Section: UTMB On-line Documentation Subject: Healthcare Epidemiology Policies and Procedures Topic: Intensive Care Units

2.5 - Policy 09.04.2008 - Revised 1994 - Author

2.5 Intensive Care Units

Purpose	To provide guidelines for prevention of infections in critical care patients.
Audience	All employees of UTMB hospitals and clinics, contract workers, volunteers and students who work in the intensive care units.
Policy: Personnel	• Personnel shall adhere to the departmental dress code and the dress code of the hospital. • Eating and drinking are not permitted in clinical care areas including patient rooms, hallways and nursing stations. • Suspected or known exposure to or acquisition of a communicable disease shall be reported to the Department of Healthcare Epidemiology or the Employee Health Center immediately. All needlesticks shall be reported to the Employee Health Center. • Personnel will comply with the Employee Health Center requirements for their area. • Hand hygiene will be performed before and after each patient contact and after the removal of gloves (see policy: Hand Hygiene for all Hospital Employees). • Do not use gloves as “pot holders”. • Prior to setting up a sterile field, employees will either wash their hands with a chlorhexidine containing solution or disinfect their hands with an alcohol hand rub. If gross contamination is present, hands must be washed with soap and water prior to applying an alcohol hand rub. • Visitors shall abide by the hospital rules for the area. Traffic shall be monitored and kept to a minimum. Visitors with colds or other obvious signs of infection should be restricted from entering patient care areas. • All cuts and lacerations will be covered with a waterproof dressing. • Clothing soiled by blood and/or body fluids must be spot cleaned or changed immediately.
Communicable Diseases	• Family members or persons caring for infected patients shall be instructed in the proper care of the patient to prevent transmission of the infection to themselves or others. • Patients with a suspected or known communicable disease may be cultured or tested as ordered by the Healthcare Epidemiologist, if necessary, for the investigation and control of outbreaks and/or to determine the effectiveness of control measures. • Personal Protective Equipment will be available at all times. • Guidelines for isolation of a patient with a communicable disease shall be followed (see policy: # 1.19 Isolation). • The Department of Healthcare Epidemiology will be notified of all patients who have a reportable disease (see policy: # 1.27 Reporting of Communicable Diseases to the Health Department).
Responsibility for Cleaning	• Daily cleaning in the intensive care units o Clinical Equipment Services will clean all medical equipment in the intensive care units on a daily basis o Environmental Services will clean environmental surfaces in the intensive care units on a daily basis o Pulmonary Care Services will clean all respiratory care equipment in the intensive care units on a daily basis o Nursing will clean environmental surfaces as needed • Discharge cleaning in intensive care units o Environmental Services will clean all environmental surfaces and medical equipment in the intensive care units o Pulmonary Care Services will clean all respiratory care equipment in the intensive care units
Equipment and Supplies Transport of Specimens	• Resuscitation bags shall be disposable or terminally cleaned and subjected to sterilization or high-level disinfection (see policy: # 1.05 Cleaning and Reprocessing of Patient Care Equipment). • Safety precautions shall be maintained in the transportation of specimens: – Containers shall be checked before transporting to ensure that lids are securely closed. – Gloves shall be worn when transporting specimens. Specimens shall be bagged. – Trays or carts used to transport specimens shall be cleaned with a disinfectant solution routinely and if they become soiled with blood, other body fluids or excretions. – Request slips shall not be placed inside or stapled to the outside of the transportation bag, but rather placed into the outside pouch of the plastic bag. • Request slips shall be discarded if soiled with blood, other body fluids or excretions.
Patient Care Procedures	• The following Healthcare Epidemiology Polices will be followed in addition to the directions for safe care of ICU patients set forth in this policy. - 1.14 Hand Hygiene for all Healthcare Workers - 1.18 Intravascular Devices and Infusion Systems - 1.9 Isolation - 1.40 Prevention of Nosocomial Pneumonia - 1.45 Prevention of Urinary Tract Infection • Oral Care - Keep oral swabs inside the baggie and do not allow them to have contact with the table or any other surface prior to placing them in the patient’s mouth. • Tube insertion and feeding - Wash off the top of the can of enteral feeding before opening it. - Cover opened cans securely with a clean cover before refrigerating. (See policy 1.24 Preparation of Enteral Feedings [Adult and Pediatric]). - Use aseptic no-touch technique when measuring and placing the feeding tube. • Respiratory Care - Small-volume medication nebulizers: In-line and hand- held nebulizers. • Between treatments on the same patient, remove the remaining medication from the cup, rinse with a saline bullet, and wipe the inside of the cup thoroughly with an alcohol pad (first remove the plunger). Reattach to system and store for next use. The nebulizer must be changed every 24 hours. • Use only sterile fluid for nebulization and dispense the fluid into the nebulizer aseptically. • Whenever possible, use aerosolized medications in single-dose vials. If multidose medication vials are used, follow manufacturers’ instructions for handling, storing, and dispensing the medications. - Using an alcohol pledget, wipe the port and the top of the MDI vial prior to attaching to the tubing. - Suction Yankeur with warm water after suctioning patient. - Store Yankeur in a clean bag on a horizontal surface between uses. - Change Yankeur every 24 hours. - Disinfect the port with alcohol prior to attaching the cuffalator. - Disinfect the cuffalator with alcohol after each use; store in cuffalator box when not in use. - Wear clean gloves when working with the heat moisture exchanger, MDI or nebulizer. • Cleaning Equipment - The ventilator must be cleaned daily by the respiratory therapist. - Upon discharge the ventilator will be thoroughly cleaned and tubing and circuit discarded. - Clinical Equipment service will clean the medical equipment in the room (the ventilator). The nurse will assure that all settings on the equipment are appropriate after each room is cleaned. • Specimen Collection - Gloves must be removed, hand hygiene accomplished and clean gloves donned before all blood draws and dressing changes and especially if the respiratory track has just been touched. • Hand Hygiene - Hand hygiene must be practiced (handwashing with an antimicrobial soap or application of an alcohol hand rub) prior to donning and after doffing gloves. Gloves must be removed followed by hand hygiene if hands have been contaminated with body fluids and a cleaner part of the body must be touched (i.e. working from clean to dirty).
Unit Practices	• Clean linen will be handled according to the policy (see policy: # 1.13 Guidelines for Handling Linen). • Wipe all ports connected to the vascular system with alcohol before each access. • Dispose of urine collection containers every 24°. Containers should be rinsed with water after every use. • Clean the glucometer with alcohol after every use. • Do not lay equipment on the glucometer tray. • Do not flush Foley catheters unless monitoring intraabdominal pressures. Do not flush catheters to remove obstructions. • Do not leave cups of irrigation fluid in patients’ rooms. • Thermometers that are shared between patients will have a disposable protective cover. The thermometer and all other non-disposable parts shall be cleaned with 70-90% isopropyl alcohol if contaminated by contact with patients’ skin or with surfaces such as a bedside table, etc. (see policy: # 1.33 Use of Thermometers). • Opened bottles of saline and water will be discarded at 24 hours. Multi-dose vials of medication will be discarded according to Pharmacy policy. Medications will be supplied in single dose containers when possible. • Single use only (disposable) equipment shall never be reprocessed unless the equipment is assigned to the hospital approved reprocessing program. • Transport equipment shall be covered prior to patient use and shall be cleaned with a disinfectant solution between each use if soiled with patient’s blood, other body fluids or excretions. • Bandage scissors shall be disinfected with 70-90% isopropyl alcohol after use on each patient. • Bedpans, urinals, and emesis basins will be emptied immediately and discarded or thoroughly cleaned between each use, and stored properly in the patient’s room. • Stethoscopes will be wiped with 70-90% isopropyl alcohol after use on each patient. • Linen or trash hampers or cans will not be overfilled so that their contents spill out on the floor. • Unit areas and patient rooms will be cleaned at least daily and more often as necessary. • Temperatures in all refrigerators will be monitored with thermometers. Specimens will not be placed in refrigerators in which food or medications are stored. Leftover food from patients shall be discarded or stored in refrigerators no longer than 24 hours (see policy: # 1.04 Care of Refrigerators and Freezers).
CHG Cloth Bathing	• The following protocol may be instituted by Health Care Epidemiology for bathing patients in response to infection control problems.

Protocol:

Chlorhexidine (CHG) bathing with 2% CHG prepackaged disposable cloths

A. Initial bath on admission to unit or prior to implementing protocol use soap and water.

B. If patient has skin allergies, use a cloth on a small area first, checking for any reaction. If itching or redness occurs, rinse that area and stop using the product.

C. Inspect the patient’s skin surfaces for evidence of a skin rash and any breaks in the skin. Avoid contact of areas with a rash or a break in the skin with the 2% CHG disposable cloths. If the patient has a generalized rash, do not bathe with the 2% CHG disposable cloths. Consult with the patient’s attending physician about bathing the patient with the 2% CHG disposable cloths.

D. AVOID TOUCHING THE EYES, EARS, OR MOUTH with the CHG cloths.

E. You will use a total of six (6) 2% CHG cloths [three (3) packs with two (2) CHG cloths in each one]. If 6 cloths are not enough to cover all skin surfaces in obese patients, use additional cloths as needed. Place the 2% CHG cloth packs in the warmer at the appropriate time prior to the planned start of body application. Use the cloths just as you would a wash cloth. Follow these directions:

NOTE: Do not warm cloths in microwave – use at room temperature.

F. Allow skin to air dry. Do not rinse or apply any lotions or moisturizers for 5 minutes after using the cloths. It is normal for the skin to have a temporary “tacky” feel for several minutes after using the cloths.

G. Discard the cloths in a trash can.

H. Do not wash the 2% CHG off of patients’ skin between daily applications.

I. Prior to each subsequent daily bath with the 2% CHG disposable cloths, examine the patients skin surfaces for redness, rash and fissures and ask the patient if they have any itching or burning of their skin. If the patient has any signs or symptoms of skin irritation, consult with the patient’s attending physician prior to bathing with 2% CHG disposable cloths.

J. CHG compatible products:

Aloe Vest soap, Aguaphor original formula ointment, Lubriderm dry skin care lotion, Eucerin original lotion, Vaseline 100% pure petroleum jelly, Provon moisturizing lotion.