Assessing the sustainability of daily chlorhexidine bathing in the intensive care unit of a Veteran’s Hospital by examining nurses’ perspectives and experiences

Healthcare-associated infections (HAIs) lead to increased morbidity, mortality and medical costs [1‐3]. In the United States alone, about 722,000 people get an HAI every year and 75,000 people with HAIs die [2]. Zimlichman et al., considering only the five major HAIs, estimated that HAIs cost the United States healthcare system $9.8 billion annually [1]. Daily bathing with chlorhexidine gluconate (CHG) for intensive care unit (ICU) patients has been shown to reduce healthcare-associated bloodstream infections (BSIs) [4‐11] and colonization by multidrug resistant organisms (MDROs) [5, 6, 10].

A lot of evidence about interventions to reduce HAIs has been generated in recent years. However, there is still a substantial gap between evidence and practice in the field of HAI prevention in general [12]. Therefore, in order to reduce the health and economic burden of HAIs, there is urgent need for the translation and sustainability of proven efficacious interventions into healthcare practice.

Implementation research is critically needed to facilitate translation of evidence into practice [13], and this research has not been done for daily CHG bathing. For an efficacious intervention such as CHG bathing, it is important to understand all the factors that can influence its successful adoption and sustainability. Sustainability generally refers to the continuation of an intervention or its effects [14, 15]. It is an essential consideration in HAI prevention interventions in order to maintain the initial momentum that occurs when the intervention first gets implemented. The long-term viability of an HAI prevention intervention is important because the hospital leadership will allocate scarce resources to efficacious and successful interventions [15, 16]. Crucial factors that influence sustainability of health care interventions include 1) factors in the broader environment; 2) those within the organizational setting; and 3) project design and implementation factors [14].

Sustainability of an intervention can be assessed in various ways such as 1) examining whether its pertinent activities and resources continue to support its primary objectives [17]; 2) examining whether there is continuation of its implementation strategy [18]; and 3) examining whether it is accepted in the institution particularly by those who actually carry it out [19, 20]. Since daily CHG bathing is a nursing task, understanding nursing staff’s perspectives and experiences with CHG bathing is key to understanding the factors that impact its sustainability.

As part of a quality improvement project to assess compliance to daily CHG bathing, we conducted direct observations of the bathing process, gathered data on CHG usage, and examined electronic medical records (EMR) for documentation of CHG bathing. After observing lower than expected compliance to daily CHG bathing (results not shown in this paper), we embarked on a qualitative inquiry to find out factors that might explain results from this prior project.

The objective of this project was to describe the process of daily CHG bathing in the ICU of a Veterans hospital from the perspective of nursing staff, and identify factors that impact its adoption and sustainability. In addition, we specifically asked about participants’ views about adding daily CHG bathing to the patient’s order set as an intervention to improve compliance to CHG bathing by nurses.

We identified five steps of bathing described by participants: 1) decision to give a bath; 2) ability to give a bath; 3) get assistance to do a bath; 4) delegation of a bath; and 5) decision about which soap to use. The bathing process resulted in one of the following three outcomes: 1) complete bath; 2) interrupted bath; and 3) bath not done. Interactions between the five bathing steps and the resulting three CHG bathing outcomes are summarized in Fig. 1.

Generally, participants did not make a distinction between CHG bathing as an infection prevention procedure and CHG being another kind of soap that could be used for patient bathing. Therefore, choosing to use CHG soap was just one of the steps involved in patient bathing.

Verbatim illustrative quotations from the interviews (Q) within the five bathing steps are presented in Table 1 (online Additional file 1: Table S1).

This quality improvement project was designed to describe the process of daily CHG bathing and to identify challenges in the implementation and sustainability of the intervention in an ICU setting. However, participants did not make a clear distinction between CHG bathing and bathing in general. They believed that CHG soap was just another kind of soap available for patient bathing. Choosing to use CHG soap was only one step of several steps necessary for conducting a patient’s bath. Therefore, our project described factors that influence patient bathing in general many of which ultimately influence CHG bathing since it is one of the steps in patient bathing.

Understanding that nurses do not make a distinction between CHG and ordinary soap bathing is important. On one hand, a hospital unit could choose to stock only the CHG soap and then the nursing staff will have no other choice but to use it; however, this may not be practical because it would mean that there would be no alternatives in case of patient sensitivity or allergy to CHG. Also, within each bath, some body parts such as the face and perineum should not have soap applied to them. More studies need to examine if using only a wet wash cloth without soap on these body parts is safe for patients. A lack of distinction between bathing patients with CHG versus regular soap is in contrast with the findings of a previous quality improvement project by Hines et al. [29], which showed that most nurses and patient care technician (PCTs) were aware that for inpatient bathing, CHG should be used instead of regular soap. This implies that they made a distinction between CHG bathing and bathing in general using regular soap. Eigsti [30], showed that 68% of nurses preferred using CHG over regular soap that is used for general bathing. Participants in Eigsti’s study also made a distinction between CHG bathing and general bathing with regular soap. It is important to note that these studies asked about participants’ preference and awareness/knowledge of whether CHG should be used rather than regular soap. Such questions were more likely to elicit socially desirable answers than in our project where we asked about nurses’ perception of the soaps. Unlike our project that employed semi-structured interviews, both of these studies used surveys that might not have provided an opportunity to obtain a richer and deeper understanding of the nurses’ perspectives on patient bathing.

In our project, one of the main barriers to bathing was perceiving bathing as a comfort measure and therefore giving it a low priority amidst the many other activities nursing staff carry out. An ICU is a fast-paced high-stress environment, therefore prioritization is very crucial in this setting [31, 32]. However, beyond patients’ comfort, bathing of ICU patients has other benefits such as patients’ relaxation, reducing pyrexia and stimulating circulation [33]. In order to mitigate the perception of low priority given to bathing, it is crucial that these other clinical benefits of patient bathing get emphasized to healthcare workers (HCWs) conducting patient baths. For CHG bathing in particular, there is need for more education of HCWs conducting baths about the importance of CHG bathing as an infection prevention intervention. Formal short training sessions focusing on CHG bathing could be used to emphasize the importance of this intervention.

Heavy workload and staffing shortage were other barriers to conducting baths. Heavy workload concerns in the ICU are well known and evidence indicates that nurse burnout is a common problem in the ICU [34, 35]. With burnout due to heavy workload, it is difficult for staff to accomplish many of their tasks, patient bathing being one of them. Also, compared to other general care areas, ICUs are affected by high vacancy rates and turnover [32]. High turnover would imply greater need for frequent training when new staff comes in and staff that are already trained in patient bathing leave. Participants in this project suggested that scheduling baths could indirectly help alleviate the heavy workload; baths could be scheduled during less busy shifts. For example, patients in odd rooms could get their baths during the day shift and others later on or a certain number of baths could be given per shift depending on how many staff are available on that shift. Although this suggestion is intended to only impact the scheduling of patients baths, it is difficult to implement given the complexity of bathing and all the various factors that influence it, and do not necessarily systematically align with room numbers.

Another important finding specific to CHG bathing was that some nursing staff seemed to imply that when a patient gets admitted to the unit, they have a 24-h window before they can actually start adminstering baths to them. This perception of having a 24-h window before nurses could start the bathing schedule for a particular patient can potentially lead to missed patient baths. This idea could have resulted from a misunderstanding of the hospital’s ICU CHG bathing protocol, which requires a single bath every 24 h. This is another opportunity for staff education on the CHG bathing protocol.

Communication about CHG baths in particular was one of the factors that influenced the choice of soap by nursing staff. Communication may break down particularly during handoffs and could result in undone patient baths. Breakdowns in communication during handoffs have been extensively documented in literature and are associated with poor patient outcomes [36]. Some of the strategies that have been tried include education for HCWs to perform effective handoffs [37] and the use of tools such as online forms and checklists [38]. In this project, participants suggested that staff should be encouraged to communicate about CHG baths by word of mouth at handoff.

In this project we also learned that communication about CHG baths had a significant impact on patient refusal, one of the barriers to actually conducting patient baths. Informing patients that they would be getting a bath was associated with much higher acceptance than asking patients if they liked to have a bath. A strategy such as standardized bathing communication messages could help to empower HCWs to effectively communicate information about baths to patients. Hines et al., reported that patient refusal was one of two major barriers to daily bathing of patients [29]. Providing educational support about the importance of CHG bathing to patients and their families was the most common suggestion to improve patient compliance to CHG bathing [29].

One of the interventions to improve compliance to CHG bathing suggested by participants was to include CHG bathing in the patient’s order set and to administer it as a bar coded medication. Bar coded medication administration systems (BCMAs) have been shown to reduce medication errors [39, 40]. Some participants in this project thought that implementation of BCMAs for CHG might increase nurses’ compliance to CHG bathing. Others thought that it might not increase actual baths conducted because there are always workarounds, where nurses might scan the CHG soap but not actually conduct the bath. Workarounds in the use of BCMAs have been extensively described [41]. To the best of our knowledge, our project was the first to seek nursing staff opinions about BCMAs use for CHG bathing. Future studies need to further explore this by seeking the perspectives of other healthcare team members, such as physicians.

We also found that for unclear reasons, probably related to the perceived importance of baths, sometimes RNs did not delegate baths to HCTs; when baths were not delegated, they were not done. This is an area that needs further examination in future studies.

Participants in this project suggested that the use of CHG-impregnated wipes as opposed to the CHG foam soap could increase compliance to CHG bathing. This was because of the perception that baths given with CHG wipes take a shorter time than those with CHG foam soap. This a plausible reason because unlike using CHG soap, there is no extra rinsing step when wipes are used [42]. Participants suggested that newly employed nursing staff need to be formally trained about CHG bathing rather than informally learning about it from their colleagues on the unit. The formal training could probably increase the priority nursing staff place on CHG bathing. Noteworthy is the participants’ mention that baths need to always be conducted in pairs. This would increase efficiency or speed up baths, something that might help reduce patient refusal of baths, particularly subsequent baths after the first one.

A limitation of this project is that the project was conducted at a single-center Veterans Affairs hospital setting; therefore, it is difficult to generalize the results to the general population of hospitals in the United States. Nonetheless, results may be transferable to other ICU settings. The other limitation is that we did not analyze the data according to professional titles—by separating findings of HCTs/CNAs, RNs or NMs. It is true that more HCTs/CNAs conduct baths than RNs, but they both spend considerable amounts of time on the units and so we did not expect that their experiences with patient bathing would vary a lot. Another possible limitation is that there might be bias introduced due to convenience sampling. We do not think this was a major limitation of this study because we interviewed more than 95% of the nursing staff on the unit. Therefore, results presented are representative of all the nursing staff on the unit.

In this project we made a plausible assumption that by studying and describing the process of bathing, we will be able to identify factors that affect adoption and sustainability of CHG bathing. For example: 1) If staff who conduct baths understand the clinical benefits of CHG bathing on top of other general bathing benefits, the assumption is that they will likely adopt the new process. Evidence shows that provision of knowledge to nurses and implementing evidenced-based interventions can improve quality care and patient outcomes [43, 44]. Any lack of knowledge or information identified by assessing the bathing process could be addressed by providing specific education. 2). Participants in this project mentioned that monitoring of CHG bathing should be a joint venture between the infection control department and the unit managers. They believed that this would increase buy-in and ownership of unit managers. We were able to identify this finding by assessing the entire bathing process. Moreover, senior staff buy-in and support is very important for the sustainability of interventions [45, 46].

In conclusion, findings showed that patient bathing is a complex process affected by many factors: 1) patient factors such as clinical stability, hypersensitivity to CHG, refusal, presence of IV lines, general hygiene and obesity; 2) nursing staff specific factors such as nurse characteristics, nursing staff perceptions and beliefs about the value bathing and prioritization of baths; and 3) organizational factors such as staffing and heavy workload, scheduling and the capacity to delegate baths. Factors that specifically facilitated daily CHG bathing were mainly organizational and included the policy of daily CHG bathing, an unfailing supply of CHG soap, and support such as reminders to conduct CHG baths by nurse managers. Since CHG bathing was not perceived as different from the usual soap and water patient bathing, interventions that address the organizational, nursing, and patient barriers to bathing in general could improve adherence to a daily CHG bathing protocol specifically and also ensure sustainability of this intervention. Therefore, future interventions aimed at improving CHG bathing should focus on improving conditions necessary to give a bath in general.