NCM 118: Critical Care Nursing

Didactic | Module #2: Bundle of Care and Transmission Precautions

Lecturers: Prof. Christy B. Verdida, MAN, RN

CONTENT ○ Respiratory hygiene/Cough Etiquette

I. Standard and Transmission Based Precautions ○ Safe injection practices
A. What Is Precaution ○ Point-of-use equipment cleaning
B. Standard Precaution
C. When is the Right Time? HAND TRANSMISSION
D. Hand Transmission ● Hands are the most common vehicle to transmit health
E. 5 Moments of Hand Hygiene care-associated pathogens (including MRSA)
F. Equipments
G. Proper Attire on 24-Hour Duty (NICU) 5 MOMENTS OF HAND HYGIENE
H. Proper Attire on 24-Hour Duty (DR) ● Before touching a patient
I. Standard Precaution ● Before clean/aseptic procedure
J. Cleaning Equipments
● After body fluid exposure risk
K. Transmission-Based Precaution
L. Transmission-Based Precaution Categories ● After touching a patient
M. Contact Precaution ● After touching patient surroundings
N. Droplet Precaution
O. Airborne Precaution
P. Needle-stick Injury
Q. Updated Hospital Guidelines (Covid-19)
II. Bundles of Care
A. What is?
B. Care Bundles Contributions
C. Specific Interventions
D. Risk Factors (CLABSI)
E. Bundles for the Prevention of CLABSI
F. Catheter Associated Urinary Tract Infection
(CAUTI)
G. Bundles for the Prevention of CAUTI
H. Proper Technique for Urinary Maintenance
I. Ventilator Associated Pneumonia (VAP)
J. Prevention of VAP
K. Methods Proposed to Reduce VAP Rates
L. Surgical Site Infections
M. Surgical Site Infection Bundle
N. Blood Transfusion EQUIPMENTS
O. SSI Prevention Checklist
● Gloves
P. Methicillin Resistant Staph A. (MRSA)
Q. MRSA BSI ○ Wear gloves when touching blood, body fluids,
secretions/excretions (including items contaminated with
STANDARD AND TRANSMISSION BASED these fluids). Mucous membranes and non intact skin
PRECAUTIONS ○ Do not wear the same pair of gloves for the care of more
than one patient
WHAT IS PRECAUTION ● Gowns
● Standard Precautions ○ Wear a gown that is appropriate to the task,to protect
○ Set of infection control practices (including the use of skin and prevent soiling or contamination of clothing
PPE) when having contact with all patients regardless during procedures and patient-care activities when
of patient diagnoses or presumed infection status contact with blood, body fluids, escretions, or excretions
● Transmission-based PRecautions is anticipated.
○ Precautions to be used in addition to standard ○ Remove gown and perform hand hygiene before leaving
precautions in documented or suspected infection or the patient’s environment.
colonization with highly transmissible or epidemiologically ○ Do not reuse gowns, even for repeated contacts with the
important pathogens to prevent transmission. same patient
● Remember ○ Routine donning of gowns upon entrance into a high risk
○ It is not always possible to identify patients with infection unit (e.g., ICU, NICU, HSCT unit) is not indicated
because some have mild or unusual symptoms ● Mask and Eye Eye Protection
○ It is important that HCW apply standard precautions ○ Used to protect the mucous membranes of the eyes,
consistently with all patients - regardless of their nose and mouth during procedures and patient-care
diagnosis - all work practices all the time! activities that are likely to generate splashes or sprays of
blood, body fluids, secretions and excretions.
● Proper attire for Residents, Fellows, INterns or Clerks on
24-hour duty in the Neonatal ICU
STANDARD PRECAUTIONS ○ Clean scrub suit and slippers
● Designed to protect HCWs and patients from contact with
infectious agents in recognized and unrecognized
PROPER ATTIRE ON 24-HOUR DUTY IN THE
sources of infection
NEONATAL ICU
● Based on the principle that all blood, body, fluids,
● Clean scrub suit and slippers
secretions, excretions (except sweat), non-intact skin, and
● Wear coat or smock gown over scrub suit if leaving NICU
mucous membranes may contain transmissible infectious
● Change back to street clothes/white clinical areas (e.g.,
agents.
cafeteria)
● Use mask and gloves as required by standard and
WHEN IS THE RIGHT TIME TO IMPLEMENT additional precautions
STANDARD PRECAUTION ● Remove hand jewelry such as rings, watches, and bracelets
● As soon as you encounter a patient
● Standard precautions includes:
PROPER ATTIRE ON 24-HOUR DUTY IN THE
○ Hand hygiene
DELIVERY ROOM
○ Use of PPE (gloves, gown, mask, eye protection, and
● Wear cap, mask, gloves and sterile long sleeved gown
face shield)
before receiving neonate

4th Year | 1st Semester | NCM 118: Critical Care Nursing | Didactic | Fesarit, Karl M. 1
● Perform surgical scrub at the OR/DR using antiseptic infectious cause
handwash in a diapered
● Continue to wear sterile gown if carrying neonate on way patient (enteric
back to NICU pathogens)
● Ungown and wear smock gown if transporting neonate in
transport bassinet ● Varicella Zoster, ● MDR organisms ● Meningitis
HSV, Zoster (Enterovirus)
STANDARD PRECAUTIONS ● Respiratory ● Abscess or ● Viral hemorrhagic
● Respiratory hygiene/Cough Etiquette viruses (RSV, draining wound fever (Ebola,
○ Cover your mouth and nose with a tissue when coughing SARS, Avian that cannot be Lassa, Marburg)
and sneezing influenza, covered (S.
○ Dispose of the tissue afterwards Parainfluenza, aureus, group A
○ After coughing or sneezing, wash your hands with soap Adenovirus, streptococcus)
and water Influenza)
○ Wear a mask if you are coughing or sneezing ● Contact precautions everyone must:
● Implementation of respiratory hygiene/cough etiquette ○ Single patient room if possible
○ Cover mouth/nose when sneezing/coughing ○ Gloves and gown should be used
○ Use and dispose of tissues in no-touch receptacle ○ During patient transport infected or colonized areas of the
○ Perform hand hygiene after soiling of hands with patient’s body should be contained or covered
respiratory secretions ○ Use dedicated or disposable equipment
○ Wear a surgical mask if tolerated or maintain spatial
separation more than 3 feet, if possible DROPLET PRECAUTIONS: PATHOGEN OR
● Safe injection practices CONDITION
● Point-of-use equipment cleaning ● N. meningitidis ● Respiratory viruses (RSV,
● Pertussis parainfluenza, adenovirus,
CLEANING OF EQUIPMENTS influenza)
● Removal of foreign materials from objects and is normally ● Group A Streptococcus ● Viral hemorrhagic fever
accomplished using water with detergents or enzymatic (Ebola, Lassa, Marburg)
products ● Droplet precautions everyone must:
● Disinfection Levels ○ Single patient room if possible, if not possible, cohort
○ Low-level Disinfection patients with the same organism (spatial separation of >6
■ A process that can kill most bacteria (except feet)
mycobacteria or bacterial spores, most viruses), and ○ Mask and eye protection/face shield should be used
some fungi ○ Masks and other PPE should be removed before leaving
■ Non-criical the room
■ Contact with intact skin but not mucous membrane ○ Patient should wear mask during transport
■ Alkyl dimethyl benzyl / ethylbenzyl ammonium chloride
○ High-level Disinfection AIRBORNE PRECAUTIONS: PATHOGEN OR
■ Complete elimination of all microorganisms in or on a
CONDITION
instrument, except for a small number of bacterial ● Mycobacterium tuberculosis
spores ● Measles
● Varicella
TRANSMISSION-BASED PRECAUTION ● SaRS-Cov2
● When is the right time to implement transmission based ● MERS-Cov
precaution? ● Avian influenza
○ Once you suspect or consider an infection or colonization ● Airborne precaution everyone must:
with highly transmissible or epidemiologically important ○ Single patient room, door kept closed at all times
pathogens. ○ Negative pressure room (6-12 air changes per hour)
● Additional precautions to be used in addition to standard ○ Respiratory protective devices (N95, N100, powered air
precautions in documented or suspected infection or purifying respirators
colonization with highly transmissible or epidemiologically ○ Remove respirators after leaving the room
important pathogens to prevent transmission
● More than one category, may be used for diseases that
SUMMARY
have multiple routes of transmission
● Hand hygiene! Hand hygiene! Hand hygiene!
● According to the 2007 HICPAC/CDC Guidelines, the most
● First tier: Standard Precaution
common mode of transmission of infection within healthcare
○ Practice ASAP. Assume that every person is potentially
settings is contact transmission.
infected or colonized with an organism that could be
transmitted in the healthcare setting and apply standard
TRANSMISSION BASED PRECAUTIONS precautions during delivery of health care.
CATEGORIES ● Second tier: Transmission-based precautions
● Contact ○ Add transmission-based precaution with suspected or
○ Direct and indirect (fomites) contact documented infection or colonization with highly
● Droplet transmissible or epidemiologically important pathogens
○ Microorganisms transmitted by respiratory droplets for which additional precautions are needed to prevent.
(large-particle droplets >um in size) that can be
generated when patient coughs, sneezes, or talks
● Airborne
○ Infectious agents transmitted person-to-person by the
airborne route (<5 um in size)

CONTACT PRECAUTIONS: PATHOGEN OR NEEDLE STICK INJURY

CONDITION
● C. difficile ● Conjunctivitis ● Acute diarrhea
with a likely

4th Year | 1st Semester | NCM 118: Critical Care Nursing | Didactic | Fesarit, Karl M. 2
 WHAT IS
● A bundle is a structured way of improving the process of
care and patient outcome.
● A small straight forward set of evidence-based practices,
generall 3-5 that when performed collectively and reliably,
have been proven to improve patient outcome.
● In order for bundle implementation to be successful each
element of the bundle must be implemented collectively with
complete consistency to achieve the most favorable
outcomes.
● “All or None Approach”
● Must be followed for every patient every single time.
● When implemented together, it produces better outcome

CARE BUNDLES CONTRIBUTE TO THE

FOLLOWING

● Do not recap
● Never stick a sharp into the bed
● Waste disposal practices
○ Sharps should be collected at source of use in
puncture-proof containers (metal or highly-density plastic) ● 95% bundle compliance is the recommended (best practice)
with fitted covers
○ Containers should be rigid, impenetrable, and
SPECIFIC INTERVENTIONS
● Central-line Associated Bloodstream Infection (CLABSI)
puncture-proof
○ Clinical definition:
○ Container made of dense cardboard may be substitute
■ CLABSI occurs when these criteria exist:
● After exposure to needle stick injury/blood or other
■ Clinical signs of infection
potentially infectious secretions, wash with soap and water,
■ No alternate source of bloodstream infection
bleed the site and apply antiseptic solution
■ Positive blood culture from a peripheral vein with one
● The employee should report the incident immediately to the
or any of the following:
infection control nurse (ICN) or nurse supervisor on duty.
● Catheter tip culture that matches grown from the
● The infection control team (ICT) will advise the employee
blood
regarding laboratory testing, vaccination, etc.
● At least three folds high number of organisms
● NSI can pose serious health risks
grown from the catheter versus the peripheral blood
● Once suspected
culture on simultaneously drawn culture
○ Report immediately
● Growth from the catheter-drawn blood culture
■ Every NSI report is acknowledged, reviewed, and
occurs at
responded to in a timely manner
● at least two hours before the growth of the same
■ Preferably within 24 hours upon injury to IPCC of the
organism from a percutaneously drawn blood
hospital you are rotating in and UERM IPCC
culture.
○ All reports will be confidential
● What is a CLABSI? Surveillance definition
○ Counseling and assessment for initiation of
○ Two definitions: surveillance and clinical
post-exposure HIV prophylaxis, if necessary.
■ NHSN surveillance definition: A laboratory confirmed
infection where a CVC is in place for greater or less
UPDATED HOSPITAL GUIDELINES FOR COVID-19
than 2 calendar days prior to a positive culture and is
PANDEMIC ALERT LEVEL 1 also in place the day of or prior to culture.
● Minimum covid-19 test requirement regardless of
■ Examples (look at the separated row)
vaccination status
● Example 1: (CLABSI) ● Example 2: (CLABSI)
Patient Type ER Direct/Elective
○ PICC placed June 1 ○ PICC placed June 2nd
Adult with Covid 19 RT-PCR RT-PCR ○ Patient febrile June 3 ○ Removed June 5th
symptomes ○ PICC in place ○ Patient febrile June 6th
Adult, without RAT RAT ○ Cultures positive for ○ Cultures positive for
Covid-19 Staphylococcus Aureus Coagulase Negative
Symptoms Staphylococci
Pediatric RT-PCR or RAT Negative RAT
Psych RAT RISK FACTORS (CLABSI)
Oncology/Cancer Negative RT-PCR Negative RT-PCR ● Patient Characteristics
Validity: 21 days Validity: 21 days ○ Immunocompromised host
● Students with symptoms must report to infirmary and IPCC ○ Severe skin burns or protein calorie malnutrition
● RAT is required (preferable RAT UERM) or RT-PCR ○ Prolonged hospital stays prior to placement
● Provider Characteristics
○ Emergency insertion
BUNDLES OF CARE ○ Excessive device manipulation
○ Incompetent adherence to safe insertion practices

4th Year | 1st Semester | NCM 118: Critical Care Nursing | Didactic | Fesarit, Karl M. 3
 ○ Failure to remove unnecessary devices
○ Low nurse-patient ratio (catheter hub care)
● Device Characteristics
○ Site of insertion
○ Number of lumens
○ Indication for use
BUNDLES FOR THE PREVENTION OF CLABSI
● Insertion Bundle
○ Have a process in place to ensure adherence to infection
prevention
○ Hand hygiene prior to catheter insertion or manipulation
○ Avoidance of the femoral vein for central vein access in
adult clients
○ Use alcoholic chlorhexidine antiseptic for skin preparation
● Maintenance Bundle (after Insertion)
○ Daily review of central line necessity
○ Disinfect catheter hubs, ports, connectors, or the like
before using the catheter.
○ Prompt removal of unnecessary lines/non-essential
catheters.
○ Change transparent dressing and disinfect sites with
chlorhexidine every 5-7 days or immediately after
dressing is soiled.
○ Change gauze dressings every 2 days or earlier if
soiled, loose or damp.
○ Daily chlorhexidine washes for ICU patients over 2
months of age.
CATHETER ASSOCIATED URINARY TRACT
INFECTION (CAUTI)
● CAUTI
○ Defined as urinary Tract Infection in a patient with current
urinary catheterization or has been catheterized for the
past 48 hours
● Indwelling catheter
○ “Foley Catheter”
○ Closed sterile system with a catheter and retention
balloon that is inserted through the urethra or suprapubic
allow for bladder drainage
○ The catheter is left in place
● Intermittent Catheterization
○ Involves a brief insertion of catheter into the bladder
through the urethra to drain urine at intervals
● External Catheter
○ Urine containment device that fits over or adheres to the
genitalia and is attached to the urinary drainage bag.
○ Most common “condom catheter”
● Sources of microorganism
○ Metal
○ Rectal or vaginal colonization
○ Contaminated hands of healthcare personnel or
equipments
BUNDLES FOR PREVENTION OF CAUTI
● Urinary catheter use
○ Insert catheter only for appropriate indications
○ Consider using alternatives to indwelling urethral
catheterization
● Proper techniques in urinary catheter insertion
○ Perform hand hygiene immediately before and after
insertion or manipulation of the catheter
4th Year | 1st Semester | NCM 118: Critical Care Nursing | Didactic | Fesarit, Karl M.
○ Only properly trained persons who knows the correct
aseptic technique are given responsibilities
○ Insert catheter using aseptic technique and sterile
equipment
○ Non-acute care setting: clean technique for intermittent
catheterization is accepted
○ Secure indwelling catheters after insertion
○ Unless clinically indicated: consider using the smallest
bore catheter possible, consistent with good drainage
○ Perform hand hygiene immediately before and after
insertion or manipulation of the catheter
○ Only properly trained persons who knows the correct
aseptic technique are given responsibilities
○ Insert catheter using aseptic techniques and sterile
equipment
○ If intermittent catheterization is used perform at a regular
intervals
○ Consider using trouble ultrasound device to assess urine
volume in patients undergoing intermittent
catheterization
PROPER TECHNIQUE FOR URINARY CATHETER
MAINTENANCE
● Do not clean the periurethral area with antiseptic to prevent
CAUTI while the catheter is in place. Routine hygiene is
appropriate
● Unless obstructions is anticipated bladder irrigation is not
recommended
VENTILATOR-ASSOCIATED PNEUMONIA
● Ventilator
○ Devices used to support, assist or control respiration
through the application of positive pressure to the airway
when delivered via artificial airway.
● Ventilator Associated Pneumonia
○ A pneumonia where a patient is on mechanical
ventilation for more than 2 calendar days (48-72 hours)
with the day of ventilator placement as day 1
● Potential reservoirs: Nosocomial Pneumonia Pathogens
○ Oropharynx
○ Trachea
○ Stomach
○ Respiratory therapy equipment
○ Paranasal sinuses
○ Sanctuary (above cuff below cords)
○ Endotracheal intubation decreases the cough reflex,
impedes mucociliary clearance, injuries the tracheal
epithelial, provides a direct conduit for bacteria from URT
to the LRT
PREVENTION OF VENTILATOR-ASSOCIATED
PNEUMONIA
● Elevate head of the bed between 30-45 degrees
● Peptic ulcer decrease prophylaxis
○ H2 blocker
○ Sucralfate
○ Proton pump Inhibitor
● Venous thrombo embolism (VTE) prophylaxis
● Use of oral chlorhexidine
● Oral care
● Safe enteral nutrition
● ABCDE bundle
○ Awakening trial for ventilated patient
○ Spontaneous breathing trials
○ Coordination between RN and RT
○ Standard delirium assessment program
○ Early mobilization and ambulation of critically ill patients
METHODS PROPOSED TO REDUCE VAP RATES
● Noninvasive ventilation
● Avoid prolonged used of paralytic agents or IV sedation
● extubate , remove NG tubes ASAP
● Elevate head of the bead >= 30 deg
4
● Maintain adequate cuff pressure
● Evaluate need and use of stress ulcer prophylaxis
● Evaluate need for transport out of ICU
● Avoid unnecessary reintubation
● Kinetic R, chest physiotherapy
● No circuit changes
● Careful drainage of tube condensate
● Single use products/devices
● Proper disinfection
● Continuous aspiration of subglottic secretions
● Hand hygiene
● Use of gloves

SURGICAL SITE INFECTIONS

● Types of surgical site infections
○ An SSI typically occurs within 30 days after surgery. The
CDC describes 3 types of SSI
■ Superficial Incisional SSI
● This infection occurs just in the area of the skin
where the incision was made
■ Deep Incisional SSI
● This infection occurs beneath the incision area in
muscle and the tissues surrounding the muscles METHICILLIN-RESISTANT STAPH A. (MRSA)
■ Organ or Space SSI ● Staphylococcus Aureus is a type of bacteria found in the
● This type of infection can be in any area of the body people’s skin
other than skin, muscle, and surrounding tissue that ● In hospital setting MRSA can cause:
was involved in the surgery. This include a body ○ Bloodstream infection
organ or a space between organs ○ Pneumonia
○ Surgical site infection
SURGICAL SITE INFECTION BUNDLE ○ Sepsis
● Parenteral Antimicrobial Prophylaxis ○ Death
○ Administer the appropriate parenteral prophylactic
antimicrobial agents before skin incision in all cesarean MRSA BSI
section procedures. ● Can result from a variety of infections and processes:
○ In clean and clean-contaminated procedures, do not
administer additional prophylactic antimicrobial agent
doses after the surgical incision is closed in the operating
room
○ Antibiotic prophylaxis should be administered 60 minutes
prior to incision
○ Redosing is administered for prolonged procedures in
patient with major blood loss and excessive burns
● Glycemic control
○ Implement glycemic control and use blood glucose target
levels below than 200 mg/dl in patients with or without
diabetes
● Normothermia
○ Maintain perioperative normothermia
● Oxygenation
○ For patients with normal pulmonary function undergoing ● How is MRSA spread in the healthcare setting?
GA with ET intubation, admisniter increase FiO2 during ○ Direct contact with an infected wound or from
surgery and after extubation in the immediate contaminated hands usually those of healthcare
postoperative period providers
● Antiseptic Prophylaxis ● Strategies to prevent hospital-onset Staph A.
○ Advise patient to shower or bathe (full body) with soap or ○ Implement interventions to reduce and procedure related
antiseptic agent on at least night before the operative day health care infections
○ Perform intraoperative skin preparation with an ■ CLABSI
alcohol-based antiseptic agent unless contraindicated ■ SSI prevention practices
■ VAP prevention practices
○ Implement source control strategies for high-risk patients
BLOOD TRANSFUSION
● Do not withhold transfusion of necessary blood products during high-risks period
from surgical patient as a means to prevent SSI

SSI PREVENTION CHECKLIST

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 ○ Implement interventions to prevent transmission of
MRSA in acute care
■ Place patients colonized or infected with MRSA in
private rooms
■ Use dedicated patient care equipment
■ Single use disposable items
■ If common use equipment is unavoidable, clean and
disinfect
○ Develop infrastructure to support SA BSI prevention
■ Develop multi disciplinary workgroup to identify and
implement strategies
■ Monitor facility HO SA BSI counts and target units with
the highest number for evaluation
■ Evaluate and train all healthcare personnel on
prevention of HO SA BSI
■ Audit and conduct competency for infection control
practices

REFERENCE: LECTURE POWERPOINT

4th Year | 1st Semester | NCM 118: Critical Care Nursing | Didactic | Fesarit, Karl M. 6