Chlorhexidine and Alcohol for Central Venous Catheter Care, Capstone Project Example

Abstract

It is beneficial for nurses to carry out evidence based practice in order to allow for patient safety and quality improvement. Many nurses handle catheter insertion and removal, and attempt to ensure that this process is sterile to prevent against adverse health effects. However, it is not currently known which antiseptic method should ideally be used in this process. Povidone-iodine based solutions are frequently used to sanitize skin prior to catheter insertion and following its removal. Alternatives to this golden standard have not been studied in depth. It is therefore valuable to determine the utility of additional antiseptics compared to povidone-iodine. Evidence-based studies determined that both chlorhexidine based solutions and alcohol based solutions are more effective at reducing bacterial contamination compared to povidone-iodine solutions. Furthermore, additional analysis revealed that a combination of chlorhexidine and alcohol were more than 50% effective compared to use of povidone-iodine solutions alone. Therefore, there is a need to alter practice in a manner that emphasizes use of this combination antiseptic. Doing so will reduce the frequency of infections due to catheter insertion. In addition, this proposal will address uncertainty that currently exists in the national guidelines stating that no preferred antiseptic has been identified for the use of sanitary purposes related to catheter insertion. It is expected that by persuading nurse managers to become involved with this new understanding, nurse teams will alter practice in a manner that will better suit the needs of patients. Therefore, this proposed change will result in a quality improvement initiative that will help shape practice by reducing the frequency of contamination seen among patients that require use of catheters.

Purpose

The purpose of this project is to propose the benefits of the use of chlorhexidine and alcohol as a combined antiseptic for the purpose of central venous catheter aftercare.

• Population: In-patients that have been provided with venous catheter treatment.
• Intervention: The use of chlorohexidine and alcohol solutions, in place of current antiseptic methods.
• Comparison: Chlorhexidine and alcohol solutions versus the standard of care.
• Outcome: Decreasing the risk of infection after catheter application.
• Time: Daily, prior to the insertion of the catheter and following its removal, or 72 hours following insertion for long-term use.

Synthesis

Traditionally, povidone-iodine has been used for the purpose of skin disinfection prior to the insertion of a catheter. However, alcohol is a more commonly used product for decontamination due to its widespread availability. Chlorhexidine based solutions have also been used for this purpose. Based on previous efficacy studies, medical professionals have learned that alcohol solutions are equally effective as povidone-iodine solutions. Since they are more widely available in the emergency and private care setting, they have been conventionally preferred for use. However, such a comparison has not been emphasized between alcohol based solutions and chlorhexidine based solutions. To compare the efficacy of these two solutions, researchers applied the solution to individuals enrolled in two different experimental arms prior to inserting the catheter and after removing it, or every 72 hours provided if long-term insertion was deemed to be necessary. Interestingly, the results of this study indicated that the use of chlorhexidine based solution was 50% more effective than the use of alcohol based solutions. A significant increase was also detected when compared to the efficacy of povidone-iodine as well. However, studies that attempted to combine both chlorhexidine and alcohol for antiseptic use found that a combination of these two substances contributed to even more significant decontamination potential.

• “Catheter-related bloodstream infections have been reported to occur in 3% to 8% of catheters inserted and are the predominant cause of nosocomial bacteremia in intensive care units (ICUs), with 80 000 cases annually at a cost of $300 million to $2.3 billion” (Mimoz et al., 2007)
• “The Centers for Disease Control and Prevention identifies catheter-associated adverse events, including bloodstream infections, as one of its 7 health care safety challenges, with a goal to reduce such complications by 50% in 5 years” (Mimoz et al., 2007)
• Chlorhexidine was found to be more effective in treating infection that alcohol in a series of studies (Mimoz et al., 2015)
• Mixtures of chlorhexidine and alcohol were found to be associated with a lower incidence of catheter-related infections than either of the two antiseptic methods were capable of on an individual basis (Mimoz et al., 2015)

Change

There is a relatively inconsistent understanding with regards to the type of antiseptic use that is the most beneficial for the purpose of decontamination prior to inserting and after removing a catheter. Many research studies claim that povidone-iodine based solutions should act as the golden standard in this regard, but none of these studies attempt to compare povidone-iodine based solutions to chlorhexidine based solutions, alcohol based solutions, or a combination of the two. It is necessary to determine how to ensure quality improvement in the health care setting, so it is valuable to constantly investigate the utility of decontaminants in the medical setting. To enact evidence-based practice, it is therefore necessary to consider the changes proposed by Mimoz et al. over the series of experiments that he has conducted regarding this topic. Both alcohol and chlorhexidine have been shown to be more effective antiseptics than povidone-iodine based solutions. Furthermore, a combination of the two have been shown to have an additive effect, further reducing the bacterial growth and other contamination that has been observed among patients receiving catheter treatment. Thus, there is a need to act on this evidence in order to improve upon the quality of patient care that is currently provided.

Implementation Strategies

Providing a summary of relevant study findings to nurse supervisors is a beneficial way to ensure that they are aware of the evidence-based findings that will contribute to this practice change. In this manner, nurse supervisors can work closely with their team to promote sanitary standards for catheter use. To remind nurses to apply this new technique, printouts can be created and posted in areas that are associated with catheter use, such as near storage cabinets and closets. Furthermore, gentle reminders provided by other staff members will help the team remember to implement this beneficial change.

National Guidelines

• For proper catheter insertion, it is necessary to use sterile gloves, drape, sponges, and an appropriate antiseptic or sterile solution for cleaning the necessary area.
• National guidelines do not currently indicate the antiseptic that should be utilized for sanitary purposes.
• Further research is needed on the effect of antimicrobial/antiseptic-impregnated catheters in reducing the risk of symptomatic UTI, their inclusion among the primary interventions, and the patient populations most likely to benefit from these catheters; currently, this issue is unresolved (HICPAC, 2009).

Long-Term Evaluation Plan

At local health care institutions, it will be necessary to determine the incidence of infection following the use of catheter insertion to reflect a baseline understanding of contamination. After switching from povidone-iodine based solutions or other alternatives, the effects of the use of chlorhexidine-alcohol solutions should be tracked over time. One month, three months, six months, and one year following the application of the intervention, it will be beneficial to determine the new incidence of infection following the use of catheter insertion. The use of a student’s t-test to test for variance between the baseline sample and the new measurement can be conducted to determine whether meaningful change occurred after the application of the chlorhexidine-alcohol intervention. If statistically significant change is detected (p-value < 0.05), then it will be beneficial to continue implementing this intervention in practice. It is recommended that findings of this study be published to contribute to evidence-based practice, whether the assessment yields positive or negative results. Practice should be modified on the basis of the results retrieved.

References

Darouiche et al. (2010). Chlorhexidine–Alcohol versus Povidone–Iodine for Surgical-Site Antisepsis. The New England Journal of Medicine, 362:18-26.

HICPAC. (2009). Guideline for Prevention of Catheter associated Urinary Tract Infection S 2009. Retrieved from http://www.cdc.gov/hicpac/pdf/CAUTI/CAUTIguideline2009final.pdf

Mimoz et al. (2007). Chlorhexidine-Based Antiseptic Solution vs Alcohol-Based Povidone-Iodine for Central Venous Catheter Care. Arch Intern Med, 167(19):2066-2072.

Mimoz et al. (2015). Skin antisepsis with chlorhexidine–alcohol versus povidone iodine–alcohol, with and without skin scrubbing, for prevention of intravascular-catheter-related infection (CLEAN): an open-label, multicentre, randomised, controlled, two-by-two factorial trial. The Lancet, DOI: http://dx.doi.org/10.1016/S0140-6736(15)00244-5