Literature Review: CLABSIs in inpatient oncology patients and daily chlorhexidine baths

Literature Review: CLABSIs in inpatient oncology patients and daily chlorhexidine baths

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Literature Review: CLABSIs in inpatient oncology patients and daily chlorhexidine baths by Mind Map: Literature Review: CLABSIs in inpatient oncology patients and daily chlorhexidine baths

1. Experimental design (control group and experimental group), variability, probability value Unknown software used. Infection= fever >38 degrees for > 24 hrs after admit, and/or positive blood cultures from either blood, urine, or stool. Infection specified either uFUO or HAI. uFUO= fever w/o culture confirmation HAI=positive blood cultures, or positive blood cultures plus fever Findings expressed as number of occurrences per 100 days (Raujli et. al., 2015).

2. Searchable Question: Are inpatient oncology patients with new or existing central lines who have daily chlorhexidine baths compared with those without daily chlorhexidine baths at decreased risk for CLABSIs (central line-associated blood stream infections) over the patient’s length of stay?

2.1. what is a CLABSI (central line associated bloodstream infection)?

2.1.1. CLABSIs were defined per CDC definition: “a bloodstream infection (i.e. a pathogen identified in a blood culture) in a patient that has a central venous catheter at the time of or within 48 hours prior to the positive blood culture, in the absence of infection at another site.” (Thom et. al., 2013.)

2.1.2. A BSI (blood stream infection), which is type of Healthcare Acquired Infection (HAI). (Raulji et. al., 2015.)

3. 1: Purpose

3.1. Reduce CLABSIs

3.1.1. Chlorhexidine in care bundle To evaluate whether a multidisciplinary central line maintenance care bundle reduced CLABSIs (central line-associated bloodstream infections) and bacteremias in pediatric oncology patients. (Rinke, 2013.) To research the effect that the presence of a unit-based quality nurse, or UQN, has on CLABSI rates in the surgical intensive care unit (SICU). (Thom et. al., 2013.) To identify staff educational deficits to standardize central line use, care, maintenance to reduce CLABSIs in oncology patients, a patient population with reduced immune competence or response. (Page, 2016)

3.1.2. Chlorhexidine baths To compare nosocomial infection rates before chlorhexidine baths are implemented and after chlorhexidine baths are implemented in oncology patients. (Raulji et. al., 2015.) To determine whether CLABSIs can be decreased by daily chlorhexidine gluconate (CHG) baths in oncology patients. (Boubekri, A., 2013).

3.2. assess microbial growth with use of Chlorhexidine

3.2.1. To assess bacterial growth in patient wash basins when chlorhexidine gluconate solution versus soap and water is used to bathe patients. (Powers, 2012)

4. 2: Sample

4.1. convenience sampling

4.1.1. Convenience sampling Total: 3257 SICU admits from 7/2008-3/2012 Pre-intervention period (7/2008-6/2010): average of 69 SICU admissions per month Intervention period (7/2010-3/2012): average of 76 SICU admissions per month During intervention period, a designated UQN nurse was present for 193 of 518, or 30%, of the days= monthly range between 0 and 61% . University of Maryland Medical Center (UMMC) in Baltimore, Maryland (Thom et. al., 2013)

4.1.2. Convenience sampling Total: 90 basin samples were taken from 90 patients in a 40 bed mixed med/surg ICU a large Midwestern tertiary care hospital -St Vincent Hospital in Indianapolis, Indiana (Powers, et. al., 2012)

4.2. non-probability sampling

4.2.1. Controlled, non-random, non-probability sampling Total=330 patient admissions, with 190 in phase 1 (control group) and 140 in phase 2 (study group). Ages 0-21 years. Children’s Hospital in New Orleans, Lousiana, a university-affiliated tertiary care facility Raujli et. al., 2015).

4.2.2. Non-probability sample, not randomized, two-part staff educational series 25 staff nurses, Adult inpatient hematology-oncology unit in an academic medical center PAGE

4.3. randomized sampling

4.3.1. Randomized controlled trial and randomized non-controlled trial Initial population control group 454 participants used 2 oz of 4% CHG solution in a half basin of warm water, Initial population treatment group 405 participantsused prepackaged 2% CHG cloths Final sample control group: 454 Final sample participant group: 402 Unknown geographical location (Boubekri et. al., 2013)

4.4. interrupted time series

4.4.1. Interrupted time-series study (of a maintenance bundle concerning all areas of central line care), not randomized Baseline period= 330patients Intervention period=339 patients Inclusion critera:oncology patients with central lines The study site was a university- affiliated children’s center within a tertiary care hospital. (Rinke, 2013.)

5. 3: Design

5.1. Quantitative

5.1.1. quasiexperimental Quantitative quasiexperimental, descriptive secondary analysis survey design (Boubekri et. al., 2013) Quantitative, quasi-experimental study The UQN nurse was responsible for performing patient safety/infection control activities with a focus on CLABSI reduction of CLABSI rates in the surgical intensive care unit (SICU). Additional to calculating SICU CLABSI rates, CLABSI rates were calculated collectively in the medical ICU, cardiac ICU, neurosurgical ICU, cardiac ICU, and trauma ICUs. CLABSIs were defined per CDC definition: “a bloodstream infection (i.e. a pathogen identified in a blood culture) in a patient that has a central venous catheter at the time of or within 48 hours prior to the positive blood culture, in the absence of infection at another site.” (Thom et. al., 2013) Quantitative, quasiexperimental, used CDC methodology to record central line days (Rinke, 2013.) Quantitative, quasi-experimental design, systematic review This new study was done and its results compared with the 2009 Johnson et. al. study findings that just used soap and water in bath basins. (Powers, et. al., 2012)

5.1.2. retrospective Quantitative, Retrospective study, (consecutive pediatric oncology inpatient admits) of a 14 month time period from December 2008- January 2010 2 phases: -phase 1: patients were not given a chlorhexidine bath during admission (control group) -phase 2: patients were given chlorhexidine baths daily during admission (study group) Bathing solution=CHG 4% (1 part) and sterile water (10 parts) given via daily sponge baths (Raujli et. al., 2015).

5.1.3. QI project Quantitative, QI project comparative time-dimensional, simulation-based used CDC definition of CLABSI as infection not secondary to another body site confirmed via laboratory as a bloodstream infection PAGE

6. 4: Data Collection

6.1. primary data

6.1.1. Data Collection:Primary data, Central line days were tracked by passive and active surveillance methods: -ambulatory and inpatient nurses (notified the study team when central lines were removed or placed)-oncology fellows (asked4 times during study to confirm which of their primary patients had central lines) -nurses (askedtwice a yearto confirm which of their primary patients had central lines) -Study focused on 3 groups: clinic nurses, homecare nurses, and patient families, since these groups are most commonly accessing the patient’s central lines. Rinke, 2013.)

6.1.2. Data Collection: primary data, Demographics of inpatient pediatric oncology admits further defined by the following characteristics: sex(M/F), age (0-4, 4-7, 7-12, 12-21), race (White, African American, Hispanic, Other), weight (mean), malignancy (Leukemia, Lymphoma, Other.) Healthcare Acquired Infections (HAIs) of inpatient pediatric oncology admits further defined by infection type: none, GI (gastrointestinal), BSI (blood stream infection), RI (respiratory tract infection), UTI (urinary tract infection), nUFO (nosocomial infection of unknown origin.) Unknown collection instruments used. Study Ethics: The researchers in this study identified central lines as an independent risk factor for blood stream infections and identified that blood stream infections caused by catheters are from microbes/bacteria on the skin. Therefore, this research study disregards the principles of beneficence (prevent harm/promote good) and nonmaleficence (do no harm) since they purposely withheld chlorhexidine baths on their control group of patients. Since the oncology patient population is so immunocompromised, withholding a measure that could prevent CLABSI for the sake of a study could be deemed unethical, as the patients/participants were not specified as being informed about this research study and given the chance to opt out. RAULJI

6.1.3. Intervention period 7/2010-10/2011, the UQN nurse role was filled by ten rotating senior clinical SICU nurses. Intervention period 11/2011-3/2012, just one nurse served as the UQN nurse. UQN Nurse provided education to SICU nursing staff about CLABSI prevention: watched 15 minute video on central line insertion provided by the New England Journal of Medicine, completed a UMMC-developed web-based training course on central line care/ maintenance, one-on-one central line maintenance/care training with the UQN with post-education assessment to evaluate competency of learned material. UQN rounded weekly to do Safety Rounds with nursing staff: discussed CLABSI prevention/occurrences of CLABSI (possible etiology). 12/ 2010, the SICU joined the “On the CUSP” (Comprehensive Unit-based Safety Program) CLABSI Initiative as well. Study Ethics: There was no mention of participant informed consent. However, it seems that the ethical principle of justice was followed since privacy/anonymity/confidentiality of the participants seemed to be upheld, as there was no specific patient demographical data beyond being at ICU admit reported. (Thom et. al., 2013)

6.1.4. Data Collection: Primary data, Tests (Educational Series): Pretest-mandatory, anonymous, online: 31-question multiple choice about central line standards of care to identify staffnurse knowledge deficits. Used to create educational curriculum on: proper identification of central lines, heparin flush use, and laboratory draw procedures (including blood cultures.) Post-test-done after one-on-one reeducation with nurse educator on overall identified knowledge deficits. Primary data, passive and active surveillance (CLABSI) -audited twice-per-week viaaudit tool: --visual inspection of the lines to verify use of Curos cap biopatch, intact dressing, and marked with date. --medical records audits to verify documentation of appropriate frequency of dressing changes and use of needleless connectors Study Ethics: Nonmaleficence or “do no harm”- staff nurses were already performing measures to prevent CLABSIs with the intent to do no harm to the patient. This study identified knowledge deficits in CLABSI prevention and reeducated staff nurses in an effort to further reduce CLABSIs. PAGE

6.2. secondary data

6.2.1. Accessible secondary data of 137,392 patient days in the ICU, trauma centers, long-term acute care hospitals. Meta-analysis.. 856 final participants. Study Ethics -Beneficence, Control versus treatment group (both groups used CHG) -Subject anonymity, participation based on diagnosis of cancer BOUBEKRI

6.2.2. Data Collected: Patient demographics: sex, type of admission (medical or surgical), diagnosis, age, admission length of stay, ICU length of stay Basin variables: number of days basins were used when cultures were taken, number of days since patient’s last bath when the basins were cultured Device variables: presence of: central catheters, arterial catheters, peripherally inserted central catheters, endotracheal tubes, tracheostomy tubes, ventilators, urinary catheters, and fecal containment devices Infection and isolation variables: presence of infection or infections at latest laboratory culture (yes or no), use of antibiotics (yes or no), isolation precautions (yes or no) Study Ethics: Study enrollment was done until a sample size of 90 basins was reached. No specifics regarding consent of participants. The ethical principle of beneficence, or doing no harm, is upheld in this study since the intervention performed by the study aimed to decrease bacterial growth in bath basins with the use of chlorhexidine. (Powers, et. al., 2012)

7. 5: Data Analysis

7.1. software known

7.1.1. A trained investigator used a data tracking sheet to collect data via a spreadsheet on Microsoft Excel. Data recorded: 90 bath basins= dated upon patient’s ICU admission, included in sample after 5 days of use, assigned a unique ID number on Excel spreadsheet to ensure basin data wasn’t duplicated. Univariate tests used to assess the extent to which independent variables were predictive of bacterial growth on basins, since there was a small number of bacterial events compared to the number of nonevents. “Pearson χ2 tests used for all nominal variable comparisons with a Fisher exact test applied to all 2 × 2 tables. The nonparametric 2-sample Wilcoxon rank sum test for median differences was used in place of 2 independent sample t tests for mean differences. Mintab Version 15 was used for statistical analysis with an α of .05 or less as the criterion for statistically significant differences. P values adjusted for ties are reported for 2-sample Wilcoxon rank sum tests.” (Powers, et. al., 2012)

7.1.2. Monthly CLABSI were reported as number of CLABSIs per 1000 central line days. The APACHE (Acute Physiology and Chronic Health Evaluation) III score measured severity of illness via the APACHE III analysis database. The effect of the UQN nurse (days per month UQN was present on the unit) on the rate of SICU CLABSIs was estimated using over dispersed Poisson regression after adjusting for the factors of time (study month), severity of illness (via APACHE III), participation in On the Cusp, and CLABSI rate in all other adult ICUs (nonequivalent control). THOM

7.2. software unknown

7.2.1. CLABSI running totals were takenduring each period category: -baseline -throughout theeducational series -6 months after the educational series -afterimplementation of the audit system Unknown software used, Regression slopes = the rate of increase over each distinct period,=compared using a two-sample test, with P <.05 considered to be statistically significant (baseline CLABSI data collected via retrospective review for 6 months prior to initiating study) PAGE

7.2.2. Pooled means of distribution of CLABSI rates confirmed via lab testing per location. Software used not addressed in this study BOUBRKRI

7.2.3. An all-or-none measurement strategy was used for audits, meaning that compliance was met when every part of the bundle element was performed Central tendency described around the mean of CLABSI and bacteremia rates CLABSIs and bacteremias were definedasas infections/instances per person per 1000 central line days Laboratory and chart review was conducted independently by a trained IP (M.P.) to conclude/diagnose all bacteremiasusing the NHSN guidelines for CLABSIs Unknown which software was used. Rinke et. al., 2013).

8. 6: Results

8.1. decrease in microbial growth

8.1.1. 90 ICU patient bath basins examined: 42 or 46.7% =female 48 or 53.3%=male Age range= 24 to 88 years old (mean= 61.6 years, SD,=14.0 years Mean lengths of stay (hospital & ICU)= were 11.1 days (SD=7.1 days, range= 5-41 days) and 9.8 days (SD= 6.6 days, range=4-42 days). 82% of patients (n = 74) admitted to ICU with a medical diagnosis, 18% (n = 16) admitted to ICU as postsurgical patients. Basins positive for microbial growth = 4 or (4.4%), gram-positive microbes, 3 identified as coagulase-negative staphylococcus (noted to be frequently found on the skin),1 identfied as gram positive cocci. The 4 basins positive for bacterial growth were from female patients (Fisher exact test, P = .04). When comparing the results of this study to the 2009Johnson et. al. study, this study found a 95.5% reduction in positive basin cultures positive, this study had only a.4% growth and the Johnson study had a 97.8% growth. (Powers, et. al., 2012)

8.1.2. decrease in CLABSIs The average CLABSI rate decreased from 5.0 per 1000 CL days to 1.5 per 1000 CL days during this study. The study concluded that money could be saved, $18000 per CLABSI incident, and by using their estimate that 11.4 CLABSIs were prevented in one year, a total of $205,200 could be saved in unnecessary medical costs with the presence of the unit-based quality nurse. Average APACHE III score, day 1 of SICU admit= 59.5 Average APACHE III score pre-intervention, day 1 of SICU admit= 58.8 -Average CLABSI rate pre-intervention= 5.0 per 1,000 CL-days Average APACHE III score post-intervention, day 1of SICU admit= 60.4 after the intervention. (no significant trend in the average APACHE score over time or around the intervention). -Average CLABSI rate post-intervention=1.5 per 1,000 CL-days (CLABSI rate decreased by 5.1% (P = .005) for each additional 1% of days of the month that the UQN was present on the unit.) *SICU central line utilization ratio during study period = 0.74 (18,193 central line days/24,576 patient days) *SICU central line utilization ratio pre-intervention= 0.82 (10,622 central line days/13,086 patient days) *SICU central line utilization ratio post-intervention= 0.66 (7,571 central line days/11,490 patient days) *All other units’ central line utilization ratio= 0.63 (157,298 central line days/248,427 patient days). The unit-based quality infection prevention nurse (i.e. the intervention) was present on the unit for 30% (193/518) of the days of the intervention period (range per month 0 to 61%). (Thom et. al., 2013) MRSA transmission decreased from 1.2 per 1,000 patient days to 0.8 per 1,000 patient days, VRE transmission decreased from 7.5 per 1,000 patient days to 6 per 1,000 patient days in treatment group. (Boubekri et. al., 2013) By differentiating by age range, results were statistically drastic: of the 330 patient admits, 33% or 110 were aged 0-4, 18.8% or 62 were aged 4-7, 20.3% or 67 were aged 7-12, 27.6% or 91 were aged 12-21. The youngest age group, 0-4 in age, had more admits than all other groups. By differentiating by type of infection, 298 of the 330 total patient admits had no infection (control group: 170, study group: 128). Both groups found nFUO as the most common cause of fever. The infection rate was lower in the study group versus the control group except in the 0-4 age group. Results show that prophylactic daily chlorhexidine bathing, in the form of a topical wash, may lead to decreased occurrence of infection in the pediatric oncology population and that older pediatric oncology patients are more likely to benefit. RAULJI During a 24 month period, CLABSIs and bacteremias were considerably reduced for a group of ambulatory pediatric oncology patientsby a clinic nurses, homecare nurses, and patient families. There was a decrease in the mean of baseline period CLABSIs to 48% from 0.63 CLABSIs per 1000 central line days to 0.32 intervention period CLABSIs per 1000 central line days. There was a decrease in the mean of baseline period bacteremiasto 54% from 1.27 bacteremias per 1000 central line days to 0.59 intervention period bacteremias per 1000 central line days. Maintenance central line care bundles decrease CLABSIs and bacteremias andshould be implemented at other ambulatory pediatric oncology sites, as well as to pediatric and adult patient populations who have central lines. RINKE Educational Series: -baseline before educational series:staff nurses scored an average of 74.3% on the pretest -after educational series: staff nurses scored an average of 91.2% on the post-testdemonstratinga 16.9% increase in knowledge CLABSI Rates -baseline (5.86 infections per 1000 line days) -throughout theeducational series (3.45 infections per 1000 line days) -6 months after the educational series (3.43 infections per 1000 line days) -afterimplementation of the audit system (1.87 infections per 1000 line days) Baseline to throughout educational series= not a statistically significant difference in CLABSI rate from 3.45 infections per 1000 line days to 3.43 infections per 1000 line days (two-tailed P 5 .3475). Baseline to after implementation of the audit system showed a statistically significant difference from 3.45 infections per 1000 line days to 1.87 infections per 1000 line days (two-tailed P 5 .0376; Table 1; Figure 1). PAGE

9. 7: Limitations

9.1. admission bias

9.1.1. It is unclear whether admission bias could’ve occurred in the 4-12 age group (bias for the very young) or the 12-21 age group (bias due to higher grade/further in disease process). (Raujli et. al., 2015).

9.2. unknown factor could've affected results

9.2.1. Although chlorhexidine is a known antimicrobial agent, basins that showed bacterial growth and basins that showed no bacterial growth had almost the same number of median days of use: median of 7.5 days versus median of 7.0 days; W = 3879.5; P = .51). One could think that the there was an additional unknown factor, other than being female, that occurred in the basins that grew bacteria versus the basin that didn’t grow bacteria, since both were used for the same amount of time. For example, was there something staff did that contaminated those positive bath basins? (Powers, et. al., 2012)

9.2.2. CLABSI rates decreased over the past decade, unknown if increased national focus on CLABSIs and public reporting of CLABSIs contributed to the reduction of occurrencesof CLABSI 1 of 5nursing central line encounters were not in full compliance with thebundle, therefore additional CLABSI and bacteremia rate reductions may have occurred with further improved compliance It is unclear how well homecare nurses and family members achieved return demonstrations and how well they implemented the CLABSI bundle, since data was unavailable for analysis. Rinke et. al., 2013).

9.3. change made during intervention

9.3.1. The study is complicated by the fact that during the intervention period, there were 10 nurses serving as UQN at first, from 7/2010-10/2011, and then just 1 nurse served in the role from 11/2011-3/2012. I think going from 10 people to 1 introduces room for concern. For example, when 10 people were UQN was their work more or less organized and thorough than when just the 1 nurse was UQN? How could 1 person do that same amount of work as 10? THOM

9.3.2. During study, potential confounders could’ve affected study results (introduction of antimicrobial disk at the central line insertion site during educational series, trial of alcohol caps on central lines that during educational series, and reintroduction of alcohol caps that duringimplementation of the audit tool.) However, the study still shows how simulation-based education can help to increase knowledge and compliance in regard tocentral line care and maintenance. Long-term impact of this study’s interventions still have potential to be evaluated over time, since the study only covered a period of time from June 1, 2011-December 31, 2013. This could help determine the ideal time period for staff reeducation. PAGE

9.4. narrow study

9.4.1. Limitation of only two infectious organisms looked at for the purposes of the study: MRSA and VRE. Other infectious organisms could have been present. (Boubekri et. al., 2013)

10. 8: Gaps

10.1. classification bias

10.1.1. A gap could be in the classification of the age groups themselves. There was no rationale in how/why the specific age group ranges were chosen as such and therefore this could skew the results of the study by differentiating via these specific age group ranges. (Raulji et. al, 2015).

10.2. lack of differentiation

10.2.1. lncusion of all infectious organisms present in CLABSIs, versus just 2 types of organismsI (Boubekri, A., 2013).

10.2.2. A gap could be the lack of differentiation in CLABSI rates reported between those managed by clinic nurses, homecare nurses, and patient families. Instead, combined as a whole. Differentiation could provide an opportunity for improvement and further research in weakest area or areas (area/areas with most CLABSIs) (Rinke et. al., 2013).

10.3. lack of follow through or explanation

10.3.1. A gap could be a missed opportunity for staff nurse reeducation after the getting one-on-one education with the educator, for those nurses who did not get 100% on their post-tests. If nurses who hadn’t gotten 100% on their post-tests could’ve been tutored/reeducated a second time by the educator it is possible that CLABSI rates could’ve been further reduced. A 91.2% on a post-test demonstrates an educational deficit. (Page et. al., 2016)

10.3.2. I would like to further understand why the four positive bath basins belonged to female patients, or if it just happened that way by chance. I think another study could be done the same way, on the same unit, using the same methods, but on just females and then just on males to see if in fact the females are still the group with positively cultured bath basins. (Powers, et. al., 2012)

10.4. introduction of additional intervention(s)

10.4.1. Since the SICU joined the “On the CUSP” (Comprehensive Unit-based Safety Program) CLABSI Initiative, this could’ve played a role in the overall decrease in CLABSIs in the SICU population. Therefore, joining “On the CUSP” could be seen as a gap in the research study that could’ve skewed the results of the study. (Thom et. al., 2013)

11. 9: Level of Evidence

11.1. Level III: Controlled Trial (without randomization): experiment where subjects are assigned in a non-random manner to a treatment or control group

11.1.1. Raulji, C. M., Clay, K., Velasco, C., & Yu, L. C. (2015). Daily bathing with chlorhexidine and its effects on nosocomial infection rates in pediatric oncology patients. Pediatric Hematology and Oncology, 32(5), 315-321. doi:10.3109/08880018.2015.1013588

11.2. Level IV: Cohort Study, an observation of cohorts to determine an outcome

11.2.1. Thom, K. A., Li, S., Custer, M., Preas, M. A., Rew, C. D., Cafeo, C., Leekha, S., Caffo, B. S., Scalea, T. M., Lissauer, M. E. (2013). Successful implementation of a unit-based quality nurse to reduce central line-associated bloodstream infections. American journal of infection control, 42(2), 139-43.

11.2.2. Powers, J., Peed, J., Burns, L., & Ziemba-Davis, M. (2012). Chlorhexidine bathing and microbial contamination in patients bath basins. American Journal of Critical Care, 21(5), 338-342. doi:10.4037/ajcc2012242

11.2.3. Page , J., Tremblay, M., Nicholas, C., & James, T. A. (2016). Reducing oncology unit central line–associated bloodstream infections: Initial results of a simulation-based educational intervention. Journal of Oncology Practice, 12(1), E83-E87. doi:10.1200/jop.2015.005751

11.2.4. Rinke, M. L., Bundy, D. G., Chen, A. R., Milstone, A. M., Colantuoni, E., Pehar, M., Herpst, C., … Miller, M. R. (2013). Central line maintenance bundles and CLABSIs in ambulatory oncology patients. Pediatrics, 132(5), e1403-12.

11.3. Level V: Systematic Review of Descriptive or Qualitative Studies

11.3.1. Boubekri, A. (2013). Reducing central line-associated bloodstream infections in the blood and marrow transplantation population: A review of the literature. Clinical Journal of Oncology Nursing, 17(3), 297–302.