealed nursing staff preference (p<0.05), ease of use (p<0.05) and perceived effectiveness (p<0.05) for CHG wipes over CHG solution. Mean compliance rate was 89% for CHG wipes (range 40% - 100%) and 36% for CHG solution (range 16% - 42%), p<0.05. Materials cost during 6 month study period was $19,734 for wipes and $7,013 for solution. CLABS rates in the study units decreased from 3.1 per 1000 central venous catheter (CVC) days in the six months prior to the study period to 1.5 per 1000 CVC days during the study period.

Conclusions: Staff preferred CHG wipes over CHG solution, and compliance with wipes was better than solution. Overall rate of CLABs was lower during the study period compared to the preceding six months in study units.