The Use of Chlorhexidine Dressing Compared with Current Practice for Patients - Term Paper Example

Table of Contents 1.0 Introduction In the nursing world, the primary aspect considered effectual and productive in terms of leading to positive outcomes is evidence-based practices, which are abbreviated as EBP. The development of this concept was facilitated by medicine principles founded on evidences gathered from the medical arena. The founder of this concept was known as Archie Cochrane, who established the principles in 1972 within the United Kingdom and United States (Afonso, Blot and Blot 2015, P.446). The applicability of this aspect was not only restricted to medicine, but could also be employed the medical practitioners from various fields of medicine in ensuring they practice techniques and apply concepts that have been verified and considered most effective in medical treatment and care to patients. It is important to understand that in the traditional setting, studies have revealed that EBP practices were still being practiced (Bleasdale et al., 2007, 2073). This claim is justified by the fact that prominent nurses who revolutionized the nursing world such as Nightingale used these practices to select the effective techniques they would employ in offering medical treatment to the injured and critically ill soldiers. The employment of statistical techniques in determining the mortality and morbidity rates allowed the nurses during this period to positively change and transform their medical practices and develop ones that would improve the recovery processes and outcomes of the treatment offered. The simplest definition of EBP is provision of treatment that will improve care for the patient through application of clinical dexterity, scientific evidence, and consideration of the patients’ standards and preferences (Paglialonga et al. 2014, S15). As previously mentioned, the likely results of the application of EBP include positive outcomes concerning the patient’s health status. Additionally, these practices are also imperative, as they are instrumental in the establishment of a safety culture, improvement of the healthcare standards as well in facilitating the reduction of healthcare costs that will ensure most patients are able to access quality and safe medical treatment (Afonso, Blot and Blot 2015, P.446). An important element to consider that further validate the essentiality of these practices is the ethical facet that is involved. In the medical profession, one of the fundamental ethical code of practice states that a nursing practitioner should avoid causing harm to the patient by doing good. EBP and their application in healthcare ensure that these professionals ethically fulfill their duties and assure responsibility as well as accountability. With this in mind, EBP are considered during decision making when selecting the proper and effective medical services that should be offered to a patient. There are important aspects considered when reviewing the implementation of EBP in the medical world. Firstly, the expertise of the medical practitioners is an influential factor that determines this implantation process (Bleasdale et al., 2007, 2073). It has been observed that profession with more experience ranging from five to ten years are better equipped to implement these practices in healthcare facilities. Their less experienced counterparts battle with confidence issues in performing these practices hence are likely to fail to implement these practices due to limited knowledge (Blot et al. 2014, 97). With consideration to the location of the study, which is Oman, it is imperative to mention the efforts directed towards ensuring that the implementation of EBP in the nation’s healthcare systems have been successful. This is validated with the inclusion of clauses in the Oman Nursing and Midwives’ Code of Professional Conduct Manuscript, which strictly states that traditional practices of care should not be practiced, but rather the Oman nurses should apply and deliver care as stipulated by the EBP (Cosgrove 2006, 2244). To further actualize the objective of maximum competence and quality healthcare provision, the manuscript also motivates the nurses to delve in updating themselves with the latest medical advancement and research that will ensure that they perform excellently and develop high levels of competence when offering care to patients. 2.0 Assignment Topic In this study assignment, the primary discussion concerns Chlorhexidine dressing which will be thoroughly explained concerning its prevention of catheter-related bloodstream infections. Within the literature review, there will be a detailed contrast and comparison between the Chlorhexidine dressing and the current modes of dressing that are inclusive of high occlusive dressing and standard dressing. The study will also provide statistical and qualitative data on the outcomes of these dressing relating to prevention of catheter associated bloodstream infections with the primary focus being placed on Oman, which is the location of the study. There has been a significant increase of bloodstream infection especially in chronically and critically ill patients in Oman. The affected population includes the geriatric population (Meyer 2009, 85). Helpful strategies have been implemented by the Ministry of Health within Oman to ensure that significant attention has been directed towards accomplishing a reduction in the rates of these infections related to catheter usage. To elaborate on the severity of catheter-related infections is a study conducted by Prakash, Arora, and Geethanjali within the Dhahira region. The findings indicated that out of the either 360 patients who participated in the clinical study, 348 patients tested positive for catheter-related infections, which were categorized as gram negative or gram positive (KP, Arora and PP 011, 241). In this study, the most affected population comprised of the chronically ill elderly male participants. The conclusive statement forwarded by the authors indicated that blood stream infections are further mutating hence becoming even more difficult to treat with the availably prescribed antibiotics. For this reason, the mode of dressing administered to a critically ill patient is seemingly important as it aids in prevention of the onset of these infections. On a global scale, catheter related infections are often a serious health concern. In the United States, there is an estimated 250,000 cases of these infections reported annually. This is a cumulative analysis of the primary and secondary infections with the latter being associated with postoperative wounds, urinary tract, skin, and lung. According to the Centers of Disease Control located within the United States, most of these catheter related infections are because of usage of central venous catheters (CVCs) and intravascular catheters used in the treatment and disease management in critically ill patients (P, Arora and PP 2011, 245). The prevalence of catheter-associated infections is further facilitated with the continuous and increased use of CVCs within outpatient and inpatient settings whereby long-term venous access is provided. This reality is justified by the statistics provided by the CDC that indicate that there is a 90% likelihood of onset of bloodstream infections when CVCs are employed in medical treatment of critically ill patients. 3.0 Aim The main aim of the study is to offer a detailed review on the effect of Chlorhexidine dressing on reduction of incidence rates of catheter-related blood infections. Additionally, the study will provide a comparative analysis of the types of dressings that are currently being used which are the high occlusive and standard dressings in comparison to the Chlorhexidine dressing. The purpose of this comparison is considered crucial in determining the effectuality of the aforementioned wound dressing modes in reduction of the prevalence rates of catheter associated blood infections in critically ill patients. The research question that will be answered by this particular research and aid in its development is based on the PICO, which is an acronym that means Population, Intervention, Comparison, and Outcome (Lorente 2014, 91). With this in mind, the query questions: In critically ill patients, does Chlorhexidine dressing prevent the onset of catheter-related as compared to the standard and high occlusive dressings? P: Critically ill patients I: Chlorhexidine dressing C: Highly occlusive and standard dressings O: Reduced prevalence rates To provide clarification and valid information that will not only answer the research question but also provide insight on wound management, the literature review will extensively analyze the essential topical areas within this medical field to ascertain the conclusions that will be drawn and support the topic. 4.0 Literature Review In a simplistic definitive manner, literature review is described as a method through which published studies are systematically analyzed with the aim of retrieving data that is pertinent to the study being conducted in terms of offering support. Several facets are considered when conducting a literature review; they include the homogeneity of the groups within the studies as well as the authenticity and validity of the findings, outcomes, and results (Kumar 2009, 107). Additionally, the heterogeneous element within the findings is also important which also implies that the tools employed during the studies should be reliable and effectual in order to create validity. 4.1 Search Strategy Several databases were used to collect the relevant material necessary for the study. Their information was received from Google Scholar. These databases include Pub Med, MEDLINE, Cochrane Library, Evidence-Based Nursing Website, CINAHL, UpToDate website, Ncbi, Wiley on line, Doctoral Dissertation abstracts, British Nursing Index, Excerpta medica, Web of Sciences, International Pharmaceuticals Abstracts, Index Medicus and Lexis Nexus. The key words that were typed when searching through the above sources as listed in the section below. There was also critical analysis of retrieved articles, which included detailed bibliographies. Data base Num of articles found Inclusion criteria Exclusion criteria Num of articles chosen cocharane 5 Within 5 years Pediatric population NCBI 6 English language Older articles Wiley Online 7 RCT Only used chlorhexidine Index Medicus 7 Meta analysis Only used current dressing methods such as highly occlusive and standard dressing 4.2 Key Words Catheter, Prevention, Vascular catheter, Chlorhexidine dressing, Central line, infection control. Chlorhexidine dressing for Critically Ill Patients, Chlorhexidine Dressing versus Standard Dressing, Chlorhexidine Dressing versus Highly Occlusive Dressing 4.4 Catheter –related Blood stream infections Timsit et al. (2012) conducted a randomized controlled trial pertaining to the effect of Chlorhexidine dressing. A Randomized Control Trial is a scientific experiment whereby the selection of the experiment unit is done randomly. It also includes the study of different experiments on a single experimental unit. The main function of these trials is to determine the cause and effect relationship between the variable under study. In this case study, the RCT was single blinded as the participants were unaware of the type of dressing they received. The main of the study was to evaluate the preventative impact of this mode of wound dressing on catheter-related infections. The main population that was studied include the critically patients within the intensive care units. The selection of the experiment samples was done using the 2:1:1 assessor-masked randomized trial. The patient population that participated in the experiment was selected based on the duration, which they had stayed with an intravascular catheter. The specific period was 48 hours and more. The outcomes of the dressing in relation to the onset of catheter-related infections and catheter colonization were compared within a three-month period that was between May and July in 2010. Several co-primary endpoints were employed in analyzing the outcomes of the trial. They included the catheter colonization rates with standard nonchlorhexidine dressing and with highly occlusive nonchlorhexidine dressing as well as serious catheter related infection without or with catheter-related blood infections using nonchlorhexidine versus Chlorhexidine dressings. Secondary endpoints were also considered (Timsit et al. 2009, 1231). They were inclusive of skin reactions, catheter colonization, and catheter-related blood stream infections. The total population size that was placed under the trial as 1, 879 patients who used an approximated 4,163 catheters within a span of 34, 339 days. The sample size was quite large hence affecting the findings. This is because when the sample size is large and is treated with different treatments, the results are likely to offer higher generalized findings as opposed to smaller sample size which provide more specific data. The findings indicated that Chlorhexidine was more effective in the prevention of CRI as compared to nonchlorhexidine dressings. This result was supported by the confidence interval approximated at 95% as well as the p value, which was at 0.0006. It is clear to observe that the p value for this trial is smaller that 0.05 hence justifying the alternate hypothesis that supports that Chlorhexidine dressing is more effective than other forms of dressing in prevention of catheter related bloodstream infections. The simplest definition of p value is a statistics in the observed sample results that is employed in testing the hypothesis. This means that it is efficient is determining the significance of the results conferred. This is validated by the 67% reduction on the CRI rates (Timsit et al. 2009, 1231). The CR-BSI was also lower in patients with Chlorhexidine dressings with an approximated 60% reduction rate (Timsit et al. 2009, 1231). An additional finding that was considered varying in usage of the Chlorhexidine dressings was reports of contact dermatitis (Maunoury et al. 2013, 356). There was an estimated 1 % occurrence rate of this skin condition on the patients with Chlorhexidine dressing as well as a 0.29% in those with nonchlorhexidine dressings. In the highly adhesive dressing, it was observed that there an increase in catheter and skin colonization estimated at 95%. However, the detachment rates were reduced by 64.3% as compared to the 71.9% in nonchlorhexidine dressings. Similarly,, Safdar et al. (2015) conducted a Randomized control trial that studied the effectiveness of Chlorhexidine impregnated dressing in the prevention of catheter related bloodstream infections. The study was used in providing a comparative analysis between Chlorhexidine dressing and the usual conventional modes of wound dressing. The focus being directed towards their preventative abilities in reducing the occurrences of catheter related bloodstream infections. The main population being evaluated in the study was generalized due to the high number of participants that were included in the study. The approximated number was 3,403 patients. Hence, this provided a much wider view on the effect of the dressings on critically and moderately ill patients. Here It is important to note that the generalization of the sample population bears a deterring effect on the reliability of the results and findings conferred in the study. This is primarily because critically ill patients are susceptible to opportunistic infection owing to the reduced immune systems as compared to the moderately ill patients. With this in mind, reliability is compromised due to the heterogeneity of the sample size, which is more reliable when homogeneity is maintained. In retrospect, it is valid to state that the findings that were derived from the results of the RCTs supported those of Timsit et al. (2012) This is primarily because the results indicated that patients that were dressed with Chlorhexidine impregnated dressings were at lower risk of developing CR-BSI. The reduction rated was estimated at 95% (Safdar et al. 2015, 69) was was also a noticeable reduction in the rate of catheter colonization, which was approximated at 955 with a relative risk of 0.52%. Clearly, based from the study, it is evident that patients dressed with Chlorhexidine benefited significantly owing to the antibacterial protection this type of wound dressing offered (Meyer 2009, 87). The main recommendation forwarded by the authors would be the continuous usage of Chlorhexidine dressing in patients that are at a higher risk of contracting bloodstream infection stemming from catheter colonization. To further provide evidence on the effectuality of Chlorhexidine dressings, Mimoz et al. (2011) carried out a RCT, which focused on the effectiveness of alcohol-based povidone-iodine and Chlorhexidine-based solutions. The study was aimed at evaluating the effectuality of the solution at preventing catheter site colonization by microbial pathogens (Mimoz et al. 2007, 2066). The unique aspect of this study is observed, as there has never been a detailed comparison between these elements of study. The study was open label controlled and randomized whereby the participants were enrolled in 11 healthcare facilities in France. A secure web based random number generator used to assign the patients with specifically treated intravascular catheters executed the randomization process. The trial was double blind as the outcome and the microbiologists and outcomes were masked with the exception of the nurses and physicians involved. The catheters that were analyzed were derived from the subclavian and jugular veins of the participating patients. Random assignment was carried out in selecting the aforementioned central venous catheters. The procedure conducted included disinfecting the catheters with 0.25 % of Chlorhexidine gluconate mixed with 0.0025 % of benzalkonium chloride and 4% benzylic alcohol (Mimoz et al. 2007, 2066). The second solution in which the catheters would be disinfected with included a 5% povidone-iodine mixed with an estimated 70% ethanol. With these two solutions, the catheters were randomly selected for disinfection prior to the catheter insertion process. The applications of the solution were done consecutively twice which each application taking duration of thirty seconds. The findings, similarly to the other random trial indicted that catheters that were disinfected with the Chlorhexidine solution elaborated a 50% (Mimoz et al. 2007, 2066). Decrease in the rate of catheter related infections as well as catheter colonization. This reduction was also observed in the onset on catheter related bloodstream infections (Mimoz et al. 2007, 2066). Hence, the main conclusive recommendation by the researchers support that Chlorhexidine based dressings and solutions were considered more effective in the reduction of catheter related blood stream infections as well as catheter colonization by pathogenic elements. 5.0 Summary of Literature In summary, it is evident to observe there are a considerable number of health benefits that are availed with the use of Chlorhexidine based dressings in critically ill patients. One of the major benefits include it high effectiveness in reducing the incidence rates of catheter related infections (Ruschulte et al. 2008, 265). It is observed that the trend was also associated with the reduction in blood stream infections. The effectiveness of this dressing is owing to its antiseptic properties, which confer its clinical efficacy and microbiological elements. It has been scientifically proven through intricate research that Chlorhexidine reduces the incident rates of catheter related infections by an approximated 50% (Solomon 2012, 543) is immensely instrumental in ensuring that critically ill patients remain healthy as they undergo extensive treatment to their medical malaises and conditions. Due to this research, it has been proven that Chlorhexidine dressings are effective against the development of bacteriemia, which is one of the most potent blood stream infections that are catheter related (Southworth et al. 2012, 47). Through this study, it is valid to state that Chlorhexidine is more effective than the current dressings in use in the medical field, particularly, the highly occlusive and standard dressings (Parks, Anderson and Peterson Pharm D 2015, 49). 6.0 Local Evidence In the Oman setting, Chlorhexidine has become widely used as explained in an article from the Oman Daily Observer. The main reason for it adoption in the medical arena in Oman is primarily because of it antimicrobial and bateriostatic properties it contains in preventing infections in critically ill patients and neonates as well who are categorized as immuno-comprised owing to the low and weakened immune systems (Moureau 2009, 15). In the neonatal department, there has been increased usage of Chlorhexidine dressing and solutions due to the increased number of infections such as neonatal tetanus that are contracted due to the traditional practices that are still being conducted (Cumbo-Nacheli 2011, 272). This pharmaceutical chemical has been manufactured in various forms with the common one being the gel pad, which is applied to the wound or skin following birth or used for catheterized patients. The main issue that has been faced regardless of the introduction of Chlorhexidine as an effective antimicrobial dressing is curbing the traditional practices with some including belief that medical applications are detrimental to a child or a critically ill adult’s fertility as it is perceived to cause harm. 7.0 Recommendation and Action Plan Chlorhexidine-based dressing is the appropriate dressing for catheterized patient. This is because it is safer and efficient in preventing catheter related infections. It has been proven to have the best outcomes in terms of preventing catheter colonization as compared to other forms of dressing (Ferrone 2006, 656). It is imperative for this practice to be inculcated in the medical health facilities to ensure that critically ill patients are provided with quality care that is cost effective and will improve their quality of life. Following the implementation of the use of Chlorhexidine dressing within Oman, there should be continuous auditing of these healthcare facilities to ensure that the patients approve the positive outcomes of this particular EBP as well as analyze the patient satisfaction which is a imperative determinant on the effectiveness of the practice. 9.0 Conclusion To ensure that quality care is provide to the clients within the medical world, it is important to adopt a culture that embrace the discovery of evidence based practices that are aimed at improving healthcare. From the study, it is evident that through EBP, a researcher is able to justify the validity of incorporating Chlorhexidine dressing in the prevention of catheter-related bloodstream infections for critically ill patients (Shah et al. 2016, 45). The comparative studies by various experts in this medical field attest to the effectiveness of this practice and have allowed for the completion of this project. References Afonso, E., Blot, K. and Blot, S. (2015). Prevention of hospital-acquired and central line-associated bloodstream infections in the intensive care unit through chlorhexidine gluconate washcloth bathing: a systematic review and meta-analysis. Intensive Care Med Exp, 3(Suppl 1), p.A446. Bleasdale, S., Trick, W., Gonzalez, I., Lyles, R., Hayden, M. and Weinstein, R. (2007). Effectiveness of Chlorhexidine Bathing to Reduce Catheter-Associated Bloodstream Infections in Medical Intensive Care Unit Patients. Arch Intern Med, 167(19), p.2073. Blot, K., Bergs, J., Vogelaers, D., Blot, S. and Vandijck, D. (2014). Prevention of Central Line-Associated Bloodstream Infections Through Quality Improvement Interventions: A Systematic Review and Meta-analysis. Clinical Infectious Diseases, 59(1), pp.96-105. Cumbo-Nacheli, G. (2011). Central Line-Associated Bloodstream Infections (CLABSI) in a Large Medical Intensive Care Unit. CHEST Journal, 140(4_MeetingAbstracts), p.272A. Ferrone, M. (2006). Risk of Catheter-Related Bloodstream Infection With Peripherally Inserted Central Venous Catheters Used in Hospitalized Patients. Nutrition in Clinical Practice, 21(6), pp.635-636. Meyer, J. (2009). A Broad-Spectrum Look at Catheter-Related Bloodstream Infections. Journal of Infusion Nursing, 32(2), pp.80-86. Gastmeier, P. and Geffers, C. (2006). Prevention of catheter-related bloodstream infections: analysis of studies published between 2002 and 2005. Journal of Hospital Infection, 64(4), pp.326-335. Moureau, N. (2009). Reducing the cost of catheter-related bloodstream infections. Nursing, 39(7), pp.14-15. KP, P., Arora, V. and PP, G. (2011). Bloodstream Bacterial Pathogens and their Antibiotic Resistance Pattern in Dhahira Region, Oman. OMJ, pp.240-247. Kumar, A. (2009). Effectiveness of Chlorhexidine Bathing to Reduce Catheter-Associated Bloodstream Infections in Medical Intensive Care Unit Patients. Yearbook of Critical Care Medicine, 2009, pp.107-108. Lorente, L. (2014). Review: chlorhexidine-impregnated dressings reduce risk of colonisation of central venous catheters and risk of catheter-related bloodstream infection. Evidence-Based Nursing, 18(3), pp.91-91. Ishizuka, M., Nagata, H., Takagi, K. and Kubota, K. (2009). Comparison of 0.05% Chlorhexidine and 10% Povidone-Iodine as Cutaneous Disinfectant for Prevention of Central Venous Catheter-Related Bloodstream Infection: A Comparative Study. European Surgical Research, 43(3), pp.286-290. Maunoury, F., Motrunich, A., Ruckly, S. and Timsit, J. (2013). Non-Homogeneous Cost-Effectiveness Modeling of a New CHG-Dressing for Preventing Catheter-Related Bloodstream Infections for Patients in Intensive Care Units. Value in Health, 16(7), p.A356. McGuigan, M., Guhadasan, R., Das, D., Paulus, S. and Darbyshire, A. (2010). 1403 An Audit of Catheter-Associated Bloodstream Infections in a Tertiary Paediatric Intensive Care Unit. Pediatr Res, 68, pp.694-694. Mimoz, O., Villeminey, S., Ragot, S., Dahyot-Fizelier, C., Laksiri, L., Petitpas, F. and Debaene, B. (2007). Chlorhexidine-Based Antiseptic Solution vs Alcohol-Based Povidone-Iodine for Central Venous Catheter Care. Arch Intern Med, 167(19), p.2066. Yamamoto, N., Kimura, H., Misao, H., Matsumoto, H., Imafuku, Y., Watanabe, A., Mori, H., Yoshida, A., Miura, S., Abe, Y., Toba, M., Suzuki, H., Ogawa, K. and Kanemitsu, K. (2014). Efficacy of 1.0% chlorhexidine-gluconate ethanol compared with 10% povidone-iodine for long-term central venous catheter care in hematology departments: A prospective study. American Journal of Infection Control, 42(5), pp.574-576. Paglialonga, F., Consolo, S., Biasuzzi, A., Assomou, J., Gattarello, E., Patricelli, M., Giannini, A., Chidini, G., Napolitano, L. and Edefonti, A. (2014). Reduction in catheter-related infections after switching from povidone-iodine to chlorhexidine for the exit-site care of tunneled central venous catheters in children on hemodialysis. Hemodialysis International, 18, pp.S13-S18. Parks, P., Anderson, M. and Peterson Pharm D, M. (2015). A chlorhexidine gluconate (CHG) containing dressing for the cost-effective reduction of catheter related bloodstream infection. Journal of Microbiology, Immunology and Infection, 48(2), pp.S48-S49. Ruschulte, H., Franke, M., Gastmeier, P., Zenz, S., Mahr, K., Buchholz, S., Hertenstein, B., Hecker, H. and Piepenbrock, S. (2008). Prevention of central venous catheter related infections with chlorhexidine gluconate impregnated wound dressings: a randomized controlled trial. Annals of Hematology, 88(3), pp.267-272. Safdar, N., O’Horo, J., Ghufran, A., Bearden, A., Didier, M., Chateau, D. and Maki, D. (2015). Chlorhexidine-Impregnated Dressing for Prevention of Catheter-Related Bloodstream Infection. Survey of Anesthesiology, 59(2), pp.69-70. Shah, H., Schwartz, J., Luna, G. and Cullen, D. (2016). Bathing With 2% Chlorhexidine Gluconate. Critical Care Nursing Quarterly, 39(1), pp.42-50. Cosgrove, S. (2006). Jeffries, I., Salas, A., Chandler, B. and Soliz, A. (2010). 471 Short Term Outcomes with Use of Chlorhexidine Gluconate (CHG) and Povidone-Iodine (PI) in VLBWI with Percutaneously Placed Central Venous Catheters. Pediatr Res, 68, pp.241-241. Evidence that prevention makes cents: Costs of catheter-associated bloodstream infections in the intensive care unit*. Critical Care Medicine, 34(8), pp.2243-2244. Solomon, J. (2012). Reducing Catheter Associated Bloodstream Infections in the Neonatal Intensive Care Unit: Challenging Nurses to Be Champions. Journal of Obstetric, Gynecologic & Neonatal Nursing, 41, p.S48. Southworth, S., Henman, L., Kinder, L. and Sell, J. (2012). The Journey to Zero Central Catheter-Associated Bloodstream Infections: Culture Change in an Intensive Care Unit. Critical Care Nurse, 32(2), pp.49-54. Timsit, J., Schwebel, C., Bouadma, L., Geffroy, A., Garrouste-Orgeas, M., Pease, S., Herault, M., Haouache, H., Calvino-Gunther, S., Gestin, B., Armand-Lefevre, L., Leflon, V., Chaplain, C., Benali, A., Francais, A., Adrie, C., Zahar, J., Thuong, M., Arrault, X., Croize, J., Lucet, J. and Dressing Study Group, f. (2009). Chlorhexidine-Impregnated Sponges and Less Frequent Dressing Changes for Prevention of Catheter-Related Infections in Critically Ill Adults. JAMA, 301(12), p.1231. Read More