Intensive care Units Role of Nursing

1. INTENSIVE CARE UNITS
ROLE OF NURSING
Dr.T.V.Rao MD
3/8/2014
Dr.T.V.Rao MD
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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..
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4. 1st principle of infection
prevention
at least 35-50% of all healthcare-associated infections are
asociated with only 5 patient care practices:
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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.
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Dr.T.V.Rao MD

6. Educating our Health Care
Workers
• Education programs for
employees and volunteers
are one method to ensure
competent infection control
practices.
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7. 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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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
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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
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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
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11. ICU : Factors that increase
cross-infections
• Hand washing facilities are inadequate
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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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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
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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
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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
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15. Strategy for Infection
Prevention
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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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16. Intensive Care Unit
Prevention of Blood stream
infections
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17. Central Venous Catheters
Indications
• IV fluids and drugs
• Blood and blood products
• Total Parenteral Nutrition (TPN)
• Hemodialysis
• Hemodynamic monitoring
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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.
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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
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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.
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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
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22. Sources of Infection
Intrinsic contamination of
infusion fluid
Port for
additives
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Connection with administration
set
Insertion site
Injection ports
Administration set connection
with IV catheter
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23. 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 attachment
Skin
Sources of Infection
2. Intraluminal Spread
Intralumunal Spread
Contaminated infusate
Contaminated
(fluid, medication)
infusate (fluid,
medication)
Skin
Fibrin
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Vein
Dr.T.V.Rao MD
3. Haematogenous Spread
Infection from distant
focus
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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
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25. Chlorhexidine Skin Antisepsis
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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

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
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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
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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 antisepticimpregnated pads eg Chlorhexidine
gluconate or povidone iodine
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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
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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
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31. Background: Prevention Strategies
Interventions
• Michigan Keystone Project
• Decrease in CLABSI in 103 ICUs in Michigan (66%
reduction)
• Basic interventions:
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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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32. Urinary Catheterization
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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
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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.
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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
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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.
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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 shorterterm 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
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40. Incidence of HAI vs. Cost
Hospital acquired
Infection
Urinary Tract
Incidence Additional
cost
45%
13%
Surgical Wound
29%
42 %
Pneumonia
9%
39%
Blood Stream
2%
4%
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Dr.T.V.Rao MD
Haley, 1986 40

41. Risk factors for bacterial pneumonia
Host Factors
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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
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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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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 30º45º degree angle) to
reduce reflux and
aspiration of gastric
bacteria.
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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.
• H2 blockers or antacids are used to prevent stress
ulcers
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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 30º- 45 º degrees
Remove NG Tube if not necessary
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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.
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46. 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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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.
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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
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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.
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50. Oxygen mask
• Change oxygen
mask and
tubing
between
patients and
more
frequently if
soiled
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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.
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52. Antibiotics use
Must avoid widespread
use of
broad spectrum antibiotics
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53. Problem-Detection of
Infection in the ICU’s
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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 foodborne, respiratory, water borne illnesses.
We don’t know the spectrum of antimicrobial activity of most preservatives
and cleaners for many viruses.
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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 105 organisms per
ml or no more than two species of organisms
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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
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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.
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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
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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
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60. Why we are not washing hands ???
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•
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•
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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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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
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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.
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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.
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64. Do remember the Reasons for Infections
are Many but solutions are few …
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65. Yet No Substitute for Hand Washing
Are You Washing ?
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66. Let us support our Hospitals with
clean hands
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67. WARNING
Nosocomial Infections in ICU are Waiting
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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
• doctortvrao@gmail.com
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