Critical care nursing lectures for undergraduate and post graduate students. The infection control in ICU includes all procedures needed to control infection among patients in ICU followed by nursing students

1. INFECTION CONTROL IN
ICU
Presented by:
Ms. Satinder Kaur
Assistant Professor
Critical care nursing

2. INTRODUCTION
 Hospital acquired infections are a major cause of
mortality and morbidity in ICU
 Effective infection prevention and control is central
to providing high quality health care for patients and
a safe working environment for those that work in
healthcare settings.
 It is important to minimize the risk of spread of
infection to patients and staff in hospital by
implementing good infection control programme.
 Hospital acquired infections and nosocomial
infections is considered as safety threat by patients
and health care team.

3.  Hospital acquired infections are among avoidable
mortality and morbidity causes.
 The three main HAIs in the general ICUs were
ventilator-associated events (VAE), urinary tract
infection (UTI), and pneumonia events & lower
respiratory tract infection (PNEU & LRI) infections.
 Hospital acquired infections are newly acquired
infections that arises after 48 hours of admission to
the hospital.
 These infections increases the cost of care, length
of ICU stay and diminishes the favorable outcome
of care.
HOSPITAL ACQUIRED
INFECTION

4. Critical care units are seat of many hospital acquired
infections because of two reasons:
 The increased number of invasive procedures in
critical care units.
 The nature of illness among patients admitted in
ICU make them immunocompromised ,thus, they
become susceptible to acquire Nosocomial
infections.
HOSPITAL ACQUIRED
INFECTION

5. The four major types of hospital acquired infections
occur among patients in ICU :
 VAP(Ventilator associated pneumonia)
 CAUTI (Catheter associated urinary tract
infections)
 CRBSI (Catheter related bloodstream infections)
 SSI (Surgical site infections)
HOSPITAL ACQUIRED
INFECTION

6.  VAP is one of the serious infection occur in ICU
 It is pneumonia that occur within 48-72hours after
intubation or tracheostomy among patients on
mechanical ventilator.
 The mortality rate among patients with VAP is
higher in comparison to other infections in ICU.
 This occurs due to introduction of artificial airway in
the respiratory tract e.g. ET tube
VAP

7. PATHOPHYSIOLOGY OF VAP
Endotracheal tube insertion , Nasogastric tube and
mechanical ventilation
Aspiration from nasogastric tube
Biofilm formation within the ET
tube
Loss of protective upper airway reflexes
Movement of these organisms down the lower airway with
mechanical ventilation
Pooling of secretions above the cuff and rapid colonization
Escape of pathogenic biofilm into trachea through fold in
the cuff
Pneumonia (VAP)
Colonization and infiltration of lower airway and lungs

9. CLINICAL FEATURES OF VAP
 Fever
 Lecukocytosis/ leukopenia
 Purulent tracheal secretions
 Positive culture for tracheal aspirate

10. VAP BUNDLE
The VAP can be prevented by following interventions:
 Keep head end of bed elevated at 300 to 450 to prevent
aspiration of gastric content and gastric reflux.
 Oral care twice to thrice a day with 0.12% chlorhexidine to
prevent colonization of bacteria in oral cavity
 Follow early weaning protocol through sedation vacation and
spontaneous breathing trial.
 Reduce unplanned Extubation and reintubation
 Institute gastric ulcer prophylaxis
 Maintain ET cuff pressure up to 20-30 to prevent tracheal
injury and necrosis
 Follow periodic suctioning to avoid pooling of secretions and
emphasis on use subglottic ET tube.

12. CLABSI
 This is catheter related blood stream
infections or central line associated
blood stream infections.
 These are laboratory confirmed
blood stream infections within 48
hours insertion of central line before
occurrence of other Nosocomial
infections
 The causative organisms are
caugalase negative staphylococci,
enterococci, klebsiella, MRSA-
positive staphylococcus aureus,
pseudomonas, acinetobactor and
E.coli.

13. CLABSI
The confirmation of blood stream infection through
central line can be stated based on following
criteria:
 Same organism has grown in blood drown from
central line and peripheral vein with three times
higher rate of growth in central line.
 Same organism extracted from the percutaneous
blood culture and catheter tip.
 Shorter time to positive culture from central line
sample than from the peripheral line sample
(>2hours)

14. RISK FACTORS CAUSING CLBSI
 Immunocompromised state: neutropenia, diabetes mellitus,
bone marrow transplant or organ transplant recipient.
 Prolonged hospitalization before catheter insertion
 Chronic illnesses
 Extremes of age
 Burns and other skin pathology
 Poor aseptic precautions during insertion of catheter and hub
contamination
 Infusion of contaminated fluid
 Migration of organisms from contaminated skin during
insertion and after that.
 Femoral catheter insertion

15. CLINICAL MANIFESTATIONS
 Fever with chills
 Advance age and presence of neutropenia patient
shows symptoms of lethargy, altered mental status,
hypotension.
 Pus formation and skin discoloration with
discharge around catheter insertion site
 Complaint of pain along the course of vein by
patient
 Poor or no blood flow return from the venous
access.

16. CLABSI BUNDLE
Prevention at the time of Central line insertion:
 Hand hygiene Maintaninence before insertion with soap and
water and alcohol rub.
 Adhere to the strict aseptic technique
 Ensure to adhere to the infection control protocol checklist
during insertion
 Clean skin with 2-70% chlorhexidine before insertion and let it
dry completely before skin puncture.
 Try to avoid to use peripheral and femoral central access
lines.

17. CLABSI BUNDLE
Central line care: Central line Maintaninence bundle
 Perform hand hygiene before touching the central line of
patient.
 Clean the catheter hubs, connectors and injection ports with
chlorhexidine 2%-70% and by busing sterile swab.
 Apply mechanical friction for no less than 5 seconds before
touching any part of tubing, hubs or connectors.
 Use the central venous access to the period most necessary
 Remove unwanted extension catheters.

18. CLABSI BUNDLE
 Regularly assess the need for central venous access and if
not necessary, remove it.
 Change the gauge dressing with all aseptic technique once in
2 days . If transparent dressing is there it can be changed in
5-7 days time.
 Blood transfusion sets have to be changed within 24 hours.
 I/V lines used for transfusion of lipid emulsion, propofol need
to be changed in 12 hours time.
 I/V line can be changed within 96 hours.

19. CATHETER ASSOCIATED URINARY TRACT
INFECTION PREVENTION -CAUTI
Catheter Insertion bundle:
 Hand hygiene before and after insertion of catheter or doing
any manipulation related to urinary catheter.
 Ensure properly trained persons should insert catheter by
using aseptic technique
 Use sterile equipments
 Use sterile gloves, drape, sponges and an appropriate
antiseptic solution for periuretheral cleaning and a single use
packet of jelly for insertion.
 Properly secure indwelling catheter after insertion to prevent
movement and urethral traction.
 Consider to use smallest bore catheter to minimize urethral
trauma.

20. CATHETER ASSOCIATED URINARY TRACT
INFECTION PREVENTION -CAUTI
Urinary Catheter Maintaninence/care bundle:
 Keep the catheter and collecting tube free from kinking
 Keep the collecting bag below the level of urinary bladder all the
time.
 Empty the collecting bag regularly using a separate ,clean
collecting container for each patient.
 Use standard precautions like gloves etc. during catheter care.
 Change the bag or urinary catheter only when clinical indications
exists such as infection, blockage or obstruction.
 Unless clinical indication exists do not use antiseptic solution to
clean urethra while catheter is in situ. Use routine hygiene like
wash .
 Unless obstruction is anticipated or post prostrate surgery,
bladder irrigation is not recommended.


21. GENERAL MEASURES FOR INFECTION
CONTROL IN ICU
Isolation:
 Identify immuno -compromised symptomatic patients like
patients with Lecukocytosis, skin rashes fever and
neutropenia and transfer them in Isolation room to prevent
infection from other patients.
 Use reverse isolation for patients with neutropenia to prevent
cross infection among them.
 Identify the patients with symptoms of Nosocomial infections
like skin rashes, diarrhea, fever etc. isolate them to prevent
other patients..

22. GENERAL MEASURES FOR INFECTION
CONTROL IN ICU
Standard
Precautions:
 Minimize contact
with blood
secretions and
patient care
areas.
 Follow five
moments of hand
hygiene

23. GENERAL MEASURES FOR INFECTION
CONTROL IN ICU
Standard Precautions:
 Wear personal protective equipments according to the
procedure and mode of contamination.
 Appropriately handle equipment and linen used for patient
care.
 Perform appropriate biomedical waste management through
segregation of waste at the site of generation and proper
disposal as per protocol.
 Prevent needle stick/ sharp injuries
 Perform appropriate spill management and environmental
cleaning.

24. GENERAL MEASURES FOR INFECTION
CONTROL IN ICU
Biomedical waste disposal:
 Strict adherence to segregation of waste at the point of
generation and disposal of waste as per the biomedical waste
management protocol
 All laboratory specimens should be packed in spillage free
container and transport at the earliest.
 Specimens taken from patients known to harbor HBV, HCV
and HIV are to be labeled with biohazard symbol and sent
separately.

26. GENERAL MEASURES FOR INFECTION
CONTROL IN ICU
Disinfection and cleaning of instrument and linen:
 Used and contaminated instruments should be thoroughly
washed with running water and dry them.
 After drying the contaminated instruments soak in 2%
Glutaraldehyde for more than 20 minutes and send for
autoclaving and sterilization.
 Contaminated linen should be soaked in 2% sodium
hypochlorite solution before wash.
 Use separate rooms for dirty linen and clean linen storage.
 Wash contaminated equipments in dirty linen room under
running water.

27. MAINTANINENCE OF ICU ENVIRONMENT
ICU is vulnerable area for spread of Infection; therefore,
it is imperative that all protocols and recommendation
practices about infection control and prevention are
observed and if there is a breakout then adequate steps
taken to control this and disinfect the ICU if indicated:
 All the Recommendations of State Pollution Control
Boards and Biomedical Waste guidelines must be
followed in letter and spirit.
 Floor cleaning twice a day with phenol
 Window sills and exhaust vents have tot be cleaned
using detergent impregnated cloth or mop head.

28. MAINTANINENCE OF ICU ENVIRONMENT
 All beds must have 24x7 Hand rub solution bottle
hanging by the bed foot end or around
 There should be one hand wash basin with elbow
operated water tap for at least 5 beds.
 All linen/equipment used in ICU procedure should
be sterilized by autoclave or any other standard
methods
 Dedicated ICU autoclave/ETO rooms are desirable
for larger ICUs
 Standard methods/protocols should be adopted to
dispose off single use disposable tubes/catheters
and lines and should be transported out of ICU
either by dedicated ducts or by closed cart.

29. MAINTANINENCE OF ICU ENVIRONMENT
 Regular fumigation of ICUs is neither possible nor
desirable. However, floor mopping, equipment
cleaning solutions and cleaning of beds are strongly
recommended with disinfectants.
 No dirty/soiled linen/material should be allowed to
stay in ICU for long times for fear of spread of bad
odor, infection and should be disposed off as fast
as possible

30. MAINTANINENCE OF ICU ENVIRONMENT
 There should be provision for hand hygiene at the
entrance of the unit.
 Properly disinfect blood spells or body fluid spills
on the floor. Treat the area with sodium hypochlorite
solution by routine cleaning of floors.

31. SPECIFIC PREVENTIVE MEASURES
Specific measures should be taken to prevent droplet
and contact infections.
 Airborne droplet infections:
a. Patients harboring agents that spread through air droplets
like through coughing or sneezing e.g. tuberculosis etc have
to be isolated in isolation room.
b. Visitors and care givers have to wear N95 mask
c. The room door should be closed with sealing and isolation
room should have negative pressure ventilation.
d. Limit the movement of visitors.

32.  Contact precautions:
a. Isolate the patient
b. Use individual items and equipments of care for
patient.
c. In avoidable circumstances proper disinfection of
the items should be done.
d. Limit the movement of patients visitors.

33. QUALITY INDICATORS OF CRITICAL CARE
The ISCCM & hospital accredited agencies provides
a set of benchmarks to assess and improve the
quality of ICU care on continuous basis.
The following table tells us about quality indicators:

34. Category Quality Indicator
Outcome indicators •Standard Mortality rate
• Morbidity Indicators : Iatrogenic
Pneumothorax, Incidence of renal failure in
noncoronary patients, Incidence of pressure
ulcers, Incidence of VAP, Incidence rate of
CLABSI
Process • Length of ICU stay
• Compliance to various protocols: Hand
hygiene compliance, Prevention of CAUTI, VAP
prevention bundle, CRBSI prevention bundle.
• ICU readmission rate
Patient Safety • Patient falls, Medication errors, Adverse
events, Needle stick injuries, Accidental
unplanned Extubation, Reintubation rate
Human resource •Employee satisfaction
• Absenteeism/Turnover
Consumer Satisfaction • Patient satisfaction
•Family satisfaction