Daily bathing of hospitalized patients with chlorhexidine gluconate (CHG) is one of many measures utilized by institutions in an attempt to decrease hospital-acquired infections. Several intensive care studies report successful reduction of central line–associated bloodstream infections and of acquisition of methicillin-resistant Staphylococcus aureus and vancomycin-resistant enterococci associated with CHG bathing of patients.Reference Bleasdale, Trick, Gonzalez, Lyles, Hayden and Weinstein ^{1 –} Reference Vernon, Hayden, Trick, Hayes, Blom and Weinstein ⁶ In our own institution, CHG bathing has been associated with a significant decrease in the number of Clostridium difficile infections.Reference Rupp, Cavalieri and Lyden ⁷

Although our institution’s nursing policy states that CHG is to be used for all inpatient bathing (exceptions: history of CHG allergy/intolerance, <2 months of age), the overall compliance rate is low (63%). This project sought to assess knowledge level, beliefs, practices, and potential barriers that influence nurses and patient care technicians (PCTs) and may impact compliance rates with daily CHG bathing. Because the project met criteria for a quality improvement initiative, institutional review board approval was not sought.

This quality improvement project was conducted at Nebraska Medicine, a 621-bed academic medical center. With the exception of those who work on hospital units that do not routinely bathe their patients with CHG (obstetrics/gynecology, newborn nursery, neonatal intensive care unit, psychiatry unit), all inpatient nurses (673) and PCTs (297) received an online survey designed by SurveyMonkey. At a later date, paper copies of the survey were distributed to units with poor response rates. All responses were anonymous.

The survey assessed demographic details of a respondent including role (nurse vs PCT) and years of experience. Knowledge level, beliefs, practices, and potential barriers to CHG bathing and bathing in general were then evaluated through a series of questions (survey available as online supplementary material). Lastly, respondents were asked what would increase their CHG bathing use.

Counts and percentages were used to summarize the response. The Fisher exact test was used to describe associations between questions. P<.05 was considered statistically significant. The kappa statistic was used to assess the agreement between the importance placed on CHG bathing and bathing in general.

A total of 401 surveys were returned, representing a 41% total response rate (45% nurse response rate and 32% PCT response rate).

Eighty-eight percent of the respondents correctly identified that CHG should be used instead of regular soap for all inpatient bathing as part of our institution’s nursing policy. Respondents with more than 5 years of experience correctly identified this more often compared with those with less experience (92% vs 84%, P=.016).

In regard to attitudes toward bathing, more respondents indicated that bathing in general was very/extremely important to the care of patients and to the improvement of their outcomes compared with the number of respondents indicating the same for CHG bathing (85% vs 63%, к=0.27). A larger proportion of PCTs indicated that CHG bathing was very/extremely important to the care and outcomes of their patients compared with nurses (73% vs 61%, P=.0493) and that CHG bathing had high/essential priority (79% vs 50%, P<.0001).

Patient refusal and lack of time were indicated as the major barriers to daily bathing of patients (74% and 62% of respondents, respectively). A larger proportion of PCTs identified patient reluctance/refusal as a barrier to daily bathing compared with nurses (88% vs 70%, P=.0007). A larger proportion of nurses identified lack of patient care support as a barrier to daily bathing compared with PCTs (47% vs 31%, P=.0064).

The most common suggestions to improve CHG bathing usage as indicated by respondents were to provide educational support for patients and their families (78%) and to increase assistance from support staff (58%).

Although overall CHG bathing compliance rates are low in our institution, the results of this project indicate that most nurses and PCTs know that CHG should be used instead of regular soap for all inpatient bathing. PCTs placed more importance and priority on CHG bathing compared with nurses. This may be explained by the fact that PCTs have more discrete job tasks, including patient bathing, compared with nurses. However, nurses are responsible for the overall bedside care of patients and should be placing as much importance and priority on ensuring that CHG bathing is completed.

Identifying patient refusal and lack of time as the major barriers to daily bathing of patients correlates with the popular suggestions of educational support for patients and their families and increasing assistance from support staff as ways to improve CHG usage. PCTs identified patient reluctance/refusal as a barrier to daily bathing more often than nurses. We surmise that this is again reflective of their respective job descriptions as well as level of authority, since nurses may tend to more assertively facilitate bathing of patients. Not unexpectedly, more nurses than PCTs identified lack of patient care support as a barrier to daily bathing of patients, which represents the expectations of each role.

CHG bathing compliance rates are likely impacted by multiple factors, including the beliefs and attitudes of the nursing staff, as well as perceived or true barriers. Limitations of this project include the single-center setting, low survey response rate, and potential response bias inherent to surveys. In spite of these limitations, we feel that this project furthers the understanding of potential barriers to compliance with CHG bathing, which is important in order to influence practice. Results from this quality improvement project will be utilized to create targeted educational interventions in an attempt to increase compliance with CHG bathing at our institution.