Running head: QUALITY IMPROVEMENT PLAN 1

Quality Improvement Plan: Bathing Logs

Ferris State University

3/23/2018

Leila Kersten, Haley Kern, Emily Hopper, Jeanette Voelker

Introduction

Surgical site infections (SSI) and antibiotic resistant organisms continue to emerge in the

health care field and cause many different complications and even death to patients. Because the

risk of infection is so great, pre and post-operation bathing with chlorhexidine gluconate (CHG)

is important in preventing infections (Wengian-Wang & Layon, 2017). A nurse manager of a

cardiology unit at Mclaren Bay Region hospital has developed a bathing log for staff members to

utilize to ensure all surgical patients or any other patients that need CHG performing as

instructed.

Identify Clinical Need

Topical chlorhexidine solution is used to clean or prep skin before a surgery, after a

surgery, or after an injury to prevent and fight bacteria that can cause infection. Surgical site

infections not only cause many complications for the patients but result in a longer length of stay

in the hospital also putting the patient at risk for more infections like pneumonia in addition to

patient deconditioning (Wengian-Wang & Layon, 2017). These infections “are a focus of many

quality improvement programs owing to increase morbidity, resources utilization, and costs”

(Alawadi, 2015, para 1).

Because of the complications to the patient and increased cost and resources surgical site

infections can create, it is extremely important for surgical patients and those with central lines to

be bathed appropriately with CHG. Patients with central lines can also develop central line-

associated bloodstream infections (CLABSI) and critical care patients are most at risk because of

this. It has been proven by Popovich (2009) and his colleagues that “central venous catheter

(CVC) associated blood stream infection (BSI) rate decreased significantly from the soap-and-
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water period to the CHG period…there were 19 cases of the CVC-associated BSI during the

soap-and-water period and 2 cases during the CHG period” (Results).

Surgical site infections and BSI are very costly for the patient, the unit, and the hospital

and also uses many more resources. Atkinson (2017) and his colleagues state that the, “Mean

cost of inpatient hospital stay was 60% higher in patients with SSI compared to those without

SSI. Inpatient hospital stay alone accounted for 59% of total costs. Return to theatre was the

second most costly intervention overall, accounting for 38% of costs, and was the most

expensive single intervention involved in the treatment of SSI” (Findings).

There also may need to be more physicians, such as an Infectious Diseases doctor,

consulted to treat the patient’s infection appropriately and ensure the patient receives the correct

antibiotics according to the bacteria they have contracted. Length of stay increases, the patient

may experience deconditioning, the patient may become depressed, wound care, and other

complications can arise.

Hartwell, a nurse manger of a very busy cardiology unit at Mclaren Bay Region, has

designed a form to help her staff ensure the appropriate patients are using the CHG solution both

pre and postoperatively and those with central lines. She has initiated a bathing log accessible at

the nursing station for both day and night shift nurses to complete and mark which patients need

to be bathed with CHG. This bathing log was initiated to help cut down on surgical site

infections as well as CVC-associated BSI.

Designs and Interdisciplinary Teams

The Institute for Healthcare Improvement (IHI) recommends that every team include at least

one member who has the following role:

Clinical leadership

This individual has the authority to test and implement a change and to problem solve

issues that arise in this process. This individual understands how the changes will affect the

clinical care process and the impact these changes may have on other parts of the organization.

Technical expertise

This individual has deep knowledge of the process or area in question. A team may need

several forms of technical expertise, including technical expertise in QI processes, health

information technology systems needed to support the proposed change, and specifics of the area

of care affected. For example, a team implementing an intensive care management clinic for

people with poorly controlled diabetes might need technical expertise in change management,

the clinic’s electronic health record, and the patient treatment protocols that will be used.

Day-to-day leadership

This individual is the lead for the QI team and ensures completion of the team’s tasks,

such as data collection, analysis, and change implementation. This person must work well and

closely with the other members of the team and understand the full impact of the team’s

activities on other parts of the organization as well as the area they are targeting.
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Project sponsorship

This individual has executive authority and serves as the link to the QI team and the

organization’s senior management. Although this individual does not participate on a daily basis

with the team, he or she may join periodically and stays apprised of its progress. When needed,

this member can assist the team in obtaining resources and overcoming barriers encountered

when implementing improvements.

The IHI also recommends a QI team have between five and eight individuals, although this

may vary by practice. The most important requirement within this group is the diversity of the

team members. It is important that the team include a diverse group of individuals who have

different roles and perspectives of patient care and or other processes if needed. This group

should include whenever possible inclusion from the patient who is our ultimate goal.

Within our QI tem will be the following individuals:

 Physician (Medical Director of the unit), representing the clinical leadership role;

 Chief Nursing officer, representing the clinical leadership role;

 Unit manager, representing the day-to-day leadership role;

 Nursing staff, representing the technical expertise;

 Medical assistants, representing the technical expertise;

 Health educators, representing the clinical expertise;

 Infection prevention specialist, representing the clinical expertise;

 Clinical Educator, representing the clinical expertise.

Data Collection Method

Quantitative methods emphasize objective measurements and the statistical,

mathematical, or numerical analysis of data collected through polls, questionnaires, and surveys,

or by manipulating pre-existing statistical data using computational techniques. Quantitative

research focuses on gathering numerical data and generalizing it across groups of people or to

explain a particular phenomenon (Earl. 2010).

Documents and records method of data collection consists of examining existing data in

the form of databases, meeting minutes, reports, attendance logs, financial records, newsletters

etc. This can be an inexpensive way to gather information but may be an incomplete data source

Documents and records is the collection method we used for this project. We placed a

bathing log at the nurse desk for all staff to utilize. This log was printed daily with current

patient room numbers; no names were listed for HIPPA regulations. This log was to be filled out

each time a patient was given their daily bath. Also on this log with the room number was the

physician order of any specific agent that was to be used for the patient (i.e. CHG for peri-

operative patients). If at any time this has not been completed the available staff wither night

shift of day shift would be able to utilize this.

A log was kept for 1 month and the information was then taken back to the QI team to

assess and implement a plan for the future.

Outcomes (Leila)

According to the Centers for Disease Control and Prevention, central line associated

blood stream infections (CLABSIs) are the most common form of health care associated

infections (2011). Many hospitals have initiatives to improve the rates of CLABSI within their

hospitals. A hospital in New York City found in 2001 staph aureus was the most common culprit

to cause these infections. Since that time, in 2009 it was found that the rates of CLABSI have

decreased from 43, 000 in the united states to 18,000. The new cause of these infections are now

most commonly candida and enterococcus (Centers for Disease Control and Prevention, 2011).

Candida is the same species to cause yeast infections on the skin, mouth, and genitalia. Along

with good dressing change practices using sterile technique, bathing patients daily, and good

hygiene practices can help decrease CLABSI. Outcomes included in this focus include within the

next year, see the rates of CLABSI decrease on this unit. In addition to infection, see a reduction

of skin issues, and finally have the number of baths done on the unit daily equal to >80%.

Implementation Strategies (Leila)

Using the ADKAR model, implementing a bath program on the unit would be attainable.

The ADKAR model is a change model developed by Jeff Hiatt. The acronym represents five

outcomes the individual or unit must achieve to accomplish success: Awareness, desire,

knowledge, ability, and reinforcement. In our scenario, the awareness step is the awareness of an

increase of infections and skin issues. To successfully proceed through the desire portion, the

manager needs to present the issue and the proposed policy to the staff in a positive manner. So,

the staff do not take the change in a negative manner. The knowledge is very important to inform

the staff of the importance of this new policy, why it is being implemented, and how it will

benefit the patients and the unit. Ability is essential to understand, what are obstacles if any,
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what are the limitations of staff, and what is the maximum potential of your staff? These are

important questions to properly implement a policy to fit the level of aptitude your staff is at.

Reinforcement is the last step of the model and is extremely important. The policy should be

reinforced to the staff to prevent them from getting lax and continuously monitor by management

should be done. This is to review monthly trends and to ensure that the baths are hitting the goal

of >80% of patients on the unit. Also, a review of skin issue data and infection rates should be

done, to see if there is a change, and if there is not, why there is no change.

Evaluation (Emily)

Since monitoring for post-surgical infections when bathing appropriately with CHG, pre-

infection date will need to be used for a baseline. The daily logs will need to be collected and

evaluated by nursing staff and the medical assistants. Deviation from protocol will be discussed

one on one with staff to reinforce importance of project and accurate data collection. Results will

be aggregated weekly and submitted to the unit manager. At the end of one month, the number of

infections will be collected, and a comparison will be made pre and post op. Results will be

shared with executive leadership to determine efficacy of a system wide program initiation.

Conclusion (Emily)

In conclusion, with the continued emergence of antibiotic resistant organisms, and the

rise in surgical site infections, preventing these infections is the top priority. Reduction in these

infections will benefit the patient’s by having less post op complications and additional costs

related to hospitalizations. This reduction also helps the hospitals with the increased cost of

infections and increase resource utilization. Implementation of a quality program with an

exceptional interdisciplinary team provides the foundation for a successful outcome for patients

and for hospitals alike.

References

Alawadi, M., & Kao, S. (2015). Chlorhexidine Gluconate, 4%, Showers and Surgical Site

Infection Reduction. JAMA surgery, 150(11), 1033-1033.

Atkinson, R., Jones, A., Ousey, K., & Stephenson, J. (2017). Management and cost of surgical

site infection in patients undergoing surgery for spinal metastasis. Journal of Hospital

Infection,95(2), 148-153.

Babbie, Earl R. The Practice of Social Research. 12th ed. Belmont, CA: Wadsworth Cengage,

2010; Muijs, Daniel. Doing Quantitative Research in Education with SPSS. 2nd edition.

London: SAGE Publications, 2010.

Centers for Disease Control and Prevention (2011). Vital Signs: Central Line--Associated Blood

Stream Infections --- United States, 2001, 2008, and 2009. Weekly Morbidity and

Mortality Report. 60(08);243-

248https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6008a4.htm

Edmonds-Wilson, S. (2016). Efficacy, Skin Care and Performance Characteristics of a Well-

Formulated Chlorhexidine Gluconate Hand Wash. AJIC: American Journal of Infection

Control, 44(6), S34. Retrieved from: http://www.ajicjournal.org/article/S0196-

6553(16)30038-4/fulltext

Popovich, K., Hota, B., Hayes, R., Weinstein, R., & Hayden, M. (2009). Effectiveness of

Routine Patient Cleansing with Chlorhexidine Gluconate for Infection Prevention in the

Medical Intensive Care Unit. Infection Control and Hospital Epidemiology, 30(10), 959-

963.
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Prosci.com (2018). ADKAR change management model overview. Retrieved from

https://www.prosci.com/adkar/adkar-model

Wengian-Wang, E. & Layon, J.A. (2017). Chlorhexidine gluconate use to prevent hospital

acquired infections—a useful tool, not a panacea. Annals of Translational Medicine 5(1):14. Doi:

21037/atm.2017.01.01