1. Sepsis bundle (Hour 1 bundle)
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Measure lactate level. |
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Obtain blood cultures before administering antibiotics. |
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Administer broad-spectrum antibiotics IV. |
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Begin rapid administration of 30mL/kg crystalloid for hypotension or lactate ≥4 mmol/L. |
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Apply vasopressors if hypotensive during or after fluid resuscitation to maintain a mean arterial pressure ≥ 65 mm Hg. |
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Remeasure lactate if initial lactate elevated (> 2 mmol/L). |
2. Ventilator Associated Pneumonia (VAP)Bundle
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Hand hygiene. |
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Elevate the Head of the Bed to at least 30-45o. |
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Use an orogastric (OG) tube instead of a Nasogastric (NG) tube in all mechanically ventilated patients. |
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Oral Care with oral chlorhexidine solution (at least 0.2%) with oral care set (suction tube brush) at least every six hourly. |
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Use stress ulcer prophylaxis in the form of IV/ Oral Ranitidine. |
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Ensure ET tube cuff pressure is between 20 – 30 cm of H2O. |
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Perform continuous aspiration of sub-glottic secretion and/or suctioning of the ET tube as per need. |
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Interrupt the sedative drug daily from 6 AM. The last dose of the sedative is to be given no later than 5 AM. (Spontaneous Awakening Trial – SAT) |
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Perform a standardized weaning protocol such as Spontaneous Breathing Trial (SBT) daily. (After 6 am) |
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Environmental cleaning: This includes cleaning the healthcare environment regularly and thoroughly with the appropriate cleaning agents. |
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Patient placement: This includes assessing the risk of HAIs when placing patients in shared rooms, and considering the needs of patients when assigning them to a separate room. |
3. Central line bundle:
The Central line bundle is an evidence-based bundle of interventions that have been proven to prevent the Central line-associated bloodstream infections (CLABSI). It consists of the following components.
3.1. During Central Line Insertion
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Hand Hygiene with appropriate antiseptic solution (alcohol 70%). |
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Use Maximal Sterile Barrier (MSB) precautions, including the use of a cap, mask, sterile gown, sterile gloves, and a sterile full body drape, for the insertion of CVCs, PICCs. |
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Optimal site selection: ● Internal Jugular> Supraclavicular Subclavian>Femoral Vein. ● Prepare clean skin with a 2% Chlorhexidine preparation with alcohol before central venous catheter and peripheral arterial catheter insertion and during dressing changes. If there is a contraindication to Chlorhexidine, tincture of iodine, an iodophor, or 70% alcohol can be used as alternatives. ● Secure with silk sutures both at the length indicator of the catheter AND also at the body of the catheter. ● Cover the full length of the catheter including the body with the sterile dressing. ● Use transparent, semipermeable dressing to cover the catheter site. |
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Complete the Central Line Insertion Checklist. This checklist has to be filled by the nurse assigned or an independent person not performing the procedure |
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Use a four or five lumen CVC in ICU in unstable patients: Port 1-IV flush/ Bolus, Port 2- vasopressors, Port 3: Antibiotics, Port 4: TPN/Blood products. |
Note: Maximum sterile barrier (MSB) precautions are defined as wearing a sterile gown, sterile gloves, and cap and using a full body drape (similar to the drapes used in the operating room) during the placement of Central venous catheter, Dialysis catheter or PICC.
3.2. Central Venous Line Care - Maintenance
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Promptly remove any intravascular catheter that is no longer essential. |
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Wear either clean or sterile gloves when changing the dressing on intravascular catheters. |
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Use Chlorhexidine solution for catheter site dressing. |
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If the patient is sweating or if the site is bleeding or oozing, use gauze dressing until this is resolved. |
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Replace catheter site dressing if the dressing becomes damp, loosened, or visibly soiled. |
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Do not use topical antibiotic ointment or creams on insertion sites. |
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Replace dressings used on short-term CVC sites every alternate day for gauze dressings. |
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Replace dressings used on short-term CVC sites at least every 7 days for transparent dressings or as needed. |
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Evaluate the catheter insertion site daily for any signs of infections. |
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Evaluate catheter lines/ ports for its patency by checking blood backflow and using NS flush every 6 hrly. |
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In patients not receiving blood, blood products or fat emulsions, replace administration sets that are continuously used at 96-hour intervals. |
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Replace tubing used to administer blood, blood products, or TPN in each use. |
4. Urinary catheter care bundle
The Urinary catheter care bundle is an evidence-based bundle of interventions that have been proven to prevent the infection to Catheter Associated Urinary Tract Infection (CAUTI). It consists of the following components.
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Insert catheter only for appropriate indications. |
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Proper technique for urinary catheter insertion. |
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Perform hand hygiene immediately before and after insertion or any manipulation of the catheter device or site. |
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Use aseptic technique and sterile equipment for insertion of urinary catheters. |
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Catheter should be secured to thigh with proper securing system or adhesive tapes. |
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Closed drainage system with bag below the bladder level, without any kinks and obstructions and the urine collection bag should be above floor level (NOT TOUCHING THE FLOOR). |
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Empty the bag when half full into a clean container. |
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Daily review of catheter needs. |
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Do not clean the periurethral area with antiseptics to prevent CAUTI while the catheter is in place. Routine hygiene is appropriate. |
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Clamping the indwelling catheter prior to removal is not necessary. |
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Close monitoring of urine output. |
The delirium prevention bundle is an evidence-based bundle of interventions that have been proven to reduce the risk of delirium in hospitalized patients. It consists of the following components.
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Early identification of patients at risk of delirium (e.g., use of validated delirium risk assessment tools like CAM ICU OR ICDSC). |
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Regular assessment of cognition and delirium symptoms. |
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Each day during the round the team will set the target RASS score for the patient to be maintained for the following 24 hours. |
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Early and adequate treatment of pain. |
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Early and adequate treatment of other medical conditions. |
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Early mobilization. |
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Environmental and psychological interventions: Delirium can be caused by environmental factors such as noise and light, or psychological factors such as confusion and delirium. These should be addressed to reduce the risk of delirium. |
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Non-pharmacological interventions such as music therapy can reduce the risk of delirium. |
6. Pressure Injury Prevention Bundle
The Pressure Injury Prevention Bundle is a set of practices that are used to reduce the incidence of pressure injuries in patients. It consists of the following components.
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Pressure injury risk assessment by using a validated Pressure risk assessment tool. |
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Pressure-relieving devices like air mattress, cushion etc. |
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Repositioning every 2 hours or as per needed. |
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Skin assessment and care. |
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Nutrition assessment and management. |
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Moisture/ Incontinence management. |
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Monitoring and documentation ● Anatomical Location. ● Degree of Pressure injury on the basis of National Pressure Injury Advisory Panel of USA. ● Description of peri wound of skin. ● Presence of odor. ● Wound measurement. ● Presence of pressure injuries upon admission or after admission to the hospital. |
Further Readings:
1. Evans, L., Rhodes, A., Alhazzani, W., Antonelli, M., Coopersmith, C. M., French, C., ... & Levy, M. (2021). Executive summary: surviving sepsis campaign: international guidelines for the management of sepsis and septic shock 2021. Critical care medicine, 49(11), 1974-1982.
2. Soundaram, G. V., Sundaramurthy, R., Jeyashree, K., Ganesan, V., Arunagiri, R., & Charles, J. (2020). Impact of care bundle implementation on incidence of catheter-associated urinary tract infection: a comparative study in the intensive care units of a tertiary care teaching hospital in South India. Indian Journal of Critical Care Medicine: Peer-reviewed, Official Publication of Indian Society of Critical Care Medicine, 24(7), 544.
3. Mart, M. F., Williams Roberson, S., Salas, B., Pandharipande, P. P., & Ely, E. W. (2020, August). Prevention and management of delirium in the intensive care unit. In Seminars in respiratory and critical care medicine (Vol. 42, No. 01, pp. 112-126). 333 Seventh Avenue, 18th Floor, New York, NY 10001, USA: Thieme Medical Publishers, Inc..
