Results of a Stepped-Wedge Cluster-Randomized Implementation Science Trial to Improve Chlorhexidine Gluconate Bathing Compliance

Background: Daily chlorhexidine gluconate (CHG) bathing in intensive care units (ICUs) is widely supported in the literature to decrease risk of central-line-associated infections (CLABSIs). However, adoption of this practice is inconsistent. The primary objective of this implementation science study was to assess the effect of a bathing intervention on compliance with the AHRQ CHG bathing protocol. Secondary objectives were to examine (1) moderating effects of unit characteristics, (2) the intervention effect on nursing staff’s knowledge and perceptions of CHG bathing, and (3) the intervention effect on CLABSI rates. Methods: A stepped-wedge cluster-randomized design was used to implement and evaluate the effectiveness of a CHG bathing intervention. At 2 large hospitals, 14 units were clustered into 4 sequences. Units included 9 adult ICUs, 3 pediatric ICUs, 1 pediatric bone marrow transplant unit, and 1 adult hematology-oncology unit. Sequences were enrolled into the active intervention phase over the course of 4 months. The intervention included 2 evidence-based implementation strategies: (1) educational outreach visits and (2) audit and feedback on CHG bathing compliance. Compliance with the CHG bathing processes and daily CHG bathing documentation were assessed. At 12 months after the last enrolled date, booster sessions were completed, and outcomes were assessed for sustainability. Results: In models of CHG bathing process compliance, the implementation strategy was significant (b = 6.97; P = .009), indicating that compliance was 6.97% higher after the intervention than before. There was a statistically significant improvement in nursing knowledge of CHG bathing (χ2 = 9.32, p = .002) and perception of the priority of CHG bathing (t = 2.56; P = .01). Daily CHG bathing documentation compliance and CLABSI rates did not significantly improve immediately following the intervention; however, a clinically significant decrease (27.4%) in CLABSI rate was observed. At 12 months after the intervention, improvements in CHG bathing documentation and process outcomes were sustained. There was no change in bathing process compliance after 12 months (b = −0.19; P = .87; intercept=96.96, p < .001), and compliance remained high at 96.96%. There was no change in documentation compliance after 12 months (b=3.89, p=.37, intercept=78.72, p < .001), and compliance remained high at 78.72%. After 12 months, CLABSI rates were statistically significantly reduced (b = −0.16; P = .009; intercept =1.97, p < .001). Conclusions: Using educational outreach visits and audit-and-feedback strategies can improve the adoption of evidence-based CHG bathing practices. CHG bathing—a simple, nurse-driven practice—can make a significant improvement in patient outcomes.Funding: NoDisclosures: None

Results of the CHlorhexidine Gluconate Bathing implementation intervention to improve evidence-based nursing practices for prevention of central line associated bloodstream infections Study (CHanGing BathS): a stepped wedge cluster randomized trial

Background Central line-associated bloodstream infections (CLABSIs) result in approximately 28,000 deaths and approximately $2.3 billion in added costs to the U.S. healthcare system each year, and yet, many of these infections are preventable. At two large health systems in the southeast United States, CLABSIs continue to be an area of opportunity. Despite strong evidence for interventions to prevent CLABSI and reduce associated patient harm, such as use of chlorhexidine gluconate (CHG) bathing, the adoption of these interventions in practice is poor. The primary objective of this study was to assess the effect of a tailored, multifaceted implementation program on nursing staff’s compliance with the CHG bathing process and electronic health record (EHR) documentation in critically ill patients. The secondary objectives were to examine the (1) moderating effect of unit characteristics and cultural context, (2) intervention effect on nursing staff’s knowledge and perceptions of CHG bathing, and (3) intervention effect on CLABSI rates. Methods A stepped wedged cluster-randomized design was used with units clustered into 4 sequences; each sequence consecutively began the intervention over the course of 4 months. The Grol and Wensing Model of Implementation helped guide selection of the implementation strategies, which included educational outreach visits and audit and feedback. Compliance with the appropriate CHG bathing process and daily CHG bathing documentation were assessed. Outcomes were assessed 12 months after the intervention to assess for sustainability. Results Among the 14 clinical units participating, 8 were in a university hospital setting and 6 were in community hospital settings. CHG bathing process compliance and nursing staff’s knowledge and perceptions of CHG bathing significantly improved after the intervention (p = .009, p = .002, and p = .01, respectively). CHG bathing documentation compliance and CLABSI rates did not significantly improve; however, there was a clinically significant 27.4% decrease in CLABSI rates. Conclusions Using educational outreach visits and audit and feedback implementation strategies can improve adoption of evidence-based CHG bathing practices. Trial registration ClinicalTrials.gov, NCT03898115, Registered 28 March 2019.

Strategies to Approach Medicines Litigation: An Action Research Study in Brazil

Background: In the last decades, litigation has been increasingly used to access medicines in Brazil. This phenomenon has led to the development of diverse strategies to reduce its negative impact on the organization of pharmaceutical services. In spite of that, managers still face difficulties dealing with lawsuits.Objective: This study aims to report the planning and implementation of strategies to approach medicines litigation in a municipality located in the southeast region of Brazil.Methods: Mixed methods were employed through an action research cycle. A network coordination team included researchers from university and municipal managers. The scenario analysis comprised the characterization of pharmaceutical services and the profile of medicines lawsuits. Afterward, strategies were planned to deal with the central problem identified. The action plan involved educational outreach visits and distribution of printed materials for health professionals, evaluated through opinion survey. Group conversations were conducted with the users of the public health system, followed by thematic analysis of reports.Results: The characterization of pharmaceutical services in the municipality revealed that treatments supplied were in accordance with the National Medicines Policy. In addition, a sector was implemented to attend demands for non-incorporated medicines. In spite of the services available, the characterization of lawsuits indicated that the main claimants were users of the public health system, requiring non-incorporated medicines, with therapeutic alternatives available. Thus, educational outreach visits were held in 14 health units (23 physicians in total). Everyone who answered the evaluation declared that they were very satisfied with the approach. Group conversations with the users of the health system reached 227 participants in total. In regard to users’ perception about pharmaceutical services, thematic analysis of reports identified three main categories including aspects related to medicines provided, users assisted, and quality of service.Conclusion: The study described the first cycle of an action research project to develop strategies to approach medicines litigation at the municipal level. The application of educational outreach visits for health professionals and group conversations with health system users is a promising approach to improve access to information about pharmaceutical services in Brazil.