| Ventilator-associated pneumonia (VAP) | – Elevation of the head of the bed to 30–45 degrees – Daily “sedation vacation” – Daily assessment for extubation – Peptic ulcer disease prophylaxis – Deep venous thrombosis prophylaxis |
| Urinary tract infection | – Evaluate daily the need for indwelling catheter – Maintain sterile technique for catheter insertion – Maintain a sterile closed drainage system – Secure the indwelling catheter to prevent migration of the catheter – Assure daily catheter care hygiene measures |
| Central venous line | – Hand hygiene – Maximal barrier precautions – Use of chlorhexidine as a skin antiseptic – Optimal catheter site selection – Daily assessment of line necessity – Prompt removal of central lines when indicated |
Ventilator-associated pneumonia bundle
VAP is defined as pneumonia developing 48 hours or longer after mechanical intubation. Ventilator-associated pneumonias are associated with the highest mortality of all HAIs. Additionally, VAP is associated with excess antibiotic use, frequently caused by multidrug-resistant organisms (MDROs), and results in a significant increase in mortality, hospital length of stay, and cost.
Bereholtz et al. demonstrated a substantial (up to 71%) and sustained (up to 2.5 years) decrease in rates of VAP following the implementation of a VAP bundle. This bundle consists of four components: elevation of the head of the bed to 30–45 degrees, daily “sedation vacation,” daily assessment for extubation, and peptic ulcer disease and deep venous thrombosis prophylaxis. In some institutions, the addition of CHG as an oral antiseptic was demonstrated as an effective VAP prevention strategy and should be included in the bundle.
Urinary tract infection bundle
Urinary catheters are utilized in more than 5 million patients in acute care hospitals and extended care facilities. Most catheter-associated UTIs are from the patient’s own flora. A significant risk factor associated with UTIs is the prolonged and unnecessary use of urinary catheters.
This bundle includes daily evaluation of the need for the indwelling catheter, the use of a sterile technique for a catheter insertion, the consistent use of a sterile closed drainage system, the utilization of a secure system to prevent migration of the catheter, and daily compliant measures with catheter care hygiene.
Central venous line bundle
A CLABSI is defined as bacteremia or fungemia recovered in peripheral blood cultures in a patient with a central intravascular device and with no apparent source of infection at another anatomic site. Five evidence-based interventions constitute the central line bundle checklist, which when consistently implemented result in safer care and improved outcomes. This bundle includes HH, the use of maximal barrier precautions, the implementation of CHG as a skin antiseptic, optimal catheter site selection with avoidance, if possible, of the femoral vein, and daily assessment of line necessity with prompt removal when indicated. During the process of catheter insertion, the bedside nurse is empowered to stop the procedure in the event that any checklist items are missed.
Hand hygiene: new technologies and compliance observation strategies
HH is essential for the prevention of HAIs and remains the most effective method limiting the spread of pathogens in the hospital setting. Despite ongoing calls for HH, compliance among HCWs remains below 40%.
Recent advances in HH are worth highlighting. To boost compliance, products, including an alcohol-based hand-rub formulation or medicated soap, water, and drying agents, such as disposable paper or cloth towels, must be conveniently available and within 3 ft (1 m) of a patient’s room. HH should be practiced by HCWs before and after all patient contact.
There are two accepted HH techniques. The first consists of hand rubbing with an alcohol-based hand-rub formulation. The procedure should take 20 to 30 seconds. The other technique is hand washing with soap and water. This procedure should take at least 15 to 30 seconds.
Alcohol-based HH formulations have certain advantages such as increased availability, higher antimicrobial efficacy, ease of use, and better skin tolerability. However, there are specific indications for the use of soap and water, such as when hands are visibly contaminated with blood, body fluids, or proteinaceous material and following exposure to spore-forming organisms such as Clostridium difficile or Bacillus anthracis.
Observation of HH is helpful to determine compliance and for feedback on methodology. Methods employed for HH observation include direct observation, self-reporting by HCWs, observation by patients, measurement of product usage, and electronic systems utilizing hand sensor technologies.
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