Surveillance of HAIs

1. IHI DEVICES BUNDLES
Ms. Jayashree Jaji Mushtaq Ahmed, BSN-RN
Infection Prevention & Control Practitioner

2. Has used improvement science to advance and sustain
better outcomes in health and health care across the world.
Bring awareness of safety and quality to millions, accelerate
learning and the systematic improvement of care, develop
solutions to previously intractable challenges, and
mobilize health systems, communities, regions, and nations
to reduce harm and deaths.

3. The Centers for Disease Control and Prevention (CDC) is a
federal agency that conducts and supports health promotion,
prevention and preparedness activities in the United States,
with the goal of improving overall public health.

4. What is a Bundle?
• A group of evidence to improved the
patients outcomes
• A bundle is a structure way of improving the
processes of care and patient outcomes; a
small, straightforward set of evidence –
based practice – generally three to five-
that , when performed collectively and
reliably , have been proven to improve
patient outcomes.

5. Who can use the bundle?
•Anyone in the clinical setting with the
agreement of the clinical team and
Quality Improvement Leads can use the
bundles.

6. Type of devices bundles
IHI Bundles
• Central Line Bundle
• Ventilator Bundle
• Urinary Catheter Bundle
CDC Bundles:
• Dialysis Bundle
• Central Line Maintenance Bundle

7. Central Line Bundle

8. Central Line
• An intravascular catheter that terminates at or close to the
heart or in one of the great vessels which is used for
infusion , withdrawal of blood, or hemodynamic
monitoring.
• The following are considered great vessels for the
purpose of reporting central line infections and counting
central line days.
• Aorta Internal Jugular Veins
• Pulmonary Artery Subclavian Veins
• Superior Vena cava External Iliac Veins
• Inferior Vena Cava Common Femoral Veins
• Brachiocephalic Veins
• In Neonates, umbilical artery/veins

10. Prevention of CLABSI
Components of Central Line Bundle
1. Hand Hygiene
2. Maximal Barrier Precautions
3. Chlorohexidine Skin Antisepsis
4. Optimal Catheter site selection, with Subclavian
vein as the preferred site for non tunneled
catheter.
5. Daily review of line necessity, with prompt
removal of unnecessary lines.

11. Prevention of CLABSI
1. Hand Hygiene
• Wash Hands if the are obviously soiled
• Wash Hands or use an alcohol-based rub between patients
• Indications
• Before and after palpitating catheter insertion site
• Before and after inserting, replacing, accessing, repairing,
or dressing an intravascular catheter
• Palpitation of the insertion site should not be performed
after the application of antiseptic, unless aseptic technique
is maintained.

12. Prevention of CLABSI
2. Maximal Barrier
• For the provider
• Non-sterile cap and mask
-all hair should be under cap
- Mask should cover nose and mouth tightly
• Sterile gown and gloves
• For the patients
• Cover patients head and body with a large sterile drapes
(use more than one if needed for large patients)

15. Prevention of CLABSI
3. Chlorohexidine Skin Sepsis
• Prepare skin with antiseptic/detergent
Chlorohexidine
Adult- 2% Chlorohexidine in alcohol
Pediatric- 2% Chlorohexidine in alcohol
Neonates- < 2 weeks or < 1500 grams:
2% aqueous chlorohexidine
Neonates >2 weeks or > 1500 grams
2% Chlorohexidine in alcohol

16. Prevention of CLABSI
3. Chlorohexidine Skin Sepsis
• Apply Chlorohexidine solution using a back &
forth friction scrub for at least 30 seconds. Do not
wipe or blot.
• Allow antiseptic solutions time to dry completely
before puncturing the site ( 2 min.)

17. Prevention of CLABSI
4. Optimal Site Selection
• Femoral site- greatest risk of infection
• Subclavian site- Lower risk of CLABSI than the
internal jugular vein
- Preferred when infection is only consideration
- Higher risk of Mechanical complications
• Physician must weigh risk-benefit of site selection
for individual patients.

18. Prevention of CLABSI
4. Optimal Site Selection
Subclavian Site : Mechanical Complications
• Pneumothorax
• Subclavian arterial puncture
• Subclavian vein puncture
• Hemothorax
• Thrombosis
• Air embolism
• Catheter Misplacement

19. Prevention of CLABSI
4. Optimal Site Selection
Relative contraindications to subclavian approach
• Chest Wall deformity
• Chronic Obstructive Pulmonary Disease
• Current or possible thrombolysis
• Hemodialysis patient and patient with advance kidney
diseases, to avoid subclavian vein stenosis.

20. Prevention of CLABSI
4. Optimal Site Selection
• Adult: Subclavian Site
• Pediatric: Femoral Site
• Neonates: umbilical or PICC
( peripherally inserted central catheter)

23. Prevention of CLABSI
5. DailyAssessment
Goal: Reduce Central Line Days
Include daily review of line necessity:
• Remove promptly when no longer needed
• Many times, central lines remain in place
simply because they provide reliable access
and become personnel have not considered
removing them.

24. Prevention of CLABSI
5. DailyAssessment
Key Change that you can do:
• Incorporate review of CVC lines into existing daily
rounds.
• Utilize a checklist that includes all patients with
CVCs and other information how long the line has
been in, etc. Provide the checklist to the physician to
be used on rounds.
• Engage physicians to raise awareness about the
importance of daily review necessity

27. Central Line Maintenance Bundle

28. Central Line Maintenance Bundle
1. Hand hygiene before catheter
access/manipulation
2. Daily review assessment of catheter necessity
with prompt removal of unnecessary lines
3. Proper dressing choice:
- Use transparent semipermeable dressing
- Use gauze only if the site is bleeding or
oozing

29. Central Line Maintenance Bundle
4.Proper frequency of dressing change:
• Replace transparent dressing every 7 days
• Replace gauze dressing every 48 hours
• Replace immediately any dressing that is soiled,
damped or loosened.
5. Proper replacement of administrative sets:
- For blood products or fat emulsion, replace
administration sets no more frequently than 72
hours intervals, but at least every 7 days.

30. Central Line Maintenance Bundle
• If used for blood/blood products, replace
administrative sets every 4 hours.
• If used for TPN/ intralipids, replace administration
sets every 24 hours
• If used for chemotherapy, replace administration
sets after each use.
• Caps are changed no more than after 72 hours or
whenever the administration set is changed.

31. Central Line Maintenance Bundle
6. Aseptic technique for accessing and changing
needleless connector, catheter hubs ad injection
ports using chlorohexidine 2% ( 30-second scrub
and 30 second air dry)
7. Use a prepackaged dressing-change kit or
supply area.

33. Ventilator Bundle

34. Ventilator
• A device to assist or control respiration
continuously, inclusive of the weaning period,
through a tracheostomy or by endotracheal
intubation.

37. Pathogenesis of VAP
VAP arises when there is bacterial invasion of
the pulmonary parenchyma in a patient receiving
mechanical ventilator.
Aspiration of secretions
• Colonization of the aerodigestive tract
• Use of contaminated equipment or medications

38. Risk Factors for VAP
• Prolonged intubation
• Enteral feeding
• Aspiration
• Paralytic Agents
• Underlying Illness
• Extremes of age

39. Complications of Mechanical Ventilations
Include;
• VAP
• Sepsis
• ARDS- Acute Respiratory Disease
Syndrome
• Pulmonary Embolism
• Barotrauma

41. Ventilator Bundle
Components
• Elevation of the head of the bed to between 30-45
degrees
• Daily sedative interruption and daily assessment or
readiness to extubate
• Peptic ulcer disease (PUD) Prophylaxis
• Deep Venous thrombosis (DVT) Prophylaxis
( unless contraindicated)
• Daily oral care with chlorohexidine

42. Ventilator
1. Elevation of Head

43. Ventilator
1. Elevation of Head
• Why?
• Reduces potential for aspiration
• Potential to improve ventilation
Identified Issues and Concern;
• Is it comfortable for the patient
• Causes the patient to slide down in bed
• Potential for skin-shearing

44. Ventilator
2. Sedation vacation
• Why?
• Has been demonstrated to reduce overall patient
sedation
• Promotes early weaning
Identified issues and concern:
• Increase potential for self extubation
• Increases potential for patient pain and anxiety
• Increases episodes of desaturation

45. Ventilator Bundle
3. Peptic Ulcer Prophylaxis
Why?
• Patient with respiratory failure have an increased risk of “
stress ulcers” and associated GI Bleeding
• Acid-suppressive therapy (H2 blockers, sucralfate,
Proton Pump Inhibitors) decrease the risk of GI Bleeding
• Identified issues and concern;
• Acid-suppressive therapy may increase the colonization
density of the aerodigestive tract with potentially
pathogenic organism
• So they should be avoided in patients who are not at the
high risk for developing a stress ulcer or stress gastritis

46. (H2 blockers, sucralfate, Proton Pump Inhibitors)
1. Omeprazole
2. Aspirin & omeprazole (Yosprala)
3. Pantoprazole

47. Infection Bleeding

48. Ventilator bundle
4. DVT Prophylaxis
Why?
• Patient with respiratory failure have an increase
risk of deep vein thrombosis
• Treatment with anticoagulants ( e.g. Heparin) has
been shown to reduce the risk and the potential
for pulmonary emboli
Identified Issues and Concern
• May increase the risk of bleeding

50. Bleeding DVT

51. Ventilator Bundle
5. Daily oral care
• IHI added this element to the Ventilator Bundle in May 2010
following continued review of the literature and use of the
element in the Ventilator Bundle in Scotland for over a year.
• The US FDA recommends 0.12% oral chlorohexidine for
use as mouth rinse.
• Chlorohexidine antiseptic has long been approved as an
inhibitor of dental plaque formation and gingivitis.

52. Ventilator Bundle
5. Daily oral care
• Dental plaque develops in patient that are mechanically
ventilated because of the lack of mechanical chewing and
the absence of saliva, which minimizes the development
of biofilm on the teeth.
• Dental plaque can be significant reservoir for respiratory
pathogens that cause ventilator associated pneumonia.

56. Urinary Catheter bundle

57. Indwelling Catheter
• A drainage tube that is inserted into urinary bladder
through the urethra, is left in place, and is connected to a
closed collection system
Also called Foley catheter
• Does not include straight in and out catheter
• Does not include suprapubic or nephrostomy catheters

60. Prevention of CAUTI
Component of urinary catheter bundle
1. Avoid unnecessary urinary catheters
2. Insert using aseptic technique
3. Maintain catheters based on recommended
guidelines ( daily care)
4. Review catheter necessity daily and remove
promptly

61. Prevention of CAUTI
1. Avoid unnecessary urinary catheters
• Studies:
• 21% of catheters not indicated at insertion
• 41-58% in place found to be unnecessary
Catheters
• Are uncomfortable for patients
• Decrease mobility, which may impair recovery and
contribute to other complications (e.g. pressure ulcers,
deep vein thrombosis)

62. Urinary Catheter Bundle
Appropriate catheter indications
1.Preoperative use for selected surgical procedures:
- Patients undergoing urologic surgery or other surgery on
contiguous structure of the genitourinary tract.
- Anticipate prolonged duration of surgery ( catheters inserted
for this reason should be removed in post-anesthesia care
unit)
- Patients anticipated to receive large-volume infusions or
diuretics during surgery.
- Need for intraoperative monitoring of urinary output

63. Urinary Catheter Bundle
Appropriate catheter indications
2. Urine output monitoring in critically ill patients.
3. Management of acute urinary retention and
urinary obstruction.
4. Assistance in healing of open sacral or perineal
wounds in incontinent patients.
5. Patient requires prolonged immobilization (e.g.
potentially unstable thoracic or lumbar spine,
multiple traumatic injuries such as pelvic
fractures.

64. Urinary Catheter Bundle
Avoidance Strategies
• External condom catheters for appropriate male patients
• Intermittent catheterization multiple times per day
• Assessing urinary retention with bladder ultrasounds
Intermittent catheter: sterile use catheters
feature polished eyelets, tip option and
funnel ends for male and females.

65. Urinary Catheter bundle
2. Insert catheter using aseptic technique:
• Perform hand hygiene immediately before and after
insertion.
• Aseptic technique of catheter insertion by using:
- Gloves, a drape and sponges
- Sterile or antiseptic solutions for cleaning the urethral –
meatus: and
• Single-use packet of sterile lubricant jelly for insertion.
Using as small catheter as possible that is consistent
with proper drainage , to minimize urethral trauma

67. Urinary catheter bundle
3. Appropriate catheter maintenance
• Maintain a sterile, continuously closed drainage
system
• Keep catheter properly secured to prevent
movement and urethral traction
• Keep collection bag below the level of the bladder
at al times
• Maintained unobstructed urine flow

68. Urinary catheter bundle
3. Appropriate catheter maintenance
• Empty collection bag regularly , using a
separate collecting container for each patient,
and avoid allowing the draining spigot to touch
the collecting container.
• Maintain meatal care for routine hygiene.
(bathing)
• Use aseptic technique when the collection
system must be replaced (incase of obstruction
or infection)

69. Avoid allowing the draining spigot to touch
the collecting container

70. Urinary Catheter Bundle
4. Daily review of catheter necessity:
• “ The duration of Catheterization is the most important
risk factor for development of infection” SHEA-IDSA
• 74 % of hospitals surveyed did not monitor catheter
duration
• 47% of patient days had no justification for continued
catheterization.
• 41% of the time, physicians were unaware of patients
inappropriate catheterized
• Daily review of catheter necessity should be conducted for
all patients with urinary catheters ( using the same criteria
for appropriate insertion shown before.

72. Urinary Catheter bundle
• Goal: Reduction of UTI by 50%
• Goal: 95 % compliance of urinary catheter bundle
components.

73. Urinary Catheter Bundle
Measurements
• Numerator: Total number of patients with
indwelling urinary catheter in the sample reviewed
with all applicable components of urinary catheter
bundle documented.
• Denominator: Total number of patients reviewed
with indwelling urinary catheter.