Universal ICU Decolonization: An Enhanced Protocol
Appendix E. Training and Educational Materials
Daily Chlorhexidine Bathing Patient Information
Why the special bathing?
This hospital is dedicated to improving medical care for our patients. Common bacteria on the skin and nose can produce infection during high-risk periods such as an ICU stay because patients are critically ill and often require lines, tubes, and other devices. The adult intensive care units (ICUs) in this hospital are providing patients with a daily no-rinse bath using special skin cleanser that removes potentially harmful bacteria on the skin and reduces the risk of infection during the high-risk period of critical care. An antibiotic ointment is also provided for the nose to remove common bacteria that can produce infection. This is part of a strategy called Universal Decolonization, and it has been proven in research studies to protect ICU patients from infection and reduce the risk of having antibiotic-resistant bacteria on the body. The ultimate goal of this effort is to prevent infections.
What is chlorhexidine?
Patients will receive daily bathing with cloths that contain an antiseptic agent called chlorhexidine gluconate (CHG), which has been used safely in hospitals for over 50 years and is available over the counter at your local drugstore.
Why is a chlorhexidine bath administered daily?
Chlorhexidine has been shown to keep bacteria off the skin for up to 24 hours. Patients in the ICU are bathed daily to protect them from infections during this high-risk period.
Am I really clean without using soap and water to bathe?
Chlorhexidine actually works better than standard soap and water for removing bacteria from the skin. It continues to work for up to 24 hours.
Who can provide me with more information?
Please talk to your nurse if you have a question or want additional information.
- What is Universal Decolonization?
Your ICU will be decolonizing all patients with mupirocin and CHG. This will include applying nasal mupirocin twice daily for 5 days. You will be using CHG for all bathing needs (below the jawline) for the entire ICU stay.
- Do MRSA-negative patients receive decolonization?
MRSA-negative patients should also receive mupirocin and chlorhexidine. Prior ICU policies for preoperative patients should remain as before. This decolonization protocol applies to ALL ICU patients, regardless of their MRSA status.
- Should the protocol continue to be applied to ICU patients who are temporarily transferred out for radiologic or surgical procedures?
Yes. The protocol should continue for patients being transferred for procedures in radiology and surgery. Mupirocin and the daily CHG bath can be applied during the time when the patient is physically in the ICU. In the event the patient is incontinent and being sent to radiology, communicate that the patient is on this intervention and, if needed, use the standard clean up available in radiology (i.e. barrier cloths) and upon returning to the ICU use the protocol for incontinence clean up.
- Some ICU patients leave the ICU for a short time and return in less than 24 hours. When these patients return, does the mupirocin 5-day regimen pick up where they left off (e.g., Day 3) or start over at Day 1?
The protocol begins anew for each readmission, regardless of the duration of absence.
- Does Universal Decolonization affect the use of chlorhexidine for preoperative bathing?
No. If your hospital already has a policy for preoperative bathing with CHG, then this practice should continue.
- Does Universal Decolonization affect the use of skin preps before a surgical procedure?
No. Standard skin preps prior to a surgical procedure or for a bedside procedure should be utilized on patients. Presurgical or preprocedure preps with CHG plus alcohol or an iodophor-based solution plus alcohol are considered the standard of care.
- Some of the ICU patients can perform their own bed bath. What should be used and can the patient do it themselves?
CHG bathing cloths should replace routine daily bathing. To ensure consistent application, the nurse should bathe the ICU patient daily with CHG even if the patient is able to bathe themselves.
- Should gloves be worn or changed during bathing with CHG cloths?
Yes. Although it is safe to handle the CHG cloths with bare skin, gloves should be worn for bathing patients. If gloves become soiled, they should be changed.
- Is it true that CHG cloths can stain sheets?
CHG can sometimes produce a brown stain if it comes into contact with bleach. To avoid this, please place CHG cloths on a chux or another surface other than directly on sheets. Once applied to skin, CHG will bind to skin proteins and will not stain sheets.
- Does Universal Decolonization affect our hand hygiene products?
No. Use your usual routine hand hygiene product.
- Will long-term use of CHG cloths cause bacteria to become resistant?
Thus far, despite wide use, CHG resistance has rarely been reported in the United States.
Stopping MRSA Screening
- Do we stop MRSA screening in the ICU?
Yes, all routine MRSA screening for ICU admissions should stop. This includes stopping screening for all high-risk groups admitted to the ICU setting (e.g., dialysis patients, nursing home residents). Nurses must be educated so that screening stops during the patient's entire ICU stay. If there is a State law or policy to screen select high-risk patients (for example, patients newly starting dialysis) or all patients with a prior MRSA history, then refer to question 4 (below) to develop a facility-specific plan to initiate screening on transfer out of a participating ICU to a non-participating location (e.g., non-ICU).
- Why are we stopping screening for MRSA?
Screening and isolating MRSA+ patients is not the only effective strategy to reduce MRSA burden and infection. The REDUCE MRSA trial showed that universal decolonization is more effective than either screening and isolating alone or screening and targeting MRSA+ patients for decolonization. Screening is costly, and results may not be returned immediately. Some people have raised the important issue that screening for all antibiotic-resistant pathogens is not feasible and that a different strategy should be entertained. Still others are concerned that placing more and more people on contact precautions raises unintended consequences, such as issues about patients feeling isolated and having fewer visits by clinical staff.
- Isn't decolonization more costly than screening with nasal swabs?
We believe it to be cost-saving. The cost burden of decolonization is a shift from lab costs (MRSA swab, nurse time, technician time, ChromAgar or PCR, incubator etc.) and isolation supplies (gowns, gloves, masks) to pharmacy (nasal mupirocin) and bathing supplies (CHG cloths). In addition, by removing bacteria, decolonization has been shown to reduce 37 percent of clinical MRSA cultures and 44 percent of all-cause bloodstream infections and their associated costs, which total approximately $18,000 per infection. Thus, one averted infection could cover the costs for numerous CHG baths. A formal cost-effectiveness analysis is being conducted for the REDUCE MRSA trial.
- Are there any exceptions to stopping MRSA screening in the ICU?
If your hospital has a policy for cardiac or orthopedic surgery patients to undergo nares screening for Staphylococcus aureus prior to surgery, then this practice should continue. In addition, if a physician orders nares screening for any reason, then screening should occur. However, physicians should be reminded that your ICU has implemented Universal Decolonization where screening should not be routinely performed on patients. As mentioned above, some facilities may have explicit screening rules for high-risk patients, such as hemodialysis patients, especially for cases of newly initiated dialysis.
- What if we want to continue to screen other high-risk patients throughout the hospital?
Several States require screening of high-risk patients, and you should continue with usual processes to identify and screen these patients. If high-risk, non-ICU patients are of interest, identification and screening outside of the ICU may continue. Some hospitals may want high-risk MRSA screening to resume when the patient is transferred to a non-ICU ward. If so, these hospitals need to develop a specific plan to reinitiate such screens upon transfer to a non-ICU location. Due to the decolonization performed in the ICU, you may have more negative results among patients screened upon transfer to a non-ICU.
The REDUCE MRSA Trial only demonstrated that universal decolonization was better than screening and targeted decolonization for ICU patients. The value of other strategies external to the ICU is not well known.
- How does Universal Decolonization affect the contact precaution policy for MRSA+ patients?
Universal Decolonization does not affect application of contact precautions. If a patient is known to be MRSA+ or positive for another multi-drug-resistant organism (MDRO) like Resistant Gram Negative Rods or vancomycin-resistant enterococci (VRE), then contact precautions should apply.
- Since stopping screening will mean that we will not know if some patients are MRSA+, should we apply contact precautions to all ICU patients?
No. Contact precautions should continue to be applied only to patients who are known to be MRSA+ or to patients who satisfy other reasons for application of contact precautions.
- Do contact precautions apply for patients who are discovered to be MRSA+ because of a screening swab taken in a non-ICU setting?
Yes. Contact precautions apply to all MRSA+ patients regardless of how or when the MRSA status came to be known. Do not disregard results from screening cultures taken from other units, even if the result returns after the patient is transferred into the ICU.
- Do contact precautions continue to apply to other MDROs?
Yes. There is no change to any precaution policy. Implement contact precautions for MRSA, Resistant Gram Negative Rods, VRE, Clostridium difficile, and other organisms that require precautions.
- What should staff tell patients and their families when decolonization products are applied?
Staff should provide the same information they would provide for any applied skin product. For example, it would be reasonable to say: “This bathing cloth is routinely used in this ICU for bathing patients. It has a skin cleanser which is antibacterial and will keep bacteria away for several hours. It is much better at removing bacteria than regular soap. It also has moisturizers in it and should not be rinsed off.”
As another example, for nasal mupirocin, it would be reasonable to say: “Some bacteria make their home in the nose and can increase your risk of infection. We routinely use an antibiotic ointment in the nose to keep bacteria away to reduce the risk of infection during your ICU stay.”
- Can patients refuse decolonization?
Similar to any medical care or routine ICU practice, patients can refuse any therapy. However, as you know, it is not routine practice to ask patients whether they want to refuse each component of usual ICU standard of care (e.g., admission orders, type of bathing or shampoo product). If, in the course of usual explanation of the bathing/decolonization process (see above question), the patient does not wish to have this done, it is their right.
- What if a patient or patient's family would like more information?
There is a patient information sheet included in this protocol discussing the use of CHG (go to Daily Chlorhexidine Bathing Patient Information). If more information is needed, the patient/patient's family should be directed to the patient's nurse or the ICU Director.
- For what types of wounds is chlorhexidine (CHG) application safe?
CHG can be applied to any superficial wound, including stage 1 and stage 2 decubitus ulcers, friable skin/rash, and superficial burns. We recommend not using CHG on large or deep open wounds.
- How firmly should I apply CHG cloths to a wound?
It depends on whether the wound is over a bony prominence or not. If the wound is not over a bony prominence, then CHG should be applied with a firm massage to ensure adequate contact and antibacterial activity. However, if the wound is in the location of a bony prominence, a gentle massaging motion should be used to avoid causing additional soft tissue damage or extension of the wound due to pressure against the bone.
- Will CHG be absorbed if I put it on a wound?
There is minimal to no systemic absorption when using CHG on a superficial wound. In addition, the CHG may be particularly important to eliminate bacteria in an open wound.
- Should I be concerned about CHG having a stinging effect on patients with wounds?
Antiseptic over-the-counter products often contain alcohol and will sting when applied to wounds. In contrast, CHG cloths do not contain alcohol and will not sting. In fact, CHG cloths contain dimethicone and aloe, which are moisturizers, and actually have a soothing effect on the superficial wound area.
- Can I use CHG cloths over a closed surgical incision?
CHG can and should be applied over a closed surgical incision to eradicate bacteria and hopefully prevent infection.
- What if my patient has a wound vac?
CHG should be applied over any semi-permeable or occlusive dressing. This includes wound dressings that meet that criteria, as well as wound vacs. CHG can also be applied over sutured or stapled wounds. If the dressing is permeable (for example, gauze), then use CHG up to the dressing.
- I am having trouble with applying bandages after bathing my patients with CHG. Does CHG weaken bandage adhesive?
If you are having trouble reapplying a bandage after bathing a patient with CHG, it's usually because not enough time has elapsed to allow for drying. After bathing a patient, please allow the CHG to dry for about 5 minutes. This should provide ample time for the CHG to absorb and not affect the bandage adhesive. If you cannot wait the full 5 minutes, and if the patient's skin still feels tacky, this will prevent the bandage from sticking properly.