Running Head: EBPP USE OF CHG WIPES PREOPERATIVELY
EBPP Use of Preoperative Chlorhexidine Gluconate Wipes
Catherine J. Groggel
Ferris State University
EBPP USE OF CHG WIPES PREOPERATIVELY
EBPP Use of Preoperative Chlorhexidine Gluconate Wipes
The purpose of this paper is to demonstrate the proper use of evidence based articles to
change something in my practice using critical thinking skills, peer review, and evaluation of the
research available. Using research articles, I will demonstrate why chlorhexidine gluconate
(CHG) wipes should be used at the facility I work in as a preoperative skin preparation to
prevent the risk of surgical site infections (SSI). The element of reasoning grid following the
annotations will help to demonstrate my thought process.
Article Annotations
Article annotation 1
Rauk, P.N. (2010). Educational intervention, revised instrument sterilization methods, and
comprehensive preoperative skin preparation protocol reduce cesarean section surgical
site infections. American Journal of Infection Control, 38(4), 319-323.
doi:10.1016/j.ajic.2009.10.004
The author of this article Phillip Rauk, MD, is board certified in fetal and maternal
medicine and in obstetrics and gynecology. He specializes with high-risk obstetrics patients
including those with disabilities and infectious disease and is an associate professor at the
University of Minnesota Medical School. The article reported the details of a study done at the
medical school on surgical site infection (SSI) rates for patients having cesarean section
deliveries; the methods used the results, and discussion of the interventions used. In their study,
the combination of many factors may have resulted in an overall decrease in the rates of SSI.
The factors which they believe lead to their positive results included; staff education, sterilization
management, and use of chlorhexidine gluconate (CHG) skin preparation. Although reductions
2
EBPP USE OF CHG WIPES PREOPERATIVELY
in SSI did occur, one cannot conclude it was primarily due to the use of CHG preparation, rather
many factors.
Article annotation 2
Johnson, A.J., Daley, J.A., Zywiel, M.G., Delanois, R.E., Mont, M.A. (2010). Preoperative
chlorhexidine preparation and the incidence of surgical site infections after hip
arthroplasty. The Journal of Arthroplasty, 25(6), 98-102. doi:10.1016/j.arth.2010.04.012
The authors in this article were from the Rubin Institute for Advanced Orthopedics and
Infection Prevention and Control, at Sinai hospital of Baltimore, Maryland. The study performed
was to compare the patients who used a chlorhexidine gluconate (CHG) preparation cloth to
patients that used no skin preparation prior to surgery for hip arthroplasty. The patients were
stratified into categories; compliance with skin preparation, type of infections, infection risk, and
total number of hip arthroplasties per year by surgeon. The study results revealed patients that
were compliant in the use of preoperative CHG preparation had a decrease in the number of
surgical site infections (SSI). Although not statistically significant, due to the size of the study,
more studies are warranted to determine CHG reducing SSI rates in hip arthroplasty. Since this
study is limited in its scope, it does show promise for the use of CHG cloths on patients
undergoing surgery.
Article annotation 3
Edmiston, C.E., Seabrook, G.R., Johnson, C.P., Paulson, D.S., Beausoleil, C.M. (2007).
Comparative of a new and innovative 2% chlorhexidine gluconate-impregnated cloth
with 4% chlorhexidine gluconate as topical antiseptic for preparation of the skin prior to
3
EBPP USE OF CHG WIPES PREOPERATIVELY
surgery. American Journal of Infection Control, 35(2), 89-96.
doi:10.1016/j.ajic.2006.06.012
This group of authors are from various backgrounds; surgery, vascular and
transplant, medical college, and bioscience laboratories. In this study they compared the 2%
chlorhexidine gluconate (CHG) impregnated cloths with a 4% CHG liquid skin preparation and
their effects on skin microbial regrowth by culturing skin at ten, thirty and six hour intervals.
The article discussed the methods used; participants, sampling procedures, application, and data
handling, results obtained and discussion of the findings. Advantages of the 2% CHG cloths
over the 4% preparation solution were; exceeded the FDA requirement in decreasing microbial
activity 6 hours after application especially in the inguinal region, it took less time to decrease
microbial activity, easy to use application, and can be used all types of pre-surgical settings. The
sample size was small and only healthy patients were used. This information encourages use of
pre-surgical skin preparation due to the reduction of skin microbial activity.
Article annotation 4
Eiselt, D. (2009). Presurgical skin preparation with a novel 2% chlorhexidine gluconate cloth
reduces rates of surgical site infection in orthopaedic surgical patients. Orthopaedic
Nursing, 28(3), 141-145.
This article was written by a bachelors prepared nurse working as an employee health
coordinator in infection prevention and control. In an attempt to decrease surgical site infections
(SSI) in her hospital setting, a new protocol was introduced using chlorhexidine gluconate
(CHG) 2% cloths as a preoperative scrub for total joint patients. The CHG cloths were used 3
4
EBPP USE OF CHG WIPES PREOPERATIVELY
5
times with each patient, the night before surgery, the morning of, and immediately prior to
gowning in the preoperative area. They compared data from three quarters before the start of the
protocol and the following three quarters after the protocol was instituted. The results of the
study showed a decrease in SSI by 50.16% in the total joint replacement patients compared to
their previous rate using a povidone-iodine product. This study indicated exfoliation properties
of the cloth and increased compliance by patients possibly contributed to the decrease in SSI
rates.
Article annotation 5
O’Malley, P. (2008). Chlorhexidine wipes: The new weapon against surgical site infections?
Clinical Nurse Specialist: The Journal for Advanced Nursing Practice, 22(2), 61-62.
The author of this article, a certified nurse specialist, questions the evidence to support
the use of chlorhexidne gluconate (CHG) cloths over other skin preparations prior to surgical
procedures. In the article she compared the results of two studies. In one of the trials she
indicated due to design flaws, “No clear evidence was found to support preoperative showering
or bathing with chlorhexidine over other products in the prevention of SSIs” (para. 7).
The
second study with built in controls, according to the author, “encourage the acceptance of the
findings” (para. 9). It compared the use of 2% CHG cloths to the 4% CHG solution in specific
sites as a preoperative skin preparation. The CHG cloths may be an acceptable alternative to
patients that may have difficulty bathing. More studies are warranted to determine whether it is
the exfoliation of the cloths or the CHG that decreases the skin microbials.
EBPP USE OF CHG WIPES PREOPERATIVELY
Elements of Reasoning Grid
Use of Chlorhexidine gluconate cloths
1-3 sentences describing your thoughts on the issue
for preoperative skin preparation.
related to that element
1. Purpose (all reasoning has a
purpose)
The purpose is to decrease the chance of surgical site
infection (SSI) in patients having surgery, by having
patients cleanse with an antimicrobial solution prior to
incision. We ask patients to shower at home using
either antibacterial soap or chlorhexidine gluconate
(CHG) solution; many do not for various reasons. I
would like to have evidence to support the use of CHG
wipes on all patients in the pre-op area prior to surgery.
2. Questions at issue or central
The use of CHG wipes may help decrease the chance
problem (all reasoning is an
of an SSI in preoperative patients compared to no
attempt to figure something
preoperative skin preparation. From the evidence I
out, to settle some question,
gathered, I am unable to determine if any populations
solve some problem)
should be excluded, the studies indicated a variety of
patient types and I saw no mention of allergic reactions
to the CHG. The studies varied slightly in the
application of the CHG, 3 times seemed to be the key;
night before, morning of, and just prior to surgery. The
cost of CHG wipes, decreasing the risk of an SSI may
6
EBPP USE OF CHG WIPES PREOPERATIVELY
far outweigh the cost of an SSI from both the patient
and hospital reimbursement perspective. Some type of
skin preparation needs to take place and the exfoliation
with the CHG impregnated cloths appears to be an
acceptable alternative. If bathing with CHG is not
possible, showering should still take place.
3. Point of view (all reasoning is
Introducing any type of foreign object into the body
done from some point of view;
can result in an infection. An SSI can cause ongoing
think about the stakeholders)
problems for the patient. If a patient develops a SSI
the insurance companies may not pay for the cost to
treat. This will add time to the pre-operative staff in
getting patients ready for surgery and cost to the
patients to purchase the CHG cloths.
4. Information (all information is
The use of CHG is supported by the Association of
based on data, information,
Operating Room Nurses (AORN) and by the articles
evidence, experience,
cited in this paper. The evidence supports the use of
research)
CHG 2% cloths over the 4% solution in decreasing
SSI, mainly due to its exfoliation properties and ease of
use for the patient. The CHG cloths are FDA approved
for skin preparation. Explanations will be needed to
inform the patients; what, why, how, where, and when
to use the wipes. A diagram should be available for
the patient to see on how to correctly use the wipes.
7
EBPP USE OF CHG WIPES PREOPERATIVELY
Some data indicated that even if the use of CHG cloths
at home did not occur that the use of them just prior to
surgery, did decrease the SSI rate as opposed to no
preparation at all.
5. Concepts and ideas (all
Precautions should be taken to decrease the risk of an
reasoning is expressed through,
SSI on any patient having surgery. If showering with
and shaped by, concepts and
an antibacterial soap prior to surgery decreases the risk
ideas)
of infection, then using an antimicrobial product
should further decrease the risk of an SSI. The fewer
the microbials and bacteria on the skin near the
incision, the less likely for them to migrate into the
body. Prior to incision, the skin is cleansed; therefore
preoperative cleansing just prior to going into the
operating room should further decrease the number of
microbials and bacteria on the patients’ skin.
6. Assumptions (all reasoning is
I am assuming that no patient or healthcare member
based on assumptions-beliefs
would want to a patient to develop a SSI. The use of
we take for granted)
CHG will benefit them by decreasing the likelihood of
a SSI and appears to be a better alternative opposed to
no or improper skin preparation. I assume all patients
will agree to wash with the CHG wipes and will use
them as directed by the pre-operative nurse. I also
think the hospital would prefer the cost of CHG wipes
8
EBPP USE OF CHG WIPES PREOPERATIVELY
as opposed to the risk and cost of a SSI in patients. I
question the need for the CHG showering solution
being used at home prior to the surgery and perhaps
using an antibacterial soap would be more cost
effective for the patient.
7.
Implications and consequences
Not all patients will wash properly with the CHG
(all reasoning leads somewhere. wipes provided or shower at home, therefore may
It has implications and when
develop a SSI and add additional cost to the
acted upon, has consequences)
organization. Not all patients can afford the cost of
CHG wipes for home use. Some patients may develop
an allergic reaction to CHG. I have seen no literature
on what alternatives there may be to CHG wipes other
than other povidine-iodine products. The risk of
cancellation, due to an allergic reaction is a better
alternative than developing a SSI for both the patient
and the hospital. The use of CHG appears to have
support from infection prevention groups and other
surgical specialists as an effective skin preparation
lasting at least 6 hours post application and has FDA
approval.
8.
Inference and interpretation
If used properly, CHG wipes will decrease microbial
(all reasoning contains
activity on the patient’s skin and may decrease the risk
inferences from which we draw
of a post-operative SSI, decreasing the chance of
9
EBPP USE OF CHG WIPES PREOPERATIVELY
conclusions and give meaning
readmission to the hospital or increased cost to the
to data and situations)
patient and hospital for treatment. In an attempt to do
no harm to our patients, this seems to be the best skin
preparation to use at this time.
There appears to be a need to further investigate
whether the cloths or the CHG is actually decreasing
the risk of SSIs. The results of further studies may
eliminate the need for the CHG component further
decreasing the cost to the hospital and patient.
10