[Asynch Activity] Critical Appraisal in EBP

In patients undergoing neurosurgery, does shaving of hair compared to no hair removal reduce the incidence of surgical site infections (SSIs)?

In patients undergoing neurosurgery, does shaving of hair compared to no hair removal reduce the incidence of surgical site infections (SSIs)?

by Kryschelle Anne May Ramoneda -
Number of replies: 3

Removal of hair from the intended site of surgical incision has traditionally been part of the routine preoperative preparation of patients undergoing surgery. Hair removal may be necessary to facilitate adequate exposure and preoperative skin marking. Furthermore, suturing and the application of wound dressings can be complicated by the presence of hair. Apart from these practical issues, hair has been associated with a lack of cleanliness and the potential to cause SSI. 


There is also the belief that hair removal inversely increases the risk of SSI by causing microscopic trauma of the skin (World Health Organization, 2018). Shaving of the head influences the normal flora in the surgical site and damages the natural barrier of the hair, and these could increase the risk of infection. Furthermore, shaving of the head seriously affects the personal image of patients and their ability to return to their normal life and to society. Hair is one of the most important components of a person’s appearance, especially for young females, and plays an important role in the patient’s social life and quality of life (Liu et al, 2021).


Neurosurgical procedures often involve large incisions on the scalp. Some guidelines suggest that no hair removal may be as effective as clipping, but this is not widely practiced.

P - Patients undergoing neurosurgery.

I - Shaving of hair before surgery

C - No hair removal before surgery

O - Incidence of Surgical Site Infections (SSIs)

PICO Question: In patients undergoing neurosurgery, does shaving of hair compared to no hair removal reduce the incidence of surgical site infections (SSIs)? 


To address my PICO question, I've searched for relevant journals and conducted critical appraisals of the selected studies:

Journal #1: Global guidelines for the prevention of surgical site infection (2nd ed.)  World Health Organization (2018)

  • Recommendation: In patients undergoing any surgical procedure, hair should either not be removed or, if absolutely necessary, it should be removed only with a clipper. Shaving is strongly discouraged at all times, whether preoperatively or in the operating room (WHO, 2018).


  • Strength of Recommendation: Strong

  • Quality of Evidence: Moderate


The guidelines on Hair Removal are based on systematic reviews and meta-analyses of RCTs and cohort studies, making the evidence highly reliable. The GRADE system was used to classify the strength of recommendations.

This provides evidence-based recommendations aimed at reducing the incidence of surgical site infections (SSIs) worldwide. An international panel of experts, including an additional eight anesthesiology specialists for the 2018 update, contributed to enhance the guidelines’ credibility and global relevance. Each recommendation is clearly stated, with distinctions between strong and conditional recommendations based on the quality of evidence.

 A Cochrane review published in 2009 and updated in 2011 found no statistically significant difference in SSI rates between hair removal and no hair removal interventions (WHO, 2018). A total of 15 RCTs or quasi-randomized trials comparing the effect of preoperative hair removal vs. no hair removal or different methods of hair removal (shaving, clipping and depilatory cream) were identified. Meta-analyses were performed to evaluate the following comparisons between no hair removal and shaving, clipping and depilatory cream individually; and revealed:

  • No significant difference in SSI rates between no hair removal and clipping.

  • Shaving significantly increased SSI risk compared to clipping.

  • Depilatory creams showed no significant benefit over shaving.

  • A combination of “no hair removal and clipping” was significantly better than shaving.


The Society for Healthcare Epidemiology of America / Infectious Diseases Society of America (2014), National Institute for Health and Care Excellence (2013), Royal College of Physicians of Ireland (2012), and Health Protection Scotland (2013) all strongly discourage shaving. Most international guidelines advocate avoiding hair removal unless necessary and, if needed, using clippers with a single-use head. 

The guidelines offer global applicability, for it can be practiced in healthcare settings of low and middle income countries. It also emphasizes strategies that are feasible to implement in settings with limited resources. However, implementing certain recommendations may be challenging in settings with limited resources, potentially affecting feasibility.


The guidelines provide a valuable framework for SSI prevention, but local adaptation may be necessary to address specific healthcare contexts and resource availability. We also need to put into consideration the surgeon’s preference, as well as the patient’s interest and cultural preferences.

Journal # 2: Effectiveness of preoperative shaving and postoperative shampooing on the infection rate in neurosurgery patients: A meta-analysis (Liu et al, 2022)

  • Recommendations: 

  • Not shaving the hair preoperatively does not increase the infection rate in neurosurgery.

  • Not shaving the hair preoperatively could help preserve the appearance of patients as much as possible.

  • Early shampooing postoperatively was a safe procedure and could significantly improve the patient’s comfort level.


The meta-analysis investigates the impact of hair management practices on surgical site infections (SSIs) in neurosurgical procedures. The authors conducted a comprehensive search of databases including Embase, CINAHL, Scopus, and PubMed up to February 1, 2022. They included comparative studies without language restrictions, minimizing selection bias. The Newcastle–Ottawa quality assessment scale was used to evaluate the risk of bias. Meta-analyses were performed using Review Manager software, assessing odds ratios (ORs) and 95% confidence intervals (CIs) for infection rates. These techniques enhance the reliability of the findings.


Out of 3,451 identified studies, 12 met the inclusion criteria, encompassing a total of 8,878 patients (4,583 unshaved and 4,295 shaved). Among these, 3,874 patients had unshaved hair with early postoperative shampooing. The meta-analysis found no significant difference in infection rates between unshaved and shaved groups. However, in shunt surgery patients, the unshaved group had a significantly lower infection rate compared to the shaved group. No significant difference was observed between the unshaved with early shampooing group and the shaved group. Therefore, preserving hair before neurosurgery and implementing early postoperative shampooing do not increase the risk of SSIs.


The study supports the practice of hair preservation and early postoperative shampooing in neurosurgical patients, suggesting these practices do not increase SSI risk. Early shampooing of the hair postoperatively was a safe procedure, which could also improve patient comfort. Therefore, during hospitalization, we need to teach patients how to wash their hair safely, so that the patients can shampoo their own hair after discharge. Ensuring the health of the surgical incision and maintaining the appearance of patients have a great influence on the patient’s psychological health. Thus, helping to preserve the appearance of the patient as much as possible, not shaving preoperatively and shampooing early postoperatively could all effectively help the patient return to his or her normal life, work and social activities more easily (Liu et al, 2022). On top of that, early shampooing can also make them feel good about themselves, and can also promote personal hygiene practices.

 

REFERENCES:

World Health Organization. (2018). Global guidelines for the prevention of surgical site infection (2nd ed.). World Health Organization. Retrieved from: https://iris.who.int/handle/10665/277399

Liu, W., Duan, Y., Chen, M., Tu, L., Yu, A., & Jiang, X. (2022). Effectiveness of preoperative shaving and postoperative shampooing on the infection rate in neurosurgery patients: A meta-analysis. International Journal of Nursing Studies, 129, 104204. https://doi.org/10.1016/j.ijnurstu.2022.104204






In reply to Kryschelle Anne May Ramoneda

Re: In patients undergoing neurosurgery, does shaving of hair compared to no hair removal reduce the incidence of surgical site infections (SSIs)?

by Alessandra Louise Lamug -
PICO

P: Patients undergoing dialysis prone to intradialytic hypotension
I: DIalysis treatment with sodium profiling
C: Standard dialysis treatment without sodium profiling
O: Reduced incidence of intradialytic hypotension

Question: In patients undergoing dialysis prone to intradialytic hypotension, does dialysis treatment with sodium profiling compared to standard dialysis without sodium profiling reduce the incidence of intradialytic hypotension?

Journal#1
Sodium and Ultrafiltration Profiling in Hemodialysis: A Long-Forgotten Issue Revisited (Erlugtu et al., 2021)


         The primary aim of the article is to evaluate the effects of sodium profiling and ultrafiltration profiling in the hemodynamic stability of patients undergoing hemodialysis. Its focus is to determine how effective sodium profiling is in reducing intradialytic hypotension and other adverse effects of hemodialysis.

         In a crossover study, 22 randomized participants underwent stepwise sodium profiling and linear sodium profiling for 12 consecutive sessions. In the control group, where patients had conventional hemodialysis without sodium profiling, 48% experienced intradialytic adverse effects such as hypotension, while 34% and 36% experienced intradialytic adverse effects in the stepwise sodium profile group and linear sodium profile group, respectively. In another randomized crossover clinical trial, 32 patients had three sessions of conventional dialysis, three sessions with a linear sodium profile, and three sessions with a stepwise sodium profile. The incidence of intradialytic hypotension was 40% in conventional hemodialysis, 26% in the stepwise profile, and 30% in the linear profile. In addition, a randomized controlled crossover study with 11 hemodialysis patients prone to intradialytic hypotension underwent 264 dialysis sessions. Incidence of adverse effects, including intradialytic hypotension, decreased but it also caused increased discomfort and increased interdialytic weight gain, as verbalized by the patients. Lastly, in a study where 8 patients had 310 dialysis sessions, sodium profiling was found to lessen the incidence of intradialytic hypotension significantly.

         The article presented relevant and comprehensive information regarding the effects of applying sodium profile methods to patients undergoing hemodialysis. It discussed both short- and long-term risks and benefits of sodium profiling. However, the study lacks a systematic selection criteria; the authors did not include any inclusion or exclusion criteria in the process of selecting the studies included in the article, thus increasing the risk of selection bias. Furthermore, there was no formal risk-of-bias assessment and there were no clear clinical guidelines in the implementation of sodium profiling in dialysis treatments.

         In conclusion, the article suggests that sodium profiling, especially stepwise sodium profiling, is a potentially effective and safe method to reduce or prevent intradialytic adverse effects, specifically hypotension. Therefore, sodium profiling can be incorporated into dialysis treatments in hospital settings and in dialysis centers. However, since there is a limitation in available research and clinical evidence, nephrologists and nurses should use it with caution.

Journal#2: The effect of ascending-descending ultrafiltration and sodium profiles on blood pressure in hemodialysis patients: a randomized cross-over study (Arasnezhad et al., 2024)


         The study aimed to gauge the impact of ultrafiltration and sodium profiling on blood pressure stability in hemodialysis patients prone to intradialytic hypotension.

         In this study, it was discovered that intradialytic hypotension was significantly reduced from 55% to 15% in patients that received A/D-UF profiling with linear sodium profiling. Patients who had routine hemodialysis experienced a drop in their blood pressure by 20 mmHg during their treatment, which shows a higher BP instability. Furthermore, blood pressure were more stable in the A/D-UF group compared to the group that only had routine hemodialysis; the latter experienced more symptoms of intradialytic hypotension such as dizziness, nausea, and fainting.

         The study had a clear and straightforward objective, which was to evaluate the impact of A/D-UF with sodium profiling on the blood pressure stability of patients on hemodialysis. It utilized a randomized crossover design, which improves the reliability of the results and ensures fairness since all patients received both of the interventions. Furthermore, selection bias is reduced since the patients were randomized using a web-based tool. However, the study only included 20 patients, reducing generalizability. Observer bias could also be possible in the study since both patients and healthcare staff were not blinded. The lack of blinding may have influenced measurements of blood pressure. Furthermore, fair comparisons and reduced variability were ensured since dialysis conditions were consistent and standardized among the patients. The participants all had the same dialysis machine, dialysate composition, blood flow rates, and dialysis flow rate.

         In conclusion, the results from the study proves to be statistically significant and clinically relevant since IDH incidence significantly decreased from 55% to 15%, p<0.05. However, long-term effects of sodium profiling were not studied due to the short duration of the study. In the Philippine setting, this approach can be applied in well-equipped dialysis units and centers with caution to decrease the incidence of intradialytic hypotension, and increase patient safety and comfort.

 

References:


  • Ertuglu, L. A., Demiray, A., Basile, C., Afsar, B., Covic, A., & Kanbay, M. (2021). Sodium and ultrafiltration profiling in hemodialysis: A long‐forgotten issue revisited. Hemodialysis International, 25(4), 433–446. https://doi.org/10.1111/hdi.12952

  • Arasnezhad, M., Namazinia, M., Mazlum, S. R., & Miri, K. (2024). The effect of ascending- descending ultrafiltration and sodium profiles on blood pressure in hemodialysis patients: a randomized cross-over study. BMC Nephrology, 25(1). https://doi.org/10.1186/s12882-024-03554-6

In reply to Kryschelle Anne May Ramoneda

Re: In patients undergoing neurosurgery, does shaving of hair compared to no hair removal reduce the incidence of surgical site infections (SSIs)?

by Kathleen Regis -

The risk factors for development of VAP have been successfully targeted by introducing the evidenced-based VAP bundles of care for the care of ventilated patients. The implementation of such bundles have been strongly recommended. Among the adjuncts included in those guidelines, the use of closed suction systems (CSS) have been encouraged as some studies suggest that CSS has been associated with reduced airway contamination in contrast to open suction systems (OSS). However, use of CSS instead of an OSS is still a matter of debate and today, there is no consensus on the use of these devices. 

 

PICO Question: 

In mechanically ventilated adult patients (P) , does closed suctioning (I) compared with open suctioning (C) minimize the incidence of ventilator-acquired pneumonia (VAP) (O)? 

 

Journal 1: Clinical experience and incidence of ventilator-associated pneumonia using closed versus open suction-system

 

In this observational cohort design by Åkerman et al., (2013), the study clearly addressed a focused issue, which is primarily to compare the incidence of VAP while using either open-suction system (OSS) or closed-suction system (CSS) among adult patients (> 18 years) on mechanical ventilator. Other outcomes include investigating the existence of contamination of the CSS circuit, the occurrence of desaturation using either OSS or CSS, and the occurrence of adverse events (AEs), endotracheal occlusion, secretion clogging, and desaturation while using OSS and CSS. 

 

One hundred and twenty-six adult patients on mechanical ventilation were consecutively included (OSS (n=61), CSS (n=65). During the study, OSS or CSS were used exclusively during a two-month period each and only one system was used at a time. In the recruitment process,authors failed to mention inclusion and exclusion criteria for the participants, and absence of which could have led to sampling bias and compromised outcomes. Sequential sampling procedure was chosen over randomization or cross over design. Randomization or cross over design could have reduced the risk for skewed data in the sample, however, authors claimed that this could have increased operator-induced bias because CSS was not the standard procedure in the unit, thus, unfamiliar to the staff. 

 

One of the strengths noticed in the study is the use of objective measurements for both groups. Culture samples from ETA and PSB were obtained at intubation, after 72h, and then every consecutive Monday, while the patient remained on mechanical ventilation. Microbiological sampling is less likely to be affected by the assessor's knowledge of exposure status and less likely to induce measurement bias. Moreover, cohort studies generally last a few years, long enough for outcomes to manifest. In this study, however, the time frame of the study is relevant to VAP with onset ranging from 1-3 days for early and >4 days for late VAP. 

 

In terms of results, authors reported that the use of CSS did not reduce the incidence of VAP. Although the authors used an objective measurement in diagnosing VAP, the result’s precision is questionable because of its several limitations including a small sample size, lack of randomization, and absence of inclusion and exclusion criteria. The small sample size can be one of the reasons for the higher SAPS III score in the CSS group. 

 

In conclusion, this observational study alone does not provide robust evidence to recommend the use of OSS over CSS. An adequately powered randomized trial would be helpful to explore the advantages and disadvantages of CSS and OSS. 



Journal 2: An open-labelled randomized controlled trial comparing costs and clinical outcomes of open endotracheal suctioning with closed endotracheal suctioning in mechanically ventilated medical intensive care patients

 

In an open-labelled RCT conducted by David et al., (2011), the researchers clearly defined the population, intervention, comparator, and the outcomes. Population involves all adult patients (>18 years) admitted to the ICU needing invasive mechanical ventilation within the first 24 hours. They aim to compare clinical outcomes of  closed endotracheal suctioning (CES) with open endotracheal suctioning (OES) over a span of 10 months. Their primary outcome measure was VAP incidence, while secondary outcomes included mortality, duration of hospitalization, and cost. 

 

In this study, two hundred participants (n=200) were recruited using a clearly identified inclusion and exclusion criteria.  Participants were randomly assigned; half was allocated to closed suction, while the other was allocated to open suction. Patients were randomized either to CES or to OES using computed-generated random numbers with blocks of varying size, reducing the risk of selection bias. In addition, allocation concealment was ensured with the use of sealed envelopes. Power calculation was undertaken; authors reported that the equivalence study had 80% power which is a widely acceptable level. A hundred participants on each side of the arm was adequate to detect a clinically significant difference between the CES and OES groups. Blinding of the participants and investigators, however,  was not possible in the view of the study and this could be a concern for bias. Only the radiologists assessing the x-rays were blinded. 

 

Authors used a clinical criteria to screen VAP. Clinical criteria was used because of its simplicity, but this could have potentially overdiagnosed VAP. The authors, however, claimed that they preferred overdiagnosing VAP instead of missing the diagnosis. Patients who were diagnosed with VAP using the clinical criteria were subjected to culture and sensitivity tests.  

 

Data were analyzed using SPSS version 15, and primary and secondary outcomes were measured using odds ratio and CI. In terms of the results, the study found out that CES reduces the incidence of VAP, particularly late onset VAP (p= 0.03). In light of cost-effectiveness, results showed that the OES (USD 2.94) was less expensive than CES (USD 5.81), however, authors argued that costing was not inclusive and did not incorporate nursing time, among others. 

 

In conclusion, the study has clearly stated objectives, strong randomization, and well-defined interventions which contribute to its validity. On the other hand, the authors acknowledge the limitations of the study including the lack of blinding except for the radiologic diagnosis of VAP and a higher proportion of patients with ischemic heart disease in CES. In addition, authors disclosed that patients who were intubated in the wards could have been subjected to the use of OES before transferring to the ICU and before randomization, which could have affected the results. 

 

Despite these limitations, overall, the study provides valuable insights into VAP prevention among mechanically intubated adult patients in the ICU.In resource-constrained developing countries like the Philippines, CES can, therefore, be proposed in patients expected to need ventilation for more than four days as the cost of CES is considerably smaller compared to the cost of a 10-day course of antibiotics to treat VAP. 



References: 

David, D., Samuel, P., David, T., Keshava, S. N., Irodi, A., & Peter, J. V. (2011). An open-labelled randomized controlled trial comparing costs and clinical outcomes of open endotracheal suctioning with closed endotracheal suctioning in mechanically ventilated medical intensive care patients. Journal of Critical Care, 26(5), 482–488. https://doi.org/10.1016/j.jcrc.2010.10.002

Åkerman, E., Larsson, C., & Ersson, A. (2013). Clinical experience and incidence of ventilator-associated pneumonia using closed versus open suction-system. Nursing in Critical Care, 19(1), 34–41. https://doi.org/10.1111/nicc.12010

 

In reply to Kryschelle Anne May Ramoneda

Re: In patients undergoing neurosurgery, does shaving of hair compared to no hair removal reduce the incidence of surgical site infections (SSIs)?

by Mary Ann Rodriguez -
Health care-associated infections (HCAIs) are infections that appear on the first 48 hours or more after hospital admission, or within 30 days after receiving health care within the institution.
Health-care associated infection includes Central line-associated blood stream infections (CLABSIs). According to CDC Centers for Disease control and prevention (CDC) 2009 it is reported to have 12%-25% of mortality rate and extended hospital stays., and in 2021, the Centers for Disease Control and Prevention (CDC) also reported a total of 30 389 CLABSIs occurring in various inpatient locations.
Proper skin antisepsis is essential in preventing CLABSI. If the skin is not cleaned properly, pathogens can travel along the external surface of the catheter from the point where it enters the skin. As a result, skin pathogens are often a major cause of CLABSI, particularly within the first week following central line catheter insertion.

BIOPATCH- polyurethane foam allowing quick absorption of fluid decreasing the likelihood of skin maceration, designed to deliver chlorhexidine gluconate a full 360 degree around the catheter insertion site providing optimized coverage and protection.
CHG - an all-in-one antimicrobial and transparent CHG gel pad securement dressing. Provides immediate and continuous antimicrobial protection with an integrated chlorhexidine gluconate (CHG) gel pad. CHG gel pad provides antimicrobial activity suppressing skin flora regrowth for up to 7 days and allows delivery of CHG under the catheter


PICO
P: Hospitalized Adult Patient with central line.
I: Use chlorhexidine impregnated dressing (CHG).
C: Use of Biopatch with Tegaderm dressing.
O: Minimize the incidence or occurrence of Central Line-Associated Bloodstream Infections.
QUESTION: In hospitalized Adult Patient with central catheter in place (P) Does the use chlorhexidine impregnated dressing (CHG) (I) compared to use of Biopatch with Tegaderm dressing (C.) minimize the incidence or occurrence of Central Line-Associated Bloodstream Infections? (O).

In the study entitled Prevention of Central Line Associated Bloodstream Infections: Aseptic Insertion and Site Selection by Centers for Disease control and prevention. CLEAN trial published in 2015 Uses Randomized controlled trial as a study design. Sample size the enrolled 2,546 patients in 11 intensive care units in France. Results reveals that Alcohol-containing chlorhexidine-gluconate is the most effective skin antisepsis at reducing CLABSI compared to povidone iodine. A systematic review significantly shows a reduced risk of CLABSIs Risk Ratio 0.51 (95%CI 0.27-0.97%). But for patients allergic to CHG or patient under two months of age, povidone iodine is a suitable alternative. This concludes that Chlorhexidine-based alcohol solutions represent standard for skin antisepsis during central venous catheter placement and Povidone iodine should be reserved for patients who are allergic to chlorhexidine or patient under two months of age.
This study helps and serve as a guide for healthcare professional in ensuring control and prevention of Health care-associated infections specifically Central Line-Associated Bloodstream Infections among critically ill patient with central catheter in place.

References
(n.d.). Centers for Disease Control and Prevention | CDC. https://www.cdc.gov/infection-control/media/pdfs/Strive-CLABSI103-508.pdf


In the study entitled Comparative Effectiveness of 2 Chlorhexidine Gluconate-Containing Dressings in Reducing Central Line-Associated Bloodstream Infections, Hospital Stay, and Costs. By Yuefeng Hou et.al
A retrospective analysis was conducted using the Premier Healthcare Database of hospitalized patients 53 149 with central venous catheters and a comparative study between 2 different types of CHG receiving either a transparent CHG gel dressing -14 488 or an opaque CHG sponge dressing 38 661 between January 1, 2019 and September 30, 2020. Result reveals
CHG gel dressings were associated with a 41% decrease in CLABSI rates compared to CHG sponge dressings, a 0.4-day shorter length of stay and a cost saving of $3576 per hospital stay was observed with CHG gel dressing use. This concludes that use of CHG gel dressings substantially lower CLABSI rates and clinical expenses compared to opaque CHG sponge dressings for hospitalized patients, this also promote economic advantage with respect to clinical cost.
The present study also emphasizes that CHG sponge dressings were gradually replaced with CHG gel dressings in reducing occurrence of Central Line-Associated Bloodstream Infections, and I personally witnessed this change of replacement from Biopatch dressing to CHG dressing in patient with central line within our institution.
Limitation of the study: Only 2 different types of CHG dressings where compared.
Reference:
Comparative effectiveness of 2 chlorhexidine gluconate-containing dressings in reducing central line-associated bloodstream infections, hospital stay, and costs. (n.d.). PMC Home. https://pmc.ncbi.nlm.nih.gov/articles/PMC10693226/?fbclid=IwZXh0bgNhZW0CMTEAAR0mIlroMCepj09nBMNHoBvgW4ZjUi_bzqq5tGYTOEGQWr6ZYji6QwNQnQo_aem_ShgqEQms9pPfISdp_YZp1Q

In summary, The two nursing journals related to use of chlorhexidine impregnated dressing (CHG) reported similar findings which also support by another study study entitled: “Fitness of use of Biopatch and Tegaderm CHG for protecting central venous catheters and arterial lines in critically ill patients “ by P Eggimann using comparative study that aim compare fitness use of biopatch and CHG Tegaderm to central line catheter site in a sample size 2000 admissions and 11’000 patients-days yearly in mixed ICU of 5 units of 7 beds. Result reveals overall satisfaction significantly increases after 14 months of Tegaderm significant improvement of fitness of use recommend replacement the Biopatch by the Tegaderm-CHG in the dressing of all central venous catheters and arterial lines for all ICU patients. Another study entitled Effectiveness of chlorhexidine dressings to prevent catheter-related bloodstream infections. Does one size fit all? A systematic literature review and meta-analysis by: Puig-Asensio M using systematic review and meta-analysis in evaluating effectiveness of chlorhexidine (CHG) dressings to prevent catheter-related bloodstream infections were studied in 18 randomized controlled trials reveals that CHG dressings significantly reduced CRBSIs by 95 %.
This suggests that usage of CHG gel dressings as a routine practice for patients with central venous catheters can help minimize the risk of central line-associated bloodstream infections that help healthcare provider in providing good quality care among the patients.
Reference :
Fitness of use of Biopatch® and TegadermTM CHG for protecting central venous catheters and arterial lines in critically ill patients - PMC. (n.d.). PMC Home. https://pmc.ncbi.nlm.nih.gov/articles/PMC4474738/
Effectiveness of chlorhexidine dressings to prevent catheter-related bloodstream infections. Does one size fit all? A systematic literature review and meta-analysis. (n.d.). PubMed.

Reflection of Applicability: This study encourages the healthcare provider in considering usage CHG gel dressings as a standard practice for patients with central venous catheter to reduce the risk central line-associated bloodstream infections and improve patient outcomes.
As an infection liaison officer in my institution and as a coronary care unit nurse that is responsible in taking good care of critically ill patient specifically patient with central catheter in place, This study serve as a guide for me to become an advocate in promoting interdisciplinary collaboration that to encourage my co-workers, superior and policy maker in our institution to implement the evidence-base intervention related to central line bundles of care, and to develop or modify existing guidelines or checklist with respect to the current trends, training of nursing staff through return demonstration and seminars in relation to strict adherence to the use of CHG dressing and aseptic technique when handling central venous catheter in preventing occurrence of central Line-Associated Bloodstream Infections among hospitalized patient.