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Good ICU Practices

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Rohan Sequeira

on 22 October 2013

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Transcript of Good ICU Practices

Good ICU Practices
Dr. Rohan Sequeira
Consultant Physician and Internist
Ex Hon. Major - United States Army Medical Corps
Unit Command AOC61F9C - Internal Medicine Battalion Surgeon

The Purpose of the Programme
The purpose of this program is to maintain a healthy and safe Hospital ICU by the prevention and control of health care related infections / diseases in intensive care units.
A Patient in Intensive Care Unit is at Risk for Many Reasons
Contributing factors
Patients in ICUs have more chronic illnesses and more
acute physiologic derangements.
The high frequency of indwelling catheters among ICU patients
The use and maintenance of these catheters necessitate frequent contact with the nursing staff, which predispose patients and many times nurses also 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 ICUs

Why are ICU patients so different?
Sickest patients
(multiple diagnoses, multi-organ failure, immunocompromised, septic and trauma)
Move less
More obtunded (Glasgow coma scale)
May be associated Diabetics and Heart failure
Usually have a poorer outcome.
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

ICU Factors that increase cross-infections
Hand washing facilities are inadequate
Patient close together
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
Infections that 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 malnutrition

Strategy for Prevention
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 technique

Strict attention to Hand hygiene
Gloves when ever in contact with body fluids
Disposable Gowns
Aseptic technique
Disinfection/Sterilization of items and equipment
Keep Environment Clean, Dry and dust free
Surveillance of nosocomial infection
Hand washing
Personal Protective Equipment

Disposable gloves: Gloves should be worn whenever there might be contact with blood and body fluids, mucous membranes or non intact skin.
They are not a substitute for hand washing.

They should be put on immediately before the task to be performed, then removed and discarded as soon as the procedure is completed.
Hands must always be washed following their removal.

Personal protective equipment (PPE) is used to protect both yourself and your patient from the risks of cross-infection.
Gloves should be worn whenever there might be contact with blood and body fluids, mucous membranes or non intact skin.
They are not a substitute for hand washing.
They should be put on immediately before the task to be performed, then removed and discarded as soon as the procedure is completed.
Hands must always be washed following their removal.
These should be worn whenever there is a risk of contaminating clothing with blood and body fluids and when a patient has a known infection, for example, direct patient care, bed making or when decontaminating equipment.

You should
discard them as soon as the intended task is completed
and then wash your hands.

Impervious gowns should be used when there is a risk of extensive contamination of blood or body fluids.
These should be worn when a procedure is likely to cause blood and body fluids or substances to splash into the eyes, face or mouth.

Masks may also be necessary if infection is spread by an airborne route – for example multi drug resistant tuberculosis or severe acute respiratory syndrome (SARS)

Do's & Donts
sharps are not passed directly from hand to hand
handling is kept to a minimum
needles are not broken or bent before use or disposal
syringes or needles are not dismantled by hand
single unit needles are never re-sheathed
sharps containers are not filled by more than two thirds and are stored in an area away from the public

High-risk sharp procedures
IV cannulae
winged steel – butterfly – needles
needles and syringes
phlebotomy needles
central lines

Safe Handling & Disposal
Sharps include needles, scalpels, stitch cutters, glass ampoules and any sharp instrument.

The main hazards of a sharps injury are The Big 3 H - Hep B, Hep C and HIV

Study between July 1997 and June 2002, there were 1,550 reports of blood-borne virus exposures in health care workers – of which
42 per cent were nurses or midwives

Some procedures have a higher than average risk of causing injury
These include intra-vascular cannulation, venepuncture and injection.

Safe handling and
disposed of as a single unit needles are never re-sheathed
staff take personal responsibility for any sharps they use
dispose of them in a designated container at the point of use.
sharps trays with integral sharps bins are in use
sharps are disposed of at the point of use
staff are aware of inoculation injury policy.

Decontaminating equipment
Inadequate decontamination outbreaks of infection in hospitals.
All nursing staff
must be aware
of the implications of safe decontamination and their responsibilities to their patients, themselves and their colleagues.

Decontamination is the combination of processes CDS
for re-usable medical device is safe for further use.

Some Devices designated for single patient use include nebulisers, disposable pulse oximeter probes and certain specified intermittent catheters.

appropriate choice of
decontamination method
Achieving and maintaining a clean clinical environment
A dirty clinical environment is one of the
factors that may contribute towards infection rates.
Conversely, high standards of cleanliness will help to reduce the risk of cross-infection.
Cleaning removes contaminants.
A Cleaning Manual acts as a resource to assist in training and setting standards to help promote high quality and consistent service levels.
Appropriate use of indwelling devices
Make sure you use the correct technique when using indwelling devices as it is vital to reduce the risk of patients acquiring infection.
80 per cent of urinary infections can be traced back to indwelling urinary catheters.

These infections arise because catheters traumatise the urethra as well as providing a pathway for bacteria and other organisms to enter the bladder.
The longer such catheters are in place, the higher the risk of infection.

Similarly, over 60% of blood infections are introduced by intravenous feeding lines, catheters or similar devices.
This is because micro-organisms on the patient’s skin (either those naturally present or those acquired whilst in hospital) can gain entry to deeper tissues or the bloodstream when a cannula or catheter is inserted into a vein.
MRSA is the biggest culprit here.

Managing the risk of Hepatitis
The risk of contracting HBV from needlestick exposure in a health care setting is much higher than HIV because the virus is both more infectious and has greater prevalence

As a result all nurses should be vaccinated against hepatitis B with monitoring of antibody titre levels and boosters, where inoculation injury occurs and titres are low.

Nursing Staff should take responsibility for this - NO EXCUSE
Managing the risk of HIV
If there has been exposure to blood, high risk blood and body fluids or tissue known or strongly suspected to be contaminated with HIV recommends the use of antiretroviral post exposure prophylaxis (PEP).
Ideally, this is given within an hour of exposure and the full course lasts for four weeks.

Where treatment is delayed but the source person proves to be HIV positive,
PEP can be given up to two weeks from the time of the injury.
Advice and follow-up care
Duovir 1-0-1 for a month

Accidental exposure to blood-borne virus
Accidental exposure to blood and body fluids can occur by:
percutaneous injury for example, from needles, instruments, bone fragments or significant bites that break the skin
exposure of broken skin – for example, abrasions, cuts or eczema, exposure of mucous membranes, including the eyes and the mouth.

The following figure illustrates the action that should be taken immediately following accidental exposure to bodily fluids, including blood.

Other Infections in ICU
Ventilator associated pneumonia
Catheter related blood stream infections
Intra-abdominal infections
Sinus infections
Prevention Strategies Interventions
Basic interventions:
Hand hygiene
Full barrier precautions during CL insertion
Skin cleansing with chlorhexidine
Alcohol based disinfectants
Avoiding femoral site
Removing unnecessary catheters
Use of insertion checklist
Promotion of safety culture

Prevention in ICU
Urinary Catheterization
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.

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

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.

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

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.

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.

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.

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.

Reprocess nebulizers daily

Oxygen mask
Change oxygen mask and tubing between
patients and more frequently if soiled

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

Hand Washing
Why are we not washing hands?
Disposable gloves
Disposable plastics aprons
Masks, visors and eye protection
Wash Hands Save Lives
Is this important?
Catheters, Intubation tubes IV Canulas
Thank You
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