Ex-Com meeting _Date

What is a bundle?

• A collection of best practices

identified by evidence-based science
as necessary to provide optimum
care for patients in certain
circumstances involving particular
risks to achieve the goal of improved
outcome.

S imp le
a r t but
e p It Sm
Ke
 S O C I AT E D
L L I N E A S
C E N R A F E C T I O N
T R E A M I N
BLO O D S
 Definition

 The central line bundle consists of a group of evidence-based

interventions for patients with central lines that, when
implemented together, have been shown to result in better
outcomes than when implemented individually.

 A strategy for reducing the risk of CLABSI is the use of

predetermined bundles of interventions that focus on a few
specific, high-yield measures to simplify and focus measures
for prevention of infection.
 Components of Bundle

 Hand Hygiene

 Maximal Barrier Precautions

 Chlorhexidine skin antisepsis

 Optimal Catheter insertion site selection

 Daily review of the necessary central lines and prompt removal of unnecessary
lines
 Hand Hygiene
• Proper Hand Hygiene reduces likelihood of central line infections.
• Hand washing or use of alcohol-gel/ rub as hand cleaner can prevent
contamination of central line sites and BSI.
• Clinicians who insert or manipulate vascular catheters should perform hand
hygiene with an alcohol-based hand rub or antiseptic soap and water.
• Hand Hygiene should be performed regardless of whether examination or surgical
gloves are worn.
 Maximal Barrier Precautions
• For the operator and those assisting in the procedure, it means strict compliance
with hand washing and wearing a cap, mask, sterile gown, and gloves.
• For the patient, it means covering the patient from head to toe with a sterile drape
with a small opening for the site of insertion.
• It Reduces the odds of developing CR-BSI.
• It reduces the rate of CR-BSI and its cost.
 Chlorhexidine Skin Antisepsis

• It provides better antisepsis than other antiseptic agents, such as povidone-iodine

solutions.

• It should be air dried completely (approx. 2 min) before beginning insertion of the
catheter.
Optimal Catheter Insertion Site
Selection
Catheter insertion site influences the likelihood of infections due to the risk of
phlebitis and density of local skin flora. Higher risk of infection is associated with
internal jugular vs subclavian catheter insertion.
The subclavian site should be preferred to femoral site.
Femoral site may be chosen for nontunneled catheters in adult patients.
Other factors such as the potential for mechanical complications, the risk for
subclavian vein stenosis, and catheter operator skills should be considered when
deciding where to place the catheter.
Core aspect of site selection is the risk-benefit analysis by a physician as to which
vein is most appropriate to the patient.
 Daily review of the necessity of all
Central Lines
• It prevents unnecessary delays in removing lines that are no longer clearly necessary
for the patient care.

• The risk of infection increases over time as the line remains in place, and that risk is
decreased if the line is removed.
 DIAGNOSIS
Clinical signs and symptoms

Local infection Systemic infection

Local inflammation Fever

Discharge around the line Rigors when the line used

Erythema Tachycardia

Pain Metastatic infection

 Definition

 CLABSI is defined as the presence of bacteremia originating

from an IV catheter.

 A primary blood stream infection in a patient who had a

central line within the 48-hour period before the
development of the bloodstream infection. [US Centers for
Disease Control and Prevention (CDC), NNIS, NHSN]
 Criteria for CLABSI

Criteria 1

Patient has a recognized pathogen cultured from 1 or

more blood cultures, and the organism cultured from the
blood is not related to infection at other site.
Criteria 2
Patient has at least 1 of the following signs and
symptoms:
Fever (Temperature, > 38°C)
Chills
Hypotension

and signs and symptoms and positive laboratory results are

not related to infection at another site and common skin
contaminant is cultured from 2 or more blood samples
drawn on separate occasions.
Criteria 3

Patient < 1 year of age has at least 1 of the following

signs or symptoms: fever (> 38°C core), hypothermia (< 36°C
core), apnea, or bradycardia

and signs and symptoms and positive laboratory results are

not related to infection at another site and common skin
contaminant is cultured from 2 or more blood samples
drawn on separate occasions.
 Prevention of Catheter
Associated Urinary Tract
Infections (CA-UTI)
 Epidemiology
Problems with Urinary Catheters

• Urinary tract infection

• Mechanical trauma to urethra and bladder
• Immobility (restraining patient)*
• Discomfort and pain to patient
• Increased length of stay
 Epidemiology of CAUTI

• Most common type of healthcare-associated

infection.

• 75% diagnosed in a hospital are associated with a

urinary catheter *CDC, 2009
 Pathophysiology
Risk Factors for CA-UTI

• Method of catheterization
• Duration of catheter
• Quality of catheter care
• Host susceptibility
Pathophysiology: Key Point

• The risk of CA-UTI increases proportionally with the duration of

the indwelling catheter.

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lling cathe
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av e to use ble!
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If you oon as poss
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 Pathophysiology
Common Pathogens
• Endogenous intestinal flora
– E. coli
– Proteus
– Enterobacter
– Enterococci
• Non intestinal or environmental pathogens
– Pseudomonas
– Candida
– Staph coagulase negative
– MRSA
– Acinetobacter
 CAUTI Bundle
Components

Insertion Maintenance Surveillance

“Life Cycle” of the Indwelling
Urinary Catheter

Catheter
Placement

Catheter Catheter
Replacement Care

Catheter
Removal
Disrupting the Life Cycle of the Indwelling
Urinary Catheter

Prevent
unnecessary
placement

Prevent Maintain
catheter proper care
replacement

Promptly
remove
catheter
 Appropriate Inappropriate
Indications Indications
for Insertion

• Hospice Care • Nursing care of incontinent

• patients
Neurogenic bladder
• A means of obtaining a urine
• Obstruction/retention
specimen when the patient can
• Stage 3 or 4 pressure ulcer voluntarily void
• Selected surgical procedures • Prolonged postoperative duration
• Critically ill pt to monitor urine without indications
output
• Prolonged immobilization
Indications based on expert
consensus
 CAUTI Bundles
Maintenance
• Maintain sterility of closed urinary drainage
• Maintain unobstructed urinary flow
• Keep collection bag below the bladder and off the
floor
• Do not change indwelling catheters or collection bags
routinely
• Wash hands prior to handling the urinary drainage
system and catheter
 Maintain Proper Care

• Hand hygiene immediately before and after insertion and before any manipulation
of the catheter device
• Use smallest bore catheter possible
• Indwelling urinary catheter must be properly secured to prevent movement or
urethral traction.
• Date the Foley collection bag with permanent marker or label
 CAUTI Bundle
Caution
C-Closed System, Catheter Selection, Consider Alternatives
A-Aseptic Management
U-Universal/Standard Precautions
T-Tie/Secure Catheter to patient/Tubing to bed
I-Indications for Use AND to Discontinue
O-Obstruction Free, Specimens from Sampling Port
N-No Dependent Loops
*CDC, 2009
 Education and training
Educate healthcare personnel involved in the insertion, care, and
maintenance of urinary catheters about CAUTI prevention, including
alternatives to indwelling catheters and procedures for catheter
insertion, management, and removal
 I ATED
SS O C
TO R A
N TI L A N I A
VE E U M O
P N
 Ventilator Associated Pneumonia (VAP) -
Key Points -
• VAP is the 2nd most common nosocomial infection =
15% of all hospital acquired infections
• Incidence = 9% to 70% of patients on ventilators
• Increased ICU stay by several days
• Increased avg. hospital stay 1 to 3 weeks
• Mortality = 13% to 55%
• Added costs of $40,000 - $50,000 per stay

Centers for Disease Control and Prevention, 2003.

Rumbak, M. J. (2000). Strategies for prevention and treatment. Journal of Respiratory Disease, 21
(5), p. 321;
Ventilator Associated Pneumonia

Ventilator Associated Pneumonia or VAP is a leading cause of

death among Hospital Acquired Infection (HAI). The patient
develops a shadow in the lung, which causes fever, rise in blood
counts and other signs of infection.
 VAP BUNDLE
The VAP bundle is already established and written by the IHI (Institute of
healthcare improvement) in collaboration with many other hospitals and
recognized as a standard of care. The following distinct elements that must be
instituted are referred to as the VAP bundle.

a) Daily interruption of sedation and assessment of readiness to wean

b) Head end elevation>30-45 degrees
c) Regular antiseptic oral care with Chlorhexidine mouth wash solution once every
four hours
d) Continuous subglottic suctioning
e) Intermittent closed ET suctioning occurring making sure that the suction
catheter will not reach beyond the ET tube level
f) Stress ulcer prophylaxis
g) DVT prophylaxis
Remember When
 Risk Factors for
Nosocomial Pneumonia
• Major risk factor = mechanical intubation
• Factors that enhance colonization of the oropharynx
&/or stomach:
– Administration of antibiotics
– Admission to ICU
– Underlying chronic lung disease
• Conditions favoring aspiration into the respiratory tract
or reflux from GI tract:
– Supine position *GERD
– NGT placement *Coma/delirium
– Intubation and self-extubation
– Immobilization
– Surgery of head/neck/thorax/upper abdomen
 Risk Factors for
Nosocomial Pneumonia (cont’d)
• Conditions requiring prolonged use of mechanical
ventilatory support with potential exposure to
contaminated respiratory devices &/or contact with
contaminated hands
• Host Factors:
– Extremes of age
– Malnutrition
– Immunocompromised
– Underlying condition/disease process
Algorithm #3: Diagnosing VAP in Children (Age >1 and <13 years)
Algorithm #4: Diagnosing VAP in Infants (Age <1 year old)
SURGICAL SITE INFECTION
(SSI) PREVENTION
Definition
1. Infection in the surgical site that occurs within 30 days of the surgical
procedure or within one year if there is an implant or foreign body such as
prosthetic heart valve or joint prosthesis.
2. Are divided into the following
a. Incisional SSIs, which are divided into the following:
i. Superficial incisional SSIs involve only the skin and subcutaneous tissue.
ii. Deep incisional SSIs involve deep soft tissues (e.g. fascial and muscle layers).
iii. An infection that involves both superficial and deep incision sites is
classified as a deep incisional SSI.
b. Organ/Space SSIs

Involve any part of the anatomy (organs or spaces) other than the incision that
was opened or manipulated during the operative procedure.
CDC Definition of Surgical Site Infections
SSI level classification
Incisional SSI
- Superficial incisional = skin and
subcutaneous tissue
- Deep incisional = involving deeper soft
tissue
Organ/Space SSI
- Involve any part of the anatomy (organs
and spaces), other than the incision,
opened or manipulated during operations
Cross Section of Abdominal Wall
Depicting CDC SSI Classifications
 Source of SSI Pathogens

• Endogenous flora of the patient

• Operating theater environment
• Hospital personnel (MDs/RNs/staff)
• Seeding of the operative site from distant focus of infection (prosthetic device, implants)
 SSI Risk Factors
• PATIENT • OPERATION

• Duration of surgical scrub

• Skin antisepsis
• Age • Preoperative shaving
• Nutritional status • Preoperative skin preparation
• Diabetes • Duration of operation
• Smoking • Antimicrobial prophylaxis
• Obesity • Operating room ventilation
• Coexistent infection at a remote body site • Inadequate sterilization of instrument
• Foreign material in the surgical site
• Colonization with microorganisms
• Surgical drain
• Altered immune response
• Surgical technique
• Length of preoperative stay • Poor homeostasis
• Failure to obliterate dead space
• Tissue trauma
Perioperative Preventive Measures
• Clipping
• Pre surgical prophylaxis (antibiotic)
• Nicotine cessation
• Glycemic control
• Pre surgical bath
 Bundle for prevention
Basic practices for prevention and monitoring of SSI recommended for all acute care
hospitals
1. Surveillance of SSI
a. Perform surveillance for SSI
b. Provide ongoing feedback on SSI surveillance and process measures to surgical and
peri-operative personnel and leadership
c. Increase the efficiency of surveillance through the use of automated data
2. Practice
a. Administer antimicrobial prophylaxis in accordance with evidence-based standards and
guidelines
b. Do not remove hair at the operative site unless the presence of hair will interfere with
the operation; do not use razors
c. Control blood glucose level during the immediate postoperative period for patients
undergoing cardiac surgery
d. Measure and provide feedback to providers on the rates of compliance with process
measures, including antimicrobial prophylaxis, proper hair removal, and glucose control
(for cardiac surgery)
e. Implement policies and practices aimed at reducing the risk of SSI that meet regulatory
and accreditation requirements and that are aligned with evidence-based standards (eg,
Centers for Disease Control and Prevention and professional organization guidelines)
 Education
a. Educate surgeons and peri-operative personnel about SSI prevention

b. Educate patients and their families about SSI prevention, as appropriate

c. Special approaches for the prevention of SSI Perform an SSI risk assessment. These special approaches
are recommended for use in locations and/or populations within the hospital for which outcome data
and/or risk assessment suggest a lack of effective control despite implementation of basic practices.

d. Perform expanded SSI surveillance to determine the source and extent of the problem and to identify
possible targets for intervention
 Surgical Site Infection Prevention
Bundle Components

1. Prophylactic antibiotic given within one hour prior to surgical incision

2. Appropriate prophylactic antibiotic selection for surgical patients
3. Prophylactic antibiotics discontinued within 24 hours after surgery end
time (48 hours for cardiac surgery)
4. Cardiac surgery patients with controlled 6 A.M. postoperative serum
blood glucose
5. Surgery patients with appropriate hair removal

6. Surgery Patients with Perioperative Temperature Management –

maintaining normothermia 

7. Urinary Catheter removal on postoperative Day 1 or 2 with day of

surgery being day zero.
Risk Stratification
 ASA (American Society of Anesthesiology) score –
given by anesthesia to reflect the patient’s health at
the time of surgery. This is a scale of 1 to 5, with 1
being a normal healthy patient to a 5 representing
death expected within 24 hrs
 Wound class – from clean to dirty (class 1-4)
 Length of time between making and closing incision
 Minimize the Risk
• Appropriate site prep
• Appropriate hand scrub
• Adequate fingernail care
• Healthy healthcare provider
 WAYS
NE A L
H YG I E
HA ND