Icu care bundles.pptx NOSOCOMIAL HEALTH AND CARE

Icu care

1. ICU CARE BUNDLES Presented by: Capt Arti Rawat Capt Lucky Maan Capt Yashoda Gaur Capt Maliya Mathew Lt Priyanka Kapthiyal Chairperson: Col Parikshit Singh

2. THE VERY FIRST REQUIREMENT IN A HOSPITAL IS THAT IT SHOULD DO THE SICK NO HARM - Florence Nightingale

3. WHAT IS CARE BUNDLE? Structured way Improving care Small , straight forward set of evidence-based practices Three to five elements Performed collectively Resar R,Pronovost p,Haraden C, Simmonds T.et al. Using Bundle approach to improve ventilator care processes and reduce ventilator associated pneumonia.Joint Commission Journal on Quality and Patient Safety. 2010;31 (5):243-248

4. HISTORY Developed over 20 – 30 years In late 1990’s applied to critical care Means of assessing quality of care Prevent morbidity and mortality Improves clinical care Focus on interventions and process of care delivery Berenholtz SM, Dorman T , ngo k, Pronovost PJ. Qualitative review of intensive care unit quality indicators ,J CRI CARE,2002VOL.17(PG 1-12)

5. INCIDENCE 8.4% Patient > 2days stay in ICU =1 Hospital Acquired Infection >2 days stay = 6% pneumonia, 45% Blood Stream Infection, 25% Urinary Tract Infection (UTI) 97% Pneumonia episodes = Ventilator Acquired Pneumonia (intubation) 44% Blood Stream Infection = Catheter Related 99% UTI = Urinary catheter European Centre for Disease Prevention and Control .Healthcare associated infections acquired in intensive care units. In: ECDC .Annual epidemiological report for 2016. Stockholm;2018

6. IMPORTANCE OF CARE BUNDLES 1 . Benefit to the patient 2. Shorter ICU stay 3. Reduced financial cost 4. Improves resource utilization 5. Best clinical practice 6. Clinical effectiveness

7. ELEMENTS OF CARE BUNDLE Ventilator Bundle Central Line Bundle Sepsis Resuscitation Bundle Sepsis Management Bundle Catheter Associated Urinary Tract Infection Bundle (CAUTI)

8. VENTILATOR CARE BUNDLE

9. VAP Ventilator associated pneumonia (VAP) is pneumonia occurring in a patient within 48 hrs or more after intubation with an endotracheal tube or tracheostomy tube and which was not present before.

10. VAP 2 nd most common nosocomial infection = 15% of all hospital acquired infections Occurs in 25% of intubated patients Increases average hospital stay by 1 to 3 weeks Mortality = 13% to 55% Torres A, Niederman MS, Chastre J, et al : International ERS/ESICM/ESCMID/ALAT guidelines for the management of hospital-acquired pneumonia(HAP)/ ventilator associated pneumonia(VAP) of the European Respiratory Society(ERS), European Society of Intensive Care Medicine(ESICM), European Society of Clinical Microbiology and Infectious Diseases(ESCMID) and ALAT. Eur Respir J. 2017; 50(3): pii : 1700582.10.1183/13993003.00582-2017

11. BUGS CAUSING VAP Early onset (less than 96 hrs of intubation) - Hemophilus influenza -Streptococcus pneumoniae -Staphylococcus aureus (methicillin sensitive) Late onset (more than 96 hrs of intubation) -Pseudomonas aeruginosa - Acinetobacter spp. -Staphylococcus aureus ( methicillin resistant / MRSA)

12. DIAGNOSTIC CRITERIA The presence of a new or progressive radiographic infiltrates in Chest X-ray At least two of three clinical features - Fever greater than 38 ºC - Leukocytosis or Leukopenia - Purulent secretions

13. VENTILATOR BUNDLE Elevation of head of bed Daily oral care with chlorhexidine Daily sedation vacation Peptic ulcer disease prophylaxis Deep vein thrombosis prophylaxis (DVT)

14. ELEVATION OF HOB 30º head elevation (max. upto 45º) Minimize aspiration of gastric, oral and nasal secretions Improves ventilation

15. DAILY ORAL CARE WITH CHLORHEXIDINE Reduces bacterial load in oral mucosa 0.12% chlorhexidine Use of chlorhexidine in ventilator patients is associated with lower risk of VAP ( Enwere EN, Elofson KA,Rachel C, Gerlach AT. Impact of chlorhexidine mouthwash prophylaxis on probable on VAP in surgical ICU, Int J Crit Illn Inj Sci. 2016 Jan- Mar; 6(1):3-8)

16. SEDATION VACATION Discontinuation of sedation after prolonged infusion (preferably early morning, before consultant’s round) Assess the readiness of patient to wean off Lowers risk of mortality and complications ( Luetz A, Goldman A, Weber- Carstens S, Spies C, Weaning from mechanical ventilation and sedation. Curr Opin Infect Dis 2012 Apr;25(2):164-169.) PMID:22246460)

17. PEPTIC ULCER DISEASE PROPHYLAXIS Decrease in gastric acid contents may protect against greater pulmonary inflammatory response to aspiration of gastrointestinal contents Prophylaxis- Proton pump inhibitors H2 receptor blockers

18. DVT PROPHYLAXIS Mechanical ventilated patients are at high risk of DVT due to immobility May lead to complications like Pulmonary Thrombo Embolism Prophylaxis may be - Mechanical therapy - Anticoagulants

19. ADDITIONAL MEASURES

20. CENTRAL LINE BUNDLE

21. A central line- associated blood stream infection(CLABSI) is defined as a laboratory – confirmed bloodstream infection not related to an infection at another site that develops within 48 hrs of a central line placement. Haddadin Y, Regunath H. Central Line Associated Blood Stream Infections(CLABSI) [Updated 2019 Jan 20]. In: StatPearls [Internet]. Treasure Island (FL) : nStatPearls Publishing;2018 jan

22. INCIDENCE CLABSIs remain a leading cause of serious healthcare associated infections in ICUs in India In India, CLABSIs rate is 27.6% Patil HV, Patil VC, Ramteerthkar MN, Kulkarni RD. Central venous catheter – related bloodstream infections in the intensive care unit. Indian J Crit Care Med 2011;15:213-23

23. ETIOLOGY Based on the NHSN data:- Gram – positive organisms Coagulase -negative staphylococci (34.1%) Enterococci (16%) Staphylococcus aureus (9.9%) Gram – negative organisms Klebsiella (5.8%) Acinetobacter (2.2%) Fungal organisms Candida species(11.8%) Haddadin Y, Regunath H. Central Line Associated Blood Stream Infections(CLABSI) [Updated 2019 Jan 20]. In: StatPearls [Internet]. Treasure Island (FL) : nStatPearls Publishing;2018 jan

24. MEANS OF ENTRY

25. TYPES OF CATHETER Tunneled catheters :- Implanted surgically for long term indications Non – tunneled catheters :- Inserted percutaneously

26. RISK FACTORS Chronic illnesses Immune compromised states Malnutrition Total parenteral nutrition Extremes of age Loss of skin integrity Prolonged hospitalization before venous catheterization Catheter type Catheter location

27. CLINICAL MANIFESTATION Central line related infections can be either localised or systemic Symptoms of localised infections include: Redness Swelling Discharge at central line exit site

28. SYSTEMIC INFECTION SYMPTOMS

29. HAND HYGIENE MAXIMAL BARRIER PRECAUTION CHLORHEXIDINE SKIN ANTISEPSIS OPTIMAL CATHETER SITE SELECTION DAILY REVIEW OF LINE NECESSITY 1. 2. 3. 4. 5. Naomi P. O’Grady,M.D.,Mary Alexander,R.N.,Lillian A.Burns.2011 Guidelines for the Prevention of Intravascular Catheter-Related Infections. Heathcare Infection Control Practices Advisory Committee(HICPAC)

30. 32 HAND HYGIENE – Just do it! Before catheter insertion Follow aseptic technique Before and after handling a central line. Naomi P. O’Grady,M.D.,Mary Alexander,R.N.,Lillian A.Burns.2011 Guidelines for the Prevention of Intravascular Catheter-Related Infections. Heathcare Infection Control Practices Advisory Committee(HICPAC)

31. 2 . MAXIMAL BARRIER PRECAUTION * * CDC guidelines

32. 3. CHLORHEXIDINE SKIN PREPARATION Naomi P. O’Grady,M.D.,Mary Alexander,R.N.,Lillian A.Burns.2011 Guidelines for the Prevention of Intravascular Catheter-Related Infections. Heathcare Infection Control Practices Advisory Committee(HICPAC)

33. 4. OPTIMAL CATHETER SITE SELECTION Risk of infection: Central line>>> Peripheral vein Femoral >>> Internal Juglar > Subclavian Subclavian = preferred

34. 5 . DAILY LINE ASSESSMENT & REVIEW Daily assessment of central line Prompt removal of unnecessary lines Dressing Tubings and devices Needleless devices

35. CAUTI BUNDLE

36. CAUTI Fourth most common type UTI accounts for 36% of Hospital Acquired Infection (80% are catheter associated) Each day - risk increases by 3% -7% To minimize effects of Catheter Associated Urinary Tract Infection(CAUTI) Development of protocols and checklist Sandhu R,Sayal P,Jakkar R,Sharma G.Catheterization associated urinary tract infections: Epidemiology and incidence from tertiary care hospital in Haryana .J Health Res Rev 2018 ;5 :135-41

37. WHAT IS CAUTI? When an Indwelling urinary catheter has been in place for more than two calendar days on the date of event Infection in urinary system including the bladder and kidneys. National Healthcare Safety Network Catheter-Associated Urinary Tract Infection Surveillance in 2018

38. CAUSATIVE ORGANISMS E coli (24%) Candida spp (21%) Klebsiella pneumoniae (10%) Pseudomonas aeruginosa (10.0%) Weiner LM, Webb AK, Limbago B, et al. Antimicrobial resistant pathogens associated with healthcare associated infections: Sumary of data reported to the national healthcare safety network at the centres for disease control & prevention , 2011-2014.Infection Control & Hospital Epidemiology.2016;37(11):1288

39. DIAGNOSTIC CRITERIA Two of the following must be met Fever (>38 °C) Chills Costovertebral tenderness Suprapubic pain, flank pain or tenderness Decrease mental or functional status New onset of hematuria , foul smelling urine

40. CAUTI BUNDLE

41. IMPORTANT REMINDERS Hand hygiene Levelling of urine bag Avoid tugging and pulling Avoid twisting and kinking Remove as early as possible

42. SEPSIS BUNDLE

43. INTRODUCTION Sepsis is a major health problem with increasing prevalence, high cost and poor outcomes The first Surviving Sepsis campaign (SSC) guidelines for sepsis management were published in the annual meeting of European Society of Intensive care medicine (ESICM) held in Barcelona in 2004 1.Dellinger RP, Levy MM, Rhodes A , et al. Surviving Sepsis Campaign: International guidelines for management of severe sepsis and septic shock:2012. Crit Care Med 2013; 41: 580-637

44. DEFINITION “Sepsis is a life threatening organ dysfunction caused by a dysregulated host response to an infection” The European Society of Critical Care medicine,3 rd international consensus definitions for sepsis-2016

45. National Guideline centre (UK).Sepsis: Recognition , Assessment and early Management. London: National Institute for health and Care Excellence (UK); 2016 Jul. (NICE Guideline, No.51) 14 ,Finding the source of infection Lung infections Blood stream infections Urinary tract infections Abdominal infections e.g. Infection of unknown source meningitis Skin or Soft tissue infections Catheter-related Infections

46. SEPSIS RESUSCITATION BUNDLE

47. SEPSIS RESUSCITATION BUNDLE 1-HOUR 3 –HOUR BUNDLE Measure Lactate level Draw blood cultures Administer broad spectrum antibiotics Administer Crystalloid fluid 30ml/Kg bolus 6-HOUR BUNDLE If persistent hypotension after initial fluid resuscitation , then Add Vasopressors Measure CVP, SVO2 Remeasure Lactate 1.Dellinger RP, Levy MM, Rhodes A , et al. Surviving Sepsis Campaign: International guidelines for management of severe sepsis and septic shock:2016. Crit Care Med 2013; 41: 580-637

48. SEPSIS 1-HOUR BUNDLE Measure Lactate level Obtain blood cultures before administering antibiotics Administer broad spectrum antibiotics Begin to rapidly administer 30ml/kg Crystalloids for hypotension or Lactate ≥ 4 mmol/L Apply Vasopressors if patient is hypotensive during or after fluid resuscitation 1. Dellinger RP ,Levy MM, Rhodes A ,et al : Surviving Sepsis Campaign : International Guidelines for management of severe shock and septic shock :2018 .Intensive care Med 2018; 39: 165-228

49. 1 . Measuring Lactate level Hyperlactatemia due to anaerobic metabolism and tissue hypoperfusion Normal Value 0.5 - 1 mmol/L During septic shock ≥4mmol/L If >2 mmol/L it should be remeasured within 2-4 hours

50. 2. Obtain blood culture Prior to antibiotics Sterilization of culture can occur within minutes of the first dose of an appropriate antibiotic At least two sets of samples should be taken from two different sites and also from central venous devices

51. 3 . Administer broad spectrum antibiotics Every hour delay of starting broad spectrum antibiotic increases mortality Should be started within 1 hour of presentation of sepsis Antibiotic coverage for Gram positive, Gram negative, anaerobic, and antifungal if indicated

52. 4. Fluid resuscitation With hypotension and elevated Lactate level ≥4mmol/L Initial fluid challenge of crystalloid 30ml/kg (Normal saline / Ringer Lactate)

53. 5. Administer vasopressors Urgent restoration of adequate perfusion pressure to vital organs is a key part of resuscitation To achieve MAP ≥65 mm Hg Recommended Vasopressor of choice in septic shock is Nor adrenaline

54. SEPSIS MANAGEMENT BUNDLE Includes evidence based goals Must be completed within 24hrs Presentation of severe sepsis or septic shock

55. PROSE GRADE DESCRIPTIONS

56. GLYCEMIC CONTROL Maintain blood sugar level below 180mg/dl If Blood glucose ≥ 180mg/dl = IV Insulin infusion Avoid hypoglycemia Monitored 1 to 2 hourly Strong recommendation , high quality of evidence

57. PREVENT EXCESSIVE INSPIRATORY PLATEAU PRESSURE Tidal volume = 6ml/kg = prevent volutrauma Plateau pressure < 30cm of H 2 O = prevent barotrauma Minimizes Ventilator Associated Lung Injury Strong recommendation , moderate quality of evidence

58. NUTRITION Administration of early nutrition Initiate IV glucose & advance enteral feeds over first 7 days Strong recommendation, moderate quality of evidence