NNN

Care Bundles for Quality and Safety

Oct 03, 20245 min read

Care Bundles are structures ways for improving care with small, straight-forward sets of evidence-based practices. Often, it consists of only three to five elements to prevent morbidity and mortality. In this discussion, five common bundles will be discussed: the ventilator bundle, central line bundle, sepsis resuscitation bundle, sepsis management bundle, and catheter-associated urinary tract infection bundle.

Ventilator Care Bundle

A care bundle mainly tackling ventilator-associated pneumonia. This type of pneumonia is one that occurs in a patient 48 hours after intubation with an endotracheal tube or tracheostomy tube, with no preceding signs and symptoms. It is the second most common healthcare-associated infection, occurring in 25% of intubated patients with a mortality rate of 13% to 55%.

Bugs Causing VAP

Early-onset VAP (<96 hours) is often caused by Hemophilus influenza, Streptococcus pneumoniae, and Staphylococcus aureus. Late-onset VAP (>96 hours) is often caused by Pseudomonas aeruginosa, Acinetobacter spp., and MRSA.

Diagnostic Criteria for VAP

  1. New or progressive radiographic infiltrates from a chest x-ray.
  2. At least two of: (1) fever >38°C, (2) leukocytosis or leukopenia, and (3) purulent secretions

Guidelines

  1. Elevation of the head of the bed to improve breathing comfort, and minimizes microaspiration/aspiration of gastric, oral, and nasal secretions.
  2. Daily oral care with chlorhexidine (0.12%) reduces the bacterial load in oral mucosa, lowering the risk for VAP.
  3. Daily sedation vacation: the removal of sedation temporarily each day to determine the possibility of weaning off and extubation.
  4. PUD Prophylaxis: raised gastric pH levels is conducive to bacterial growth. Risk of stress ulcers increase during mechanical ventilation. This may utilize proton pump inhibitors (PPI) and H₂ receptor blockers.
  5. DVT Prophylaxis: a common problem in immobilized/bed-ridden patients. This may utilize mechanical therapy and anticoagulants (heparin, warfarin, -xabans)

Additional measures include the use of sub-glottic secretion drainage for ETTs, airway humidification, the use of closed suction systems (prevent aerosolization of pathogens), and ventilator circuit management (changing if soiled/per patient).

Central Line Bundle

A central line-associated blood stream infection (CLABSI) is defined as a laboratory-confirmed bloodstream infection not related to an infection at another site that develops within 48 hours of central line placement. Patients at risk for developing a CLABSI are the chronically ill, immunocompromised, malnourished, on TPN, extremely old or young, has impaired skin integrity, and those with prolonged hospitalization even before venous catheterization.

Clinical Manifestations

CLABSIs can either be localized or systemic. Local infection include rubor, tumor, and discharge at the central line exit site.

Guidelines

  1. Always observe proper hand hygiene
  2. Utilize maximal barrier precaution
  3. Skin antisepsis with chlorhexidine
  4. Optimal catheter site selection
  5. Review line necessity daily

Urinary Catheter Care Bundle

The fourth most common nosocomial infection involves catheter-associated urinary tract infections (CAUTI). They account for 36% of hospital acquired infections, with 80% of them being catheter-associated. Every day of catheterization increases the risk for CAUTI by 3% to 7%. This is also diagnosed as the appearance of infection two days after the insertion of an indwelling catheter.

Bugs Causing CAUTI

E. coli is responsible for 24%, Candida spp. is responsible for 21%, Klebsiella pneumoniae is responsible for 10%, and Pseudomonas aeruginosa is responsible for 10%.

Diagnostic Criteria

At least two of:

  • Fever (>38°C)
  • Chills
  • Costovertebral Tenderness
  • Suprapubic or Flank Pain/Tenderness
  • Decreased mental or functional status
  • New-onset Hematuria or Foul-smelling Urine

Guidelines

  1. Hand Hygiene before and after every procedure
  2. Maintain aseptic technique
  3. Regularly evaluate the need for the catheter and remove it if it no longer necessary.
  4. Maintain a closed drainage system, to prevent ascension of organisms from the drainage up the catheter.
  5. Explain the patient’s role in decreasing the risk of infection.
  6. Regular emptying of drainage bag. Always make sure to avoid tugging, pulling, twisting, or kinking the catheter and bag.

Sepsis Bundle

Sepsis is a life-threatening organ dysfunction caused by dysregulated host response to an infection. Sepsis can result from the infection of many body systems such as from meningitis, lung infections, blood stream infections, abdominal infections, CAUTIs, UTIs, skin infections, soft tissue infections, etc.

Sepsis Resuscitation Bundle

Two guidelines exist for different time spans:

  1. 1-Hour Bundle: measure the lactate level, draw blood cultures, then administer broad spectrum antibiotics and, if the patient is hypotensive or the lactate level is greater than or equal to 4 mmol/L crystalloid fluid at 30 mL/kg in a bolus (fluid resuscitation).
  2. 6-Hour Bundle: if fluid resuscitation does not correct hypotension, add vasopressors, and monitor CVP, SVO2, and lactate.
  • Lactate is elevated in sepsis due to anaerobic metabolism and tissue hypoperfusion. It should normally sit at 0.5 to 1 mmol/L, but elevates up to 4 and above during septic shock. If the lactate level is 2 mmol/L, rechecking of lactate is done every 2 to 4 hours.
  • Obtaining Blood Cultures: this is done before the administration of antibiotics, as antibiotics can mask the pathogens that a blood culture is attempting to locate. At least two sets of samples should be taken from two different sites or central venous devices.
  • Administering Broad Spectrum Antibiotics: mortality rate increases with every hour that passes that the patient is not on antibiotics. After the presentation of sepsis, antibiotics should be initiated within an hour. Broad-spectrum should include gram positive, gram negative, anaerobic, and even fungal microorganisms if indicated.
  • Fluid Resuscitation: done if hypotension and elevated lactate levels (4 mmol/L and above) are present. The initial fluid used is a crystalloid fluid (e.g., NSS, LR) set at 30 mL/kg given as a bolus.
  • Administering Vasopressors: if perfusion remains inadequate, vasopressors (noradrenaline) can aid in resuscitation to achieve adequate perfusion pressure to vital organs. The MAP to be achieved is ideally 65 mm Hg or higher.

Backlinks

Graph View