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Authors Paediatric Intensive Care Unit, Birmingham Children’s Hospital NHS Foundation Trust Birmingham, UK Email: Title PHONE 0300 200 1100 WWW.WMPRS.NHS.UK Care Bundle Cards. Elevation of the head of the bed 1. Tilt the head of the bed to 30. 2. Neocribs and incubators can also be elevated to 25. Gastric Ulcer Prophylaxis 1. If feeds are not fully established and pH is less than 5, consider prescribing ranitidine or omeprazole. 2. Aspirate the naso gastric tube 4 hourly (Pruitt 2006). Mark the position of the naso or oro gastric tube at the site of the nares or lips (Best 2005) 3. Ensure w hen feeding your patient you follow the feeding guidelines carefully to prevent high residual volumes of feed in the stomach. Oral and Nasal Care 1. Hands must be w ashed prior to nasal and oral care. Non sterile gloves should be applied 2. Mouth care should be performed every 2-4 hours. Teeth (if they have them!) should be brushed every 12 hours (Evans 2001) 3. The mouth should be suctioned prior to the nose. 4. The yankeur sucker, once opened, should be changed every 24 hours. If soiled it must be changed. It must also be covered in betw een use. Disconnection of the Ventilator tubing 1. Wash hands before disconnecting the ventilator tubing (Hess 2003) 2. Cover the ventilator tubing w ith a non sterile glove w hen disconnected 3. Change ventilator tubing w hen soiled, malfunctioning or weekly and document on chart w hen the tubing has been changed (Kollef 1998) 4. Condensate should be drained every 2-4 hours and prior to moving the patient Hand Washing 1.Remove all jew ellery, cover cuts and abrasions w ith water proof dressing. (Nice, 2003). Nails should be kept short, be unvarnished and be your own. 2. Wash hands, using the Ayliffe/Taylor method before and after patient contact. 3. Wash w ith an appropriate agent i.e. betadine, chlorhexidine or soap. 4. Hands should be dried thoroughly and alcohol gel applied, rubbed in and allowed to dry. Suction Technique 1. Hands should be w ashed prior to and immediately after suctioning. Universal precautions should be adhered to at all time; w hich includes gloves, apron and goggles. 2. Pre oxygenate the patient if necessary. 3. The suction catheter should be slid from the cover avoiding contact with anything else. 4. If there are tw o people carrying out this procedure then the catheter maybe used for suctioning twice. 5. The first person should disconnect the child from the ventilator and the second should introduce the catheter w ithout suction to a maximum depth of 1cm beyond the tracheal tube. Deeper suction maybe required in patients w ho are paralysed or have an inadequate cough reflex. 6. If single person suctioning then one hand should disconnect from the ventilator and the second hand should be used for suctioning – maintaining a clean technique. 7. As the suction catheter is w ithdrawn the vacuum should be interrupted every 1-2 seconds but rotating or ‘stirring’ should be avoided. Ventilator Associated Pneumonia Care Bundle Kate Butler 01/09/2007 version 1.0.0 Approved PICUCPM Under review H Winmill 1/1/2010 1 Catheter Type 5 Dressing 4 Skin Preparation Clean with ChloraPrep® (2% CHG/ 70% ISA) 3 Maximum aseptic / barrier precautions 6 Document insertion details in patient notes Care Bundle for the Insertion of Intravenous access Version 1.1.0, Created by HW , approved by PICU CPM, Aug 2009, for review November 2010 2 Insertion site Aim: To prevent or reduce catheter related blood stream infection. Why use it? The risk of infection reduces when all elements within this process are performed every time for every patient. The risk of infection increases when one or more of the elements are not performed. Catheter Type: Use a CVC w ith a minimum number of lumens required. Use maximum aseptic / barrier precautions when inserting CVC: 1) Use Personal protective equipment (PPE) -facemask, cap, sterile gow n, sterile gloves and sterile drapes. Use goggles w here there is a risk of splashing w ith blood. 2) Use correct hand hygiene procedure before & after inserting the CVC. Steps to effective hand hygiene: - Remove all w rist and hand jew ellery. Cover cuts and abrasions w ith a w aterproof dressing. Roll up your sleeves. -Alw ays dry hands thoroughly. Management of sharps: 1) Attempt insertion in least amount of needle sticks. 2) Dispose of sharps & other contaminated materials. 3) Do not disassemble needle. Documentation: Complete CVC insertion sheet (this can be photocopied & placed in the patient notes). Information detailing the date of insertion of CVC, reason for insertion, use of aseptic precautions and technique used to locate vessel must be available in the clinical notes. Hand Hygiene & PPE: Use 6 step technique to decontaminate hands before & after patient contact & before applying gloves (gloves to be w orn if there is a risk of exposure to body fluids). An apron & eye / face protection are indicated if there is a risk of splashing w ith blood or bodily fluids. Skin Preparation: Skin should be cleaned using 2% / 70% alcohol sw ab in repeated up & dow n & back & forth strokes then allow to dry (avoid palpating once cleaned). Please note: Any visibly soiled skin should be cleaned w ith soap & w ater before using the sw ab. Safely dispose of sharps. Dressing: Use a sterile, semi-permeable, transparent dressing to allow observation of the site. Documentation: Date & site of insertion / date & time of blood culture should be recorded in the notes. Blood culture bottle: Clean the top of culture bottle using 2% CHG/ 70%IPA sw ab & allow to dry before inserting blood sample (if inserted using a needle, do not disassemble the needle before discarding in the sharps bin). Insertion Site: Subclavian, internal jugular & femoral veins are all suitable sites for CVC insertion. Consideration must be given to complications associated w ith the selected site. Dressing: Use a sterile, transparent, semi- permeable dressing to allow observation of the insertion site . (Biopatch dressing to be used for all MRSA +’ve patients). CVC Insertion Supporting Documents: BCH Aseptic technique & ANTT policy 2009. BCH IV Policy 2008 DoH (2007) Saving Lives: Reducing infection, delivering clean & safe care. Peripheral Venous Cannula Insertion / Venepuncture for blood collection eg. Peripheral cultures: 1 2 3 6 5 4 Skin Preparation: Clean applying friction using up & dow n, back & forth, then circular strokes & allow to dry. Repeat if the site is contaminated. Caution! Extra care to be taken in the cleaning technique for babies <1000g or < 30w eeks gestation. Use povidone iodine if chlorhexidine is contra- indicated. The Intravenous Access Care Bundle The IV Access Care Bundle: For use with CVC’s, cannula’s & PICC (long lines) 1 Hand hygiene 3 Dressing Change at least every 7 days using ANTT 4 Catheter Access (2% 70%) “SCRUB THE HUB!” 6 Daily review of IV access Hand Hygiene 1 Decontaminate hands before and after patient contact / when soiled. 2 Use correct hand hygiene procedure before & after accessing / manipulating the IV line. Steps to effective hand hygiene: - Remove all w rist and hand jew ellery. Cover cuts and abrasions w ith a w aterproof dressing. Roll up your sleeves. - Alw ays dry hands thoroughly. - Create an environment w here good hand hygiene is encouraged through interpersonal communication betw een staff, patient & family. Catheter Access 1 Alw ays keep the number of manipulations to a minimum. 2 Decontaminate hands appropriately & use a pair of gloves appropriate to the procedure to be performed (sterile gloves to be used for PN). 3 Use aseptic non touch technique (ANTT) . Scrub ports / hub w ith 2% chlorhexidine gluconate in 70% isopropyl alcohol & allow to dry before accessing the line. (Please use the aseptic technique if accessing the designated PN line) 4 Use a clean flat surface as aseptic field (blue tray, dressing trolley) for accessing or manipulating all IV lines. 5 Identify and protect key parts at all times during procedure. 6 A sharps container should be available at point of use & should not be overfilled. 7 Flush the line as prescribed after each use. Nb. PICC lines should have a continuous flush of at least 1ml/hr if there is no infusion running. 8 After accessing the IV line alw ays replace cap w ith a new sterile cap. Administration set / Infusion line replacement Immediate / after every use: - Blood / Blood products (including albumin solution) 24hrs - Lipid bag & administration set - Vamin bag - Maintenance bag & administration set if >10% glucose or if additives have been added. - Intravenous Infusions (please follow guidance) 72hrs - Maintenance bag & administration set (if bag is pre-prepared) - Flush system 96hrs - Vamin administration set & filter Nb. Please remember to change the 3 w ay tap w ith the line / set change w herever it is safe to do so. Dressing 1 Change CVC site dressing at least every seven days and w hen soiled, loose or damaged (2 person technique). Nb. PICC line dressing should be changed w ith a Dr present. 2 Alw ays w ash hands prior to changing CVC dressing. 3 Use an ANTT throughout dressing change. 4 After removing old dressing, remove old gloves, rew ash / alcogel your hands as appropriate and apply new gloves before applying new dressing. 5 Assess area for signs of infection (erythema, sw elling, heat pain, tenderness and pyrexia). 6 Clean the CVC site area using 2%CHG, 70% Isopropyl Alcohol) & allow to dry (If the site is soiled use normsol & gauze before the alcohol sw ab). 7 Use a transparent semi-permeable dressing such as tegaderm or opsite (Biopatch dressing to be used for all MRSA +’ve patients and surgically implanted lines eg. Broviac / Hickman – see separate guidelines). 8 If there is bleeding or oozing from the CVC site consider using sterile gauze underneath the dressing. 9 Document date of dressing change and highlight date dressing change is next due on regular changes sheet For use by everyone who accesses IV lines 1 4 5 6 Aim: To prevent or reduce catheter related blood stream infection. Why use it? The risk of infection reduces when all elements within this process are performed every time for every patient. The risk of infection increases when one or more of the elements are not performed. Version 2.1.0 Created for PICU by M.S 2007 & amended by H.W June 2009, Review Nov 2010 2 Catheter site Inspection 5 Giving set, 3 way tap, line, replacemen t Catheter / Line Site Inspection 1 Document extravasation & phlebitis score hourly if line is in continuous use, at least 8hrly w hen used intermittently. 2 Flush line as prescribed / at least 12hrly if not in frequent use. 3 Regular observation (at least daily) for signs of infection, eg.erythema, sw elling, heat pain, tenderness and pyrexia. 2 3 Daily Review of IV access (cannula’s & CVC’s) 1 Daily review of line necessity and incorporate this practice into regular patient assessment (Bedside nurse & PICU fellow ). 2 Document line assessment and justify continued need for CVC placement 3 Prompt removal of any unnecessary lines after discussion with the medical team. 4 Inform anaesthetic department of all central lines that are removed. Ext. 9621 – Details requested: Name & w ard of caller, patient name & Reg. number, date of birth, date of line removal & reason for removal. 5 Send all CVC tips for MC&S on removal (at least 4cm long w here possible). Supporting Documents: DoH (2007) Saving Lives: Reducing infection, delivering clean & safe care. BCH CVC Standard operating procedure. BCH Aseptic technique & ANTT policy 2009 BCH Extravasation Policy 2009 BCH IV Policy 2008 Care Bundle Compliance Audit Form. Introduction The West Midland’s Paediatric Retrieval Service (WMPRS) is a 24 hour children's acute retrieval and advice service, specialising in the management of critically ill children requiring Intensive Care in the West Midlands. It is a collaboration between the Paediatric Intensive Care Units of Birmingham Children’s Hospital (BCH) and the University Hospital of North Staffordshire and is hosted by BCH. WMPRS receives more than 1000 referrals and transports over 500 critically ill children per year. It is committed to ‘Intensive Care Without Walls’ by taking good practice and local policy to the hospitals of the West Midlands, ensuring the delivery of high quality care. Matching Michigan is a quality improvement project led by the NPSA. It has many connections with existing interventions promoted by Patient Safety First and builds on the Department of Health’s High Impact Interventions. Outcomes Due to the desire for ‘Intensive Care Without Walls’ and the drive to support the Directorate with its performance rating within the Trust, the scorecards were adapted to reflect the interventions that were appropriate to the retrieval environment. A member of the retrieval team completes documentation of adherence to the care bundles for both themselves and his/her colleagues for every patient retrieved. The results are audited and submitted to the infection control team monthly and are discussed at monthly directorate meetings. The audit showed that WMPRS had 100% compliance in each category. The small and cohesive retrieval team plays a part in the 100% compliance, as does the awareness of presenting a professional image to the local hospitals. Future application for this data would be to; • Monitor if BSI/Line Infections occur more frequently with retrieved patients or is it dirty DGH lines? • Monitor if WMPRS care bundle compliance influences the incidence of BSI/Line infections/VAP etc on PICU. • Link with PICU HCAI Group to learn of WMPRS’s impact on Line Infection/VAP etc. • Consider if HII care bundle compliance reduces length of stay on PICU? Limitations The limitations of the audit are that it is a self assessment. To improve validity, future development of the audit would be for the referring team to audit the retrieval team to ensure objectivity. Acknowledgements http://www.nrls.npsa.nhs.uk/matchingmichigan http://www.patientsafetyfirst.nhs.uk/ BCH infection control team. Outline In April 2010, BCH Directorate of Specialised Services introduced a monthly ‘balanced scorecard’ to be completed and presented by Lead Nurses at monthly Directorate Meetings. This was to provide evidence that the Directorate Dashboard was being monitored and areas of poor performance addressed. WMPRS took on the challenge of meeting BCH infection control guidelines and attempting to ‘Match Michigan’ whilst ‘on the road’. It believed that it was possible for a mobile intensive care unit to adhere to infection control policy, HII care bundles AND have 100% compliancy from all members of the team. By working closely with BCH’s infection control team, WMPRS made itself accountable to the trust for compliance with various HII’s. Discussions considered whether WMPRS should use same scorecard definition set as PICU for monitoring safety and quality relating to other HCAI? Emma Bull 1; Anneke Gyles 1 1 West Midlands Paediatric Retrieval Service Email: [email protected]/[email protected] INFECTION CONTROL: GOOD PRACTICE CAN BE ADHERED TO ON RETRIEVAL
