Intensive care Units Role of Nursing

Intensive care Units Role of Nursing

1. INTENSIVE CARE UNITS ROLE OF NURSING Dr.T.V.Rao MD 3/9/2014 Dr.T.V.Rao MD 1

2. The very first requirement in a hospital is that it should do the sick no harm

3. A Patient in Intensive Care Unit is at Risk for Many Reasons.. 3/9/2014 Dr.T.V.Rao MD 3

4. 1st principle of infection prevention at least 35-50% of all healthcare-associated infections are asociated with only 5 patient care practices: Use and care of urinary catheters Use and care of vascular access lines Therapy and support of pulmonary functions Surveillance of surgical procedures Hand hygiene and standard precautions

5. The Purpose of the Programme The purpose of this program is to maintain a healthy and safe Hospital by the prevention and control of health care related infections / diseases in particular intensive care units. This is achieved by surveillance and investigation of infectious diseases and public education. Dr.T.V.Rao MD 5 3/9/2014

6. Educating our Health Care Workers Education programs for employees and volunteers are one method to ensure competent infection control practices. Dr.T.V.Rao MD 6 3/9/2014

7. Why ICU patients are different Sickest patients (multiple diagnoses, multi-organ failure, immunocompromised, septic and trauma) Move less Malnourished More obtunded (Glasgow coma scale) May be associated Diabetics and Heart failure 3/9/2014 Dr.T.V.Rao MD 7

8. EPIDEMIOLOGY Contributing factors Patients in ICUs have more chronic comorbid illnesses and more severe acute physiologic derangements . The high frequency of indwelling catheters among ICU patients The use and maintenance of these catheters necessitate frequent contact with health care workers, which predispose patients to colonization and infection with nosocomial pathogens . 3/9/2014 Dr.T.V.Rao MD 8

9. Multi Drug Resistant Bacteria Multidrug-resistant pathogens such as methicillin-resistant Staphylococcus aureus (MRSA) and Vancomycin-resistant enterococci (VRE) are being isolated with increasing frequency in ICUs 3/9/2014 Dr.T.V.Rao MD 9

10. ICU Care is Invasive at many Stages More invasive lines and procedures including surgeries Longer length of stay More IV and parenteral drugs More tube feeding and Parenteral nutrition More ventilation 3/9/2014 Dr.T.V.Rao MD 10

11. ICU : Factors that increase cross-infections Hand washing facilities are inadequate Patients close together or sharing rooms Understaffing Preparation of IVs on the unit Lack of isolation facilities No separation of clean and dirty AREAS Excessive antibiotic use Inadequate decontaminatio n of items & equipment's Inadequate cleaning of environment 3/9/2014 Dr.T.V.Rao MD 11

12. Some Health-Care Associated Infections May Occur in ICU Patients UTI associated with Foley catheters Lower respiratory tract infection (post-op and ventilator dependent) Skin necrosis (skin breakdown) Blood stream infection (and line associated) Surgical-site infection Nutrition-related and malnutrition 3/9/2014 Dr.T.V.Rao MD 12

13. Strategy for Prevention Hand washing Use gloves to prevent contamination of the hands when handling respiratory secretions Wear gloves and gowns (contact precautions) during all contact with patients and fomites potentially contaminated with respiratory secretions Use aseptic technique 3/9/2014 Dr.T.V.Rao MD 13

14. Strategy for Prevention Clean and decontaminate all equipment after use Sterilise or use high-level disinfection for all items that come into direct or indirect contact with mucous membranes Rinse and dry items that have been chemically disinfected Package and store items to prevent contamination before use Keep environment clean, dry and dust free 3/9/2014 Dr.T.V.Rao MD 14

15. Strategy for Infection Prevention Strict attention to Hand hygiene Prudent Antibiotic use Aseptic technique Disinfection/Sterilization of items and equipment Education of staff infection control awareness Keep Environment Clean, Dry and dust free Surveillance of nosocomial infection to identify problems areas & set priorities 3/9/2014 Dr.T.V.Rao MD 15

16. Intensive Care Unit Prevention of Blood stream infections 3/9/2014 Dr.T.V.Rao MD 16

17. Central Venous Catheters Indications IV fluids and drugs Blood and blood products Total Parenteral Nutrition (TPN) Hemodialysis Hemodynamic monitoring 3/9/2014 Dr.T.V.Rao MD 17

18. Serious Infective Complications Blood Stream Infections (BSI) Septic pulmonary emboli Metastasis infection Acute endocarditis Osteomyelitis Septic arthritis Shock and organ failure Poor outcome: Staph.aureus or Candida spp. 3/9/2014 Dr.T.V.Rao MD 18

19. Incidence of CR-BSI Type of catheter Teflon or Polyurethane ( < infections) vs Polyvinyl chloride or Polyethylene Site of insertion Subclavian (< infections) vs Internal Jugular & Femoral (high risk of colonization & deep venous thrombosis) No. of Lumen Single-lumen catheter (< infections) vs Multi-lumen catheter 3/9/2014 Dr.T.V.Rao MD 19

20. Prevention Strategies: Core Proper Insertion Practices Ensure utilization of insertion bundle: Chlorhexidine for skin antisepsis Maximal sterile barrier precautions (e.g., mask, cap [i.e., similar to those worn in the O.R.], gown, sterile gloves, and large sterile drape) Hand hygiene Many CLs in patients on non-ICU hospital wards are placed outside those wards (Emergency room, ICU, Operating room, or Pre-operative areas) Trick et al. Am J Infect Control 2006;34:636-41. 3/9/2014 Dr.T.V.Rao MD 20

21. Prevention Strategies: Core Chlorhexidine Skin Cleansing Chlorhexidine is the preferred agent for skin cleansing for both CL insertion and maintenance Tincture of iodine, an iodophores, or 70% alcohol are alternatives Recommended application methods and contact time should be followed for maximal effect Prior to use should ensure agent is compatible with catheter Alcohol may interact with some polyurethane catheters Some iodine-based compounds may interact with silicone catheters 3/9/2014 Dr.T.V.Rao MD 21

22. Intrinsic contamination of infusion fluid Connection with administration set Insertion site Injection ports Administration set connection with IV catheter Port for additives Sources of Infection 3/9/2014 Dr.T.V.Rao MD 22

23. Intralumunal Spread Contaminated infusate (fluid, medication) 2. Intraluminal Spread Contaminated infusate (fluid, medication) 1. Extra luminal Spread Patient’s own skin micro flora Microorganism transferred by the hands of Health Care Worker Contaminated entry port, catheter tip prior or during insertion Contaminated disinfectant solutions Invading wound 3. Haematogenous Spread Infection from distant focus Fibrin Skin Vein Skin attachment Sources of Infection 3/9/2014 Dr.T.V.Rao MD 23

24. Prevention of CR-BSI Written Protocol Must be performed by trained staff according to written guidelines Sterile procedure Sterile gown, Sterile gloves, Sterile large drapes Don't shave the site Hand disinfection With an antiseptic solution eg Chlorhexidine gluconate 3/9/2014 Dr.T.V.Rao MD 24

25. Chlorhexidine Skin Antisepsis Prepare skin with antiseptic/detergent chlorhexidine 2% in 70% isopropyl alcohol. Pinch wings on the applicator to pop the ampule. Hold the applicator down to allow the solution to saturate the pad . Press sponge against skin, apply chlorhexidine solution using a back and forth friction scrub for at least 30 seconds. Do not wipe or blot. Allow antiseptic solution time to dry completely before puncturing the site (~ 2 minutes).

26. Prevention of CR-BSI Skin antisepsis 2% Chlorhexidine gluconate has shown to have lower BSI than 10% Povidone-iodine or 70 % Alcohol 2-min drying time before insertion Maki DG et al. Lancet 1991;338:339-43 No difference between 0.5% Chlorhexidine gluconate or 10% Povidone-iodine Humar A et al . Clin Infect Dis 2000;31:1001-7 3/9/2014 Dr.T.V.Rao MD 26

27. Prevention of CR-BSI Dressing Gauze dressings every 2 days Transparent dressing every 7 days on short term catheter Replace dressing when catheter is replaced or dressing becomes damp or loose. Grady NP et al , HICPAC draft guidelines: 2002 3/9/2014 Dr.T.V.Rao MD 27

28. Prevention of CR-BSI Catheters removal Don’t replace it routinely Replace it if: Inserted in an Emergency Non functioning Evidence of local or systemic infection General handling Opening of hub : Use antiseptic-impregnated pads eg Chlorhexidine gluconate or povidone iodine 3/9/2014 Dr.T.V.Rao MD 28

29. Prevention of CR-BSI Administration sets Replacement at 72-h intervals No difference in phlebitis if left for 96 hours Lines for lipid emulsion: replacement at 24-h intervals Lines for blood product : remove immediately after use 3/9/2014 Dr.T.V.Rao MD 29

30. Prevention of CR-BSI Topical antibiotic Prophylactic use of topical Mupirocin (Bactroban) at insertion site or in nose is not recommended Rapid development of Mupirocin resistant Mupirocin affect the integrity of Polyurethane catheter Systemic antibiotic Prophylactic use of antibiotic is not recommended at the time of catheter insertion 3/9/2014 Dr.T.V.Rao MD 30

31. Background: Prevention Strategies Interventions Michigan Keystone Project Decrease in CLABSI in 103 ICUs in Michigan (66% reduction) Basic interventions: Hand hygiene Full barrier precautions during CL insertion Skin cleansing with chlorhexidine Avoiding femoral site Removing unnecessary catheters Use of insertion checklist Promotion of safety culture Pronovost et al. NEJM 2006;355:2725-32. 3/9/2014 Dr.T.V.Rao MD 31

32. Urinary Catheterization 3/9/2014 Dr.T.V.Rao MD 32

33. CATHETER - ASSOCIATED UTI Other important risk factors for CAUTI Patients with other sites of active infection Long hospital stay Malnutrition Female sex Abnormal serum creatinine Improper catheter care (particularly placement of the drainage tube above the level of the bladder)

34. External urethral meatus & urethra Pass catheter when bladder full for wash-out effect. Before catheterization prepare urinary meatus with an antiseptic ( e.g. povidone iodine or 0.2% chlorhexidine aqueous solution) Inject single-use sterile lubricant gel (e.g. 1-2%) lignocaine into urethra and hold there for 3 minutes before inserting catheter. Use sterile catheter. Use non-touch technique for insertion 3/9/2014 Dr.T.V.Rao MD 34

35. Junction between catheter & drainage tube Do not disconnect catheter unless absolutely necessary. For urine specimen collection disinfect outside of catheter proximal to junction with drainage tube by applying alcoholic impregnated wipe and allow it to dry completely then aspirate urine with a sterile needle and syringe. 3/9/2014 Dr.T.V.Rao MD 35

36. Junction between drainage tube & collection bag Keep bag below level of bladder. If it is necessary to raise collection bag above bladder level for a short period, drainage tube must be clamped temporarily . Empty bag every 8 hours or earlier if full . Do not hold bag upside down when emptying 3/9/2014 Dr.T.V.Rao MD 36

37. Tap at bottom of collection bag Collection bag must never touch floor. Always wash or disinfect hands (eg with 70% alcohol) before and after opening tap. Use a separate disinfected jug to collect urine from each bag. Don't put disinfectant into urinary bag. 3/9/2014 Dr.T.V.Rao MD 37

38. Prevention The condom catheter is a good alternative to the indwelling catheter for men and is associated with lower rates of bacteriuria Intermittent bladder catheterization has been shown to reduce the incidence of UTI in long - term spinal cord injury patients compared to an indwelling catheter, this approach has not been studied in patients with shorter - term indwelling bladder catheters . Suprapubic catheters might be more comfortable for patients and have been shown to lower the incidence of bacteriuria

39. Intensive Care Unit Nosocomial Pneumonia 3/9/2014 Dr.T.V.Rao MD 39

40. Incidence of HAI vs. Cost Hospital acquired Infection Incidence Additional cost Urinary Tract 45% 13% Surgical Wound 29% 42 % Pneumonia 9 % 39% Blood Stream 2% 4 % Haley, 1986 3/9/2014 Dr.T.V.Rao MD 40

41. Risk factors for bacterial pneumonia Host Factors Factors that facilitate reflux & aspiration into the lower RT Elderly Severe Illness Underlying Lung Disease - Mechanical ventilation Depressed Mental Status - Tracheostomy Immunocompromising - Use of a Nasogastric Tube Conditions or Treatments - Supine Position Viral Respiratory Tract Factors that impede normal Infection Pulmonary Toilet Colonisation - Abdominal or thoracic surgery Intensive Care Setting - Immobilisation Use of Antimicrobial Agents Contaminated hands Contaminated Equipment 3/9/2014 Dr.T.V.Rao MD 41

42. Prevention in ICU Turn patients to encourage postural drainage Encourage to take deep breaths and cough. Maintain an upright position (elevate patient’s head to 30º- 45º degree angle) to reduce reflux and aspiration of gastric bacteria. 3/9/2014 Dr.T.V.Rao MD 42

43. Gastric Ulcer Prophylaxis Stomach of a healthy person : Acidic pH ( ) & normal peristalsis movement prevent bacterial growth Alkaline pH () and loss on normal peristalsis lead to bacterial colonisation which increases the risk of ventilator-associated pneumonia Mechanical ventilation patients are at increased risk for upper GI hemorrhage from stress ulcers. H 2 blockers or antacids are used to prevent stress ulcers 3/9/2014 Dr.T.V.Rao MD 43

44. Nasogastric Tube May erode the mucosal surface Block the sinus ducts Regurgitation of gastric contents leading to aspiration. Verify placement of the feeding tube in the stomach or small intestine by X ray Elevate the head of the bed 30 º - 45 º degrees Remove NG Tube if not necessary 3/9/2014 Dr.T.V.Rao MD 44

45. Ventilators After every patient, clean and disinfect (high-level) or sterilize re-usable components of the breathing system or the patient circuit according to the manufacturer’s instructions. 3/9/2014 Dr.T.V.Rao MD 45

46. Suctioning mechanically ventilated patients Hand washing before and after the procedure. Wear clean gloves to prevent cross-contamination Use a sterile single-use catheter ; if it is not possible then rinse catheter with sterile water and store it in a dry, clean container between uses and change the catheter every 8 - 12 hours. 3/9/2014 Dr.T.V.Rao MD 46

47. Suction Bottle Use single-use disposable, if possible Non-disposable bottles should be washed with detergent and allowed to dry. Heat disinfect in washing machine or send to Sterile Service Department. 3/9/2014 Dr.T.V.Rao MD 47

48. Nebulizers Use sterile medications and fluids for nebulization Fill with sterile water only. Change and reprocess device between patients by using sterilization or a high level disinfection or use single-use disposable item. Small hand held nebulizers minimise unnecessary use between uses for the same patient disinfect, rinse with sterile water, or air dry and store in a clean, dry place Reprocess nebulizers daily 3/9/2014 Dr.T.V.Rao MD 48

49. Humidifiers Clean and sterilize device between patients. Fill with sterile water which must be changed every 24 hours or sooner, if necessary. Single-use disposable humidifiers are available but they are expensive. 3/9/2014 Dr.T.V.Rao MD 49

50. Oxygen mask Change oxygen mask and tubing between patients and more frequently if soiled 3/9/2014 Dr.T.V.Rao MD 50

51. The Scientific study ( SENIC ) gives guidelines Study of the Efficacy of Nosocomial Infection Control (SENIC) project was published, validating the cost-benefit of infection control programs. Data collected in 1970 and 1976-1977 suggested that one-third of all nosocomial infections could be prevented if all the following were present: One infection control professional (ICP) for every 250 beds. An effective infection control physician. A program reporting infection rates back to the surgeon and those clinically involved with the infection. An organized hospital-wide surveillance system. Dr.T.V.Rao MD 51 3/9/2014

52. Antibiotics use Must avoid widespread use of broad spectrum antibiotics 3/9/2014 Dr.T.V.Rao MD 52

53. Problem-Detection of Infection in the ICU’s 3/9/2014 Dr.T.V.Rao MD 53

54. Examples of difficult to detect infections: Uncultivable organisms Viruses are under appreciated as causes of nosocomial infections. Except in cases of high morbidity viral cultures are not done in resource scarce settings. Impact food-borne, respiratory, water borne illnesses. We don’t know the spectrum of anti-microbial activity of most preservatives and cleaners for many viruses. 3/9/2014 Dr.T.V.Rao MD 54

55. Examples from the NNIS Manual Symptomatic Urinary Tract Infection: Patient must have one of the two criteria: Fever >38 C OR urgency OR frequency OR dysuria OR suprapubic tenderness without other cause OR Urine culture with at least 10 5 organisms per ml or no more than two species of organisms 3/9/2014 Dr.T.V.Rao MD 55

56. Definition of surgical site infection (no implant) Occurs within 30 days of surgery AND has one of the following: Purulent drainage from drain OR Organism isolated from aseptically obtained fluid in the organ space 3/9/2014 Dr.T.V.Rao MD 56

57. Prior to starting any surveillance Agree upon a written case definition that is practical given the laboratory facilities and patient work load in your facility. 3/9/2014 Dr.T.V.Rao MD 57

58. Our plan for future should include Unlike scheduled activities, occasional clusters of patients who are colonized or infected will trigger further investigation including a case-control study. New laboratory methods developed and refined within the last decade can now determine how related the strain is at the molecular level. The QI/IC plan should include special problem-focused studies that describe personnel or environmental sampling, including what circumstances and who has the authority to order Dr.T.V.Rao MD 58 3/9/2014

59. Hand washing Single most effective action to prevent HAI - resident/transient bacteria Correct method - ensuring all surfaces are cleaned - more important than agent used or length of time taken No recommended frequency - should be determined by intended/completed actions Research indicates: poor techniques - not all surfaces cleaned frequency diminishes with workload/distance poor compliance with guidelines/training Dr.T.V.Rao MD 59 3/9/2014

60. Why we are not washing hands ??? Working in high-risk areas Lack of hand hygiene promotion Lack of role model Lack of institutional priority Lack of sanction of non-compliers Dr.T.V.Rao MD 60 3/9/2014

61. EPIDEMIOLOGY A multicenter, prospective cohort surveillance study of 46 hospitals in Central and South America, India , Morocco, and Turkey . Rates of device - associated infection were determined between 2002 and 2005; an overall rate of 14.7 percent or 22.5 infections per 1000 ICU days was found . Specific devices : Ventilator associated pneumonia ( VAP ) ; 24.1 cases/1000 ventilator days ( range 10.0-52.7 ) CVC - related bloodstream infections; 12.5/1000 catheter days ( 7.8-18.5 ) Catheter - associated urinary tract infections; 8.9/1000 catheter days ( 1.7-12.8 ) 3/9/2014 Dr.T.V.Rao MD 61

62. Our Vision to Future Infection control programs must maintain training records of employees. The minimum training required is annual OSHA blood borne pathogen, tuberculosis prevention and control and new employee orientation. Dr.T.V.Rao MD 62 3/9/2014

63. Why we need better ICU’s For an incidence as well as for a prevalence population of critically ill patients, there is a window of critical opportunity for admission into the ICU , much like the golden our for the trauma patient. Efforts should be made to avail ICU facilities to as many recently deteriorated patients as possible, especially those who could be transferred into the ICU very early after deterioration, such as patients on hospital wards. 3/9/2014 Dr.T.V.Rao MD 63

64. Do remember the Reasons for Infections are Many but solutions are few … 3/9/2014 Dr.T.V.Rao MD 64

65. Yet No Substitute for Hand Washing Are You Washing ? 3/9/2014 Dr.T.V.Rao MD 65

66. Let us support our Hospitals with clean hands Dr.T.V.Rao MD 66 3/9/2014

67. WARNING Nosocomial Infections in ICU are Waiting Dr.T.V.Rao MD 67

68. Be kind to your patients REMEMBER ONE THING PLEASE WASH YOUR HANDS

69. The Programme Created by Dr.T.V.Rao MD for Paramedical and Health care workers in the Developing world Email [email protected] 3/9/2014 Dr.T.V.Rao MD 69