Pet peeve, bad practice, or overly critical?

[NewICU]

So, I'm fairly new to the ICU environment. I am a somewhat new grad, and I have worked in an ICU for almost a year now. There are some things that are happening in my unit that are driving me a little crazy, and I'm hoping to bounce them off of some experienced ICU nurses to find out if I'm being overly critical or if this is a legitimate concern. I'm also wondering if this is happening in other ICUs.

So, here is my issue. When a new patient is admitted at night, we generally try to get our CHG bath knocked out within the first half hour. Our policy requires us to CHG bathe our patients within 12 hours of admission. Management has been getting on us pretty hard as of late, since our numbers are rarely 100%. The issue I have with this is that many nurses seem to focus on the bath as part of the admission over getting them onto the monitor. Patients are generally admitted to us because of a serious issue that will impact a vital sign...as such, my focus is on getting them on a monitor as soon as they are in the bed and developing a game plan for abnormal vitals as soon as possible. Are my priorities in order here or am I being overly dramatic? In my thinking, a patient can be absolutely stay dirty until I get a monitor on them. Why are these nurses okay with bathing the patient and getting the dirty sheets from transport out from under them while they are off the monitor? I feel like I must be missing something. Is this only happening on my unit or is this common elsewhere?

[SubSippi]

It can be easy for nurses to be focus on tasks, especially when they have management looking over their shoulder. I've only been a nurse for almost two years, CVICU for almost a year, but I agree with you. I don't think it would be out of line to bring up at a staff meeting. You don't want it to take something bad happening with a patient before it's addressed.

If nobody wants to listen, just keep doing what you're doing. Nobody will take "but I had to give my CHG bath" as an excuse when a patient loses consciousness during all this bathing and rearranging and it turns out they've been in V-tach the whole time.

We don't allow any visitors while the patient is being admitted, and it's not so we can hurry up and swab for MRSA and get the med rec done. It's so we can do an assessment without any interruptions and know what our baseline is, as soon as the patient is in our care.

Being able to prioritize is one of the most important skills a nurse can have. What you're talking about is one of the many examples of how all these ridiculous boxes we have to check gets in the way of getting people healthy.

I don't disagree with having a CHG bath be part of your admission process, it's a good way not to get dinged for it being overlooked. But it should probably be one of the very last things you do.

I mean my goodness, if there is a time frame for a dang CHG bath, why isn't it standard to have a set of vital signs and the heart rhythm interpreted within the first five minutes?

[meanmaryjean, DNP, RN]

I view that bath as a great way to assess every square inch of skin. When our CLABSI rates fell to almost zero after the institution of the admission CHG bath- I became a believer. In theory, if you are hooking them up to the monitor first- you are leaving unbathed areas AND contaminating your lead wires- which have been shown to grow all types of nasties.

Just my two cents

[dexm]

To the OP, you are not being dramatic. We bathe our patients as part of their admission to the ICU, but AFTER they're on the monitor, assessed, labs are drawn, and meds are given.

[Emergent, RN]

I'm on the other end of it, accompanying my ICU pts up to the unit. Always the pt is immediately hooked up to the monitor. I had to look up what this CHG bath thing is, I'd never heard of it, is it a newer protocol?

I think you ought to stick to what you are doing, it seems to be more commonsense. ABCs are always first! They're in the ICU because they are potentially unstable and need constant monitoring!

[strength4unityRN]

It depends on the patient/situation. Use your nursing judgement. I agree it's a great way to assess the skin etc. Plus a CHG bath and doing a quick turn doesn't take long at all in most cases. However it depends on patient and situation, if drips (pressors,etc) are already infusing. I like to know what the vital signs are (have the monitor applied, blood pressure taken, art line zeroed, etc) prior to turning the patient, changing sheets and bathing them. Plus there are quite a few other situations there that I did not mention. What I think has happened is a CHG has become a requirement in general and if not done disciplinary action is taken to those who don't complete it in a timely manner (this is what I have observed in some facilities). You have your priorities right, but one thing I have learned is every nurse does he/she nursing routine differently.

[wanderlust99]

It depends on the situation, but I generally help with transfer to the new bed, hopefully several nurses are assisting me in placing the patient on the monitor and I will quickly remove dirty sheets under them and assess their backsides while I actually have help in the room. It only takes 30 seconds or so. It's important to check the skin, and you'll find patients have been left in soiled linens all too frequently.

If someone wants to do the CHG bath while I am doing other things, then that's fine with me. But if no one is helping me with my admit I would leave it for later. Also take into consideration, maybe there aren't any orders yet, the patient is stable etc.. it all varies depending on how the patient is doing.

[Altra, BSN, RN]

In my experience this is a group effort by 2-3 staff -- simultaneous rolling, linen change, obtaining vital signs, basic assessment, and drawing labs & cultures within 10 - 15 minutes of arrival. I'm also assuming that patients are arriving on your unit on some kind of transport monitor - so you can take a quick glance at the rhythm while transferring them to the bed. For those patients truly too unstable to tolerate that much activity, of course I would defer the CHG bath to some other time within those first 12 hours.

[canigraduate]

When I was in ICU, the admission process was a 3-4 person team effort. The CHG bath was one person's task while another hooked stuff up, a third recorded, and a fourth did the swabs/draws/glucose. It usually went like a tag team operation, with the first person taking off the old stickers, the second swiping the front with CHG, first person putting on new stickers/O2 sensor/etc., so on and so forth, so that it all happened nearly simultaneously. If I did it myself, I had the CHG wipes waiting and swiped the front while switching out stickers, then completed the bath as I was doing my skin assessment.

[delphine22]

In our unit, only those with central lines get CHG baths (not everyone, believe it or not), and it's q24, not necessaril within the first 12 hours of admission. So bathing isn't a regular part of the admission process at the get go, though we do turn to take out linens and assess the skin. ED report is at the bedside, which is not the best place to look up orders, so often other team members will get the pt on the monitor and get vitals while the primary nurse steps out of the room for report with the ED nurse. Not our favorite wat to do it, but since the nurse has to come up with the pt they see it as a duplication of their time to have to call us report first, like they would do for the floor (and send the pt up with transport).

[Lennonninja, MSN, APRN, NP]

When I was in ICU, the admission process was a 3-4 person team effort. The CHG bath was one person's task while another hooked stuff up, a third recorded, and a fourth did the swabs/draws/glucose. It usually went like a tag team operation, with the first person taking off the old stickers, the second swiping the front with CHG, first person putting on new stickers/O2 sensor/etc., so on and so forth, so that it all happened nearly simultaneously. If I did it myself, I had the CHG wipes waiting and swiped the front while switching out stickers, then completed the bath as I was doing my skin assessment.

This is how my unit operates too, admissions are a team effort and it's really great to get everything done at once!

[icuRNmaggie, BSN, RN]

The OP is correct. It is absurd to make a chlorhexidine bath THE priority on an ICU admission instead of ensuring that the pt is hemodynamically stable.

Removing the soiled sheets while assessing lungs and skin integrity comes second to getting them on the monitor.

If the pt is unstable, that can wait as well.

The CDC has some literature on chlorhexidine resistance that I found interesting.