ICU Care Bundle

Introduction

The ICU care bundle (ABCDEF) is an evidence-based guide for clinicians to coordinate multidisciplinary patient care in the ICU.

Definition

ICU care bundles are evidence-based care components given for certain conditions, for better outcomes, and aid in preventing the hospitalized patient from developing hospital-acquired infections (HAIs).

Purposes

• To prevent HAIs.
• To monitor and regularize care of patients with a certain condition to prevent further deterioration.

Common Care Bundle

• VAP bundle.
• Central line (CLABSI) bundle.
• Catheter-associated urinary tract infection (CAUTI) prevention bundle.
• Surviving Sepsis Campaign (SSC) guidelines: Bundled care for septic shock.

Nursing Care in Providing ICU Care Bundle

1) VAP bundle: Criteria for VAP

• Ventilated for more than 48 hours.
• Deteriorating oxygenation.
• Active SIRS criteria with the initiation of new antimicrobial agents, for >4 days (infection, leukopenia/leukocytosis, changes in the characteristic of sputum, worsening cough, plural chest pain, positive chest radiology).
• Elevation of the head of the bed to 30°-45°.
• Daily “sedation vacations” and assessment of readiness to extubate.
• Stress ulcer prophylaxis [proton pump inhibitors (PPIs) and histamine 2 receptor agonists (H2RAs) to prevent UGI bleed and aspiration pneumonia].
• Deep venous thrombosis/venous thromboembolism prophylaxis for preventing pulmonary embolism.
• Low-molecular-weight or unfractionated heparin products.
• Intermittent compression devices.
• Graduated compression stockings.
• Contraindications for heparin: Thrombocytopenia, coagulopathy, active hemorrhage, and intracerebral hemorrhage.
• ETT colonization reduced and contaminated microaspiration prevented by daily oral care with chlorhexidine.

2) Central line bundle (CLABSI bundle) Criteria

• Patients on intravascular catheterization (peripheral/central lines for therapeutic interventions).
• Hand hygiene.
• Maximal barrier precautions during insertion (PPE, sterile drape).
• Chlorhexidine 2% solution for skin antisepsis.
• Optimal catheter site selection, with avoidance of the femoral vein for central access in adult patients.
• Daily review of line necessity with prompt removal of unnecessary lines.
• Disinfecting catheter hubs before accessing the catheter, use of needless ports, replacement of medications, tubing, and dressing changes.

3) CAUTI prevention bundle

• Assess for catheter indication, connection to the drainage bag, and use of aseptic precautions.
• ABCDE checklist for CAUTI bundle.
• Adherence to infection control principles, standard supplies, procedures, and processes.
• Hand hygiene-the most important factor in preventing nosocomial infections.
• Aseptic catheter insertion procedure.
• Proper Foley catheter maintenance, education, and care by nursing staff.
• Foley catheter use surveillance and feedback
• Bladder ultrasound use protocol should be in place to avoid unnecessary catheterizations.
• Catheter alternatives.
• Intermittent (“in and out”) catheterization for incomplete bladder emptying.
• External condom catheter for men with urinary incontinence.
• Absorbent pads and products for men and women with urinary incontinence.
• Do not use the Foley catheter unless medically appropriate; know appropriate indications.
• Early removal of the catheter using a reminder or nurse-initiated (i.e., automatic “stop orders”); removal protocol appears warranted.
  
  

4) SSC guidelines: Bundled care for septic shock

• To be completed within 3 hours.
• Measure the lactate level.
• Obtain blood culture prior to the administration of antibiotics.
• Administer broad-spectrum antibiotics.
• Within 1 hour of recognition of septic shock, administer 30 mL/kg crystalloid for hypotension or lactate >4 mmol/L.
• To be completed within 6 hours.
• Measure serum lactate, sending blood culture before initiating antibiotics.
• Broad-spectrum antibiotics should be given within 3 hours of A&E admission and within 1 hour of non-A&E admission.
• Treat hypotension and/or elevated lactate with fluids.
• Consider an initial minimum of 20 mL/kg bolus of crystalloid or equivalent.
• Give vasopressors (for hypotension that does not respond to the initial fluid resuscitation) to maintain.
• Mean arterial pressure (MAP) >65 mmHg.
• CVP-target >8 mmHg.
• Central venous oxygen saturation (ScvO₂)-target >70%
• Normalization of lactate.

Special Considerations

Caring for patients using ICU care bundles requires a structured approach to improve outcomes and ensure consistent, evidence-based care. Here are some special considerations:

1. Standardized Protocols

• ICU care bundles consist of multiple interventions that work better when implemented together rather than individually.
• Common bundles include sepsis management, ventilator-associated pneumonia (VAP) prevention, and delirium reduction.

2. Infection Control Measures

• Strict hand hygiene and aseptic techniques are essential to prevent hospital-acquired infections.
• Early removal of invasive devices (like catheters and central lines) reduces infection risks.

3. Ventilation and Respiratory Support

• Spontaneous breathing trials (SBTs) help assess readiness for extubation.
• Elevating the head of the bed (30–45 degrees) minimizes aspiration risk and prevents VAP.

4. Pain, Sedation, and Delirium Management

• ICU care bundles emphasize pain assessment and management to improve patient comfort.
• Delirium prevention strategies include early mobility, cognitive stimulation, and minimizing sedative use.

5. Early Mobility and Rehabilitation

• Encouraging early mobilization reduces complications like muscle atrophy and pressure ulcers.
• Physical therapy and passive range-of-motion exercises help maintain function.

6. Family Engagement and Communication

• ICU care bundles promote family involvement to improve patient outcomes and emotional well-being.
• Clear communication about treatment plans and prognosis helps reduce anxiety for both patients and families.

REFERENCES

1. Annamma Jacob, Rekha, Jhadav Sonali Tarachand: Clinical Nursing Procedures: The Art of Nursing Practice, 5th Edition, March 2023, Jaypee Publishers, ISBN-13: 978-9356961845 ISBN-10: 9356961840
2. Omayalachi CON, Manual of Nursing Procedures and Practice, Vol 1, 3 Edition 2023, Published by Wolters Kluwer’s, ISBN: 978-9393553294
3. Sandra Nettina, Lippincott Manual of Nursing Practice, 11th Edition, January 2019, Published by Wolters Kluwers, ISBN-13:978-9388313285
4. Adrianne Dill Linton, Medical-Surgical Nursing, 8th Edition, 2023, Elsevier Publications, ISBN: 978-0323826716
5. Donna Ignatavicius, Medical-Surgical Nursing: Concepts for Clinical Judgment and Collaborative Care, 11th Edition ,2024, Elsevier Publications, ISBN: 978-0323878265
6. Lewis’s Medical-Surgical Nursing, 12th Edition,2024, Elsevier Publications, ISBN: 978-0323789615
7. AACN Essentials of Critical Care Nursing, 5th Ed. Sarah. Delgado, 2023, Published by American Association of Critical-Care Nurses ISBN: 978-1264269884

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