INTENSIVE CARE UNITSRole of Nursing Care by Dr.T.V.Rao MD

1. INTENSIVE CARE UNITS
Role of Nursing Care
Dr.T.V.Rao MD
1/18/2018 Dr.T.V.Rao MD 1

2. A Patient in Intensive Care Unit is
at Risk for Many Reasons..
1/18/2018 Dr.T.V.Rao MD 2

3. Florence Nightingale
• It may seem a
strange principle
to enunciate as
the very first
requirement in a
hospital that it
should do the sick
no harm"
Dr.T.V.Rao MD 3

4. The Purpose of the Programme
• The purpose of this program
is to maintain a healthy and
safe Hospital by the
prevention and control
of health care related
infections / diseases in
particular intensive care
units. This is achieved by
surveillance and investigation
of infectious diseases and
public education.
Dr.T.V.Rao MD4
1/18/2018

5. Why ICU patients are different
• Sickest patients (multiple diagnoses, multi-
organ failure, immunocompromised, septic
and trauma)
• Move less
• Malnourished
• More obtunded (Glasgow coma scale)
• May be associated Diabetics and Heart
failure
1/18/2018 Dr.T.V.Rao MD 5

6. EPIDEMIOLOGY
• Contributing factors
– Patients in ICUs have more chronic comorbid illnesses
and more severe acute physiologic derangements.
– The high frequency of indwelling catheters
among ICU patients
– The use and maintenance of these catheters
necessitate frequent contact with health care
workers, which predispose patients to
colonization and infection with nosocomial
pathogens.
– Multidrug-resistant pathogens such as methicillin-
resistant Staphylococcus aureus (MRSA) and
Vancomycin-resistant enterococci (VRE) are being
isolated with increasing frequency in ICUs1/18/2018 Dr.T.V.Rao MD 6

7. Early survival benefit for immediate
ICU Care
• Early survival benefit for immediate
ICU care
• Difficulty in explaining lack of ICU
advantage later: could be related to the
more aggressive monitoring and therapy
in the ICU, which may be beneficial
early by stabilizing the patient but may be
deleterious afterward, due to infections,
for example.1/18/2018 Dr.T.V.Rao MD 7

8. ICU Care is Invasive at many
Stages
• More invasive lines and
procedures including
surgeries
• Longer length of stay
• More IV and parenteral
drugs
• More tube feeding and
Parenteral nutrition
• More ventilation
1/18/2018 Dr.T.V.Rao MD 8

9. ICU : Factors that increase
cross-infections
• Hand washing facilities are inadequate
• Patient close together or sharing rooms
• Understaffing
• Preparation of IVs on the unit
• Lack of isolation facilities
• No separation of clean and dirty AREAS
• Excessive antibiotic use
• Inadequate decontamination of items &
equipment's
• Inadequate cleaning of environment
1/18/2018 Dr.T.V.Rao MD 9

10. Some Health-Care Associated
Infections May Occur in ICU Patients
• UTI associated with Foley catheters
• Lower respiratory tract infection (post-
op and ventilator dependent)
• Skin necrosis (skin breakdown)
• Blood stream infection (and line
associated)
• Surgical-site infection
• Nutrition-related and malnutrition1/18/2018 Dr.T.V.Rao MD 10

11. Strategy for Prevention
• Hand washing
• Use gloves to prevent contamination of the
hands when handling respiratory
secretions
• Wear gloves and gowns (contact precautions)
during all contact with patients and fomites
potentially contaminated with respiratory
secretions
• Use aseptic technique1/18/2018 Dr.T.V.Rao MD 11

12. Strategy for Infection
Prevention
• Strict attention to Hand hygiene
• Prudent Antibiotic use
• Aseptic technique
• Disinfection/Sterilization of items and equipment
• Education of staff infection control awareness
• Keep Environment Clean, Dry and dust free
• Surveillance of nosocomial infection to identify
problems areas & set priorities
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13. Intensive Care Unit
Prevention of Blood stream
infections
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14. Central Venous Catheters
Indications
• IV fluids and drugs
• Blood and blood products
• Total Parenteral Nutrition (TPN)
• Hemodialysis
• Hemodynamic monitoring
1/18/2018 Dr.T.V.Rao MD 14

15. Serious Infective Complications
• Blood Stream Infections (BSI)
• Septic pulmonary emboli
• Metastasis infection
– Acute endocarditis
– Osteomyelitis
– Septic arthritis
• Shock and organ failure
• Poor outcome: Staph.aureus or Candida spp.
1/18/2018 Dr.T.V.Rao MD 15

16. Incidence of CR-BSI
• Type of catheter
Teflon or Polyurethane ( < infections) vs Polyvinyl
chloride or Polyethylene
• Site of insertion
Subclavian (< infections) vs Internal Jugular &
Femoral (high risk of colonization & deep venous
thrombosis)
• No. of Lumen
Single-lumen catheter (< infections) vs
Multi-lumen catheter
1/18/2018 Dr.T.V.Rao MD 16

17. Prevention Strategies: Core
Proper Insertion Practices
• Ensure utilization of insertion bundle:
– Chlorhexidine for skin antisepsis
– Maximal sterile barrier precautions (e.g., mask, cap
[i.e., similar to those worn in the O.R.], gown, sterile
gloves, and large sterile drape)
– Hand hygiene
• In one study, 49% of CLs were present on
admission to the ward. Rates of BSI in this
study were higher in CLs placed in
Emergency Room
• Define where placement occurs and
review technique in those areasTrick et al. Am J Infect Control 2006;34:636-41.
1/18/2018 Dr.T.V.Rao MD 17

18. Prevention Strategies: Core
Chlorhexidine Skin Cleansing
• Chlorhexidine is the preferred agent for skin
cleansing for both CL insertion and maintenance
– Tincture of iodine, an iodophor, or 70% alcohol are
alternatives
– Recommended application methods and contact time
should be followed for maximal effect
• Prior to use should ensure agent is
compatible with catheter
– Alcohol may interact with some polyurethane
catheters
– Some iodine-based compounds may interact
with silicone catheters
1/18/2018 Dr.T.V.Rao MD 18

19. Intrinsic contamination of
infusion fluid
Connection with administration
set
Insertion site
Injection ports
Administration set connection
with IV catheter
Port for
additives
Sources of Infection
1/18/2018 Dr.T.V.Rao MD 19

20. Intralumunal Spread
Contaminated
infusate (fluid,
medication)
2. Intraluminal Spread
Contaminated infusate
(fluid, medication)
1. Extra luminal Spread
Patient’s own skin micro flora
Microorganism transferred by
the hands of Health Care
Worker
Contaminated entry port,
catheter tip prior or during
insertion
Contaminated disinfectant
solutions
Invading wound
3. Haematogenous Spread
Infection from distant
focus
Fibrin
Skin
Vein
Skin attachment
Sources of Infection
1/18/2018 Dr.T.V.Rao MD 20

21. Prevention of CR-BSI
Written Protocol
Must be performed by trained staff
according to written guidelines
Sterile procedure
Sterile gown, Sterile gloves, Sterile large
drapes
Don't shave the site
Hand disinfection
With an antiseptic solution eg
Chlorhexidine gluconate
1/18/2018 Dr.T.V.Rao MD 21

22. Prevention of CR-BSI
Skin antisepsis
• 2% Chlorhexidine gluconate has shown to
have lower BSI than 10% Povidone-iodine or
70 % Alcohol
• 2-min drying time before insertion
Maki DG et al. Lancet 1991;338:339-43
• No difference between 0.5% Chlorhexidine
gluconate or 10% Povidone-iodine
Humar A et al. Clin Infect Dis 2000;31:1001-7
1/18/2018 Dr.T.V.Rao MD 22

23. Prevention of CR-BSI
Dressing
• Gauze dressings every 2
days
• Transparent dressing
every 7 days on short
term catheter
• Replace dressing when
catheter is replaced or
dressing becomes damp
or loose.
Grady NP et al, HICPAC draft guidelines: 2002
1/18/2018 Dr.T.V.Rao MD 23

24. Prevention of CR-BSI
Catheters removal
• Don’t replace it routinely
• Replace it if:
– Inserted in an Emergency
– Non functioning
– Evidence of local or systemic infection
General handling
• Opening of hub: Use antiseptic-
impregnated pads eg Chlorhexidine
gluconate or povidone iodine
1/18/2018 Dr.T.V.Rao MD 24

25. Prevention of CR-BSI
Administration sets
• Replacement at 72-h intervals
• No difference in phlebitis if left for 96
hours
• Lines for lipid emulsion: replacement
at 24-h intervals
• Lines for blood product : remove
immediately after use
1/18/2018 Dr.T.V.Rao MD 25

26. Prevention of CR-BSI
Topical antibiotic
• Prophylactic use of topical Mupirocin (Bactroban) at
insertion site or in nose is not recommended
– Rapid development of Mupirocin resistant
– Mupirocin affect the integrity of Polyurethane catheter
Systemic antibiotic
• Prophylactic use of antibiotic is not recommended at
the time of catheter insertion
1/18/2018 Dr.T.V.Rao MD 26

27. Background: Prevention Strategies
Interventions
• Michigan Keystone Project
• Decrease in CLABSI in 103 ICUs in Michigan (66%
reduction)
• Basic interventions:
– Hand hygiene
– Full barrier precautions during CL insertion
– Skin cleansing with chlorhexidine
– Avoiding femoral site
– Removing unnecessary catheters
– Use of insertion checklist
– Promotion of safety culture
Pronovost et al. NEJM 2006;355:2725-32.
1/18/2018 Dr.T.V.Rao MD 27

28. Urinary Catheterization
1/18/2018 Dr.T.V.Rao MD 28

29. External urethral meatus &
urethra
• Pass catheter when bladder full for wash-out effect.
• Before catheterization prepare urinary meatus with
an antiseptic ( e.g. povidone iodine or 0.2%
chlorhexidine aqueous solution)
• Inject single-use sterile lubricant gel (e.g. 1-2%)
lignocaine into urethra and hold there for 3 minutes
before inserting catheter.
• Use sterile catheter.
• Use non-touch technique for insertion
1/18/2018 Dr.T.V.Rao MD 29

30. Junction between catheter &
drainage tube
• Do not disconnect catheter unless
absolutely necessary.
• For urine specimen collection disinfect
outside of catheter proximal to junction
with drainage tube by applying alcoholic
impregnated wipe and allow it to dry
completely then aspirate urine with a
sterile needle and syringe.
1/18/2018 Dr.T.V.Rao MD 30

31. Junction between drainage tube
& collection bag
• Keep bag below level of bladder. If it is
necessary to raise collection bag above
bladder level for a short period, drainage
tube must be clamped temporarily.
• Empty bag every 8 hours or earlier if full.
• Do not hold bag upside down when
emptying
1/18/2018 Dr.T.V.Rao MD 31

32. Tap at bottom of collection bag
• Collection bag must never touch floor.
• Always wash or disinfect hands (eg with
70% alcohol) before and after opening
tap.
• Use a separate disinfected jug to collect
urine from each bag.
• Don't put disinfectant into urinary bag.
1/18/2018 Dr.T.V.Rao MD 32

33. Intensive Care Unit
Nosocomial Pneumonia
1/18/2018 Dr.T.V.Rao MD 33

34. Incidence of HAI vs. Cost
Hospital acquired
Infection
Incidence Additional
cost
Urinary Tract 45% 13%
Surgical Wound 29% 42 %
Pneumonia 9 % 39%
Blood Stream 2% 4 %
Haley, 19861/18/2018 Dr.T.V.Rao MD 34

35. Risk factors for bacterial pneumonia
Host Factors Factors that facilitate reflux
& aspiration into the lower RT
• Elderly
• Severe Illness
• Underlying Lung Disease - Mechanical ventilation
• Depressed Mental Status - Tracheostomy
• Immunocompromising - Use of a Nasogastric Tube
Conditions or Treatments - Supine Position
• Viral Respiratory Tract Factors that impede normal
Infection Pulmonary Toilet
Colonisation - Abdominal or thoracic surgery
• Intensive Care Setting - Immobilisation
• Use of Antimicrobial Agents
• Contaminated hands
• Contaminated Equipment
1/18/2018 Dr.T.V.Rao MD 35

36. Prevention in ICU
• Turn patients to
encourage postural
drainage
• Encourage to take deep
breaths and cough.
• Maintain an upright
position (elevate patient’s
head to 30º- 45º degree
angle) to reduce reflux
and aspiration of gastric
bacteria.
1/18/2018 Dr.T.V.Rao MD 36

37. Gastric Ulcer Prophylaxis
• Stomach of a healthy person : Acidic pH () &
normal peristalsis movement prevent bacterial
growth
• Alkaline pH () and loss on normal peristalsis lead to
bacterial colonisation which increases the risk of
ventilator-associated pneumonia
• Mechanical ventilation patients are at increased risk
for upper GI hemorrhage from stress ulcers.
• H2 blockers or antacids are used to prevent stress
ulcers
1/18/2018 Dr.T.V.Rao MD 37

38. Nasogastric Tube
• May erode the mucosal surface
• Block the sinus ducts
• Regurgitation of gastric contents leading to
aspiration.
• Verify placement of the feeding tube in the
stomach or small intestine by X ray
• Elevate the head of the bed 30º- 45 º degrees
Remove NG Tube if not necessary
1/18/2018 Dr.T.V.Rao MD 38

39. Ventilators
• After every patient,
clean and disinfect
(high-level) or
sterilize re-usable
components of the
breathing system or
the patient circuit
according to the
manufacturer’s
instructions.1/18/2018 Dr.T.V.Rao MD 39

40. Suctioning mechanically
ventilated patients
• Hand washing before and after the procedure.
• Wear clean gloves to prevent cross-
contamination
• Use a sterile single-use catheter ; if it is not
possible then rinse catheter with sterile water
and store it in a dry, clean container between
uses and change the catheter every 8 - 12
hours.
1/18/2018 Dr.T.V.Rao MD 40

41. Suction Bottle
 Use single-use
disposable, if possible
 Non-disposable bottles
should be washed with
detergent and allowed
to dry. Heat disinfect in
washing machine or
send to Sterile Service
Department.
1/18/2018 Dr.T.V.Rao MD 41

42. Nebulizers
• Use sterile medications and fluids for nebulization
• Fill with sterile water only.
• Change and reprocess device between patients by
using sterilization or a high level disinfection or use
single-use disposable item.
• Small hand held nebulizers
– minimise unnecessary use
– between uses for the same patient disinfect, rinse
with sterile water, or air dry and store in a clean,
dry place
• Reprocess nebulizers daily
1/18/2018 Dr.T.V.Rao MD 42

43. Humidifiers
• Clean and sterilize
device between
patients.
• Fill with sterile water
which must be changed
every 24 hours or
sooner, if necessary.
• Single-use disposable
humidifiers are
available but they are
expensive.
1/18/2018 Dr.T.V.Rao MD 43

44. Oxygen mask
• Change oxygen
mask and
tubing
between
patients and
more
frequently if
soiled1/18/2018 Dr.T.V.Rao MD 44

45. The Scientific study ( SENIC )
gives guidelines
• Study of the Efficacy of Nosocomial Infection Control (SENIC)
project was published, validating the cost-benefit of infection
control programs. Data collected in 1970 and 1976-1977
suggested that one-third of all nosocomial infections could be
prevented if all the following were present:
• One infection control professional (ICP) for every 250 beds.
• An effective infection control physician.
• A program reporting infection rates back to the surgeon and
those clinically involved with the infection.
• An organized hospital-wide surveillance system.
Dr.T.V.Rao MD 451/18/2018

46. Antibiotics use
Must avoid widespread use
of
broad spectrum antibiotics
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47. Chlorhexidine Skin Antisepsis
• Prepare skin with
antiseptic/detergent
chlorhexidine 2% in 70%
isopropyl alcohol.
• . Hold the applicator down to
allow the solution to saturate
the pad.
• Press sponge against skin,
apply chlorhexidine
solution using a back and
forth friction scrub for at
least 30 seconds. Do not
wipe or blot.
• Allow antiseptic solution
time to dry completely
before puncturing the site (~ 2

48. Problem-Detection of
Infection in the ICU’s
1/18/2018 Dr.T.V.Rao MD 48

49. Examples from the NNIS
Manual
• Symptomatic Urinary Tract Infection:
– Patient must have one of the two criteria:
• Fever >38 C OR urgency OR frequency OR
dysuria OR suprapubic tenderness without
other cause
OR
• Urine culture with at least 105 organisms per
ml or no more than two species of organisms
1/18/2018 Dr.T.V.Rao MD 49

50. Definition of surgical site infection
(no implant)
• Occurs within 30
days of surgery
AND has one of the
following:
Purulent drainage
from drain OR
Organism isolated
from aseptically
obtained fluid in the
organ space
1/18/2018 Dr.T.V.Rao MD 50

51. Prior to starting any surveillance
• Agree upon a
written case
definition that is
practical given the
laboratory
facilities and
patient work load
in your facility.
1/18/2018 Dr.T.V.Rao MD 51

52. Our plan for future should include
• New laboratory methods developed and
refined within the last decade can now
determine how related the strain is at the
molecular level. The QI/IC plan should include
special problem-focused studies that
describe personnel or environmental
sampling, including what circumstances and
who has the authority to order
Dr.T.V.Rao MD 521/18/2018

53. Hand washing
• Single most effective action to prevent HAI -
resident/transient bacteria
• Correct method - ensuring all surfaces are cleaned -
more important than agent used or length of time taken
• No recommended frequency - should be determined by
intended/completed actions
• Research indicates:
– poor techniques - not all surfaces cleaned
– frequency diminishes with workload/distance
– poor compliance with guidelines/training
Dr.T.V.Rao MD 531/18/2018

54. Why we are not washing hands ???
• Working in high-risk areas
• Lack of hand hygiene promotion
• Lack of role model
• Lack of institutional priority
• Lack of sanction of non-compliers
Dr.T.V.Rao MD 541/18/2018

55. EPIDEMIOLOGY
• A multicenter, prospective cohort surveillance study of 46
hospitals in Central and South America, India, Morocco,
and Turkey.
• Rates of device-associated infection were
determined between 2002 and 2005; an overall rate
of 14.7 percent or 22.5 infections per 1000 ICU days
was found.
• Specific devices:
– Ventilator associated pneumonia (VAP); 24.1 cases/1000
ventilator days (range 10.0-52.7)
– CVC-related bloodstream infections; 12.5/1000 catheter days
(7.8-18.5)
– Catheter-associated urinary tract infections; 8.9/1000 catheter
days (1.7-12.8)
1/18/2018 Dr.T.V.Rao MD 55

56. Our Vision to Future
• Infection control
programs must
maintain training
records of employees.
The minimum training
required is annual OSHA
blood borne pathogen,
tuberculosis prevention
and control and new
employee orientation.
Dr.T.V.Rao MD 561/18/2018

57. Why we need better ICU’s
• For an incidence as well as for a
prevalence population of critically ill
patients, there is a window of critical
opportunity for admission into the ICU,
much like the golden our for the
trauma patient.
• Efforts should be made to avail ICU facilities to as
many recently deteriorated patients as possible,
especially those who could be transferred into the
ICU very early after deterioration, such as
patients on hospital wards.
1/18/2018 Dr.T.V.Rao MD 57

58. Your Unwashed Hand a Great
Concern to Your Patient
Dr.T.V.Rao MD 58

59. Do remember the Reasons for Infections
are Many but solutions are few …
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60. WARNING
Nosocomial Infections in ICU are Waiting
Dr.T.V.Rao MD 60

61. Let us support our Hospitals with
clean hands
Dr.T.V.Rao MD 611/18/2018

62. • Program Created by Dr.T.V.Rao
MD for Medical, Nursing and
Paramedical professionals in the
developing world
• Email
• doctortvrao@gmail.com
1/18/2018 Dr.T.V.Rao MD 62