TY - JOUR
AU - Talbot, Laura A
AB - ABSTRACT INTRODUCTION AND SCOPE OF THE PROBLEM Surgical site infections (SSIs) are associated with increased length of hospital stays, poor patient outcomes, and increased health care costs making prevention of SSI a high priority for the U.S. Military Health Care System. The focus of this project was to develop and pilot a preoperative antiseptic bathing regimen on an inpatient medical-surgical telemetry unit using 4% chlorhexidine gluconate (CHG), and to compare SSI rates with this new protocol to previous SSI rates on the unit. MATERIALS AND METHODS A literature review guided the development of the protocol and clinical question. A unit project was conducted using SSI rates from an inpatient military medical-surgical telemetry unit over 4 yr. From 2014 to 2016, 3 yr before implementing the protocol, a non-standardized CHG scrub was compared to 12 mo after implementing the standardized 4% CHG protocol in 2017 using up to four daily washings (three evenings and one morning surgery) on inpatient admissions to the unit. SSI rates were compared. RESULTS After implementing a 4-d preoperative bathing regimen with 4% CHG for patients scheduled for surgery, SSI rates decreased from an average rate of 0.0072 infections (7.2 infections per 1,000 surgeries) to 0.0035 infections (3.5 infections per 1,000 surgeries) in the subsequent year of data collection. Although not a statistically significant change, further analysis using a Bayesian Poisson regression model found an 84% probability the new protocol would lower SSI rate by 1 or more cases per 1,000 surgeries on this inpatient unit. CONCLUSION The findings suggest the proposed approach to control infection that may reduce the number of SSIs on a military medical-surgical unit, but this needs to be demonstrated through further longitudinal research on military surgical units. Introduction and Scope of the Problem Some military treatment facilities have been cited for higher expected rates of surgical complications and surgical site infections (SSIs), making SSI prevention a high priority for the U.S. Military Health System.1–3 Brooke Army Medical Center (BAMC), the largest military hospital in the Department of Defense, was named as having a higher occurrence of SSIs and postoperative complications as compared to similar civilian hospitals for 2010 and 2011.4 SSI rates from 2009 to 2014 at BAMC declined from 0.0536 to 0.0054, with expected rates from 0.0293 to 0.0243 (trend significance 0.0013, p < 0.05).4 As the only Level 1 Trauma Center in the Department of Defense, it is unique in that it cares for combat causalities, service members’ families, veterans, and civilian emergency trauma patients. It is unclear if these SSI rates represent the differences in severity of injury, patient population, aspects of care, or some other reason. The associated consequences of SSI and postop complications are longer hospital stays, increased hospital readmission, poor patient outcomes, and increased health care costs.5,6 In 2014, our unit had an increased incidence of SSIs as compared to previous years. There were nine SSIs with a rate of 0.0025 infections (2.5 infections per 1,000 surgeries) in surgical patients. Given an increased SSI incidence on our unit, a team of inpatient surgical staff nurses found a variance in preoperative cleansing procedures using chlorhexidine gluconate (CHG) and decided to initiate this pilot project. These inconsistencies included preoperative washings using 2% CHG cloth wipes and 4% CHG soap as well as the variance of frequency and duration of the washings. Hospital policy recommended showering with an antibacterial soap or 2% CHG wipes, the night before surgery, and again, the morning of the surgery as a minimum. Preoperative total body shower or bathing with an antiseptic skin wash is standard practice for preventing postoperative infections. Frequently, CHG bathing instructions are given to preoperative patients and performed by using an over-the-counter CHG-based soap such as Hibiclens (4% chlorhexidine solution). These preoperative showers have been shown to reduce bacterial skin colonization. Repeated washings with an antiseptic soap, such as CHG-based soap or wipes, further enhances this reduction in bacterial count on the skin. However, it is not clear if these preoperative shower/bath lead to a reduction in SSIs. Thus, the purpose of this unit project was to implement a pilot standardized CHG-based cleaning protocol for our inpatient medical-surgical telemetry unit to reduce SSI rates using available unit resources of 4% CHG liquid soap. Materials and Methods Setting Our 28-bed military medical-surgical telemetry unit consisted of a diverse patient population that required continuous telemetry and pulse oximetry monitoring. Types of patients include, but not limited to, neurosurgical, trauma, obstetrician/gynecology, cardiology, gastroenterology, hospice, otolaryngology, orthopedic, urology, and psychiatry patients. Surgical patients ranged from 22% to 35% of admissions to the unit over the 4 yr of this project (Table I). Surgical procedures included, but are not limited to: thyroidectomy, tonsillectomy, total joint arthroplasty, laparoscopy, amputation, hysterectomy, appendectomy, hernia repair, spinal fusion, and laminectomy. Table I Surgical Site Infections by Year Year . Bathing Procedure . Admissions . Surgeries . Infections . Surgical Infection Rate . 2014 Non-standard 3,668 1,268 9 0.0071 2015 Non-standard 3,545 1,193 7 0.0059 2016 Non-standard 3,396 747 7 0.0094 2017 Pilot project 2,385 573 2 0.0035 Year . Bathing Procedure . Admissions . Surgeries . Infections . Surgical Infection Rate . 2014 Non-standard 3,668 1,268 9 0.0071 2015 Non-standard 3,545 1,193 7 0.0059 2016 Non-standard 3,396 747 7 0.0094 2017 Pilot project 2,385 573 2 0.0035 Open in new tab Table I Surgical Site Infections by Year Year . Bathing Procedure . Admissions . Surgeries . Infections . Surgical Infection Rate . 2014 Non-standard 3,668 1,268 9 0.0071 2015 Non-standard 3,545 1,193 7 0.0059 2016 Non-standard 3,396 747 7 0.0094 2017 Pilot project 2,385 573 2 0.0035 Year . Bathing Procedure . Admissions . Surgeries . Infections . Surgical Infection Rate . 2014 Non-standard 3,668 1,268 9 0.0071 2015 Non-standard 3,545 1,193 7 0.0059 2016 Non-standard 3,396 747 7 0.0094 2017 Pilot project 2,385 573 2 0.0035 Open in new tab Review of the Literature The first phase of our project was to conduct a literature search with the goal to explore what was known about preoperative washings, antiseptic skin cleansers, and their association to SSIs. Before initiating the unit project, the team first had to determine the type and concentration of antiseptic skin cleanser or soap, exposure time to antiseptic agent, number of washings, and amount of antiseptic soap or number of wipes. The literature review was conducted in 2016 and used the Internet search engines of Cumulative Index to Nursing and Allied Health (CINAHL), Cochrane Library, and MEDLINE/PubMed to identify published systematic reviews or meta-analysis studies on CHG preoperative cleansing for SSIs at any site. We used search terms to identify literature that examined the impact of CHG bathing with the emphasis placed on SSIs: preoperative care, chlorhexidine, and bathing. For inclusion in the review, articles had to be published within the last 10 yr from the time of the search in 2016 (2007–2016), written in English, have full text availability and had to be categorized as a systematic review or meta-analysis. We limited our search to systematic reviews or meta-analysis to examine literature already evaluated by experts. Four systematic reviews met our inclusion criteria. One of the four systematic reviews supported the use of 4% CHG in preoperative bathing to prevent SSIs.7 This comprehensive literature review found 8 out of 10 relevant studies with a significant reduction of skin flora after repeated use of CHG. Although there was no definitive evidence on the number of showers that best prevents SSIs, Jakobsson, Perlkvist, and Wann-Hansson endorsed three to five preoperative disinfection showers based on the cumulative effect of CHG and previous guideline recommendations.7 A Cochrane review analyzed seven clinical trials, which had involved 10,157 participants, evaluated the use of 4% CHG with varying comparison groups and found no conclusive evidence that CHG bathing reduced the incidence of SSI.8 Webster and Osborne published another review in 2015, which resulted in similar results.9 The authors did find that skin flora was reduced by showering an antiseptic. A limitation was, most trials in this review only used one or two applications of CHG. In a meta-analysis, Chlebicki et al. evaluated 16 trials with a total of 17,932 patients.10 Most of the 16 trials were poorly designed and did not include details on chlorhexidine application (frequency, time, and duration). They concluded that there was no benefit of preoperative CHG bathing to prevent SSIs. However, despite the marginal benefits, the investigators still recommend that preoperative CHG bathing can be implemented, given the low cost and risk for patients. In summary, the literature review completed in 2016 seemed to be inconclusive in the use of 4% CHG in preoperative bathing to prevent SSIs. However, two systematic reviews support the use of preoperative 4% CHG bathing because of low cost, low patient risk, and possible benefit of SSI reduction.7,10 Clinical Practice Guidelines Historically, preoperative clinical practice guidelines regarding CHG bathing have been supported by national organizations.11–13 Our next step was to look at clinical practice guidelines specific to surgery type and SSIs found on our military medical-surgical unit. The following guidelines were reviewed in 2016: (1) Association of periOperative Registered Nurses (AORN) Guideline for Preoperative Patient Skin Antisepsis, (2) Centers for Disease Control and Prevention (CDC) Guideline for Prevention of Surgical Site Infection, and (3) Institute for Healthcare Improvement (IHI).11–13 It is important to note that during our project, various clinical practice guidelines were updated and the new standards are mentioned later in our discussion. The AORN guideline recommended a shower or bath before surgery with either soap or a skin antiseptic the night before or the day of surgery.11 Similarly, the CDC recommended a preoperative bath or shower with an antiseptic agent the night preceding surgery.12 The IHI guidelines specified 3 d of preoperative bathing with CHG soap.13 Since more than 78% of the SSIs on our military medical-surgical unit were bone- and joint-related, the decision was to initiate the most stringent protocol as a result of the serious consequences and frequency of these infections. IHI’s frequency of bathing recommendations of 3 d before surgery were incorporated into our new protocol.13 We incorporated all three clinical practice guidelines to guide our unit protocol with up to 3 d of bathing with CHG soap before surgery plus the morning of surgery. Development and Implementation of a Preoperative Cleansing Protocol Clinical Question Our clinical question was posed as follows. In adult surgical inpatients, does preoperative bathing using 4% CHG liquid soap 1–3 d before surgery plus the day of surgery, compared to the current practice of bath 1 d prior plus the day of surgery, decrease the rate of SSIs (two to four washings versus two washings)? The unit project was submitted for approval to the unit Clinical Nurse Specialist, who coached the team through the approval process. The project was reviewed by the military medical facility’s Institutional Review Board (IRB) and determined to be IRB exempt. SSI data would be tracked by an Infection Control Team with reports provided to the nursing staff team. Washing Protocol The project was undertaken to test the effects of 4% CHG preoperative washings while monitoring SSI incidence on the unit. The protocol used a range of one to three daily CHG washings before surgery (with a maximum of three) and one washing on the day of surgery for a total of two to four washings as compared to the traditional, non-standard unit approach of two washings on the military medical-surgical telemetry unit. The 4% CHG solution contains 4% w/v CHG, with inactive ingredients: fragrance, isopropyl alcohol 4%, purified water, Red 40, and a mild, suds base solution that was adjusted to a pH of 5.0–6.5. The new protocol was initiated as soon as the surgical patient was admitted to the unit. Frequently, patients are admitted to our unit for monitoring before surgery (ie obstructive sleep apnea patients, cardiac dysthymia patients). Furthermore, trauma surgical patients also have extended admissions for multiple surgeries. Education of Staff To aid in the facilitation of the practice change, an informal discussion during unit staff meetings was conducted to identify barriers to implement this protocol change. These barriers included reluctance to alter the existing practice, a lack of awareness of the new CHG protocol, and a dearth of evidence on preoperative bathing in SSI prevention. To address these barriers, a unit in-service was conducted to educate nursing staff and medical technicians on the new CHG bathing protocol. A step-by-step checklist and detailed instructions for CHG bathing protocol were provided to ensure consistent and standardized bathing techniques by staff (Fig. 1). The checklist was an adapted version of Hospital Quality Institute’s Pre-Surgery CHG Body Cleansing: Instructions.14 Figure 1 Open in new tabDownload slide Presurgery CHG body cleansing instruction. The checklist annotated which patients would be excluded from CHG bathing—pregnant women, and individuals who had experienced a previous allergic reaction to CHG—and provided guidance for ambulatory versus non-ambulatory patients. For ambulatory inpatients, the care team would advise them to first shower head-to-toe with regular bar soap and shampoo, and then rinse. They were then to follow with 5 mL (per manufacturer’s instructions) of 4% CHG liquid soap, performing a total body washing from the neck down avoiding the face, scalp hair, genitals, and any open wounds. Next, they were instructed to wash the CHG soap over the body for 3 min with a wash cloth to optimize its antiseptic properties. The eyes, ears, and mouth were to be avoided. After 3 min, the CHG soap would be rinsed off the skin, and nursing staff would provide fresh towels, change all linens, and provide a clean hospital gown. After educating ambulatory patients on the cleansing instructions, the checklist was also given to ambulatory patients to be completed unassisted. For non-ambulatory inpatients, patients were bathed in bed using ConvaTec Aloe Vesta body cleansing foam and rinsed. This was followed by a 4% CHG liquid soap applied from the neck down for 3 min and then rinsed again. The instruction checklist was made available for easy reference by nursing staff and usage on the unit. Evaluative Method A pretest was administered before the in-service and a posttest following the in-service. One hundred percent of staff completed the in-service awareness training. Results from the testing showed a 16-point increase in the scores for staff knowledge, from a mean pretest score of 79.5% to a mean posttest score of 95%. Measures This project evaluated the rate of SSIs on a military medical-surgical telemetry unit over 4 yr, comparing 3 yr of using a non-standardized approach with variance in methods before implement the protocol (2014–2016) and 1 yr (2017) using 4% CHG skin cleanser with up to four daily washings (one to three evenings and one morning of surgery). Analysis Data were obtained for the number of patients on a single military medical-surgical unit while tracking the number of corresponding SSI for 3 yr (2014–2016). The data obtained in these years used a non-standardized approach of two washings. In 2017, during the pilot implementation, data were obtained for the number of patients in one full calendar year, while using the new standardized protocol (4% CHG soap for a maximum of four baths). Again, the corresponding SSIs in 2017 were obtained. The SSI outcome data obtained gave infection counts with a low frequency of occurrence and did not show a significant difference in SSI rates between 2014–2016 and 2017. However, the current number of patients included in the project would not result in a significant p value at p < 0.05, even if the 4% CHG soap with four baths reduced the infection count to zero. For this reason, a Bayesian Poisson regression approach was used to determine whether there was evidence that suggested that the 4% CHG protocol with up to four baths was better than the prior standard, based on the distribution of the rate of events using the Stan language (http://mc-stan.org) and R 3.4.1 (https://www.r-project.org). Results Census data were obtained for the single surgical unit for the period from 2014 to 2016, inclusive. A total of 10,609 patients were admitted to the unit with 3,208 surgeries for 2014–2016 (Table I). After the new protocol was implemented, data for 2017 consisted of 2,385 admissions with 573 surgeries. Of the 23 total SSIs on our unit for the first 3-yr period 2014–2016, 78% were bone and joint surgeries, 13% were abdominal surgeries, and 8% were thyroid surgeries. For year 2017, the following two SSIs were recorded: femur nail fixation (bone/joint surgery) and open distal pancreatotomy (abdominal surgery). For 2014–2016, the average rate was 0.0072 SSI (7.2 infections per 1,000 surgeries), while the average for 2017 was 0.0035 SSI (3.5 infections per 1,000 surgeries). The distribution from the Bayesian Poisson model gave a mean (SD) for the standard method rate of 0.0072 (0.0015) and for the proposed 4% CHG method rate 0.0035 (0.0025). The 4% CHG with up to four baths approach had a mean reduction in the rate of −0.0037 (0.0029) SSI from the standard approach, with 89.8% of the differences favoring the 4% CHG washing with up to four baths, and 84.1% of the distribution showing a reduction of greater than 1 case/1,000 surgeries. Discussion This inpatient medical-surgical telemetry unit project explored the feasibility of implementing a standardized preoperative bathing protocol by using up to four washings using 4% CHG skin cleanser compared to the non-standardized approach of two washings. We found preliminary evidence that the proposed protocol may reduce SSI for a single surgical unit. However, the observation on this single military medical-surgical telemetry unit over a 1-yr period is not sufficient to currently recommend the protocol, but rather suggests that it should be further studied as a potential means to reduce SSI on similar military surgical units. SSIs result in hundreds of deaths every year, as well as incurring billions of dollars in health care costs. Adherence to evidence-based practice guidelines and institutional protocols may be important for preventing SSIs. The AORN, CDC, and IHI published clinical practice guidelines with varying recommendations for preoperative bathing. In 2017, the CDC updated their guideline, which advised patients to shower or bathe with antibacterial soap or an antiseptic agent (ie, CHG) on at least the night before the surgery.15 The AORN also updated their guidelines in 2018; however, all guidelines continue to recommend preoperative bathing to reduce risk of SSIs.16 Furthermore, the IHI acknowledged the importance and benefit of 4% CHG preoperative bathing.13 There are numerous prevention strategies to reduce the risk of SSIs for preoperative patients. Those strategies include observations of the patients’ preexisting conditions and infections, preoperative skin bathing, hair removal, intranasal screening for Staphylococcus aureus, prophylactic antibiotics, preoperative length of hospital stay, and wound classification. This specific project only monitored one of those strategies: preoperative skin bathing. With the numerous SSI risk factors throughout the preoperative continuum, it can be difficult to isolate one prevention strategy that is effective. Every surgical patient is different, which results in various prevention strategies. This project was an inpatient unit project on CHG bathing, with the test protocol only conducted for 1 yr. In further studies, we recommend incorporating standardization of up to four CHG baths with both in-patient and out-patient units or clinics, in a longitudinal study over several years. Implementation Challenges/Limitations and Keys to Success After conducting our literature review, we found sufficient evidence to support piloting a standardized, step-by-step preoperative bathing protocol on the unit. Educating all clinical nursing staff and medical technicians and piloting a new protocol could potentially impact our unit’s SSI occurrence. Current literature on the efficacy and effectiveness of CHG in the prevention of SSIs had mixed reviews and opinions. Two systematic reviews continue to be consistent with their inconclusive findings in the efficacy of CHG.17,18 Clinical practice guidelines specific to our SSI population recommended bathing 3 d before surgery and the morning of surgery. Although, we found a decline in SSI during the years of CHG usage, there is a lack of evidence in the literature that preoperative washing with CHG actually decreases SSI’s while official organizations continue to support the practice. Upon identifying the clinical problem of a high number of SSIs on the unit, there was concern for the variance in bathing techniques, lack of a standardized clinical protocol, and inconsistent adherence to proper bathing techniques with 4% CHG soap. After creating the protocol, all staff were educated on proper bathing techniques and increased frequency of bathing up to a maximum of four washings. This was a change in current practice from the traditional, standard practice of two showers (usually the evening before and the morning of surgery). This project was aimed at first establishing an approach to using a 4% CHG bathing protocol, then tracking the SSI rate throughout the year of the pilot project. Project takeaways include forming an interprofessional team for standardizing the preoperative skin washing protocol and educating staff. The interprofessional team should include staff nurse, medical technicians, operating room nursing staff, physicians, and infection control personnel. A preoperative step-by-step protocol is strongly encouraged to maintain adherence to consistent and accurate bathing techniques. The bedside nurse and medical technicians are in a crucial position to facilitate preoperative bathing. Consistent staff for patient teaching should be addressed for sustainability. We also recommend accurate documentation using the electronic medical record to track frequency of CHG washings. During the project, admissions and surgeries dropped because of the addition of two units in the hospital adding continuous pulse oximetry and telemetry monitoring. Before 2016, our unit was one of only two units that had this capability. We attribute the lower admission and surgeries in 2017 to the addition of these two additional specialty units. Conclusion The findings from this unit project suggest that the proposed approach to infection control may reduce the number of postoperative SSIs on a military surgical unit. The findings are based on limited observations on a single military surgical unit with 1 yr of application of the proposed protocol. However, our observations suggested that further, more extensive comparisons are warranted for this approach in investigating the incidence of SSIs on military surgical units and their abatement. The view(s) expressed herein are those of the author(s) and do not reflect the official policy or position of Brooke Army Medical Center, the U.S. Army Medical Department, the U.S. Army Office of the Surgeon General, the Department of the Air Force, the Department of the Army or the Department of Defense or the U.S. Government. References 1. Defense of Defense : Military Health System Review: Final Report to The Secretary of Defense , 2014 . Available at https://www.health.mil/Military-Health-Topics/Access-Cost-Quality-and-Safety/MHS-Review; accessed December 8, 2017 . 2. Hagel C : Secretary of Defense Speech: Statement on Military Health System Review , 2014 . Available at https://dod.defense.gov/News/Speeches/Speech-View/Article/605615/statement-on-military-health-system-review/; accessed December 6, 2017 . 3. Defense of Defense : FACT SHEET: The Department of Defense’s 90-Day Review of the Military Health System , 2014 . http://archive.defense.gov/home/features/2014/0614_healthreview/docs/MHS_REVIEW_FACT_SHEET.pdf; accessed December 6, 2017 . 4. Maturo S , Hughes C, Kallingal G, et al. : Improving surgical complications and patient safety at the nation’s largest military hospital: an analysis of National Surgical Quality Improvement Program Data . Mil Med 2017 ; 182 ( 3 ): e1752 – 5 . Google Scholar Crossref Search ADS PubMed WorldCat 5. de Lissovoy G , Fraeman K, Hutchins V, Murphy D, Song D, Vaughn BB: Surgical site infection: incidence and impact on hospital utilization and treatment costs . Am J Infect Control 2009 ; 37 ( 5 ): 387 – 97 . Google Scholar Crossref Search ADS PubMed WorldCat 6. Kirkland KB , Briggs JP, Trivette SL, Wilkinson WE, Sexton DJ: The impact of surgical-site infections in the 1990s: attributable mortality, excess length of hospitalization, and extra costs . Infect Control Hosp Epidemiol 1999 ; 20 ( 11 ): 725 – 30 . Google Scholar Crossref Search ADS PubMed WorldCat 7. Jakobsson J , Perlkvist A, Wann-Hansson C: Searching for evidence regarding using preoperative disinfection showers to prevent surgical site infections: a systematic review . Worldviews Evid-Based Nurs 2011 ; 8 ( 3 ): 143 – 52 . Google Scholar Crossref Search ADS PubMed WorldCat 8. Webster J , Osborne S: Preoperative bathing or showering with skin antiseptics to prevent surgical site infection . Cochrane Database Syst Rev 2015 ; ( 2 ): CD004985 . Google Scholar OpenURL Placeholder Text WorldCat 9. Webster J , Osborne S: Preoperative bathing or showering with skin antiseptics to prevent surgical site infection . Cochrane Database Syst Rev 2012 ; ( 9 ): CD004985 . Google Scholar OpenURL Placeholder Text WorldCat 10. Chlebicki MP , Safdar N, O’Horo JC, Maki DG: Preoperative chlorhexidine shower or bath for prevention of surgical site infection: a meta-analysis . Am J Infect Control 2013 ; 41 ( 2 ): 167 – 73 . Google Scholar Crossref Search ADS PubMed WorldCat 11. Association of periOperative Registered Nurses, Inc. Guidelines for Perioperative Practice. Denver, CO: Association of periOperative Registered Nurses, Inc. 2015 . 12. Mangram AJ , Horan TC, Pearson ML, Silver LC, Jarvis WR: Guideline for prevention of surgical site infection 1999. Centers for Disease Control and Prevention (CDC) Hospital Infection Control Practices Advisory Committee . Am J Infect Control 1999 ; 27 ( 2 ): 97 – 132 . Google Scholar Crossref Search ADS PubMed WorldCat 13. Institute for Healthcare Improvement . How-to Guide: Prevent Surgical Site Infection for Hip and Knee Arthroplasty . Cambridge, MA , Institute for Healthcare Improvement 2012 . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC 14. Hospital Quality Institute : Pre-Surgery CHG Body Cleansing: Instructions , 2016 . Available at http://www.hqinstitute.org/sites/main/files/file-attachments/5b_instructions_chg_hibiclens_cleansing_pre_surg.pdf; accessed August 18, 2016 . 15. Berrios-Torres SI , Umscheid CA, Bratzler DW, et al. : Centers for Disease Control and Prevention Guideline for the prevention of surgical site infection, 2017 . JAMA Surg 2017 ; 152 ( 8 ): 784 – 91 . Google Scholar Crossref Search ADS PubMed WorldCat 16. Association of periOperative Registered Nurses, Inc. Guidelines for Perioperative Practice . Denver, CO : Association of periOperative Registered Nurses, Inc. 2018 . 17. Wang Z , Zheng J, Zhao Y, et al. : Preoperative bathing with chlorhexidine reduces the incidence of surgical site infections after total knee arthroplasty: a meta-analysis . Medicine 2017 ; 96 ( 47 ): e8321 . Google Scholar Crossref Search ADS PubMed WorldCat 18. Franco LM , Cota GF, Pinto TS, Ercole FF: Preoperative bathing of the surgical site with chlorhexidine for infection prevention: systematic review with meta-analysis . Am J Infect Control 2017 ; 45 ( 4 ): 343 – 9 . Google Scholar Crossref Search ADS PubMed WorldCat Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2020. This work is written by (a) US Government employee(s) and is in the public domain in the US. This work is written by US Government employees and is in the public domain in the US. Published by Oxford University Press on behalf of the Association of Military Surgeons of the United States 2020. This work is written by (a) US Government employee(s) and is in the public domain in the US.
TI - Preoperative Chlorhexidine Gluconate Bathing on a Military Medical-Surgical Unit
JF - Military Medicine
DO - 10.1093/milmed/usz186
DA - 2020-06-19
UR - https://www.deepdyve.com/lp/oxford-university-press/preoperative-chlorhexidine-gluconate-bathing-on-a-military-medical-7oyd4lAbAM
SP - 15
EP - 20
VL - 185
IS - Supplement_2
DP - DeepDyve
ER -