The document discusses care bundles, which are groups of evidence-based interventions that are more effective at improving patient outcomes when implemented together rather than individually. It provides examples of common care bundles, such as ventilator bundles and central line bundles. The ventilator bundle includes elements like keeping the head of the bed elevated, daily sedation vacations, stress ulcer prophylaxis, deep vein thrombosis prophylaxis, and oral decontamination with chlorhexidine. The central line bundle outlines best practices for insertion, maintenance, and care of central lines to reduce central line-associated bloodstream infections.

3. INTRODUCTION
 The care bundle is a new concept in critical care ,which
is currently being promoted by the national Health
service modernization agency for critical care .
 Care bundle originated in north American and are
described best as groups of evidence –based practice
intervention .
 The theory behind care bundle is that when several
evidence based interventions are grouped together in a
single protocol, it will improve patient outcome.

4. HISTORY

5. DEFINITION OF BUNDLE CARE
A small set of evidenced – based practice protocol
which is a grouping of elements for a particular
symptom of a wider range of conditions in the future.
A small set of evidenced – based interventions for a
defined patient segment or population care setting
that, when implemented together , will result in
significantly better outcomes than when implemented
individually.

6. BUNDLE DESIGN
 The bundle has three to five interventions (elements), with
strong clinician agreement.
 Each bundle element is relatively independent.
 The bundle is used with a defined patient population in
one location.
 The multidisciplinary care team develops the bundle.
 Bundle elements should be descriptive rather than
prescriptive, to allow for local customization and
appropriate clinical judgment.
 Compliance with bundles is measured using all-or-none
measurement, with a goal of 95 percent or greater.

7. ELEMENTS OF BUNDLE CARE
All the elements of the bundle are necessary and
removing any one of them will result in inferior result.
All the elements in the bundle are based on randomized
controlled trial and the recommendations are beyond any
controversy.
A bundle focuses on how to deliver this evidence of
care rather than what the right care should be.
All elements in the bundle involve an all or none
phenomenon and the Bundle itself also bears the same
characteristic.

8. That is to say each element in the bundle is either
“performed” or “not performed” and entire Bundle
performance also follows the same principle without leaving
any scope for partial performance.
Implementation of all Bundle elements should take place
simultaneously at a specific time and place with a minimum
delay.

9. TYPES OF BUNDLE
1.Ventilator bundle
2.Central line bundle
Central line associated blood
stream infections (CLABSI)
3. Catheter associated urinary tract
infections (CAUTI)

10. ELEMENTS OF
VENTILATOR BUNDLE

11. 1.VENTILATOR BUNDLE
Elevation of the head of the bed (up to 30-45 degrees)
 Patients on ventilator have a risk of getting
pneumonia.
 One of the ways to prevent patient from getting
pneumonia is the elevation of head at the proper
angle.
 Head end elevation to 45 degree has been
recommended in most ventilator care bundles when
feasible.

12. Daily sedation vacation and assessment of
readiness to extubate.
 Sedation vacation is a colloquial term for an
interruption of the infusion of sedatives in a
mechanically ventilated patients, decreasing the depth
of sedation in a critically ill patient to facilitate
weaning from mechanical ventilation .
 Sedation vacation was first introduced in 2000 by
J.P. KRESS.
 Measures like daily sedation vacation facilitates early
weaning and extubation.

13. Stress ulcer disease prophylaxis
 Stress ulcer is seen in patients who are seriously ill,
including those with respiratory failure requiring
mechanical ventilation, increased stress cause
sympathetic nervous system activation , increased
catecholamine release, vasoconstriction and secretion of
cytokine.
 When this condition persist they cause injury or
ulceration.
 Proton pump inhibitor and H2 receptor antagonist both
prevent GI bleeding by raising the gastric pH.

14. Deep vein thrombosis prophylaxis
 Whenever blood moves too slowly through veins it can
cause clump of blood cells called clot, which causes deep
vein thrombosis.
 People in ventilator are high risk for deep vein thrombosis.
 Low molecular weight
heparin or unfractionated
heparin products are
effective in preventing
deep vein thrombosis.

15. Oral decontamination with chlorhexidine
 Chlorhexidine is a disinfectant and antiseptic that is
used for skin disinfection, cleansing wounds and
preventing dental plaques.
 Nosocomial pneumonia is common
in ICU patients oral cleansing with
chlorhexidine has been shown to
decrease incidence of pneumonia
in patients.

18. Steps for Clinicians:
Follow proper insertion practices
 Perform surgical hand washing before insertion. (3minutes)
 Adhere to aseptic technique (especially medical hand
washing for up to 1 minute).
 Use maximal sterile barrier precautions (i.e. mask, cap,
gown, sterile gloves, and sterile full body drape).
 Choose the best insertion site to minimize infections and
noninfectious complication based on individual patient
characteristics. Avoid femoral site in obese adult patients.
 Prepare the insertion site with >0.5% chlorhexidine with
alcohol.
 Place a sterile gauze dressing or a sterile, transparent,
semipermeable dressing over the insertion site

19.  For patients of age18 or more, use a chlorhexidine
impregnated dressing with an FDA cleared label that
specifies a clinical indication for reducing CLABSI for
short term non-tunneled catheters.
Handle and maintain central lines appropriately
 Comply with hand hygiene requirements.
 Bathe ICU patients over 2 months of age with a
chlorhexidine preparation on a daily basis.

20.  Scrub the access port or hub with friction immediately prior
to each use with an appropriate antiseptic (chlorhexidine,
povidone iodine, an iodophor or 70% alcohol)
 Use only sterile devices to access catheters.
 Immediately replace dressings that are wet, soiled, or
dislodged.
 Perform routine dressing changes using aseptic technique
with clean or sterile gloves.
 Change gauze dressings at least every two days or
semipermeable dressings at least every seven days.

21.  Change administrations sets for continuous infusions not
more frequently than every 4 days, but at least every 7 days.
If blood or blood products or fat emulsions are
administered change the tubing every 24 hours.
If propofol is administered, change tubing every 6-12
hours or when the vial is changed.
For Healthcare Organizations:
 Educate healthcare personnel about indications for central
lines, proper procedures for insertion and maintenance, and
appropriate infection prevention measures.

22.  Designate personnel who demonstrate competency for the
insertion and maintenance of central lines.
 Periodically assess knowledge of and adherence to
guidelines for all personnel involved in the insertion and
maintenance of central lines.
 Provide a checklist to clinicians to ensure adherence to
aseptic insertion practices.
 Reeducate personnel at regular intervals about central line
insertion, handling and maintenance, and whenever related
policies, procedures, supplies, or equipment changes.

23.  Empower staff to stop non-emergent insertion if proper
procedures are not followed.
 Ensure efficient access to supplies for central line insertion
and maintenance (i.e. create a bundle with all needed
supplies)
 Use hospital-specific or collaborative-based performance
measures to ensure compliance with recommended
practices.

24. CATHETER ASSOCIATED URINARY TRACT
INFECTION

25. Core Measures
 Insert catheters only for appropriate indications.
 Leave catheters in place only as long as needed .
 Only properly trained persons insert and maintain
catheters.
 Insert catheters using aseptic technique and sterile
equipment
 Maintain a closed drainage system.
 Maintain unobstructed urine flow.
 Hand hygiene and standard (or appropriate
isolation)precautions.
 Alternatives to indwelling urinary catheterization.
 Portable ultrasound devices to reduce unnecessary
catheterizations.