1. ICU care bundles are structured ways to improve care through implementing small, evidence-based practices together. Common bundles include ventilator, central line, sepsis resuscitation, and catheter-associated urinary tract infection bundles. 2. The ventilator bundle aims to prevent ventilator-associated pneumonia through practices like elevating the head of the bed, daily oral care with chlorhexidine, and peptic ulcer disease prophylaxis. 3. The central line bundle seeks to reduce central line-associated bloodstream infections through practices such as proper hand hygiene, skin antisepsis with chlorhexidine, and daily review of line necessity.

1. ICU CARE BUNDLES
Reshma vijay

2. THE VERY FIRST REQUIREMENT IN
A HOSPITAL IS THAT IT SHOULD DO
THE SICK NO HARM
- Florence Nightingale

3. WHAT IS CARE BUNDLE?
• Structured way
• Improving care
• Small , straight forward set of evidence-based practices
• Three to five elements
• Performed collectively
Resar R,Pronovost p,Haraden C, Simmonds T.et al. Using Bundle approach to improve ventilator care processes
and reduce ventilator associated pneumonia.Joint Commission Journal on Quality and Patient Safety. 2010;31
(5):243-248

4. HISTORY
• Developed over 20 – 30 years
• In late 1990’s applied to critical care
• Means of assessing quality of care
• Prevent morbidity and mortality
• Improves clinical care
• Focus on interventions and process of care delivery
Berenholtz SM, Dorman T ,ngo k, Pronovost PJ. Qualitative review of intensive care unit quality indicators ,J CRI
CARE,2002VOL.17(PG 1-12)

5. INCIDENCE
1. 8.4% Patient > 2days stay in ICU =1 Hospital Acquired
Infection
2. >2 days stay = 6% pneumonia, 45% Blood Stream
Infection, 25% Urinary Tract Infection (UTI)
3. 97% Pneumonia episodes = Ventilator Acquired
Pneumonia (intubation)
4. 44% Blood Stream Infection = Catheter Related
5. 99% UTI = Urinary catheter
European Centre for Disease Prevention and Control .Healthcare associated infections acquired in
intensive care units. In: ECDC .Annual epidemiological report for 2016. Stockholm;2018

6. IMPORTANCE OF CARE BUNDLES
1. Benefit to the patient
2. Shorter ICU stay
3. Reduced financial cost
4. Improves resource utilization
5. Best clinical practice
6. Clinical effectiveness

7. ELEMENTS OF CARE BUNDLE
 Ventilator Bundle
 Central Line Bundle
 Sepsis Resuscitation Bundle
 Sepsis Management Bundle
 Catheter Associated Urinary Tract
Infection Bundle (CAUTI)

8. VENTILATOR CARE
BUNDLE

9. VAP
• Ventilator associated pneumonia (VAP) is
pneumonia occurring in a patient within 48 hrs or
more after intubation with an endotracheal tube or
tracheostomy tube and which was not present
before.

10. VAP
• 2nd most common nosocomial infection = 15%
of all hospital acquired infections
• Occurs in 25% of intubated patients
• Increases average hospital stay by 1 to 3 weeks
• Mortality = 13% to 55%
Torres A, Niederman MS, Chastre J, et al : International ERS/ESICM/ESCMID/ALAT
guidelines for the management of hospital-acquired pneumonia(HAP)/ ventilator
associated pneumonia(VAP) of the European Respiratory Society(ERS), European
Society of Intensive Care Medicine(ESICM), European Society of Clinical Microbiology
and Infectious Diseases(ESCMID) and ALAT. Eur Respir J. 2017; 50(3): pii:
1700582.10.1183/13993003.00582-2017

11. BUGS CAUSING VAP
• Early onset (less than 96 hrs of intubation)
-Hemophilus influenza
-Streptococcus pneumoniae
-Staphylococcus aureus (methicillin sensitive)
• Late onset (more than 96 hrs of intubation)
-Pseudomonas aeruginosa
-Acinetobacter spp.
-Staphylococcus aureus (methicillin resistant /
MRSA)

12. DIAGNOSTIC CRITERIA
• The presence of a new or progressive radiographic
infiltrates in Chest X-ray
• At least two of three clinical features
- Fever greater than 38 ºC
- Leukocytosis or Leukopenia
- Purulent secretions

13. VENTILATOR BUNDLE
• Elevation of head of bed
• Daily oral care with chlorhexidine
• Daily sedation vacation
• Peptic ulcer disease prophylaxis
• Deep vein thrombosis prophylaxis (DVT)

14. ELEVATION OF HOB
• 30º head elevation (max. upto 45º)
• Minimize aspiration of gastric, oral and nasal
secretions
• Improves ventilation

15. DAILY ORAL CARE WITH
CHLORHEXIDINE
• Reduces bacterial load in oral mucosa
• 0.12% chlorhexidine
• Use of chlorhexidine in ventilator patients is
associated with lower risk of VAP
(Enwere EN, Elofson KA,Rachel C, Gerlach AT. Impact of chlorhexidine mouthwash
prophylaxis on probable on VAP in surgical ICU, Int J Crit Illn Inj Sci. 2016 Jan- Mar; 6(1):3-8)

16. SEDATION VACATION
• Discontinuation of sedation after prolonged infusion
(preferably early morning, before consultant’s round)
• Assess the readiness of patient to wean off
• Lowers risk of mortality and complications
( Luetz A, Goldman A, Weber-Carstens S, Spies C, Weaning from mechanical
ventilation and sedation. Curr Opin Infect Dis 2012 Apr;25(2):164-169.)
PMID:22246460)

17. PEPTIC ULCER DISEASE PROPHYLAXIS
• Decrease in gastric acid contents may protect
against greater pulmonary inflammatory response to
aspiration of gastrointestinal contents
• Prophylaxis-
Proton pump inhibitors
H2 receptor blockers

18. DVT PROPHYLAXIS
• Mechanical ventilated patients are at high risk of
DVT due to immobility
• May lead to complications like Pulmonary Thrombo
Embolism
• Prophylaxis may be
- Mechanical therapy
- Anticoagulants

19. ADDITIONAL MEASURES

21. CENTRAL LINE BUNDLE

22. A central line- associated blood stream
infection(CLABSI) is defined as a laboratory –
confirmed bloodstream infection not related to
an infection at another site that develops within
48 hrs of a central line placement.
Haddadin Y, Regunath H. Central Line Associated Blood Stream Infections(CLABSI) [Updated 2019 Jan 20]. In: StatPearls
[Internet]. Treasure Island (FL) :nStatPearls Publishing;2018 jan

23. INCIDENCE
• CLABSIs remain a leading cause of serious
healthcare associated infections in ICUs in India
• In India, CLABSIs rate is 27.6%
Patil HV, Patil VC, Ramteerthkar MN, Kulkarni RD. Central venous catheter – related bloodstream infections in the intensive
care unit. Indian J Crit Care Med 2011;15:213-23

24. ETIOLOGY
Based on the NHSN data:-
Gram – positive organisms
 Coagulase-negative staphylococci (34.1%)
 Enterococci (16%)
 Staphylococcus aureus(9.9%)
Gram – negative organisms
 Klebsiella (5.8%)
 Acinetobacter(2.2%)
Fungal organisms
 Candida species(11.8%)
Haddadin Y, Regunath H. Central Line Associated Blood Stream Infections(CLABSI) [Updated 2019 Jan 20]. In: StatPearls [Internet]. Treasure Island (FL)
:nStatPearls Publishing;2018 jan

25. MEANS OF ENTRY

26. TYPES OF CATHETER
• Tunneled catheters:- Implanted surgically for long
term indications
• Non – tunneled catheters:- Inserted percutaneously

27. RISK FACTORS
• Chronic illnesses
• Immune compromised states
• Malnutrition
• Total parenteral nutrition
• Extremes of age
• Loss of skin integrity
• Prolonged hospitalization before venous
catheterization
• Catheter type
• Catheter location

28. CLINICAL MANIFESTATION
Central line related infections can be either localised or
systemic
Symptoms of localised infections include:
• Redness
• Swelling
• Discharge at central line exit site

29. SYSTEMIC INFECTION
SYMPTOMS

31. HAND HYGIENE
MAXIMAL BARRIER
PRECAUTION
CHLORHEXIDINE
SKIN ANTISEPSIS
OPTIMAL CATHETER
SITE SELECTION
DAILY REVIEW OF
LINE NECESSITY
1. 2.
3.
4.
5.
Naomi P. O’Grady,M.D.,Mary Alexander,R.N.,Lillian A.Burns.2011 Guidelines for the Prevention of Intravascular Catheter-Related Infections. Heathcare Infection Control
Practices Advisory Committee(HICPAC)

32. 32
1. HAND HYGIENE – Just do it!
A. Before catheter insertion
B. Follow aseptic technique
C. Before and after handling a central line.
Naomi P. O’Grady,M.D.,Mary Alexander,R.N.,Lillian A.Burns.2011 Guidelines for the Prevention of Intravascular Catheter-Related
Infections. Heathcare Infection Control Practices Advisory Committee(HICPAC)

33. 2. MAXIMAL BARRIER PRECAUTION
*
* CDC guidelines

34. 3. CHLORHEXIDINE SKIN
PREPARATION
Naomi P. O’Grady,M.D.,Mary Alexander,R.N.,Lillian A.Burns.2011 Guidelines for the Prevention of Intravascular Catheter-Related
Infections. Heathcare Infection Control Practices Advisory Committee(HICPAC)

35. 4. OPTIMAL CATHETER SITE
SELECTION
Risk of infection:
 Central line>>> Peripheral vein
 Femoral >>> Internal Juglar > Subclavian
Subclavian = preferred

36. 5. DAILY LINE ASSESSMENT &
REVIEW
• Daily assessment of central line
• Prompt removal of unnecessary lines
• Dressing
• Tubings and devices
• Needleless devices

37. CAUTI BUNDLE

38. CAUTI
• Fourth most common type
• UTI accounts for 36% of Hospital Acquired Infection
(80% are catheter associated)
• Each day - risk increases by 3% -7%
• To minimize effects of Catheter Associated Urinary
Tract Infection(CAUTI)
• Development of protocols and checklist
Sandhu R,Sayal P,Jakkar R,Sharma G.Catheterization associated urinary tract infections: Epidemiology and incidence
from tertiary care hospital in Haryana .J Health Res Rev 2018 ;5 :135-41

39. WHAT IS CAUTI?
• When an Indwelling urinary catheter has been in
place for more than two calendar days on the
date of event
• Infection in urinary system including the bladder
and kidneys.
National Healthcare Safety Network Catheter-Associated Urinary Tract Infection Surveillance in 2018

40. CAUSATIVE ORGANISMS
• E coli (24%)
• Candida spp (21%)
• Klebsiella pneumoniae (10%)
• Pseudomonas aeruginosa(10.0%)
Weiner LM, Webb AK, Limbago B, et al. Antimicrobial resistant pathogens associated with healthcare
associated infections: Sumary of data reported to the national healthcare safety network at the
centres for disease control & prevention , 2011-2014.Infection Control & Hospital
Epidemiology.2016;37(11):1288

41. DIAGNOSTIC CRITERIA
Two of the following must be met
 Fever (>38 °C)
 Chills
 Costovertebral tenderness
 Suprapubic pain, flank pain or tenderness
 Decrease mental or functional status
 New onset of hematuria , foul smelling urine

42. CAUTI BUNDLE
1
• HAND HYGIENE BEFORE AND AFTER
PROCEDURE
2
• ASEPTIC TECHNIQUE
3
• CATHETER IS STILL REQUIRED? IF NOT
REMOVE
4
• MAINTAIN CLOSED DRAINAGE SYSTEM
5
• EXPLAIN TO THE PATIENT HIS/HER ROLE
IN DECREASING RISK OF INFECTION
• REGULAR EMPTYING OF URINARY BAG

43. IMPORTANT REMINDERS
• Hand hygiene
• Levelling of urine bag
• Avoid tugging and pulling
• Avoid twisting and kinking
• Remove as early as possible

44. SEPSIS BUNDLE

45. INTRODUCTION
Sepsis is a major health problem with increasing
prevalence, high cost and poor outcomes
The first Surviving Sepsis campaign (SSC)
guidelines for sepsis management were published in
the annual meeting of European Society of Intensive
care medicine (ESICM) held in Barcelona in 2004
1.Dellinger RP, Levy MM, Rhodes A , et al. Surviving Sepsis Campaign: International guidelines for
management of severe sepsis and septic shock:2012. Crit Care Med 2013; 41: 580-637

46. DEFINITION
“Sepsis is a life threatening organ
dysfunction caused by a dysregulated host
response to an infection”
The European Society of Critical Care medicine,3rd international consensus definitions for sepsis-2016

47. National Guideline centre (UK).Sepsis: Recognition , Assessment and early Management. London:
National Institute for health and Care Excellence (UK); 2016 Jul. (NICE Guideline, No.51) 14 ,Finding the
source of infection
Lung infections
Blood stream
infections
Urinary tract
infections
Abdominal infections e.g.
Infection of unknown source
meningitis
Skin or
Soft
tissue
infections
Catheter-
related
Infections

48. SEPSIS RESUSCITATION BUNDLE

49. SEPSIS RESUSCITATION BUNDLE
1-HOUR
• 3 –HOUR BUNDLE
 Measure Lactate level
 Draw blood cultures
 Administer broad
spectrum antibiotics
 Administer Crystalloid
fluid 30ml/Kg bolus
• 6-HOUR BUNDLE
 If persistent
hypotension after initial
fluid resuscitation , then
 Add Vasopressors
Measure CVP, SVO2
Remeasure Lactate
1.Dellinger RP, Levy MM, Rhodes A , et al. Surviving Sepsis Campaign: International guidelines for management of
severe sepsis and septic shock:2016. Crit Care Med 2013; 41: 580-637

50. SEPSIS 1-HOUR BUNDLE
Measure Lactate level
Obtain blood cultures before administering antibiotics
Administer broad spectrum antibiotics
Begin to rapidly administer 30ml/kg Crystalloids for
hypotension or Lactate ≥ 4 mmol/L
 Apply Vasopressors if patient is hypotensive during or
after fluid resuscitation
1. Dellinger RP ,Levy MM, Rhodes A ,et al : Surviving Sepsis Campaign : International Guidelines for management of severe
shock and septic shock :2018 .Intensive care Med 2018; 39: 165-228

51. 1. Measuring Lactate level
 Hyperlactatemia due to anaerobic metabolism and
tissue hypoperfusion
 Normal Value 0.5 - 1 mmol/L
 During septic shock ≥4mmol/L
 If >2 mmol/L it should be remeasured within 2-4
hours

52. 2. Obtain blood culture Prior to
antibiotics
 Sterilization of culture can occur within minutes of
the first dose of an appropriate antibiotic
 At least two sets of samples should be taken from
two different sites and also from central venous
devices

53. 3. Administer broad spectrum
antibiotics
 Every hour delay of starting broad spectrum
antibiotic increases mortality
 Should be started within 1 hour of presentation of
sepsis
 Antibiotic coverage for Gram positive, Gram
negative, anaerobic, and antifungal if indicated

54. 4. Fluid resuscitation
 With hypotension and elevated Lactate level
≥4mmol/L
 Initial fluid challenge of crystalloid 30ml/kg
(Normal saline / Ringer Lactate)

55. 5. Administer vasopressors
 Urgent restoration of adequate perfusion
pressure to vital organs is a key part of
resuscitation
 To achieve MAP ≥65 mm Hg
 Recommended Vasopressor of choice in septic
shock is Nor adrenaline

57. SEPSIS MANAGEMENT BUNDLE
• Includes evidence based goals
• Must be completed within 24hrs
• Presentation of severe sepsis or septic shock

58. PROSE GRADE DESCRIPTIONS

59. GLYCEMIC CONTROL
• Maintain blood sugar level below 180mg/dl
• If Blood glucose ≥ 180mg/dl = IV Insulin infusion
• Avoid hypoglycemia
• Monitored 1 to 2 hourly
Strong recommendation , high quality of evidence

60. PREVENT EXCESSIVE INSPIRATORY
PLATEAU PRESSURE
• Tidal volume = 6ml/kg = prevent volutrauma
• Plateau pressure < 30cm of H2O = prevent barotrauma
• Minimizes Ventilator Associated Lung Injury
Strong recommendation , moderate quality of evidence

61. NUTRITION
• Administration of early nutrition
• Initiate IV glucose & advance enteral feeds over first
7 days
Strong recommendation, moderate quality of evidence