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I need you to work on this project from part 4 forward (everything highlighted in yellow). Attached are the first 3 parts of the project and the rubric with the instructions of the whole project so you can work on what’s missing. Also, even though the due date for the project is next week I need to submit part 4 for tomorrow which covers the following

Part 4: Develop Recommendations for Practice

From the synthesized evidence, determine if validity and strength are sufficient to incorporate it into practice.

What are your plans and strategies for implementing recommended changes?

oIs this applicable for larger group of population or for an individual patient?

Address factors like – time and monetary investment to train staff, and cost of supplies, who will be involved in implementing these changes

Is theory- practice gap? How can nurses bridge this gap?

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I would appreciate if you can send me tomorrow a word document with just part 4 so I can submit it and then you’ll have the rest of the week to finish the rest of the project

The main idea of this research project is how can we, as nurses, prevent or decrease the
risk of CAUTI (catheter acquired urinary tract infection). While doing research on the previous
topic, the group came across a myriad of articles that, in fact, established CAUTI as a recurrent
problem in most hospitals, especially in the geriatric population. As we moved forward in our
paper, we decided for the sake of the research, to find which bacteria were the most common in
CAUTI; according to the CDC Escherichia coli (Gram negative) accounts for 21.4% of cases,
Enterococcus spp (gram positive) accounts for 14.9%, and Pseudomonas aeruginosa (gram
negative) accounts for 10%.
Escherichia coli is a common bacterium of the intestinal flora, and Enterococcus spp is a
normal bacteria found in the GI tract. Given this information, it is safe to assume that the
presence of these two bacteria in the vaginal or penis area is due to erroneous perineal care,
either by the nurse or by the patient. Therefore, the following recommendations have been put in
place:
•
•
•
Educate patient on how to perform correct perineal care
Ensure all nurses or personnel providing perineal care are aware of the specific
guidelines that have been put in place to decrease UTI’s.
Bathe patient with chlorhexidine to help decrease the risk of infection.
Pseudomonas aeruginosa is a bacterium that is not found in the GI or intestinal flora of the
patient, instead is brough by the nurse of HCP from an outside source. After a brainstorm we
concluded that the following recommendations are potential solutions for the present issue:
•
•
Have the nurse or personnel applying the catheter wash their hands up to their
elbow w/ chlorhexidine.
Have the nurse or personnel applying the catheter perform extended perineal care
to places like the inside of the tights and the pelvis (w/ chlorhexidine).
Why do we recommend the usage of chlorhexidine as an antiseptic?
We recommended chlorhexidine as the best antiseptic to be used because it provides a
wide range of coverage, including gram-positive and gram-negative bacteria, fungi, enveloped
viruses, and Mycobacterial tuberculosis (Bednarik et al., 2022). As previously stated, the most
common organism for nosocomial infections are bacteria that range from gram-positive to gramnegative, therefore this antiseptic seems like an adequate option. Furthermore, in a comparative
study done the results showed that in a group of women where chlorhexidine was used, the
incidence of UTI was significantly lower (13.3), while in the group where normal saline was
used the UTI incidence was 76.7% (Hamed, 2020).
How can this antiseptic be used?
Chlorhexidine can be used to bathe the patient prior to catheterization, it can also be used
by the nurse to wash their hands before the procedure, and as mentioned before it can be used to
clean the perineal area. As of today, there have been no studies that make emphasis on how
patient that need catheterization would benefit from chlorhexidine baths. However, a study done
by Janette Denny and Cindy L Munro on 2016 provide evidence to support incorporating a CHG
bathing regimen to reduce the incidence of CLABSIs (central bloodline stream infection), SSIs
(surgical site infections), VRE (vancomycin-resistance enterococci), and MRSA (methicillinresistant Staphylococcus aureus).
More research on the topic shows that chlorhexidine was associated with a reduced total
incidence of infection, corresponding toa reduction of 1.69%; similarly, it was associated with a
reduction in the incidence of infection among patients in the moderate risk and the high-risk
category (Wang et al., 2017). Since this antiseptic has been proven useful on preventing
nosocomial infections, then we can conclude that it would work for CAUTI as it is a hospital
acquired infection.
What is a safe concentration of the antiseptic that can be applied to the client w/o causing
damage?
Pre-operative instructions for chlorhexidine (CHG) shower/bath show a 2%-4%
concentration of chlorhexidine (CHG) solution. Despite the effort to search for articles that
supports or condemns this concentration, we were not able to find any. However, if a patient
presents any symptoms like a rash, or anything that can indicate an allergic reaction, then the use
of said antiseptic should be stopped, and the HCP should be contacted.
Is this antiseptic cost effective?
A recent study explored the effectiveness of using a 2% chlorhexidine wipe bath to
reduce central line associated blood stream infection, the results were the following: CLBASI
infections decreased from 8.69 to 1.83; with 2 % CHG monthly costs was US$2,698.00,
achieving 30% savings (Feriani et al., 2021).
Why should we educate patents/healthcare workers on how correctly perform perineal
care?
It is important that all patients have a correct understanding of the proper procedure to
perineal cleansing to avoid having foreign bacterium that can cause infection. It is also important
that the healthcare workers have this knowledge as well, as there are many bed-bound patients
that rely on nurses for hygiene care, therefore all personnel should be thoroughly trained on the
appropriate technique.
References:
Bednarek RS, Nassereddin A, Ramsey ML. Skin Antiseptics. [Updated 2022 Jan 21]. In:
StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available
from: https://www.ncbi.nlm.nih.gov/books/NBK507853
Cao, Y., Gong, Z., Shan, J., & Gao, Y. (2018, September 20). Comparison of the preventive
effect of urethral cleaning versus disinfection for catheter-associated urinary tract
infections in adults: A network meta-analysis. International Journal of Infectious Diseases.
Retrieved March 15, 2022, from
https://www.sciencedirect.com/science/article/pii/S120197121834520X
Centers for Disease Control and Prevention. (2015, November 5). Background. Centers for
Disease Control and Prevention. Retrieved March 15, 2022, from
https://www.cdc.gov/infectioncontrol/guidelines/cauti/background.html
Denny, J., & Munro, C. L. (2017). Chlorhexidine Bathing Effects on Health-Care-Associated
Infections. Biological research for nursing, 19(2), 123–136.
https://doi.org/10.1177/1099800416654013
Feriani, D., Souza, E. E., Carvalho, L. G. M., Ibanes, A. S., Vasconcelos, E., Barbosa, V. L.,
Kondo, S. K., & Abboud, C. S. (2021, January 27). Is it cost effective to use a 2%
chlorhexidine wipes bath to reduce central-line associated blood stream infection? A
quasi-experimental study. The Brazilian Journal of Infectious Diseases. Retrieved March
15, 2022, from https://www.sciencedirect.com/science/article/pii/S1413867021000015
Hamed Sarani, Z. P. M. (2020, July 12). Comparison of the effect of perineal care with normal
saline and 2% chlorhexidine solution on the rate of catheter-associated urinary tract
infection in women hospitalized in Intensive Care Units: A quasi-experimental study.
Medical – Surgical Nursing Journal. Retrieved March 15, 2022, from
https://brief.land/msnj/articles/106739.html
Musuuza, J. S., Roberts, T. J., Hundt, A. S., Carayon, P., Zimbric, M. L., Schuetz, V., Reppen,
M., Smith, W., Koffarnus, K., Brown, R. L., Bowling, J., Jalali, K., & Safdar, N. (2020).
Implementing daily chlorhexidine gluconate treatment for the prevention of healthcareassociated infections in non-intensive care settings: A multiple case analysis. PloS
one, 15(4), e0232062. https://doi.org/10.1371/journal.pone.0232062
Tennant K, Rivers CL. Sterile Technique. [Updated 2021 Sep 21]. In: StatPearls [Internet].
Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from:
https://www.ncbi.nlm.nih.gov/books/NBK459175/
Tenke, P., Mezei, T., Bőde, I., & Köves, B. (2016, October 18). Catheter-associated urinary
tract infections. European Urology Supplements. Retrieved March 15, 2022, from
https://www.sciencedirect.com/science/article/abs/pii/S1569905616301439
Vallejo, R., Fernandez, D. S., Cervera, L. A., Aragón, L. M., Iglesias, M., Yurrita, L., & Lopez,
D. L. (2018). Effectiveness of surgical hand antisepsis using chlorhexidine digluconate
and parachlorometaxylenol hand scrub: Cross-over trial. Medicine, 97(42), e12831.
https://doi.org/10.1097/MD.0000000000012831
Wang, Z., Zheng, J., Zhao, Y., Xiang, Y., Chen, X., Zhao, F., & Jin, Y. (2017). Preoperative
bathing with chlorhexidine reduces the incidence of surgical site infections after total
knee arthroplasty: A meta-analysis. Medicine, 96(47), e8321.
https://doi.org/10.1097/MD.0000000000008321
Author (s)
Mangal, Sabrina et al.
Foster MD, Charles B., et
al.
Year
Title
Research
Method
Findings
Recommendations
Systematic
Review
Studies reviewed and evaluated found
that patient and family engagemnt in
CAUTI prevention mechanisms that
were used to incooporate these
groups were varied in content.
However, less than half of the studies
did show statistically significant
results on the engagemnet of family
and paitent on CAUTI prevention
They state more research
should be done to
systematiccaly develop a
method for delivery of
information to achieve the
intended effect.
2021
Patient and Family
Engagement in
Catheter-Associated
Urinary Tract Infection
(CAUTI) Prevention: A
Systematic Review
2020
After the introduction of the pediatric
CAUTI IBs and MBs, CAUTI rates
across the network decreased 61.6%,
from 2.55 to 0.98 infections per 1000
catheter-line days. After the
Catheter-Associated
introduction of the SPS CAUTI
Urinary Tract Infection
prevention bundles, the CAUTI rate
Reduction in a Pediatric
across the network decreased 61.6%,
Safety Engagement
Quantitative
from 2.55 to 0.98 infections per 1000 introduction of the SPS
Network
longitutinal study CLDs.
CAUTI prevention bundles
Lona Mody, MD, MSc1,2;
M. Todd Greene, PhD,
MPH3,4; Jennifer
Meddings, MD, MSc3,5,6;
Sarah L. Krein, PhD,
RN3,4; Sara E. McNamara,
MPH, MT(ASCP)2; Barbara
W. Trautner, MD, PhD7,8;
David Ratz, MS3,4; Nimalie
D. Stone, MD, MS9; Lillian
Min, MD, MSHS1,2; Steven
J. Schweon, RN, MPH,
MSN10; Andrew J. Rolle,
MPH11; Russell N.
Olmsted, MPH12; Dale R.
Burwen, MD, MPH13;
James Battles, PhD13;
Barbara Edson, RN, MBA,
MHA11; Sanjay Saint, MD,
MPH3,4,5
2017
Mohamed H. Gad, Hesham
H. AbdelAziz
A National
Implementation Project
to Prevent
Catheter-Associated
Urinary Tract Infection in
Nursing Home
Original
Residents
Investigation
Catheter-Associated
Urinary Tract Infections
in the Adult Patient
Group: A Qualitative
Systematic Review on
the Adopted
Preventative and
Interventional Protocols
From the Literature
2021
Systematic
Review
The initiative focusing on technical
and socioadaptive interventions
included 404 community-based
nursing homes. The results showed a
decrease of UTI by 54% and the urine
cultures decrease by 15% in the
duration of this longitudinal analysis. A pt should be thoroughly
Overall, catheter utilization was
assessed before the use of a
unchanged.
catheter. If it is not necessary,
pt should not be ordered a
catheter. When placing, caring
for or removing a catheter,
only trained personnel should
perform the procedure. Do not
maintain the catheter for more
than 3 days, do an evaluative
assessment to reconsider the
change of the assistive
device. Perform extensive
perineal care accordingly.
During the experiment it was found
that the time associated with
catherization played an important role
in the rate of CA-UTI. The lower the
time the catheter was inside the
patient, the lower the risk for UTI. No
significance difference was found
between the clamping and
unclamping groups in the outcomes of
UTI and patients bladder function.
Results showed that lower CA-UTI
rate with intermittent catheterization
compared to an indwelling catheter
left in place for seventy-two hours.
It is recommended that if a
patient does not need to have
an indwelling catheter, then
do not use it. Since
intermittent catheters are
associated with lower risk of
UTI, then it would be
recommended to use those,
and leave the indwelling
catheter as a last result.
Düzkaya, Duygu Sönmez;
Uysal, Gülzade; Bozkurt,
Gülçin; Yakut, Tülay; Çitak,
Agop
Povidone-Iodine, 0.05%
Chlorhexidine
Gluconate, or Water for
Periurethral Cleaning
Before Indwelling
Urinary Catheterization
in a Pediatric Intensive
Care
2017
Vargas-Cruz, Nylev, et al.
2019
Randomized
Controlled Trial
Pilot Ex Vivo and In
Vitro Evaluation of a
Novel Foley Catheter
with Antimicrobial
Periurethral Irrigation for
Prevention of
Extraluminal Biofilm
Colonization Leading to
Catheter-Associated
Urinary Tract Infections
(CAUTIs)
System Review
Subjects were assigned to three
groups: periurethral cleaning with
0.05% chlorhexidine; 10%
povidone-iodine; or sterile water. UTI
occurred in 15 % of the patient in the
povidone-iodine, 4.8% in the
chlorhexidine gluconate group, and
7.5% in the sterile water group. Even
though the group that showed the
least UTI infection was the one with
chlorhexidine gluconate, the results
were not statistically significant.
Uniform periurethral irrigation was
demonstrated in ex vivo porcine
model by adding a dye to the
antimicrobial urethral irrigation
solution. An in vitro biofilm
colonization model was adapted to
study the ability of periurethral
irrigation with a new antimicrobial
combination consisting of
polygalacturonic acid+caprylic acid
to prevent axial colonization of the
extraluminal urethral indwelling
catheter shaft by common
uropathogens. A trial of seven
different tests were performed. The
novel foley catheter and pg+cap
antimicrobial irrigant prevented
biofilm colonization in a vitro CAUTI
model.
Even though the numbers
superficially show a lower UTI
infection for those with
chlorhexidine gluconate, the
numbers obtained were not
statistically significant.
Therefore, further research
with a larger group is
recommended.
Other interventions have been
proposed for minimizing both
extraluminal and intraluminal
colonization pathways with
conflicting reports and
guidance for effectiveness in
preventing CAUTI.
Fasugba, Cheng, et al.
Mitchell, Brett, et al.
2019
2017
Chlorhexidine for meatal
cleaning in reducing
catheter-associated
urinary tract infections:
a multicentre
stepped-wedge
randomized controlled Cross-sectional
trial
study
The use Chlorohexedine
solution for metal cleaning
The intervention (Chlorhexedine for
before catheter insertion
metal lceaning) was associated with a decreased the incidence of
74% reduction in incidence of catheter catheter associated
associated asymptomatic bacteriuria asymptomatic bacteria and
and a 94% decrease in incidence of
UTI and can potentially
catheter associated UTI.
improve patient safety.
Reducing
cather-associated
urinary tract infections in
hospitals:study protocol
for a multi-site
Step wedge
randomized controlled randomized
study
controlled study
This study addresses the identified
gap that exists in infection control
research and practice. Despite the
fact that there are many patients with
CAUTI, there are not enough studies
done to to surveillance how this can
be prevented. This trialed focused on
the effectiveness of antiseptic vs
no-antiseptic metal cleaning agents to
prevent CAUTI.
It is important that urinary
catheter strategies for CAUTI
prevention are supported by
evidence obtained from
rigorously conducted
research. Therefore it is
imperative to conduct further
reseaech that provides
significant data on how the
use antiseptics would be
beneficial pver non-anticeptic.
Results from these studies showed no
difference in the incidence of CAUTIs
when comparing antiseptic and
non-antiseptics agents, or when
comparing different agent:
povidone-iodine vs routine care;
povidone-iodine vs soap and water;
chlorhexidine vs water;
povidone-iodine vs saline;
povidone-iodine vs water; and green
soap and water vs routine care.
Subgroup analyses showed no
difference in the incidence CAUTIs in
terms of country, setting, risk of bias,
sex and frequent administration.
However, comparison of an
antibacterial agent with routine care
indicated significance.
The results that were provided
in this systemic analysis
provide good evidence to
inform infection control
guidelines in catheter
management. However, there
was some significance un UTI
reduction when antibacterial
agent was provided in
perineal care.
Systematic review and
meta-analysis of the
effectiveness of
antiseptic agents for
meatal cleaning in the
prevention of
catheter-associated
urinary tract infections.
O. Fasugba, J. Koerner,
B.G. Mitchell, A. Gardner
2016
Systematic
Review
Brett Mitchell, Cassie
Curryer, Elizabeth Holliday,
Claire M Rickard, Oyebola
Fasubga
2017
Effectiveness of metal
cleaning in the
prevention of
catheter-associated
urinary tract infections
and bacteriuria: an
updates systematic
review and
meta-analysis.
Systematic
Review
Total of 18 studies were included in
this systematic review. The results of
these studies showed potential
benefits of using antiseptics,
compares with non-antiseptic for
meatal cleaning to prevent bacteriuria
and or CAUTI.
There is more evidence now
that using antiseptic agents
like chlorhexidine prior to
urinary catheterization plays a
role in decreasing CAUTI.

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