Recommended Citation
Johnson MR. One and done - A process for improving CHG bathing compliance. Quality Improvement poster presentation at Empowering Nursing Excellence: Recognizing the Value and Impact of Nurses, Advocate Health Midwest Region Nursing Research & Professional Development Conference 2023; November 15, 2023; virtual.
Presentation Notes
Quality Improvement poster presentation at Empowering Nursing Excellence: Recognizing the Value and Impact of Nurses, Advocate Health Midwest Region Nursing Research & Professional Development Conference 2023; November 15, 2023; virtual.
Abstract
The prevention of hospital-acquired infections is a growing topic in healthcare. This has resulted in an increased focus being placed on CHG bathing, as it helps to reduce the patients’ risk for developing infections while hospitalized, as well as the associated costs. At Carolinas Rehabilitation, the expectation is that all patients who have central lines inserted and those who have tested positive for MRSA infections will receive CHG daily CHG baths for a specified period. Chart audits helped to confirm the lack of consistency with getting the CHG baths completed and/or documented by our Nursing and Therapy teammates.
We tried different approaches to addressing this problem. We finally landed on what we now call the “One and Done” program, which involved setting the expectation that all CHG baths would be completed and documented by 1300 daily. Between 1300 and 1400, the Clinical Supervisor/Charge Nurse would review the medical record to ensure the documentation had been completed per policy. If the documentation had not been completed the leader would follow up with the teammate individually.
The implementation of the One and Done program resulted in increased compliance with the completion and documentation of CHG baths. We now consistently exceed the target of 85% compliance. The process took approximately two months to hardwire with our teammates and we continue to watch compliance by conducting random chart audits within the department. Since the implementation of the One and Done program, there have been zero hospital-acquired infections related to CHG bathing at Carolinas Rehabilitation – Northeast. With the noted success of this initiative, the One and Done program has been shared with all Carolinas Rehabilitation Nursing units within the central market, with noted improvements in compliance.
Document Type
Poster
Publication Date
11-15-2023
One and done - A process for improving CHG bathing compliance
The prevention of hospital-acquired infections is a growing topic in healthcare. This has resulted in an increased focus being placed on CHG bathing, as it helps to reduce the patients’ risk for developing infections while hospitalized, as well as the associated costs. At Carolinas Rehabilitation, the expectation is that all patients who have central lines inserted and those who have tested positive for MRSA infections will receive CHG daily CHG baths for a specified period. Chart audits helped to confirm the lack of consistency with getting the CHG baths completed and/or documented by our Nursing and Therapy teammates.
We tried different approaches to addressing this problem. We finally landed on what we now call the “One and Done” program, which involved setting the expectation that all CHG baths would be completed and documented by 1300 daily. Between 1300 and 1400, the Clinical Supervisor/Charge Nurse would review the medical record to ensure the documentation had been completed per policy. If the documentation had not been completed the leader would follow up with the teammate individually.
The implementation of the One and Done program resulted in increased compliance with the completion and documentation of CHG baths. We now consistently exceed the target of 85% compliance. The process took approximately two months to hardwire with our teammates and we continue to watch compliance by conducting random chart audits within the department. Since the implementation of the One and Done program, there have been zero hospital-acquired infections related to CHG bathing at Carolinas Rehabilitation – Northeast. With the noted success of this initiative, the One and Done program has been shared with all Carolinas Rehabilitation Nursing units within the central market, with noted improvements in compliance.