INTENSIVE CARE UNITS

ROLE OF NURSING
Dr.T.V.Rao MD

3/8/2014

Dr.T.V.Rao MD

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

A Patient in Intensive Care Unit is at Risk for Many Reasons..

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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

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.
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Educating our Health Care Workers

Education programs for employees and volunteers are one method to ensure competent infection control practices.
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Why ICU patients are different

Sickest patients (multiple diagnoses, multiorgan failure, immunocompromised, septic and trauma) Move less Malnourished More obtunded (Glasgow coma scale)

May be associated Diabetics and Heart failure

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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.
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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
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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
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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 decontamination of items &

equipment's Inadequate cleaning of environment
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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
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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

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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
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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
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Intensive Care Unit

Prevention of Blood stream infections

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Central Venous Catheters

Indications
IV fluids and drugs Blood and blood products Total Parenteral Nutrition (TPN) Hemodialysis Hemodynamic monitoring
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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.

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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
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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.
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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
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Sources of Infection
Intrinsic contamination of infusion fluid
Port for additives

Connection with administration set Insertion site Injection ports Administration set connection with IV catheter

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1. Extra luminal Spread Patients 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 Skin attachment
Skin Fibrin

Sources of Infection
2. Intraluminal Spread Intralumunal Spread Contaminated Contaminatedinfusate (fluid, medication) infusate (fluid, medication)

Vein

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3. Haematogenous Spread Infection from distant focus

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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
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With an antiseptic solution eg Chlorhexidine gluconate

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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

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

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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

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Prevention of CR-BSI
Catheters removal
Dont replace it routinely Replace it if: Inserted in an Emergency Non functioning

Evidence of local or systemic infection General handling

Opening of hub: Use antisepticimpregnated pads eg Chlorhexidine gluconate or povidone iodine

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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
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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
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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.

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Urinary Catheterization

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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)

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

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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.
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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
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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.
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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

Intensive Care Unit Nosocomial Pneumonia

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Incidence of HAI vs. Cost

Hospital acquired Infection Urinary Tract Incidence Additional
cost

45%

13%

Surgical Wound Pneumonia

Blood Stream
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29% 9%
2%
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42 % 39%
4%
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Risk factors for bacterial pneumonia

Host Factors
Elderly Severe Illness Underlying Lung Disease Depressed Mental Status Immunocompromising Conditions or Treatments Viral Respiratory Tract Infection Colonisation Intensive Care Setting Use of Antimicrobial Agents Contaminated hands Contaminated Equipment

Factors that facilitate reflux & aspiration into the lower RT

- Mechanical ventilation - Tracheostomy - Use of a Nasogastric Tube - Supine Position Factors that impede normal Pulmonary Toilet - Abdominal or thoracic surgery - Immobilisation

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Prevention in ICU
Turn patients to encourage postural drainage
Encourage to take deep breaths and cough. Maintain an upright position (elevate patients head to 3045 degree angle) to reduce reflux and aspiration of gastric bacteria.
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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. H2 blockers or antacids are used to prevent stress ulcers
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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- 45 degrees

Remove NG Tube if not necessary

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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 manufacturers instructions.
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Suctioning mechanically ventilated patients

Hand washing before and after the procedure. Wear clean gloves to prevent crosscontamination 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.
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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.

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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
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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.
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Oxygen mask
Change oxygen mask and tubing between patients and more frequently if soiled
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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.
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Antibiotics use
Must avoid widespread use of broad spectrum antibiotics
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Problem-Detection of Infection in the ICUs

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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 foodborne, respiratory, water borne illnesses. We dont know the spectrum of antimicrobial activity of most preservatives and cleaners for many viruses.
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 Symptomatic Urinary Tract Infection:

Examples from the NNIS Manual

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 105 organisms per ml or no more than two species of organisms
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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
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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.
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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
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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
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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
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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)

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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.
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Why we need better ICUs

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.
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Do remember the Reasons for Infections are Many but solutions are few

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Yet No Substitute for Hand Washing

Are You Washing ?

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Let us support our Hospitals with clean hands

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WARNING

Nosocomial Infections in ICU are Waiting

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Be kind to your patients REMEMBER ONE THING

PLEASE WASH YOUR HANDS

 The Programme Created by Dr.T.V.Rao MD for Paramedical and Health care workers in the Developing world Email doctortvrao@gmail.com

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