Bundle of care use in Intensive care units.

1. BUNDLES OF CARE
NPCC
POOJA BHANDARI

2. BUNDLE OF CARE
A SET OF INTERVENTIONS BETTER OUTCOME.
A CARE BUNDLE IS A GROUP OF THREE TO FIVE EVIDENCE-BASED
INTERVENTIONS WHICH, WHEN PERFORMED TOGETHER, HAVE A
BETTER OUTCOME THAN IF PERFORMED INDIVIDUALLY.(CARE
BUNDLE IN INTENSIVE CARE, ST. JAMES’S UNIVERSITY HOSPITAL ,
UK JULY 2021)

3. CONT…
CARE “BUNDLES” ARE SIMPLE SETS OF EVIDENCE-
BASED PRACTICES THAT, WHEN IMPLEMENTED
COLLECTIVELY, IMPROVE THE RELIABILITY OF THEIR
DELIVERY AND IMPROVE PATIENT OUTCOMES
(INTERNATIONAL SOCIETY FOR INFECTIOUS DISEASES)

4. Fast

5. FAST HUGS BID
•Bowel care
•Indwelling
catheter
•De-escalation
of antibiotics
•Head of the bed
elevated.
•Ulcer prophylaxis
•Glycemic control
•Spontaneous
Breath Trial(SBT)
•Feeding
•Analgesic
•Sedation
•Thromboembolic
prophylaxis
FAST HUGS
BID

8. • Critically ill patient – hyper catabolic state- due to various factors- Burn, Infection, Sepsis,
Trauma/Injury, Sever inflammations and Organ failure ,etc.
• Adequate nutritional requirement – prevent from malnutrition.
• As early as possible within 12 hours .
• NBM/Enteral feeding / Parenteral route.
• Requirement: Calories 20-25Kcal/kg/day
Protein 1-1.5gm/kg/day
Protein 2gm/kg/day (Burn-hyper catabolic Pt.)
• 1200calories/30gm protein
Enteral
Oral
Nasal Tube
(Gastric
gavage)
Directly to GI
Tract
*Gastrostomy
*Jejunostomy
Parental
Central
Peripheral
Source : South zone critical care-2018

10. NUTRITIONAL ASSESSMENT
1.BMI=Weight in Kilograms/Square of height in meter.
Normal BMI=18.5-24.5
2. Height and weight measurement.
3.Body composition:
- Tricesps skin fold measurement.
- Mild-arm muscle circumference.

11. TRICEPS SKIN
FOLDMEASEREMENT Upper arm circumference

12. DIAGNOSTIC
TEST
Common laboratory indices:
1.Serum pre-albumin
2.Albumin
3. Transferrin
4.Lymphocyte count
5.Hemoglobin/Hematocrit
6.Urine specific gravity
7.24-hour urine test.

13. • Pain : Assess as fifth vital sign , it’s an unpleasent feeling of distress or suffering.
• Round the clock.
• Pain related behaviour:
1. Subjective measure- facial expression, movements
2. Physiologic measure- Heart rate , blood pressure.
• Pharmacological therapies: Non- steriodal anti-inflammatory
drug(Ibuprofen,Naproxen,Indomethacin) ,Non opiates( Acetaminophen, Acetylsalicyclic acid)
and Opioid {Morphine sulphate, Fentanyl, Meperidine(Demerol)}
• Side effect: Respiratory depression, Constipation , Hypotension and Hallunications.
Source : South zone critical care-2018

14. • Non-Pharmacological approach:
1. Alter pain stimulation: Electrical stimulator(Modify pain stimulus by blocking or changing the
pain stimulus, Neurosurgical procedure{Neurectomy: presacral area(dysmenorrhea),
Rhynotomy: severe pain in upper trunk(ca.lung), Cordotomy: severe pain in lower body
(ca.pelvic)},Nerve block and aucupunture.
2. Therapeutic touch
3. Distraction and relaxation exercises
4. Modifying pain stimulus: Back rub, application of hot and cold , supporting limbs, placing
pillows, avoid bumping or moving the bed suddenly, use dim light and control the no of
visitors.
Source:Text book of fundamental nursing, Makalu publication.

17. • TO CALM, COMFORTABLE AND QUIET PATIENT.
• DAILY SEDATION HOLD– TO LOOK FOR EXTUBATION
READINESS(SEDATION HOLIDAY)
• OVERSEDATION INCREASED RISK OF :
venousthrombosis
Decreased
intestinal motility
Hypotension
ICU
polyneuropathy
Prolong ICU stay

18. 1.Early ambulation
2.Adequate
hydration
3.Mechanical
method
Pharmacological
method
Pharmacological method:LMWH are preferred
over other anticogulant.
Mechinical
methods:
Venous foot pump

20. • Stress Ulcer prevention is important.
• Notably for patient with respiratory failure or cogulation abnormality,
Undergoing steroid therapy , or with the history of gastroduodenal ulcer, who
are risk of developing stress related gastrointestinal hemorrhage.

22. GLYCEMIC CONTROL
Aim to keep blood sugar level below about 180mg/dl.
Short acting insulin is preferred agent until the patient is
stabilized, hemodynamics are acceptable and enteral feeding is
tolerated.

23. • SBT should be started early once the patients fulfils the criteria for weaning.
• Weaning has two component: 1. Liberation from ventilation and
2. Extubation.
The sooner the patient is liberated from ventilator, the lesser the chance of Ventilator Associated
Pneumonias(VAP) , Ventilatory-induced lung injury, Decreased ICU stay and overall reduced
mortality.
Source: ISCCM-ICU Protocols A stepwise approach

24. STEPS:
• Weaning should never be hurried as it can be successful only when the patient is physically and
mentally ready.
• Whenever possible, position the patient upright in bed
• Throughly suctioning the endotracheal tube and ensure patency.
• Mode for SBT:
1. T-piece:
Patient are disconnect from ventilator and made to breath humidified oxygen – air mixed through T-
piece connected to the endotracheal / tracheostomy tube for 30-120 min
Source: ISCCM-ICU Protocols A stepwise approach

25. Increased respiratory load. Dyspnea and fatigue should be carefully avoided.
2. Pressure support:
The pressure support level is to be gradually reduced, titrate to RR and patient comfort.
A level of 6-8 cm H2O pressure support is considered to overcome the tube resistance.
PEEP of 4-6cm H2O.
Duration: 30-120 minutes
• Adequate cough reflex-spontaneous or while suctioning.
• Patient should be able to protect airway, and they should follow simple command.
• No radiological and surgical procedure is being planned in the near future.
• Extubation should not be done at the end of the day.
Source: ISCCM-ICU Protocols A stepwise approach

26. we can prevent patient
from VAP by 40%.
Rs.7,560per day (BD)
10days 75,600

28. Penetrate through the body natural
mechanism.
High risk for local and systemic
infection.
Discontinue/removal , when not medically
necessary.

30. • VAP, defined as a new pneumonia occurring > 48 hours after endotracheal
intubation.
• VAP is common and serious hospital-acquired infection.
• It occurs in up to 20% of pt receiving mechinical ventilation, & is associated with
increased antibiotic use, length of hospitalization and healthcare cost.

31. SOURCE : South zone critical care-2018
• Best hand washing practice.
• Head end to be elevated 30-45 degree.
• Oral care with Chlorexidine solution.
• Suction should be done only when required. Closed suction should be encouraged when increased
secretions are anticipated.
• Sedation vacation (early morning sadation should be hold)
• Prevanting VAP by 40%.
• Provide early exercise and early mobilization.

33. Source:International Society for Infectious Disease
1. INSERTION BUNDLE:
• Maximal sterile barrier precautions (surgical mask, sterile gloves, cap, sterile gown, and large sterile drape).
• Skin cleaning with alcohol-based chlorhexidine (rather than iodine).
• Avoidance of the femoral vein for central venous access in adult patients; use of subclavian rather than jugular veins.
• Standardized insertion packs.
• Availability of insertion guidelines (including indications for central line use) and use of checklists with trained
observers.
• Use of ultrasound guidance for insertion of internal jugular lines.

34. Source:International Society for Infectious Disease
• 2. Maintenance bundle:
- Daily review of central line necessity.
- Prompt removal of unnecessary lines.
- Disinfection prior to manipulation of the line.
- Daily chlorhexidine washes (in ICU, patients > 2 months).
- Disinfect catheter hubs, ports, connectors, etc., before using the catheter.
- Change dressings and disinfect site with alcohol-based chlorhexidine every 5-7 days (change
earlier if soiled).
- Replace administration sets within 96 hours(4days) (immediately if used for blood products or
lipids).
- Ensure appropriate nurse-to-patient ratio in ICU (1:2 or 1:1).

35. • Best hand washing practice.
• Insertion under strict asceptic precaution.
• Catheter to be secured – no pulling from cot.
• Bag should be kept below the bladder level.
• Empty the bag once it reaches 2/3 rd of capacity.
• Avoiding the use of urinary catheters by considering alternative methods for urine
collection.
- methods include: condom catheters, intermittent catheterization, use of nappies.
SOURCE : South zone critical care-2018

36. • SSIS are infections of the incision or organ or space that occur after surgery.
• Administration of parenteral antibiotic prophylaxis.
- Antibiotic prophylaxis should be administered within 60 minutes prior to incision, including for
caesarean section.
- Re-dosing is recommended for prolonged procedures and in patients with major blood loss or excessive
burns.
• Patients should be washed with soap or an antiseptic agent within a night prior to surgery.

37. OURCE : International Society for Infectious Disease
• Use alcohol-based disinfectant for skin preparation in the operating room.
• Maintain intraoperative Glycemic control with target blood glucose levels < 200
mg/dl (in patients with and without diabetes).
• Maintain perioperative normothermia.
• Administer increased fraction of inspired oxygen during surgery and
• After extubation in the immediate postoperative period in patients with normal
pulmonary function.

38. The interventions above should be implemented with a
multimodal package of infection prevention including:
Hand hygiene,
Sterilization of surgical equipment,
The use of appropriate surgical attire,
and staff education and feedback.