With support from CDC’s Division of Healthcare Quality Promotion, NACCHO has supported University of California Irvine’s work to study and promote the use of chlorhexidine (CHG) for routine bathing and showering in nursing homes. CHG, which is a disinfectant and antiseptic, is shown to reduce the extent to which residents in nursing homes or patients in other long-term care facilities (LTCF) are colonized with certain bacteria. Colonization indicates that the bacteria are living on the individual’s skin, and while not causing an active infection, can pose a risk for spreading the germs or lead to a healthcare-associated infection (HAI) if there are changes to the individual’s condition.

This area of research has shown that CHG bathing, combined with a specific protocol for use of nasal povidone-iodine, can reduce patient transfer to a hospital due to infection. Given the danger that multi-drug resistant organisms can pose to nursing home residents and LTC patients, this approach could effectively prevent HAIs. NACCHO, with technical assistance from the UCI research team, worked with seven BUILD HAIAR sites to explore the role of local health departments (LHDs) in promoting CHG bathing for decolonization in nursing homes or LTCFs. Selected LHDs submitted reports outlining their efforts, challenges, and successes related to CHG bathing, and these are summarized below.

The Current Role of LHDs in Supporting CHG Bathing Practices

In general, the LHDs identified education and monitoring & evaluation as the two main means by which they could help implement the decolonization strategy.

Providing training to healthcare staff on bathing techniques, facilitating public awareness campaigns about the effectiveness of the decolonization strategy, serving as a connection between experienced facilities and those looking to implement the strategy for the first time, and providing technical assistance, i.e., answering questions on the process and products used, are several examples of how LHDs can support facilities in learning about the decolonization strategy. Educational topics can also include the burden of MDROs, the importance of reducing infections, and how the decolonization strategy can reduce hospital admissions among residents at LTCFs.

LHDs also discussed providing evaluation and surveillance for facilities by auditing bathing practices or by providing auditing tools for facilities to do so independently.

Challenges to Implementing the CHG Bathing Strategy

Several challenges limit the ability of local health departments and other health facilities to implement the CHG bathing strategy in their jurisdiction(s), including:

1. Limited funds: Sufficient funding to cover the cost of supplies, monitoring & evaluation systems, training, and public awareness campaigns is essential for implementation. Some facilities also found the costs of the CHG soap and antiseptic iodine nasal swabs prohibitive.
2. Buy-in from facility leadership: Many LHDs described the difficulty of getting buy-in from upper management or administration at the healthcare facilities. Some of the concern stemmed from costs, but one LHD also noted that because they have smaller facilities (<100 beds) in their jurisdiction than the facilities evaluated in the research study done by the UCI team, they had difficulty demonstrating the effectiveness of the decolonization strategy. Another challenge they described was getting leadership on board when many facilities are run by large corporations. This means LHDs must seek approval from multiple stakeholders. A lack of sufficient incentives to implement the strategy is also a challenge. Effective incentives could include funding for supplies, regulatory requirements (to use CHG bathing and nasal swabs), and/or higher insurance pay or reimbursements for facilities that have implemented the decolonization strategy.
3. Challenging protocol requirements: Some facilities discussed the challenges of integrating new protocols on bathing into existing healthcare practices. Protocol changes can be very complex, requiring meticulous planning and coordination. Having multiple protocols to implement can also present a challenge. Two LHDs reported that the Centers for Medicare & Medicaid Services (CMS) requirements for Enhanced Barrier Precautions (EBP) happened at around the same time as this project, and facilities prioritized staff education and training on the former.
4. Staff turnover: Three LHDs described rapid turnover of staff in administrative positions and infection prevention positions as a challenge to implementation. LHDs have to reestablish contacts and redo training, which can be time-consuming and reverses previous progress made to implement the decolonization strategy.
5. Facility-reported barriers: One LHD conducted a bathing needs assessment and identified challenges surrounding bathing that could make implementing the decolonization strategy difficult. The most common issues were residents refusing bathing, the burden that bathing presented on staff time, and inadequate training on bathing techniques.

Recommendations

LHDs interested in introducing the decolonization strategy to facilities in their jurisdictions, or funders interested in supporting LHDs in doing so, should consider the following in preparation for implementation:

• Success Stories: Examples of facilities who have successfully implemented the decolonization strategy can provide context on challenges, lessons learned, or advice for other facilities to help encourage adoption of the strategy.

• Templates: Templates of useful documents, such as a communication letter or modifiable quality assurance performance plan, can be distributed by LHDs to facilities. Each LTCF’s needs are different and being able to adapt documents to different cultures or languages will help increase rates of facility adoption of decolonization programs.

• Finances: A method of estimating and demonstrating cost savings specific to facilities would also help when presenting the strategy to administrators.

• Incentives: LTCF incentives to fund supplies and staff training, higher insurance pay or reimbursements for facilities that have implemented decolonization, and/or regulatory requirements (mentioned above) can help encourage adoption of the strategy.

• Virtual Trainings: Virtual bathing trainings, such as those on NACCHO University, can help educate different types of facility staff on how to implement this decolonization strategy.

Conclusion

Using CHG soap is an effective method for decolonization and can help reduce the spread of HAIs in nursing homes and other long-term care facilities. However, several challenges limit widespread adoption of this strategy in facilities, including resource costs, staff turnover, insufficient support from facility leadership, challenging protocol requirements, and various facility-reported barriers.

Local public health may play a role in proper CHG bathing by providing training and support for facilities but are still in the early days of exploring the benefits and challenges. As LHDs continue to partner with their healthcare facilities and look for strategies to reduce the spread of HAIs in their communities, this may be one approach to consider as part of a broader program, particularly if facilities express interest and resources are available.