Annexure B: Infection Control Bundles for Prevention of HAIs

Prevent ventilator-associated pneumonia (VAP) in adults
Prevent surgical site infections (SSI)
Prevent central-line associated bloodstream infections (CLABSI)
Prevent catheter-associated urinary tract infections (CAUTI)

The following descriptions of infection control bundles are sourced from BestCare.⁵³

Prevent ventilator-associated pneumonia (VAP) in adults

Definition of VAP:

Pneumonia occurring in a patient:

• requiring continuous ventilation^* through either a tracheostomy or endotracheal tube
• where the infection occurs during the period of ventilation or within 48 hours of the removal of the assisting device
• diagnosis of pneumonia is based on radiological features  as well as clinical features of infection

This (summarised) definition must be read together with the full CDC/NHSN surveillance criteria in order to diagnose a VAP in practice.

Background:

• Ventilator-associated pneumonia (VAP) is the leading cause of death among healthcare associated infections. Studies show that the hospital mortality of ventilated patients who develop VAP is 46% compared to 32% for ventilated patients who do not develop VAP.

• VAP leads to an extended period of mechanical ventilation and a longer length of stay (LOS) in critical care units and in hospital.

Intervention:

There are key elements contained in the VAP bundle

1. Elevate the head of the bed to 45 degrees when possible, otherwise attempt to maintain the head of the bed greater than 30 degrees
2. Daily evaluation of readiness for extubation
3. Subglottic secretion drainage
4. Oral care and decontamination with chlorhexidine
5. Initiation of safe enteral nutrition within 24- 48 hours of ICU admission

Prevent surgical site infections (SSI)

Background:

• Surgical site infections (SSI) are the second most common type of adverse event occurring in hospitalised patients in the United States. Surgical complications, including SSIs, were the most frequent type of adverse event reported in the 2004 Canadian Adverse Event Study.
• SSIs can increase mortality, re-admission rate, length of stay and costs in terms of more out-patient/ wound care visits, emergency room visits, radiology services, laboratory investigations, antimicrobial therapy and home wound care services for patients who acquire a healthcare-associated SSI.

Intervention:

There are 4 components of the SSI Bundle:

1. Appropriate use of prophylactic antibiotics (including appropriate selection, timing and duration/ discontinuation)
2. Appropriate hair removal: Avoid shaving; where depilation is necessary, use of clippers or depilatory creams
3. Maintain post-operative glucose control (^*for major cardiac surgery patients cared for in an ICU)
4. Post-operative normothermia (^** for all open abdominal surgery patients).

*Glucose control: Review of evidence shows that the degree of hyperglycaemia in the postoperative period correlates with the rate of SSI in patients undergoing major cardiac surgery. Although glucose control may benefit other surgical populations, for the BCA Campaign, this measure will apply only to the cardiac surgery population for the purposes of national measurement.

^**Normothermia: Evidence suggests that patients have a deceased risk of surgical site infection if they are not allowed to become hypothermic during the perioperative period. Although temperature control may benefit other surgical populations, for the BCA Campaign, this measure will only apply to the colorectal or open abdominal surgical population for the purposes of measurement of compliance.

Additional evidence-based components of good quality surgical care may be added by each individual facility.

Compliance with the SSI bundle has been most successful when all elements are executed together.

Prevent central-line associated bloodstream infections (CLABSI)

Background:

• Ninety percent of catheter-related bloodstream infections occur with central venous catheters (CVCs)
• Central-line associated bloodstream infections (CLABSI) prolong hospitalisation by a mean of seven days
• CLABSI mortality (controlled for underlying severity) is between 4% and 20%
• The odds ratio for developing CLABSI was 2.2 – 6.6 times greater without maximum barrier precautions

Intervention:

There are key elements contained in the CLABSI Bundle:

1. Hand hygiene
2. Maximal barrier precautions
3. Chlorhexidine skin antisepsis
4. Optimal catheter insertion site selected after weighing infection risk^* and possible complications
5. Daily review of necessity for line, prompt removal of unnecessary central lines

^*The subclavian route has the lowest risk of infection; the femoral site the highest (especially in obese adult patients)

Other evidence-based element of care are not excluded and may be added to the Central Line 

Bundle by individual facilities, for example:

• Line is secured
• Dressing is clean and intact

Compliance with the CLABSI bundle has been most successful when all elements are executed together.

Prevent catheter-associated urinary tract infections (CAUTI)

Background:

• Urinary tract infections account for approximately 40% of all hospital associated infections annually and 80% of these can be attributed to indwelling catheters.
• Between 12% and 15% of all hospitalized patients will have a urinary catheter inserted during their hospital stay and up to half of these do not have an appropriate indication.
• Duration of catheterisation is directly related to risk of developing a urinary tract infection. Although CAUTIs are not usually life-threatening, a complication of a CAUTI (e.g. urethritis, urethral strictures, haematuria, bladder obstruction, and sepsis secondary to the UTI) does cause suffering and can increase a patient’s length of stay and costs.
• Application of accepted evidence based prevention guidelines has led to considerable reductions in CAUTI rates.

Intervention:

There are key elements contained in the CAUTI Bundle (“Bladder Bundle”):

1. Avoid unnecessary urinary catheters
2. Insert urinary catheters using aseptic technique
3. Maintain urinary catheters based on recommended guidelines
4. Review urinary catheter necessity daily and remove promptly

The bundle elements are not exclusive and other scientifically proven elements of available evidence-based guidelines can be added by each individual facility.

Compliance with the CAUTI bundle has been most successful when all elements are executed together.

⁵³ Based on the Best Care... Always! Bundles, available from www.bestcare.org.za