Standardized Nursing Protocol: Basin Bed Bathing With 2% Liquid Chlorhexidine (CHG) and Showering With 4% CHG Liquid Soap

Decolonization of

Non-ICU Patients With Devices

Section 9-2 – Standardized Nursing Protocol:

Basin Bed Bathing With 2% Liquid Chlorhexidine

(CHG) and Showering With 4% CHG Liquid Soap

Background: The Active Bathing to Eliminate (ABATE) Infection Trial found that decolonization

of adult non-intensive care unit (ICU) patients with specific medical devices (i.e., central lines,

midline catheters, and lumbar drains) resulted in a 32 percent reduction in all-cause

bloodstream infections, and a 37 percent reduction in positive methicillin-resistant

Staphylococcus aureus (MRSA) and vancomycin-resistant enterococcus (VRE) clinical cultures.

The following protocol details the process for performing skin decolonization in this population.

Protocol Overview

• Daily chlorhexidine gluconate (CHG) bathing/showering for non-ICU adult patients with

medical devices for the duration of the hospital stay

CHG for Targeted Decolonization

• Target patient population

o Include: Adult non-ICU patients with medical devices, particularly:

 Central lines (including dialysis catheters and port-a-caths)

 Midline catheters*

 Lumbar drains

o Exclude: Patients with known allergies to CHG

• Initiate the protocol each time an eligible patient is admitted to the hospital, even if the

patient has received the protocol in a prior admission.

To support the inclusion of midlines, note that the ABATE Infection Trial showed the same 32 percent reduction in

bloodstream infection for midlines as it did for central lines.

Decolonization of Non-ICU Patients With Devices Protocol: Basin Bathing/ 2

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Protocol for No-Rinse Bed Bath With 2% Chlorhexidine

Provide one-page CHG information sheet for patients to read prior to beginning bath (see

Section 10: “Bathe Daily with Chlorhexidine (CHG) Cloths - Patients”).

Before each CHG bath: Clean all incontinence or gross soilage using CHG-compatible baby

wipes or cloths with water. Do not use other soaps, as these can inactivate CHG. Ensure a trash

can is nearby for disposal of wipes after use.

Inform the patient that the CHG bed baths work better than soap and water in removing

bacteria from the skin and that the cloths serve as their routine bath (not a top coat).

If the patient wishes to self-bathe, provide verbal instructions, and assist with hard-to-reach

areas.

What You Will Need

4% liquid CHG to be diluted

Measuring cup

Bath basin

Six disposable wipes (more if needed for

lines, tubes, drains, or larger patients)

How To Perform a No-Rinse Bed Bath

With 2% Chlorhexidine

• Obtain a bath basin and dispense 1/2 cup of 4% liquid CHG into basin.

• Add 1/2 cup of water (Do not dilute more than equal part of water to CHG. The goal is to

achieve 2% CHG.) (Figure 9-2-1).

• Bring basin to bedside. Soak disposable wipes in basin. Wring each disposable wipe prior

to application. Only soak and wring each disposable wipe once. DO NOT apply wipe to

patient and place back in basin to rinse and apply again. Use each of the six wipes for

bathing skin areas as instructed below. Ensure that wipes are applied to skin by firm

massage to ensure the binding of CHG to skin proteins. This allows CHG to continue to

kill germs for a minimum of 24 hours.

o Wipe 1: Face,

neck, and chest. Avoid eyes and ear canals.

o Wipe 2: Both shoulders, arms, and hands

o Wipe 3: Abdomen and then groin/perineum

o Wipe 4: Right leg and foot

o Wipe 5: Left leg and foot

o Wipe 6: Back of neck, back, and then buttocks

*CHG has been safely used on the face and hair in several large clinical trials.

1-4

Pay special attention to avoid the eyes

and ear canals, as would be done when using all soaps. The risk associated with having CHG in the ear canal is that if

a patient has a perforated ear drum, that would allow CHG to come in direct contact with deep nerves of the ear. If

CHG comes in contact with the eye itself, flush well with water or saline.

Figure 9-2-1. How To Create 2% Chlorhexidine

Decolonization of Non-ICU Patients With Devices Protocol: Basin Bathing/ 3

Showering With CHG

• After applying a CHG wipe to a designated body section, use a clean section of the CHG

wipe (or a new wipe) to clean any device that is on that part of the body. This includes

not only any central line, midline catheter, or lumbar drain), but also any other drain

and tube on that patient’s body. In accordance with the ABATE Infection Trial protocol,

clean the 6 inches of ALL lines, drains, and tubing (e.g., central lines, midline catheters,

chest tubes, surgical drains, G-tube/J-tube, urinary catheter, rectal tube) that are

closest to the body using a clean portion of the CHG cloth, or a new CHG cloth. Wipe

over nonpermeable dressings. This will help remove bacteria close to where devices

penetrate the skin. CHG is safe to use on devices and should be used over non-gauze

dressings.

• If incontinence occurs, or if there are other secretions on the skin, remove soilage with

disposable wipes or towels. Rinse or wipe the affected area with water. Then, clean skin

with wipes soaked with CHG. If needed, use CHG-compatible barrier protection products

for barrier protection (contact product manufacturers to confirm CHG compatibility).

• Allow skin to dry naturally – do not wipe off.

• If additional moisturizer or lotion is needed, only use lotions that are known to be

compatible with CHG based on manufacturer information.

• Do not place wipes soaked with CHG directly on bedding. When washed in the laundry

cycle, CHG has a chemical interaction with bleach and will leave a brown stain.

NOTE: Once CHG is applied to the skin, it binds to skin proteins and will not rub off

onto bedding.

• Dispose of wipes in trash. Do not flush in toilet.

NOTE: Use as many additional CHG wipes as are necessary to thoroughly cleanse the

body.

Protocol for Showering With 4% Liquid Chlorhexidine

• Provide one-page patient instruction sheet on CHG showering (see Section 10: “Patient

CHG Shower Instructions”) for patients to read prior to beginning showers. Patients will

be more likely to read the instructions in their spare time.

• Provide patient with a single-use rinse-off 4 oz 4% CHG bottle for each shower.

• Wrap all devices as needed, to protect from water in shower.

• Provide patient with a mesh sponge, which allows CHG to lather well and aids

application to the skin. Do not use cotton cloths – cotton binds CHG and does not

release CHG well onto the skin. In addition, when laundered, CHG on cloths can mix with

bleach and cause a brown stain.

• Inform the patient that CHG works better than soap and water in removing bacteria

from the skin and that additional non-CHG soap should not be used.

• Provide the patient with the shower handout and the following verbal shower

instructions:

o Use liquid CHG as shampoo in addition to body cleansing.

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o Wet skin with water. Turn off water or stand out of water stream.

o Pour CHG onto wet sponge or cloth and rub sponge until it is foamy.

o Firmly massage soapy sponge all over skin in the same order as indicated for the

CHG cloth instructions (see Section 10). Reapply CHG generously to keep

sponge or cloth full of foamy lather. Be sure to clean from top down (cleanest to

dirtiest areas).

 Neck and chest, including under breasts for women

 Back of neck, shoulders, and back

 Armpits, arms, and hands

 Abdomen, hip, and groin

 Both legs and feet

 Perineum (genitals) last

o For best results, leave soapy lather on skin for 2 minutes before rinsing.

Lathering all body areas twice before rinsing generally takes about 2 minutes.

• CHG should be encouraged for hair, face, and body use. However, if patients insist on

using personal shampoo or face products, instruct them to use their personal products

first with a separate wash cloth, rinse well, and keep personal bathing products off of

the body because many regular soaps and all shampoos can inactivate CHG and prevent

its germicidal activity.

• After the shower, unwrap devices and use a single packet of two 2% CHG cloths to

clean the 6 inches of ALL lines, drains, and tubing (e.g., central lines, midline catheters,

chest tubes, surgical drains, G-tube/J-tube, urinary catheter, rectal tube) that are

closest to the body. Wipe over non-permeable dressings. This will help remove

bacteria close to where devices penetrate the skin. CHG is safe on devices and should be

used over non-gauze dressings.

Additional Important Instructions for CHG Bathing and Showering

• CHG replaces regular soap for bathing. CHG works better than soap and water to deeply

cleanse the skin.

• Do not use regular soap with CHG. Many soaps inactivate CHG.

• Ensure thorough cleaning, with special attention to commonly soiled areas such as the

neck, axilla, skin folds, and groin/perineal areas. CHG is safe to use on perineal areas,

including the female labia and genital surface.

• CHG is safe for superficial wounds, including stage 1 and 2 decubitus ulcers and

superficial burns, as well as rashes and abrasions. Use of CHG on these areas kills germs

and helps prevent infections. Do not use on large or deep wounds (e.g., wounds that are

packed with gauze or other products).

Decolonization of Non-ICU Patients With Devices Protocol: Basin Bathing/ 5

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• Use CHG for all bathing purposes, including once-a-day full-body bathing, cleaning after

soiling, or any other reasons for additional cleaning. This includes the face; however,

avoid contact with eyes and ear canals.

• If moisturizer is needed, provide patient with CHG-compatible lotion.

• Allergic reactions are rare but can occur. If your patient experiences a reaction possibly

related to CHG use, contact the patient’s treating physician for all clinical decisions on:

o whether to stop using the product

o whether to provide medication to address a possible reaction

• Adhere to facility policies for covering vascular access devices, dressings, etc., to prevent

water penetration and introduction of waterborne bacteria.

• Generally, patients with lumbar drains are not permitted to shower. However, use the

showering protocol if patient is able to shower with a covered waterproof dressing.

Escalation Efforts for Patient Refusals

As is the case with other medical care, patients can refuse any portion of decolonization, either

the CHG bath or the nasal product. In order to make sure your patient is maximally informed

before a refusal is accepted, perform the following:

1. Review tools in Section 14, which provide suggested responses to common patient

questions and scenarios for how to address patient refusals.

2. If patient initially declines

a. Assess why: Is your patient tired? Uncomfortable due to poor bed positioning? In

pain? These things need to be addressed before they will be likely to accept a

bath.

3. If patient declines after bedside nurse explains concept

a. An escalation pathway is recommended, not because a patient refuses, but

because some patients may respond to a different approach or style with better

understanding. For example, if a patient refused a critical antihypertensive or

diabetic medication, their healthcare providers should ensure that the person

truly understood the implications of that refusal and make every attempt to help

the patient take their medication. Similarly, the goal here is to ensure that the

patient understands that they are refusing a protective product that has been

proven to reduce their infection risk. Escalating simply means asking a more

senior or experienced leader or peer to attempt to communicate key concepts to

your patient. An escalation pathway may include asking an expert peer

champion, a nurse manager or director, or other member of unit or hospital

leadership to speak to the patient about their refusal.

b. In the ABATE Trial, escalation pathways were commonly used, to help explain

and reinforce the importance of the protection and safety provided by targeted

decolonization. If the patient refused after the concepts and purposes were

clearly conveyed through more than one attempt by the primary nurse and

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through escalation to at least one other person, the refusal was accepted as

being well-informed.

References

1. Huang SS, Septimus E, Kleinman K, et al. Chlorhexidine versus routine bathing to prevent

multi drug-resistant organisms and all-cause bloodstream infection in general medical

and surgical units: the ABATE Infection Cluster Randomized Trial. Lancet. 2019. Mar

23;393(10177):1205-15. PMID: 30850112.

2. Huang SS, Singh R, McKinnell JA, et al. Decolonization to reduce post-discharge infection

risk among MRSA carriers. N Engl J Med. 2019;380(7):638-50. PMID: 30763195.

3. Mupirocin-Iodophor ICU Decolonization Swap Out Trial.

https://clinicaltrials.gov/ct2/show/NCT03140423. Accessed August 11, 2019.

4. Huang SS. Chlorhexidine-based decolonization to reduce healthcare-associated

infections and multidrug-resistant organisms (MDROs): who, what, where, when, and

why? J Hosp Infect. 2019 Nov;103(3):235-43. PMID: 31494130.

AHRQ Pub. No. 20(22)-0036

March 2022