INTEGRATIVE REVIEW PAPER

Integrative Review Paper

Michelle Duesberry-Woody
Bon Secours Memorial College of Nursing
Nursing Research
NUR 4222
Kelly Spann

On my honor, I have neither given nor received aid on this

assignment or test, and I pledge that I am in compliance
with the BSMCON Honor System.

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Abstract

Surgical site infections can lead to 7-10 additional postoperative

hospital days, practically double the rate of re-hospitalization, and increase
hospital charges by $2,000 to $4,500 per patient (National Association of
Orthopaedic Nurses, 2011). The purpose of this integrative review is the
evaluation of literature concerning preoperative chlorhexidine preparation,
more specifically whether multiple applications are more successful than a
single application at the prevention of SSIs. The search for studies to be
used in the integrative review were computer-based using: EBSCO Nursing
Resources, PubMed, the Centers for Disease Control, and the Journal of
Orthopaedic Nursing. When the search results were completed, it yielded 23
articles. There were 19 research articles among the 23 articles, and 5 met
the criteria for inclusion in the review. The research showed that there was a
decreased incidence of SSIs with multiple applications of a chlorhexidine
gluconate containing preoperative wash. The research did not include
varying numbers of applications for preoperative washes or length of time for
each application. This would be a topic for additional research in the
prevention of surgical site infections.

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An Integrative Review: Preoperative Chlorhexidine Use

There is a great deal of research on ways to prevent SSIs with
preoperative cleansing. Since SSIs can double the rate of re-hospitalization
and add to length of stay, prevention methods in their various forms are
continually researched (NAON, 2011). Bundled payments are quickly
becoming the standard, and the Surgical Care Improvement Project (SCIP) is
also being used for reimbursement. These provide motivation for the
prevention of SSIs, as well as the desire to provide the best possible
evidence-based practice for all patients. This is an area of interest, because
of the researchers work in various areas of both pre and postoperative areas
within the hospital setting. The PICO question that is being proposed is: Do
Multiple Applications of a Chlorhexidine Gluconate Wash Prior to Surgery Decrease Surgical
Site Infections More Than a Single Application?
Research Design, Search Methods, & Search Outcomes
The research design for this assignment is an integrative review.
Research was largely conducted using the internet databases EBSCO Nursing
Reference Center and PubMed. Research was also conducted using the CDC
website, and it was also conducted using print articles from Orthopaedic
Nursing, the journal of the National Association of Orthopaedic Nurses. The
terms that were used in the search were total knee replacement,
chlorhexidine gluconate, and preoperative wash. PubMed yielded 19
articles. EBSCO, the CDC, and Orthopaedic Nursing had no articles, just four
informational items on the prep. The articles had to contain information on a

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preoperative wash with chlorhexidine gluconate (CHG) prior to the arrival at

the hospital, and the article had to be no more than five years old. Each of
the journal articles were peer-reviewed quantitative or qualitative articles,
and they needed to be in English with no jargon or slang. Articles were
excluded from the review if they did not meet the criteria mentioned above.
Findings/Results
Each of the articles that were used in the integrative review showed
that multiple applications of a CHG containing preoperative wash decreased
the number of SSIs following surgery greater than a single application
immediately before surgery (Anderson et al, 2014; Johnson, A., Kapedia, B.,
Molina, C., & Mont, M., 2013; Kapadia, B., Issa, K., McElroy, M., Pivec, R.,
Daley, J., & Mont, M., 2013; Kapedia, B., Zhou, P., Jauregui, J., & Mont, M.,
2016; Zywiel, M., Daley, J., Delanois, R., Naziri, Q., Johnson, A., & Mont, M.,
2011). The data from the research is presented following this review in the
attached table. See Table 1 for information in the following categories:
outcomes with single prep of CHG, outcomes with at least two washes with
CHG, and outcomes that were statistically significant.
Preoperative Chlorhexidine Preparation
Each of the studies that were chosen agreed that multiple applications
of the CHG preparation decreased the incidence of surgical site infections
greater than the use of a single application (Anderson et al, 2014; Johnson et
al, 2013; Kapadia et al, 2013; Kapadia et al, 2016; Zywiel, 2011). All of the
studies indicated that the use of a hospital infection control database

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assisted in the collection of the information for the studies, and each of the
studies was a quantitative study. In the study conducted by Anderson et al.
(2014), the researchers used both iodine and CHG as preoperative cleansing
agents for their study. In the group with a single prep the rate of infection
was 7.1% per 100 cases. In cases with two preparations, either CHG or CHG
and iodine, the rate of infection was 6.4% per 100 cases (Anderson et al.,
2014). Zywiel et al. (2013) had similar findings. Patients were provided with
the CHG cloths and instructions for use on the night before and morning of
surgery. In the patients with the CHG wipes none of the 136 patients had
SSIs, but of the 711 patients who did not use the cloths the incidence of SSIs
was significantly higher at 3.0%.
Kapadia et al. (2106) also did a study where patients were provided
with CHG wipes as well as an instruction sheet for home use. Among the
patients who used the preparation at home, there was a 0.3% rate of SSIs,
and there was a 1.9% infection rate among patients who had only a single
prep immediately prior to surgery. Johnson et al. (2013) found that patients
who used the CHG wipes at home had a 0.6% rate of infection, and those
with a single prep had a 2.2% rate of infection. Kapadia et al. (2013) also
had similar findings. Their study used the same data from the same single
facility, but used different analysis tools. They yielded the same 0.6%
infection rate with wipes, and 2.2% infection rate with single in hospital prep.
Variables Used for Analysis

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All five of the studies used a quantitative approach (Anderson et al,

2014; Johnson et al, 2013; Kapadia et al, 2013; Kapadia et al, 2016; Zywiel,
2011). The application of a single CHG containing preparation was a variable
in all of the studies. In the Johnson et al. (2013) a second application of
either CHG or iodine was used immediately prior to surgery (Johnson et al,
2013). In the remaining studies, a second application of CHG was used as a
variable (Anderson et al, 2014; Kapadia et al, 2013; Kapadia et al, 2016;
Zywiel, 2011). Each study used patients having either a total knee
replacement or revision as the test population (Anderson et al, 2014; Johnson
et al, 2013; Kapadia et al, 2013; Kapadia et al, 2016; Zywiel, 2011). The
Kapadia et al. (2016) study used the National Healthcare Safety Network or
NHSN categories to assess potential risk of infection in the patients
preoperatively (Kapadia et al, 2016). The patients were grouped into low
and medium risk groups based on wound class, length of procedure in
minutes, and American Society of Anesthesiology Score (Edwards et al.,
2009).
Outcomes with Statistical Significance
Each of the studies provided significant statistical evidence that a
preoperative application of CHG and a second application of either CHG or
iodine reduced the number of postoperative surgical site infections
(Anderson et al, 2014; Johnson et al, 2013; Kapadia et al, 2013; Kapadia et
al, 2016; Zywiel, 2011). Anderson et al. (2014) showed a 0.7% reduction
rate with multiple preparations. Johnson et al. (2013) and Kapadia et al.

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(2013) both saw a 1.6% reduction in the patients who had multiple CHG
applications prior to surgery from 2.2% to 0.6%. Kapadia et al. (2016) had a
reduction from 1.9% to 0.3%, which was also a 1.6% reduction in SSIs.
Zywiel et al. (2011) had a 3.0% reduction rate, since none of the patients
who completed multiple applications later reported a SSI.
Discussion/Implications
This integrative review findings are related to multiple applications of a
chlorhexidine gluconate containing preoperative wash. This study was
undertaken to support the PICO question asking if multiple applications of a
CHG containing wash decreased incidence of SSIs better than a single
application. All five of the quantitative studies utilized indicated that there
was at least a 0.7% reduction rate in SSIs when multiple applications of a
CHG containing wash or cloths were used.
The implications of the findings in the study indicate that multiple
applications of a CHG was can decrease the number of postsurgical
infections that occur. There are also implications for further study related to
a preoperative wash. An adjustment in the number of days that a
preoperative wash is completed may be necessary if future studies find that
three or four days decreases the number of SSIs even more significantly.
Limitations
There are a number of limitations associated with the integrative
review. This is the first integrative review undertaken by the researcher, and
the researcher has limited knowledge literature review. The researcher is

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currently a full-time student with a position as a registered nurse, which

allows for limited time to complete assignments that has to be divided
among classes. This is also the researchers first time attempting research
without the aid of instructors.
Conclusion
Surgical site infections (SSIs) are the second most common
healthcare-associated infection and are associated with substantial morbidity
and mortality rates (NAON, 2011). The use of chlorhexidine gluconate
containing washes or wipes can significantly reduce these SSIs. Further
findings indicate that multiple applications preoperatively can further reduce
the total knee replacement patients risk for infection. Additional study into
length of use for the preoperative wash could show an even greater
reduction in the incidence of SSIs. As the population continues to age the
number of individuals who choose to have total knee replacement increases.
Prevention of surgical site infections in those patients will be essential to
improve patient outcomes and improve quality of life. Knowledge and use of
current evidence-based practice will continue to allow nurses that care in the
prevention of SSIs.

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Table 1

Do Multiple Applications of a Chlorhexidine Gluconate Wash Prior to Surgery Decrease Surgical Site
Infections More Than a Single Application?

Research Question:
Complete
Citation:

Anderson, D. J., Pidgorny, K., Berrio-Rorres, S., Bratzler, D., Dellinger, E.

P., Greene, L., ... Kaye, K. S. (2014, June). Strategies to Prevent
Surgical Site Infections in Acute Care Hospitals: 2014 Update.
Infection Control and Hospital Epidemiology, 35(6), 1-24. Retrieved
from
http://apic.org/Resource_/TinyMceFileManager/Academy/ASC_101_r
esources/Guidelines-APIC-CDCWHO/SSI_Prevention_2014_SHEA_Guidelines.pdf

Research Aims/
Questions/
Hypotheses:

Prevention of SSIs/What methods can be used to decrease SSIs?

Study Design:

Quantitative study

Sample
Selection &
Characteristics
:

Randomized control trials

Setting:

Acute care setting

Variables/

Single preparation/multiple preparation; 6.4 per 100 for dual application & 7.1 per 100 for
single prep

Measures:
Data Collection
Instrument

Use of CHG and antibiotics decrease SSIs.

Confidence intervals for relative risk

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Used:
Data Collection
Methods:

Direct observation from inpatient physicians, infection control database

Description of
Intervention:

Multiple applications of preoperative wash

Data Analysis:

Both CHG and iodine can be effective in SSI prevention in multiple applications.

Major
Findings:

6.4 SSIs per 100 for dual application & 7.1 SSIs per 100 for single prep

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Do Multiple Applications of a Chlorhexidine Gluconate Wash Prior to Surgery Decrease Surgical Site
Infections More Than a Single Application?

Research Question:
Complete
Citation:

Johnson, A. J., Kapedia, B. H., Molina, C. B., & Mont, M. A.

(2013, June). Chlorhexidine reduces infections in knee
arthroplasty. The Journal of Knee Surgery, 26(3), 213218. http://dx.doi.org/10.1055/s-0032-1329232

Research Aims/
Questions/
Hypotheses:

Reduction of SSIs

Study Design:

Quantitative study

Sample Selection
&
Characteristics:

All total knee replacement patients between 2007 and 2011.

Setting:
Single acute care hospital

Variables/
Measures:

Data Collection
Instrument Used:

Multiple application of surgical preoperative wash

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Infection control database

Data Collection
Methods:

Description of
Intervention:

Excel spreadsheet software, x2, GraphiPad Prism Software

Patients provided with packets of CHG wipes for home use.

Data Analysis:
X2 with 95% CI

Major Findings:

Patients using three applications of CHG cloths at home had a 0.6% rate of
SSIs versus those with a single hospital prep of 2.2%.

Do Multiple Applications of a Chlorhexidine Gluconate Wash Prior to Surgery Decrease Surgical Site
Infections More Than a Single Application?

Research Question:
Complete
Citation:

Kapadia, B. H., Issa, K., McElroy, M., Pivec, R., Daley, J. A., &
Mont, M. (2013, June). Advance pre-operative chlorhexidine
preparation reduces periprosthetic infections following total joint
arthroplasty. Seminars in Arthroplasty, 24(2), 83-86.
http://dx.doi.org/10.1053/j.sart.2013.07.006

Research Aims/
Questions/
Hypotheses:

Reduction in SSIs

Study Design:

Quantitative study

Sample Selection
&
Characteristics:

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Database research of patients undergoing total knee replacement

Setting:

Acute care hospital

Variables/

Patient application of preoperative wash at home prior to knee replacement

Measures:
Data Collection
Instrument Used:

Hospital infection database

Data Collection
Methods:

Excel spreadsheet

Description of
Intervention:

Patient use of preoperative wash in addition to preoperative scrub versus

single application at hospital

Data Analysis:

Major Findings:

Patients using CHG cloths at home had a 0.6% rate of SSIs versus those
with a single hospital prep of 2.2%.

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Do Multiple Applications of a Chlorhexidine Gluconate Wash Prior to Surgery Decrease Surgical Site
Infections More Than a Single Application?

Research Question:
Complete
Citation:

Kapadia, B. H., Zhou, P. L., Jauregui, J. J., & Mont, M. A. (2016).

Does Preadmision Cutaneous Chlorhexidine Prepatation Reduce
Surgical Site Infections After Total Knee Arthroplasty? Retrieved
from https://www.ncbi.nlm.nih.gov/pubmed/26956247

Research Aims/
Questions/
Hypotheses:

Reduction of SSIs

Study Design:

Quantitative study

Sample Selection
&
Characteristics:

All patients between 2007 and 2013 in an single facility

Setting:

Acute care hospital

Variables/

Patients who used provided CHG cloths preoperatively versus no use of

cloths

Measures:
Data Collection
Instrument Used:

Data Collection
Methods:

Description of
Intervention:

Patient medical records and an infection-tracking database

NHSN risk category, relative risk with confidence intervals

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Patients who used provided CHG cloths preoperatively versus no use of

cloths

Data Analysis:

Relative risk with confidence interval

Major Findings:

Patients with multiple CHG prep had a 0.3% SSI rate versus a 1.9% rate in
patients with only the CHG immediately prior to surgery.

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Do Multiple Applications of a Chlorhexidine Gluconate Wash Prior to Surgery Decrease Surgical Site
Infections More Than a Single Application?

Research Question:
Complete
Citation:

Zywiel, M. G., Daley, J. A., Delanois, R. E., Naziri, Q.,

Johnson, A. J., & Mont, M. A. (2011, July). Advance preoperative chlorhexidine reduces the incidence of
surgical site infections in knee arthroplasty.
International Orthopaedics, 35(7), 1001-1006.
http://link.springer.com/article/10.1007%2Fs00264010-1078-5

Research Aims/
Questions/
Hypotheses:

Reduction in SSIs

Study Design:

Quantitative study

Sample Selection
&
Characteristics:

All knee arthroplasties from January 2007-December 2008

Setting:
Single acute care hospital

Variables/
Measures:
Data Collection

Patients who used CHG cloths prior to arrival at the hospital versus the
single prep at the hospital alone

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Instrument Used:

Data Collection
Methods:
Description of
Intervention:

Medical record review

Infection tracking database

Patients were provided with instructions and CHG cloths prior to surgery.

Data Analysis:
statistical
Major Findings:

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No infection in 136 patients who completed preoperative wash as

instructed. In the 711 who did not complete 21, or 3.0%, had SSIs.

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References

Anderson, D. J., Pidgorny, K., Berrio-Rorres, S., Bratzler, D., Dellinger, E. P.,
Greene, L., ... Kaye, K. S. (2014, June). Strategies to Prevent Surgical
Site Infections in Acute Care Hospitals: 2014 Update. Infection Control
and Hospital Epidemiology, 35(6), 1-24. Retrieved from
http://apic.org/Resource_/TinyMceFileManager/Academy/ASC_101_reso
urces/Guidelines-APIC-CDCWHO/SSI_Prevention_2014_SHEA_Guidelines.pdf
Edwards, J. R., Peterson, K. D., Banerjee, S., Allen-Bridson, K., Morrell, G.,
Dudeck, M., ... Horan, T. (2009). National Healthcare Safety Network
Report: Data Summary for 2006 Through 2008, Issued December 2009.
Retrieved from
http://www.cdc.gov/nhsn/PDFs/dataStat/2009NHSNReport.pdf
Guideline for Prevention of Surgical Site Infection, 1999. (2011). Retrieved
from http://www.cdc.gov/hicpac/SSI/004_SSI.html
Johnson, A. J., Kapedia, B. H., Molina, C. B., & Mont, M. A. (2013, June).
Chlorhexidine reduces infections in knee arthroplasty. The Journal of
Knee Surgery, 26(3), 213-218. http://dx.doi.org/10.1055/s-00321329232
Kapadia, B. H., Issa, K., McElroy, M., Pivec, R., Daley, J. A., & Mont, M. (2013,
June). Advance pre-operative chlorhexidine preparation reduces
periprosthetic infections following total joint arthroplasty. Seminars in
Arthroplasty, 24(2), 83-86. http://dx.doi.org/10.1053/j.sart.2013.07.006

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Kapadia, B. H., Zhou, P. L., Jauregui, J. J., & Mont, M. A. (2016). Does
Preadmision Cutaneous Chlorhexidine Prepatation Reduce Surgical Site
Infections After Total Knee Arthroplasty? Retrieved from
https://www.ncbi.nlm.nih.gov/pubmed/26956247
National Association of Orthopaedic Nurses. (2011). Practice Points:
Nosocomial Surgical Site Infection. Orthopaedic Nursing. Retrieved
from http://www.orthonurse.org/p/se/in/q=chlorhexidine
Zywiel, M. G., Daley, J. A., Delanois, R. E., Naziri, Q., Johnson, A. J., & Mont, M.
A. (2011, July). Advance pre-operative chlorhexidine reduces the
incidence of surgical site infections in knee arthroplasty. International
Orthopaedics, 35(7), 1001-1006. http://dx.doi.org/10.1007/s00264-0101078-5