Universal ICU Decolonization: An Enhanced Protocol

Protocol Training, Part 1: Mupirocin

Background

• 2% Topical cream FDA approved December 1987.
• 2% Nasal ointment FDA approved August 1995.
• Anti-staph action by stopping RNA synthesis.
• Commonly used for:
  • MRSA decolonization.
  • MRSA or MSSA decolonization prior to cardiac and orthopedic surgery.
  • Topical wound treatment.
• Nasal ointment is not systemically absorbed.
• High rate of MRSA and MSSA eradication for first 2 weeks after 5-day application.
• Goal is to prevent MRSA and MSSA infection during high-risk periods (ICU stays, post-op).

Application

• Apply twice a day.
• Repeat for 5 days of ICU stay.
  • Discontinue once transferred to non-ICU.
  • Begin again if readmitted to ICU (includes transfer between ICUs).
• Place patient's bed at 30 degrees, if tolerated.
• Apply 0.5 g (blueberry-size) amount of mupirocin onto sterile cotton swab.
• Apply swab directly into nostril.
• Repeat for other nostril.
• Press nostrils together and massage gently for 60 seconds.
• Do this twice a day for 5 days during ICU stay.
• Avoid contact with eyes and other intranasal products.
• If nasal devices are in place (e.g., nasal intubation, NG tubes), place mupirocin around tubing and massage gently to distribute ointment.

Safety

• U.S. Trials (N=210):
  • Headache 9%.
  • Rhinitis 6%.
  • Congestion 5%.
  • Pharyngitis 4%.
  • Taste perversion 3%.
  • Burning/stinging 2%.
  • Cough 2%.
  • Pruritis 1%.
• European Trials (N=2130):
  • Rhinitis 1%.
  • Taste perversion 0.8%.
  • Pharyngitis 0.5%.

Protocol Training, Part 2: Chlorhexidine (CHG)

Background

• Topical cleansing agent, over the counter.
• Used in health care for more than 50 years.
• Marked reduction in skin/room bacteria.
• Commonly used for:
  • MRSA decolonization.
  • Preoperative bathing/showering.
  • Skin prep before central lines/operations.
• Not systemically absorbed in adults.
• CHG reduces bacteria for up to 24 hours and prevents infection.
• Rapid drop in skin bacteria counts.
• Kills almost all bacteria and viruses.
• Goal is to prevent MRSA during high-risk periods (ICU stays, post-op).
• 2% CHG bathing cloths:
  • Fast-acting.
  • Broad spectrum.
  • Continued antimicrobial activity up to 24 hours after application.
  • Alcohol-free.
  • Contain moisturizers.
  • Rinse-free.
  • Disposable.

CHG Bathing Cloths

• Six-cloth bundle (three packets).
• Use all six cloths.
• Do not use above jawline.
• Disposable.

CHG Bathing Process

• There are six total cloths in each bundle, three banded packages of two cloths per package.
• If using a cloth warmer, warm cloths before use.
• If using a warm CHG cloth, check the temperature of the CHG cloth prior to use. Gloves diminish sense of heat.
• Cloths may be used without being warmed.
• Open bundle by using notch on back of package.
• Bathe with CHG once daily for entire ICU stay.
• Use a clean CHG cloth for each area of the body to reduce the chance of spreading germs from one area to another.
• Do not use above jawline.
• Do not not rinse off.

Use Prior Routine for Face, Scalp, and Hair

• Wash face and head first before starting with CHG.
• Use shampoo cap or directly use shampoo sparingly, avoid contact with rest of the body, as it may deactivate CHG.
• Cleanse face with regular washcloth.
• Do NOT use 2% CHG cloths near eyes or ears.

CHG Bathing Process—Using All Cloths

• Use all six cloths in the following order:
  1. Cloth 1: Neck, shoulders, and chest.
  2. Cloth 2: Both arms, both hands, web spaces, and axilla.
  3. Cloth 3: Abdomen and then groin/perineum.
  4. Cloth 4: Right leg, right foot, and web spaces.
  5. Cloth 5: Left leg, left foot, and web spaces.
  6. Cloth 6: Back of neck, back, and then buttocks.

• After application to each body site, be sure to clean tubing from Foleys, drains, G-tube/J-tubes, rectal tubes, chest tubes within 6 inches of the patient.
• Use additional cloths if needed for incontinence or for obese patients.

CHG Bathing Process—Key Points

• Firmly massage skin with CHG cloth.
  • Skin may feel sticky for a few minutes.
• Clean neck well even if it is not visibly soiled.
• The neck:
  • Commonly accumulates debris and moisture.
  • Is a high-risk area for contaminating lines.
• CHG replaces routine bathing:
  • Do NOT bathe with soap and water while using CHG.
  • Exception: hair and face washed per previous routine.
  • Avoid contact of shampoo and facial soap with body.
  • Shampoo and many soaps will inactivate CHG.
• Use CHG cloths after incontinence clean up.
• Do NOT rinse, wipe off, or dry with another cloth. Let air dry.
• CHG cloths have built-in moisturizers. Skin may feel sticky for a few minutes.
• If additional moisturizer is needed, use only CHG-compatible products.
• Certain lotions will inactivate CHG, ensure to check with manufacturer for compatibility.
• Dispose of leftover cloths.
• Do NOT save, reheat, or reuse.

CHG Bathing Process—Bacteria Colonization on Skin

Stool spreads:

• Cleansing of Perineum/Vagina:
  • Critical area for cleaning.
  • CHG is safe to use on the perineum and external mucosa.
  • Use CHG cloths to remove bacteria and clean area.

CHG Bathing Process—Cleaning Up

Dispose of each washcloth in the trash. 

Do NOT flush washcloths in the toilet.

Protocol Training, Part 3: Top 10 Special Circumstances

#1: Nasal Devices

• Nasal prongs.
  • Temporarily remove nasal prongs from nostrils.
  • Apply mupirocin per protocol, including massage.
  • Replace prongs.
• Endotracheal tube/NG tube.
  • Apply mupirocin around tube.
  • Gently massage nostrils for 60 seconds.

#2: Nasal Trauma

• Do NOT use mupirocin if nostril(s) are packed.
• If only one nostril is affected, apply mupirocin to other nostril.

#3: Central Line Care

• CHG cloth is normally used for catheter line skin prep.
• Bathe with CHG liberally around and over dressing.
  • Use CHG cloth on semipermeable dressing only.
  • Do NOT use CHG over gauze.
• Clean skin folds well (neck, groin).
• Clean tube (up to 6 inches) last and discard cloth.
• This applies to all line locations.

#4: Other Devices

• Drains, G tubes, rectal tubes, chest tubes, EKG leads, and Foley catheters.
• Clean tubing itself with CHG cloths.
  • Clean up to 6 in. of drains/tubing including point of connection.
• If dressing is to be changed, clean entire area well with CHG and allow to dry before replacing dressing.
• If dressing is in place, clean tube and skin up to dressing.
• CHG will not harm occlusive dressing or EKG leads.
• Be careful to avoid deep surgical wounds.

#5: Incontinence

• Remove urine/stool with usual chux/cloths and water.
• Do NOT use soap.
• Cleanse with CHG and allow to air dry (about a minute).
• Use as many CHG cloths as necessary.
• Apply CHG-compatible barrier product over affected area, as needed.
• During the day:
  • If additional barrier protection is needed during day, it is okay to use another CHG-compatible barrier product.
  • If additional bathing is required throughout the day, clean with CHG cloths, then reapply CHG-compatible barrier product, as needed.

#6: Decubitus Ulcers

• Stage 1 or 2 ulcers:
  • If dressing is to be changed, clean area well with CHG, allow to dry.
  • If dressing is to be left intact, cleanse over dressing.
• Stage 3 or 4 ulcers:
  • Bathe with CHG around dressing/wound.

#7: Friable Skin/Rash

• CHG is safe to use on superficial wounds, abrasions, and rashes.
• Using CHG, gently massage.
• CHG cloths have built-in moisturizers.
• If more moisturizer is needed, use only CHG-compatible products.

#8: Surgical Wounds

• If there is no dressing or dressing is changed, bathe with CHG up to healed or superficial wound.
• If dressing is to be left intact, bathe with CHG around dressing.
• CHG will not harm occlusive dressing (e.g., wound vacs).
• Do NOT use on large or deep wounds.
• Do NOT rinse or wipe dry.

#9: Obese Patients

• If one set of six cloths is not sufficient, use more.
• Make sure to clean between all skin folds.
• Discard any unused cloths.

#10: Burns

• 1^st and 2^nd degree:
  • If dressing is to be changed, clean area well with CHG, allow to dry.
  • If dressing is to be left intact, clean around dressing.
• Do NOT use on 3^rd and 4^th degree burns.

Universal ICU Decolonization

Just in Time Training

1. STOP all admission MRSA screens unless screening is required by law or surgical protocol.
2. Continue to place patients known to be MRSA-positive in contact isolation.
3. Decolonization Protocol:
   • Mupirocin ointment twice a day for 5 days only.
   • Chlorhexidine (CHG) bathing cloths for ALL bathing needs for entire ICU stay.
   • Decolonization stops when patient is discharged or transferred out of the ICU.
   • If readmitted or transferred to a participating ICU, protocol begins anew.
4. How to Bathe:
   • You should be assigned an RN trained on the universal decolonization protocol for bathing to oversee this process (buddy system).
   • A CHG bathing wall poster is posted in each ICU room (see image below).
   • Only use CHG cloths below the jawline.
   • Let air dry. Do NOT wipe or rinse off.
   • Do NOT flush cloths. Discard in trash.
   • Do NOT use soap (can inactivate CHG).
   • For incontinence, clean debris with chux (water if needed), cleanse with CHG cloth, and then use CHG-compatible barrier product.

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