Results of the CHlorhexidine Gluconate Bathing implementation intervention to improve evidence-based nursing practices for prevention of central line associated bloodstream infections Study (CHanGing BathS): a stepped wedge cluster randomized trial

Staci S Reynolds, Patricia Woltz, Edward Keating, Janice Neff, Jennifer Elliott, Daniel Hatch, Qing Yang, Bradi B Granger, Staci S Reynolds, Patricia Woltz, Edward Keating, Janice Neff, Jennifer Elliott, Daniel Hatch, Qing Yang, Bradi B Granger

Abstract

Background: Central line-associated bloodstream infections (CLABSIs) result in approximately 28,000 deaths and approximately $2.3 billion in added costs to the U.S. healthcare system each year, and yet, many of these infections are preventable. At two large health systems in the southeast United States, CLABSIs continue to be an area of opportunity. Despite strong evidence for interventions to prevent CLABSI and reduce associated patient harm, such as use of chlorhexidine gluconate (CHG) bathing, the adoption of these interventions in practice is poor. The primary objective of this study was to assess the effect of a tailored, multifaceted implementation program on nursing staff's compliance with the CHG bathing process and electronic health record (EHR) documentation in critically ill patients. The secondary objectives were to examine the (1) moderating effect of unit characteristics and cultural context, (2) intervention effect on nursing staff's knowledge and perceptions of CHG bathing, and (3) intervention effect on CLABSI rates.

Methods: A stepped wedged cluster-randomized design was used with units clustered into 4 sequences; each sequence consecutively began the intervention over the course of 4 months. The Grol and Wensing Model of Implementation helped guide selection of the implementation strategies, which included educational outreach visits and audit and feedback. Compliance with the appropriate CHG bathing process and daily CHG bathing documentation were assessed. Outcomes were assessed 12 months after the intervention to assess for sustainability.

Results: Among the 14 clinical units participating, 8 were in a university hospital setting and 6 were in community hospital settings. CHG bathing process compliance and nursing staff's knowledge and perceptions of CHG bathing significantly improved after the intervention (p = .009, p = .002, and p = .01, respectively). CHG bathing documentation compliance and CLABSI rates did not significantly improve; however, there was a clinically significant 27.4% decrease in CLABSI rates.

Conclusions: Using educational outreach visits and audit and feedback implementation strategies can improve adoption of evidence-based CHG bathing practices.

Trial registration: ClinicalTrials.gov, NCT03898115 , Registered 28 March 2019.

Keywords: Audit and feedback intervention; Catheter-related bloodstream infection; Chlorhexidine gluconate; Educational outreach; Implementation science; Nursing care; Patient bathing.

Conflict of interest statement

The authors declare that they have no competing interests.

Figures

Fig. 1
Fig. 1
CHG Bathing process compliance by month. *Vertical line denotes when the randomization group entered the intervention month
Fig. 2
Fig. 2
CHG bathing documentation compliance by month. *Vertical line denotes when the randomization group entered the intervention month
Fig. 3
Fig. 3
CLABSI Rates by month. *Vertical line denotes when the randomization group entered the intervention month
Fig. 4
Fig. 4
CLABSI rates over follow-up period

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