Clinical Review

Nurse-Driven Protocol Reduces HAIs in Burn Patients


The Burn Center of Shands Hospital at University of Florida Health in Gainesville admits about 500 burn patients every year. Using standard prevention “care bundles,” the multidisciplinary team caring for patients with thermal injuries brought down the rates of hospital-acquired infections (HAIs) and burn-wound infections, but they had not been able to eliminate them.

Noting that previous research in nonthermal injuries had suggested that daily bathing with chlorhexidine gluconate (CHG) reduces bloodstream infections and vancomycin-resistant enterococci, the burn team developed a study to evaluate this protocol in preventing HAIs in patients with thermal injuries. Researchers from Shands Hospital, University of Florida Health and the University of Florida College of Medicine, both in Gainesville; and Geisinger Health System in Danville, Pennsylvania, conducted the study. They say that, to their knowledge, this is the first study to evaluate CHG baths for burn patients, a group at high risk for infections. At first, they were concerned that CHG, which is not recommended for use on mucous membranes, might further injure compromised skin but decided significant benefits would result if the protocol worked.

Standard procedures and care bundles were not changed, but the bathing protocol for adults with thermal injuries was switched from twice daily with soap and water to twice daily with 0.9% CHG solution. This concentration is similar to that found in commercial wipes, the researchers say, and significantly more than the concentration found to be useful in surgical wounds. The diluted CHG solution was used on the patient’s entire body except the face and eyes. The only protocol change was to not allow the CHG solution to dry before rinsing. They also used appropriate analgesia, since this was a bedside “mini-debridement.”

The 17-month trial included 203 patients in the pretrial group and 277 in the posttrial group. The median burn area was 25% of the total body surface area. At baseline, the rates of HAI were ventilator-associated pneumonia (VAP), 2.2 cases; catheter-associated urinary tract infection (CAUTI), 2.7 cases; and central line–associated bloodstream infection (CLABSI), 1.4 cases.

Using the CHG solution lowered the HAI rate to nearly zero. Over the first 17 months, no VAPs, CAUTIs, or CLABSIs were reported. From the start of the study in February 2011 through June 2013, those results were sustained, apart from 1 case of CAUTI. No integumentary complications were associated with the use of the CHG solution.

Popp JA, Layon AJ, Nappo R, Richards WT, Mozingo DW. Am J Infect Contr. 2014;42(2):129-132.
doi: 10.1016/j.ajic.2013.08.015.

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