ICU Care Bundles
- 1. ICU Care Bundle Practices Dr. Jayaprakash Appajigol Associate Professor of Medicine, JNMC, Belgaum. Consultant Physician KLE’s Dr. Prabhakar Kore Hospital and MRC, Belgaum.
- 2. Bundles, According to the IHI A "bundle" is a group of evidence-based care components for a given disease that, when executed together, may result in better outcomes than if implemented individually. Institute for Health Care Improvement (IHI)
- 3. • In a bundle, the individual elements are built around best evidence-based practices. • The science supporting the individual treatment strategies in a bundle is sufficiently mature such that implementation of the approach should be considered either best practice or a reasonable and generally accepted practice. Bundles, According to the IHI
- 4. • Ventilator Associated Pneumonia Prevention Bundle (VAP) • Central Line Bundle • Severe Sepsis Bundles IHI Critical Care Bundles
- 6. –DVT prophylaxis –GI prophylaxis –Head of bed (HOB) elevated to 30-45° –Daily Sedation Vacation –Daily Spontaneous Breathing Trial connected Ventilator-Associated Pneumonia (VAP)Bundle
- 7. DVT prophylaxis: tips • Include deep venous prophylaxis as part of your ICU order admission set and ventilator order set. Make application of prophylaxis the default value on the form. • Include deep venous prophylaxis as an item for discussion on daily multidisciplinary rounds. • Empower pharmacy to review orders for patients in the ICU to ensure that some form of deep venous prophylaxis is in place at all times on ICU patients. • Post compliance with the intervention in a prominent place in your ICU to encourage change and motivate staff. Ventilator-Associated Pneumonia (VAP)Bundle
- 8. GI prophylaxis: tips • Include peptic ulcer disease prophylaxis as part of your ICU order admission set and ventilator order set. Make application of prophylaxis the default value on the form. • Include peptic ulcer disease prophylaxis as an item for discussion on daily multidisciplinary rounds. • Empower pharmacy to review orders for patients in the ICU to ensure that some form of peptic ulcer disease prophylaxis is in place at all times on ICU patients. • Post compliance with the intervention in a prominent place in your ICU to encourage change and motivate staff. Ventilator-Associated Pneumonia (VAP)Bundle
- 9. Head of Bed elevation: tips I • Implement a mechanism to ensure head-of-the-bed elevation, such as including this intervention on nursing flow sheets and as a topic at multidisciplinary rounds. • Create an environment where respiratory therapists work collaboratively with nursing to maintain head-of-the-bed elevation. • Involve families in the process by educating them about the importance of head-of-the-bed elevation and encourage them to notify clinical personnel when the bed does not appear to be in the proper position. Ventilator-Associated Pneumonia (VAP)Bundle
- 10. Head of Bed elevation: tips II • Use visual cues so it is easy to identify when the bed is in the proper position, such as a line on the wall that can only be seen if the bed is below a 30-degree angle. • Include this intervention on order sets for initiation and weaning of mechanical ventilation, delivery of tube feedings, and provision of oral care. • Post compliance with the intervention in a prominent place in your ICU to encourage change and motivate staff. Ventilator-Associated Pneumonia (VAP)Bundle
- 11. Daily sedation vacation/ Spontaneous Breathing Trials: tips I • Implement a protocol to lighten sedation daily at an appropriate time to assess for neurological readiness to extubate. • Include precautions to prevent self-extubation such as increased monitoring and vigilance during the trial. • Include a sedation vacation strategy in your overall plan to wean the patient from the ventilator • if you have a weaning protocol, add "sedation vacation" to that strategy. Ventilator-Associated Pneumonia (VAP)Bundle
- 12. Daily sedation vacation/ Spontaneous Breathing Trials: tips II • Assess that compliance is occurring each day on multidisciplinary rounds. • Consider implementation of a sedation scale such as the Riker scale to avoid oversedation. • Post compliance with the intervention in a prominent place in your ICU to encourage change and motivate staff. Ventilator-Associated Pneumonia (VAP)Bundle
- 15. – Hand Hygiene – Maximal Barrier Precautions Upon Insertion – Chlorhexidine Skin Antisepsis – Optimal Catheter Site Selection, with Avoidance of the Femoral Vein for Central Venous Access in Adult Patients – Daily Review of Line Necessity with Prompt Removal of Unnecessary Lines Central line bundle
- 16. Hand Hygiene: tips I • Empower nursing to enforce use of a central line checklist to be sure all processes related to central line placement are executed for each line placement. • Include hand hygiene as part of your checklist for central line placement. • Keep soap/alcohol-based hand washing dispensers prominently placed and make universal precautions equipment, such as gloves, only available near hand sanitation equipment. Central line bundle
- 17. Hand Hygiene: tips II • Post signs at the entry and exits to the patient room as reminders. • Initiate a campaign using posters including photos of celebrated hospital doctors/employees recommending hand washing. • Create an environment where reminding each other about hand washing is encouraged. • Signs often become "invisible" after just a few days. Try to alter them weekly or monthly (color, shape size). Central line bundle
- 18. Maximal Barrier Precautions Upon Insertion: tips • Empower nursing to enforce use of a central line checklist to be sure all processes related to central line placement are executed for each line placement. • Include maximal barrier precautions as part of your checklist for central line placement. • Keep equipment ready stocked in a cart for central line placement to avoid the difficulty of finding necessary equipment to institute maximal barrier precautions. Central line bundle
- 19. Chlorhexidine skin antisepsis: tips • Empower nursing to enforce use of a central line checklist to be sure all processes related to central line placement are executed for each line placement. • Include Chlorhexidine antisepsis as part of your checklist for central line placement. • Include Chlorhexidine antisepsis kits in carts storing central line equipment. Many central line kits include povidone-iodine kits and these must be avoided. • Ensure that solution dries completely before an attempted line insertion. Central line bundle
- 20. Optimal catheter site selection: tips • Empower nursing to enforce use of a central line checklist to be sure all processes related to central line placement are executed for each line placement. • Include optimal site selection as part of your checklist for central line placement with room for appropriate contraindications (e.g., bleeding risks). Central line bundle
- 21. Daily review of Lines/ Prompt removal: tips • Empower nursing to enforce use of a central line checklist to be sure all processes related to central line placement are executed for each line placement. • Include daily review of line necessity as part of your multidisciplinary rounds. • Include assessment for removal of central lines as part of your daily goal sheets. • Record time and date of line placement for record keeping purposes and evaluation by staff to aid in decision making. Central line bundle
- 23. Severe Sepsis BUNDLES Severe Sepsis The 3-Hour Resuscitation Bundle and The 6-Hour Septic Shock Bundle
- 24. Severe Sepsis BUNDLES The Severe Sepsis 3-Hour Resuscitation Bundle contains the following elements, to be completed within 3 hours of the time of presentation: 1.Measure Lactate Level 2. Obtain Blood Cultures Prior to Administration of Antibiotics 3. Administer Broad Spectrum Antibiotics 4. Administer 30 mL/kg Crystalloid for Hypotension or Lactate ≥4 mmol/L
- 25. Severe Sepsis BUNDLES 6-Hour Septic Shock Bundle: Evidence-based goals that must be completed within 6 hours for patients with severe sepsis. 1.Apply Vasopressors (for Hypotension That Does Not Respond to Initial Fluid Resuscitation to Maintain a Mean Arterial Pressure (MAP) ≥65 mm Hg) 2. In the Event of Persistent Arterial Hypotension Despite Volume Resuscitation (Septic Shock) or Initial Lactate ≥4 mmol/L a. Measure Central Venous Pressure (CVP) b. Measure Central Venous Oxygen Saturation (ScvO2) 3. Remeasure Lactate If Initial Lactate Was Elevated
- 26. Sepsis resuscitation bundle • describes seven tasks that should begin immediately, but must be accomplished within the first 6 hours of presentation for patients with severe sepsis or septic shock. • Some items may not be completed if the clinical conditions described in the bundle do not prevail in a particular case, but clinicians should assess for them. • The goal is to perform all indicated tasks 100 percent of the time within the first 6 hours of identification of severe sepsis. Severe Sepsis BUNDLES
- 27. Critical Care Bundle: Conclusions • Listed the contents of the IHI Critical Care bundles – VAP – Central Line – Severe Sepsis Institute for Health Care Improvement (IHI)
- 28. Care bundles originated in North America and are described best as groups of evidence-based practice interventions The theory behind care bundles is that when several evidence- based interventions are grouped together in a single protocol, it will improve patient outcome Care bundles are relatively easy to develop, implement and audit, and provide practitioners with a practical method for implementing evidence-based practice More and more data that the use of these patient-safety bundles are associated with improved outcomes Some clinicians disagree with the validity of the combined content Critical Care Bundle: Conclusions
- 29. Nevertheless, it is becoming part of standard practice for us to document our awareness of these patient-safety initiatives Critical Care Bundle: Conclusions
- 34. Insertion ◦ Insert only for specific reasons Urinary output in critical ill Bladder outlet obstruction or neurogenic bladder dysfunction Prevent contamination of sacral wounds Terminal care ◦ Competent HCW to insert ◦ Aseptic technique ◦ Closed system with bag below bladder Urinary Catheter Care Bundle
- 35. Management ◦ Review need for catheter daily ◦ Empty when ¾ full and use clean container for each patient ◦ Secure catheter to leg/abdomen ◦ Urine samples from sampling port only ◦ Hand hygiene & PPE before and after any catheter care Urinary Catheter Care Bundle