Proactive (Hygiene)

lnterventional Patient Hygiene: Proactive (Hygiene) Strategies to Improve Pat1ients' Outcomes By Kathleen Vollman,

AN, MSN, CCNS, CCRN;

Robert Garcia,

lEarn CE Credit Upon completion of this article. the reader w111 be able to: t . Deftne rnlerventional patient hygiene and understand its rmportance. 2. Identify nurse-sensitive outcomes improved by tntervenhonat patient hygfer1e. 3. Discuss real-life examples of performance 1mprovement 1111tiatives related to interventional patient hygiene targeted to reduce the frequency of ventilator-associated pneumonra. pressure ulcers. and other problems related to sktn breaL{down. 4. Develop a ohecklrst to start simrlar performance 1mprovement strategies withrn your institut1on. More lhan 140 ye;u·, :!!-'"· l ' lon~n:: c Ni ght ingale' 0utlincd some· of the same cli ••!l~n~e ' that 11H1th:•rn mn't'' 1":1cl' tuday . " I N ur,ingj ha,.. been lnnit.:d to ~> ignd~ little- mon: than tJJe' adrni nisLration of medicurc., and th.: apphe·atrnn u U ponltlt:l'' (dre,sm~'t It ''llf'lll tO ,j~~nify rhe prupn 11'" "f frc'h ui1. light. 11 .tnllth. ch: anli11.-". qllill!l. ~tnd the prup.:r ~c lccliun aild adm inistral ion dict- ;Ill of thL'\C al LhL' lc:~,( L'~ Jll'II"C of vital Jl"WLT tn the patient. .. Sin.: undL•r,tnod tiL II nur,·in ~ wa' ffiOfL' than lhc Oldmini,tJ';Iliorr of llll'thcatlons :md ,]eli\L'rlfl~ treatHJt'llh. Shig nili c:mt level' of de111al plaque' ' Denial plaque worsens particularly in patient. receiving mec hanical ven tilation because of th e lack of I t o rhbru~hin g and good oral e:m:.'•

A Clinical Study A · tudy 1 conducted a1 the Brookd ale 11i vcr, ity Medic·~ I Center inN w York . ho' :-.reduced rate · or YAP among patients in the meuical inten,ive care unit (tvUCU) after implcmentalion of a comprehen~i e oral care program . The initial preintervention study period (J;mu and direct ub>crvalion of prac ti ce of respirator th erap i~ t . nur~e , . and phy~ician~ did r101 immediatel y n: vcal any · ignifknnt

break ~ in a cptk tec hnique (eg. l 1andw a~lti n g. c hangi n~ ve nli lator circui t every 7 day1>. replacement or clo d uction device ·. u c of HME filter'. h~u1tlling of humidifier . use r semi rec umben t po, itinnin"' as indicated. and the u c of stres. ulcer dru gs). Howe er. ~ev eral prac tice~> related to mouth and denta l care . P".!:''-' 1:!-1-1

Table 5 Example of a basinless bathing protocol POLICY: Patient Basinless Bathing The Basin less Cleansing batll will be used on all patients wllo requ ire a bed batll unless the patient declines or sensitivities to ingredients.

~1as

any known

PURPOSE: The purpose of a bath is to cleanse the skin. remove harmful bacteria, control odor. stimulate tissue. and promote relaxation and comfort. while providing an opportunity for thorough skin monitoring andlor assessment. ARTICLES NEEDED: • Basinless Cleansing bath (t package) ·Towel (1 , optional) • Pads for incontinence care (if necessary) • Cleansing agent for incontinence care (if necessary) • Designated microwave and/or warmer PROCEDURE: 1. Warmin g t11e Basinless Clean sing bath a. Warm according to directions on the package. b. Consult package for complete indications. ingredients and warnings. 2. Bathing with Basinless Cleansing bath a. Ensure a private environment. Key Point: Use a towel or sheet to cover the patient appropriately to protect their privacy as you progress through the bath. b. Remove the Skin Check label from the bath package and place in an accessible location. c. Peel back the package label and test the temperature of the washcloths If temperature is acceptable to your touch. yo1.J may proceed with tl1e bathing process. Key Point: Remember. gloves diminish your sensitivity to heat. Obtain feedback from your patient on his or her comfort with the bath. d. Remove the first wasl1cloth. Clean the lace. neck and upper torso with the #I washcloth and discard . No rinsing or drying is required. Key Point: Following the bathing procedure in a sequenced order red uces the chance of cross contamination by providing a cl ean washcloth lor separate are as of the body while max1m1zing appropriate use of the product to prevent waste In pat1ents who have a potential fo r moisture entrapment in skin folds. it may be necessary to pat dry with a clean soft towel. e. Remove the ii 2 washcloth. Clean the right arm with the 112 washclotf1 and discard. f. Remove the #3 washcloth. Clean the left arm with the #3 washcloth and discard. g. Remove the #4 washcloth Clean the peri neal area wilh the /14 washcloth and discard . II patlent is incontinent. clean perineal area according to the incontine nce care policy and procedure. h. Remove the #5 washcloth Clean the right leg with th e #5 washcloth and discard. I. Remove the #6 washcloth. Clean th e left leg w1th th e #6 washcloth and d1scard. j. Remove the #7 washcl oth. Ask the patient to turn on their s1de, 11 able , or obtain ass1stance. as necessary. Clean the upper back wit h the 117 washcloth and discard. k. Remove the #8 washcl oth. Cl ean the buttocks with the 118 w ashcloth and d1sca rd . If additionaJ clean ing 111 the buttock.s reg ion is necess ary due to incontinence , refer to incontinence care policy and procedure. I. Once the bath is completed. apply cle an gown. cover th e patient as appropriate and return side rails to correct position. m. Complete additional personal hygiene activitie s as necessary (oral care . comb hair and clean nail beds ; wash hair and sh ave facial hair as r1ecessary). 3. Instruct th e patient about importance of personal hygiene. 4. Clean the work environment and leave the patient in a safe, comfortable position. Return the head of bed to a 30° position if no contraindications . 5. Documentation: a . Using the Skin Ch eck label , mark areas of skin redness or breakd own on the appropnate body diagram. Document patient's name, location and who completed th e skin monitoring check. If skin monitonng was completed by a nursing assistant. g1ve the completed label to the RN assigned to ihe patient for follow-up skin assessment. Otherwise. place the Skin Ch eck label in a designated documentation location as applicable b. Document completion of the procedure on t11e appropriate form. · ADVANCING NURSING 2004 Aeprmled wilh permrssoolrom Kathleen Vollman

ll.:•/Jriull•fl from . t I ('.\ ,\'/~'II 'S, f llf!l/.ur face~. We di ~ overed our current maure~~L'' cou ld '-Uppc rt only 2 p~>u n cb ( 11_ kg). but the bed frame wa. ap::tbk or acc ommoda tin g up to 400 pound, ( 1RO kg). This discnvct , Jed tr) the u~e of rL·nt al haria tric t · ds an I ma 11rc~ s es in the intcn ·ivc care unit and ~ tcp - down nnit t meet the n eed~ 1)f ou r h;niat ric patient:,. \ h compri · abnut 0 r of our patiem population.

·o

Making the Change Happen The new bundle wa., prbcnh::d to our intcn ,[vL' care unit ommittce anti a1 proved b. ur medical executive L'Ommill The ~ t-tandardized. Best re earL·h practice' were evaluated to determine how best to meet our patiems' need~. One problem VJ cxperic n.:ed wa ~ e a· soon m. possible by dail. as. e. ~mcnt of nt'L'U Juring rntH1 (k Immediate impro ve ment w m; noted: during the nex t 4 mon th s. th ere were no UTr · in o ur Lmit, an d our Tl r;ue i' onl v I % for th e. cpir:lt< r') Infection , ecrion of the· article. Li"" l'vl illcr c• •ntributcd the Effccii V47-1 655 . 6. Rodngm"I- Roldan .J M . Al!un:.t-Cuesta . Lope~ A. ct al. f r •vention of nowcomial lun • infection in ventilated p:l tlc nt': u'c- (>! an anrimicrobral nonab~orba hle p :r~ t c. rll C(lrl! M t>tl. 1990; I R: I_ l). 1242. 7. Pugin J. Aucl.cnthn lcr R. l .'w DP. Suter PM. Oropharyng~:a l d • Onl:lminatiun d ' l·~:t-C\ im:idenc uf \' lllilator-a_"ociatctl 1 n.:umonia: a randomiLcd. plncchn-conlroll.:d. doublc-bhnd tliniL'a l trial. .lAMA. 1991:265:1704-2710.

,5

. Gibhon' RJ. EtJt~rden I. - ibron.: rin-d grnding enzyme, in ancl their relation to oral clean li ne"'· .I Peridonwl R£"'. 1'), 6:2 1:JS6- _,9- . 9. Kerwr AJ. Rnmme. JH , Mevi~scn-Yerh"gl' E:\. cl aL C0lo nintit>n :111d infection in surgical intetNI c care paricrm: a pro~pCL't ivc , tudy. l ntensiv()' Core M d. I() '7: I :"1:.147-l' Re>fJir Di~. 199.' : 14l'i:3 2-357 I I. "r:t\'L"tl DE. Steger KJ-\ . N , o.-omial pneumonia in mcchaniL-a lly ventilated adult patient ~: cpidcmiol(>g_ and prcwntion in 1996- SPmitl J?,··'t'ir Jnfeo . 19'l6: I I :32-53. 12. Scann;1pieco -A . Role of ora l bacte-ria in l'l:'piratory infection. J Paiodont. 1999;70:7'13-R02. 13 "c~mn ;rpieco F , Sl ·wru·t E. Mylouc J. oiOtll lallOn of 1.kntal plaque by rc•,pirarory pathogens in tm:di ·al intL'rt>ive c~ rt: patienh. "rit Cn rc ,vJed 19()2:20:740- 7-15. 14 . Ft'utTi ' r F, Dovi\ ier B. Boutigny H. Rott"~l- Dc h allt:t M. Chopitt ~olnni7iiUOn of t.knta l plnque. :r sou rce of nn\ocom i~ll infL·c-tinn., in int n'ive c;u·e unit paticnh . Crit Cnre M t·tl. 199~: ~6 :c'O 1-.~0•. 15. G ~rrL"ia R. Jetlilre,l-y L. Colbert L. R~cl u •tinn of micmhial coil nin n inn in the o mpharynx nnu dental plaque red uce · ventilator· a,,ocimeu pneumoni;l lab,trm.:t 1. _; I ~t Annual Educarinn Cnnf·rence unJ lmemati nnal Meetine of thL· ' ' uciation of Profc-.\Sional~ in lnkctinn Con tr J & 8pi..iemiolo y (A PI ·,. Jun~ 2004. Phooni)(, Ari,, I6. Ccnter' for Di c;" t: Control :rod Prn pit:.t lit atio n ;t ot" I prc,,w-c ulc~ r ? a . -~ L:. 5 1 .4 d. 6

- · A s on intcrv~ntionul h)•gicnc mc~w rc. or;d c at';, moot meant 10 target ' hich of the follt> v. in g . a. Pf('v~n t• nn of dental c ;u·ic: ~ b. Improved oral intake c. P r ·v~ n t ion of vcntilator-a,:-.odut ·d pneun um ia ( VAl' ) d. Prop T admi ni ,trntion nt Ordl m~d kation '

II). Pn"sure ulcer-. and kin injurie' havc: been ide ntifkd a:-: which of the lead in•• pl' tJmt wh icl1 uf the fo llowing primary ,ource of rc,piwwr. -related infection ' . a . tom:iL"I-1 l'. Ornl ca" it · b. Gut d. aso p h ary n ~

i~

the

h. 15'k

Wh;u 1~ the "· 4000 b. $ 10000

e~timate d

t:'

1 of 11

d. 25'k

. Which of the fo llowi ng mea ur.;, u .:s not dccrca'c th · .:ro,_,.c, ntnmi n:.nion with illcOn tiot!nl p:..ti 'tl t~ '! a. Di spt»~•h l c mattrc s pi!d> b. J3a,inJc.,;. protl ucts ·. Di, po able b:Hh cloth ' d. in gle- u~ • produ ct~

-. Re,ear ·h on the usl" of oml C:Hre l w.~ de mnnq rated what perccntag de rcJ'" in rnte' of V P'! a. I- " ..'l\ i( b._() d. -12% li.

d. 4000

I __p,..,~ ure ulcer, incr.:a.~c :1parient', ri \~ of d ~;: ' d opin:-_> a hospi ta l-acquired infc 11011 by what percentage? a. I or· c. ~0'7

c. 'O ,r d. 40"

ri ~ ~

of

14 . Lm pl"mentation o f a urinary tract bundle in one intcrvcmiona l byg_i 'II ' 'llld y r.;duct::d th~ incidenCe Of infection~ tO what percc nt agc'l

ca_o,e of V P infc:c tiu n' •. 2 000 d. 0000

u. IO b. '1

i. What is the e~timmed morr:t lity rote of VAP? fl . JQ~ II' -10 ,r C. 'Q tO 50'Jt b. 25'1} tO iS % d. 40%- ILl '1) '#-

e. 5'7" cl .l ~

15. Wha t i• tile rc ·ommc nu ed frcq u"nc)' or moni t