I’ve written this post in preparation for Wednesday’s IPS Journal Club (register here) in collaboration with IPC Partners

The paper that I have chosen for the Journal Club is this one in the Journal of Infection Prevention, describing a real time intervention to increase chlorhexidine (CHG) bathing to reduce central line-associated blood stream infections (CLABSIs).

Why I choose this paper?

• CHG bathing has shown promise in reducing various infections (such as CLABSIs) therefore evidence demonstrating the effect on infections is welcome
• A recent estimate of the cost of CLABSIs is extremely high – $48,108 for every case according to the Agency for Healthcare Research and Quality
• I was really interested in the use of a ‘real time intervention’ given the challenges which are faced around effective implementation of interventions

Design and methods

• The study was a quality improvement project (QIP) which aimed to increase the rate of daily CHG bathing adherence for patients
• The QIP was conducted at a 166-bed acute care community hospital in the US over 4 months
• A Fishbone Diagram and an Impact Effort Matrix were used to identify barriers. Barriers identified included difficulty in identifying CHG documentation, as well difficulties in identifying patients that are due for CHG bathing
• This led to the development of a ‘Time Since Bathing Column’ to make identification of missing CHG bathing opportunities more apparent within the Electronic Health Record (EHR). This allowed the hospital IPC team to provide real-time feedback when CHG bathing was overdue for a specific patient
• A consistent message and message platform within the EHR allowed standardisation of the message content and the method of delivery
• A sustainability plan was introduced using tools and dashboards to create individual plans focusing on ownership and empowerment of frontline staff to ensure frontline bathing  

Key findings

• Prior to the intervention CHG bathing rate adherence was 94.9% (already very impressive) with a CLABI rate of 1.89
• Following the implementation of the real intervention a 0.42% increase in CHG bathing adherence was detected (which was not significantly significant)
• When including weekend CHG adherence rates in the analysis, a 2.8% increase in CHG adherence was detected (97.6%), which was statistically significant (the QIP identified that CHG bathing adherence was low on weekends)
• No CLABSIs were identified in the 3-month study period, and 12-month CLABSI rolling rate decreased from 1.78 to 1.07 (however the sample size was too small to perform statistical analysis)

Strengths and limitations

• CHG adherence was already extremely high, so challenges in a detecting a significant change however the QIP identified reduced CHG adherence over weekend periods
• Although CLABSIs rate decreased the sample size was too small to identify any statistical significance  

What does this mean for IPC?

• Cross functional working with informatic and digital teams can improve CHG adherence and potentially reduce CLABSI rates
• Real time interventions can identify falls in CHG adherence at times where staffing levels are low, such as weekends
• Real time feedback accompanied by multidisciplinary team engagement with clinicians were important success factors
• Outreach and reminders effectively improved CHG bathing adherence by emphasizing the importance of consistent communication and follow-up