Intensive Care Unit Introduction The Intensive Care Unit (ICU) is one of the busiest units in the hospital

and uses some of the most sophisticated equipment and advanced medical practices. However, the ICU may also experience higher infection rates due to the severity of illness of the ICU patients and to the frequent use of invasive devices. Invasive devices (e.g., Intravascular (IV) catheters) bypass the patients natural defenses against infection and place them at risk of infection from their own endogenous microorganisms. There is also a risk of becoming contaminated with another patients microbes or with those in the environment if staff do not maintain basic hand hygiene between patients. This may occur, for example, during direct contact if secretions from one patient are transferred on HCW hands to another patient or indirectly if a HCW handles soiled equipment and contacts a patient before carrying out hand hygiene. If patients become colonized with infectious agents from another source, they may develop an infection at a later time as the microbes gain access during device manipulation.

Endotracheal Suction Catheters

Introduction

Endotracheal suctioning (ES) is an essential and frequently performed procedure for patients requiring mechanical ventilation. By ES, secretions from the tracheobronchial tree are cleared, guaranteeing optimal oxygenation and avoiding accumulation of secretions, leading to tube occlusion, increased work of breathing, atelectasis, and pulmonary infections. Yet ES may also have adverse effects, such as disturbances in cardiac rhythm, hypoxemia (due to interruption of the mechanical ventilation and subsequently the decay of intrathoracic pressure), microbial contamination of airway and environment, and development of ventilator-associated pneumonia (VAP). The frequency with which ES is performed differs per patient, with reported mean values varying from eight to 17 times per day. Nowadays, two systems are available to perform ES: the singleuse, open suction system (OSS) and the multiple-use, closed suction system (CSS). OSS requires disconnection from the ventilator during ES, which is not necessary when using CSS. Moreover, in contrast to OSS, the closed suction catheter can remain connected to the patient for as long as 24 hrs, according to the manufacturer, and thus can be used for multiple ES procedures. CSS has become increasingly popular in the past decade. In the United States, 58% and 4% of intensive care units (ICUs) exclusively used CSS and OSS, respectively. Preference of CSS more than OSS is mainly based on assumed advantages, like lower incidence of VAP, fewer physiologic disturbances, decreased microbial contamination (and thus lower risk on cross-infections), and lower costs. In a recently published international guideline for the prevention of VAP, it was suggested that cost considerations favor the use of CSS that is changed as indicated, and the system is therefore recommended. This advice, however, is based on one trial that compared costs of CSS with or without daily changes of the system; trials on cost-effectiveness of CSS compared with OSS are lacking.

So far, the evidence to prefer CSS more than OSS has not been systematically reviewed. Therefore, we performed a meta-analysis in which we compared the effectiveness of CSS with that of OSS with respect to infection and survival, cardiorespiratory variables, bacterial contamination, and costs.

It is important to remember that: The purpose of performing oral suction is to maintain oral hygiene and comfort for the patient or to remove blood and vomit in an emergency situation. The purpose of tracheal/endotracheal suction is to remove pulmonary secretions in patients who are unable to cough and clear their own secretions effectively. The patient may be fully conscious or have an impaired conscious level. Secretions are cleared from these patients airways in order to maintain airway patency, to preventatelectasis secondary to blockage of smaller airways (Royal Free Hampstead NHS Trust 1999), and to ensure that adequate gas exchange (particularly oxygenation) occurs.

DISCUSSION
The results of this meta-analysis reveal that generally assumed advantages of CSS compared with OSS, like lower incidences of VAP, lower costs, reduced bacterial contamination, and improved patient outcome, are not supported by scientific evidence. The only assumption that is supported by evidence is that CSS causes fewer physiologic disturbances, but the differences were rather small and do not seem clinically relevant. Few studies (n = 15) have compared the effects of OSS and CSS in a randomized design. In general, the methodological quality of the included studies was not high. Although all trials used some kind of randomization, methods of concealment were provided in only six studies, of which only four were considered adequate. Inadequate or unclear allocation concealment may lead to larger estimates of effect.[29] Furthermore, performance of ES was not described accurately in most studies and differed between studies in the use of normal saline, preoxygenation, or duration of suctioning (10-20 secs). The latter aspects may have profound effects on physiologic variables such as oxygenation and heart rate. Finally, when we considered studies assessing the effects of different ES systems and the risk on VAP, patient categories and criteria to diagnose VAP differed somewhat. In all studies noninvasive methods were used to diagnose VAP, and main differences were in the specification of leukocytosis (<3000 or <4000/mm3) and the necessity of all criteria to be met. Although studies differed in methodology (design and conduct) as well as clinically (patient characteristics and performance of ES), a meta-analysis could be performed for five outcomes, since heterogeneity was low. The most frequently evaluated outcome variable was VAP, which was determined in eight studies. A significant reduction associated with the use of CSS was only

found in the smallest study (n = 24).[11] Neither in the larger studies nor in meta-analysis were significant incidence reductions found, as was also concluded in a recently published metaanalysis.[38] Because of differences in diagnosis of VAP, we performed a sensitivity analysis that included only those studies that used comparable criteria to diagnose VAP,[1, 4, 8, 9, 30, 32] and findings did not alter (I 2 0%; pooled relative risk, 0.95; 95% CI, 0.76-1.20). Therefore, it seems unlikely that subsequent and larger randomized trials will change this finding. This interpretation conflicts with recently published international guidelines in which the use of CSS is recommended as part of a VAP prevention strategy.[17, 39] These recommendations are based on qualitative analyses of three[39] or four[17] similar randomized studies, which all conclude that type of suctioning system has no effect on the incidence of VAP. Despite this lack of evidence (and without performing a meta-analysis), both guidelines favor CSS. The second largest outcome measured was mortality (four studies, 1062 patients), and no significant differences were found in either of the studies or in meta-analysis. Statistically significant differences were found in cardiorespiratory variables: MAP and heart rate were lower after using CSS. However, the actual difference for heart rate was 6 beats/min and seems, therefore, of little clinical relevance. This also applies to MAP, in which we found a significant but clinically very small difference (3-5 mm Hg) in favor of CSS. There is no evidence that CSS is beneficial for arterial oxygen saturation. This outcome was higher after using OSS in each study, but the five studies were too heterogeneous to perform pooled analysis. Despite differences in cardiorespiratory variables, it is not possible to draw firm conclusions due to the paucity and clinical heterogeneity of data. Available data do not support the idea that CSS is cost reducing compared with OSS. A rigorous cost-effectiveness analysis of both systems is needed and should include the societal perspective (real costs being made to perform ES, e.g., used materials and personnel time) and benefits (in terms of patient outcomes) across the healthcare continuum.[40] Prolongation of CSS device use, from the recommended 24 hrs to several days, will definitely influence cost efficacy. This approach has been pursued in six studies.[3, 32, 41-44] Prolonged use of CSS was associated with increased microbial colonization of the device[43] without raising the incidence of VAP[3, 41, 44] and was considered safe and cost-effective.[3, 41-44] A survey among 27 ICUs in the United States revealed that CSS devices were changed every 72 hrs, as needed, or weekly in 37% of ICUs, [45] with no negative effects mentioned. Conceptually, prevention of bacterial transmission from patient to patient could be a beneficial, and highly relevant, effect of using CSS instead of OSS. However, up to now cross-transmission or environmental bacterial contamination has not been studied in a randomized design. Environmental contamination after ES with either OSS or CSS was compared in a nonrandomized crossover study with nine patients.[16] After 144 ES procedures, both OSS and CSS were associated with significant increased colony counts measured by air sampling, but, on average, colony counts were lower after use of CSS.[16] In another small observational study (n = 14), visible droplet dissemination was detected in all OSS procedures, with bacteriologic contamination in the inanimate environment of 37% of patients.[46] There are no data on environmental contamination when changing the CSS device, a procedure that also needs tube disconnection. Interestingly, the assumed reduction in environmental contamination is a reason to use CSS, not only to minimize cross-transmission of pathogens but also to allow performance of ES without the use of sterile gloves, which are recommended when using OSS.[47] Without

scientific justification, such a change in nursing practice may in fact increase hand contamination and subsequent spread of nosocomial pathogens. This meta-analysis has some limitations. First, as in all meta-analyses, publication bias cannot be excluded. A funnel plot of the included studies on the incidence of VAP (data not shown) indeed indicated that publication bias might play a role; that is, larger studies showing beneficial effect appear to be missing. This is, however, in contrast with the concerns about publication bias, namely that positive (significant) results in favor of the newer system (CSS) are more likely to be published than negative results (type I error).[48, 49] Second, selection bias might have occurred as a consequence of our language restriction. As far as we know, we only missed one Korean study on the effects of CSS on arterial oxygen saturation and VAP in 70 patients.[28] We could not assess study quality, randomization procedures, and criteria used to diagnose VAP (incidence significantly higher in OSS group). Results on arterial oxygen saturation could, however, be read from the tables and were in agreement with our findings. This first meta-analysis on open and closed suction systems reveals that the increased popularity of CSS is yet not sufficiently supported by scientific evidence. Randomized trials to assess one of the most pronounced assumptions, the potential benefits of CSS in reducing cross-transmission, are needed. Such trials should be specifically designed to identify the true effect measures. When randomizing individual patients, resulting in a mix of patients receiving ES with CSS and OSS, beneficial effects of CSS might be obscured by cross-transmission occurring from neighbor patients randomized to OSS. Therefore, a large multiple-center crossover trial, with fixed periods in which either of both systems is used, appears to be most appropriate.

Increased risk is associated with: The severity of the patients illness and underlying conditions. The exposure to multiple invasive devices and procedures. Increased patient contact with health-care personnel. A longer ICU stay which prolongs the risk of exposure. Space limitations that increase the risk of contaminating equipment. 10 Since patients in the ICU are likely to have multiple devices for treating or monitoring their care, it is not surprising that the most common nosocomial infections are pneumonia (endotracheal tubes), urinary tract infections (urinary catheters) and catheter-related blood stream infections. Policies for infection prevention and control in the ICU must be clear and must be meticulously implemented. Urinary catheter, ventilator-associated, and catheter-associated bloodstream infection are common complications of care provided in the ICU. Urinary catheter associated infection is the most frequent of these followed by ventilatorassociated or other types of lower respiratory tract infection. Attributable mortality for pneumonia occurring in the ICU population is between 5 14%. 15Intensive Care Unit 57 Sources of Cross-Infection in the ICU Hands of staff and attendants (via two-bowl handwashing and communal towels or no handwashing); Assisted ventilation equipment; Suction and drainage bottles; I.V. lines central and peripheral; Urinary catheters; Wounds and wound dressings; Disinfectant containers; Dressing trolleys (on which disinfectants jars/bottles are stored). 15 Strategies to Reduce Infection Risk Patient Assessment for Infectious Risk Patients needing ICU care should be assessed for: Diarrhea, Rashes or skin conditions; Recognized communicable disease; Known carrier of an epidemic strain of bacterium;

 Isolation: Patients suspected or known to have communicable diseases should be admitted directly to an isolation cubicle in the ICU or referred to a Fever Hospital as appropriate (after stabilization with dedicated equipment and staff). An isolated ICU patient ready to be transferred to an open ward must first be cleared.. 15 Hand hygiene [See also Part I: Hand Hygiene.] Hands are the most common vehicle of transmission of organisms and therefore sinks should be provided for handwashing. All visitors and staff should wash their hands before direct contact with patients. Intensive Care Unit 58 Note: Aseptic hand wash or alcohol based hand rub should be performed: - Before entering the ICU - Before performing any invasive procedure inlcuding peripheral cannula insertion and removal. - Before use of multidose vials. - Before adminstration of iv fluids or medications/drugs Routine hand wash should be performed: - Before and after any contact with the patient - After touching environmental surfaces - Whenever soiled. Procedures requiring aseptic technique (Intravenous Therapy, Urinary Catheterization, & Respiratory Care Equipment /Practices) [See also Part I: Aseptic Technique] IV care practices Clean injection ports with 70% alcohol or an iodophor before accessing the system. Cap all stopcocks when not in use. Use aseptic technique including a cap, mask, sterile gown, sterile gloves, and a large sterile sheet for the insertion of central venous catheters (including PICCs) or guidewire exchange. Do not routinely replace central venous catheters, hemodialysis catheters, or pulmonary artery catheters. Do not remove CVCs or PICCs on the basis of fever alone. Use clinical judgment regarding the appropriateness of removing the catheter if infection is evidenced elsewhere or if a noninfectious cause of fever is suspected. Do not routinely replace peripheral arterial catheters. Respiratory care Patient-Based Interventions: If there is no medical contraindication, elevate the head of the bed of a patient at high risk for aspiration pneumonia, e.g., a person receiving Intensive Care Unit 59

mechanically assisted ventilation and/or who has an enteral tube in place, at an angle of 30-45 degrees. Periodically drain and discard any condensate that collects in the tubing of a mechanical ventilator, taking precautions not to allow condensate to drain toward the patient. Decontaminate hands with soap and water or a waterless antiseptic agent after performing the procedure or after handling the fluid. If available, use an endotracheal tube with a dorsal lumen above the endotracheal cuff to allow drainage (by continuous suctioning) of tracheal secretions that accumulate in the patient's subglottic area. Use sucralfate, H2-blockers, and/or antacids interchangeably for stress-bleeding prophylaxis in a patient receiving mechanically assisted ventilation (H2-blockers alone decrease gastric acidity and increase gastric colonization and increases the susceptibility to respiratory infections). Instruct preoperative patients, especially those at high risk of contracting pneumonia, regarding taking deep breaths and ambulating as soon as medically indicated in the postoperative period. High-risk patients include those who will have an abdominal, thoracic, head, or neck operation or who have substantial pulmonary dysfunction. Follow manufacturers' instructions for use and maintenance of wall oxygen humidifiers unless data show that modifying the instructions poses no threat to the patient and is cost-effective. Between patients, change the tubing, including any nasal prongs or mask used to deliver oxygen from a wall outlet. Small-volume medication nebulizers: "in-line" and hand-held nebulizers: Between treatments on the same patient, disinfect; rinse with sterile or pasteurized water; and air-dry small-volume in-line or hand-held medication nebulizers. Use only sterile or pasteurized fluid for nebulization and dispense the fluid into the nebulizer aseptically. If multidose medication vials are used, then handle, dispense, and store them according to manufacturers' instructions using sterile techniques. Personal protective equipment for routine patient care Gloves should be selected according to need.(e.g., sterile for procedures using aseptic technique such as insertion of central venous catheter and non-sterile for procedures such as emptying urinary Intensive Care Unit 60 drainage bags, insertion of peripheral IV catheters, contact with contaminated surfaces or equipment); Wear gloves for handling respiratory secretions or objects contaminated with respiratory secretions of any patient. Change gloves and decontaminate hands, as above: o Between contacts with different patients. o After handling respiratory secretions or objects contaminated

with secretions from one patient. o Before contact with another patient, object, or environmental surface. o Between contacts with a contaminated body site and the respiratory tract of, or respiratory device on, the same patient. When exposure to respiratory secretions from a patient is anticipated, wear a gown and change it after soiling occurs and before providing care to another patient. Plastic aprons may be worn when contact with patient body fluids is anticipated; Disposable high-efficiency filter masks may be used for wound care. Shoe and head coverings are not required for routine care 15 . ICU Personnel All staff working on the unit should be offered hepatitis B vaccine before beginning work on the unit (See Part I: Occupational Safety and Employee Health); Orientation to the unit should include basic infection control concepts that include hand hygiene, management of sharps, and associated risks of disease transmission. Training and education should include formal and informal infection control lectures and tutorials, ward rounds, and assessment of practices through periodic observations. Intensive Care Unit 61 Environment Factors and Design Issues for the ICU Unit Design Unit design should consider the following to enhance infection control strategies. Space Beds The beds should be 2.5 - 3 meters (7-9 feet) apart, to allow free movement of staff and equipment, reducing risk of crosscontamination. Ideally, a sharps container should be within easy access of each bed. Partitions Privacy partitions should be of material that is easily cleaned and should be cleaned weekly and any time that it becomes soiled or contaminated. If curtains are used, they should be changed weekly and between patients. Toilets May be located outside the ICU. Medication preparation Medication prep areas should be separate from patient care areas and should be maintained as a clean area.

 Clean storage An area should be identified and maintained for clean storage and should be separate from care and waste disposal alreas. Soiled and waste storage An area should be identifed for storing collected bedside waste and should be maintained separate from direct care and clean medication areas. Ideally, this area should have a clinical sink for the disposal of blood and body fluid waste. The area should include storage of filled sharps containers until these containers can be removed. Ventilation Type The source of clean air should be determined including central or through-the wall air conditioning units. System should be evaluated for proper functioning and preventive maintenance. Intensive Care Unit 62 Windows Windows should remain closed in order to control all airborne risks; plants and flowers should be kept outside the ICU. 15 Sinks and Waterless Handrub Dispensers Sinks should be placed near the ICU entrance and at key points within the unit in order to provide ease of access to the caregivers. If this is not feasible, waterless handrub dispensers should be available at the ICU entrance and at each bedside. If the design permits scrub sinks, an adequate number of easily accessible Elbow/Foot operated sinks should be available. Sinks should not be plugged or used for storage. Sinks assigned for handwashing should not be using for washing instruments. Traffic flow The unit may be situated close to the operating theatre and to the emergency department for accessibility, but should be separate from the main ward areas. Policies should consider controlling traffic flow to and from the unit in order to reduce sources of contamination from visitors, staff and equipment. Visitors Design of the unit should permit staff to assess visitors for communicable disease (eg, rash, respiratory infection) before permitted to enter unit. They should be instructed in washing their hands if assisting the patient. Non-ICU Staff Staff not assigned to the ICU should follow the following protocol: Street coats and white coats must be removed; Hands should be washed on entering the ICU; The proper procedure should be followed when attending the patient; Hands should be washed before leaving the unit. 15Intensive Care Unit

63 Patient Care Equipment Cleaning and disinfection or sterilization of patient care equipment should not be carried out in the ICU. Used equipment should be sent to the Sterile Service Department or designated reprocessing area. A policy on disposable and reusable items should be clearly defined. [For more details see Part I: Cleaning, Disinfection, and Sterilization of Medical Equipment] 15 Table 6: Reprocessing & patient care practices for specialized equipment in the intensive care unit (ICU) Equipment and patient-care articles Reprocessing Method 1. Ventilatory circuits Disposable tubing does not routinely need to be changed for a single patient unless it becomes visibly contaminated, malfunctions or within 3-4 days. Multiple-use tubing must be heat-disinfected for a at least 76C for 30 minutes or sterilized (see manufacturers guidelines). The use of nondisinfected tubing between patients increases the risk of chest infection due to gram-negative bacilli, e.g. Pseudomonas aeruginosa. If properly maintained, a ventilated patient may use the same circuit for 3-4 days before reprocessing becomes necessary. When cost-effective and unless medically contraindicated, use a heat-moisture exchanger (HME) to prevent pneumonia in a patient receiving mechanically assisted ventilation. Change the HME when it malfunctions mechanically or becomes visibly soiled. Do not routinely change an HME more frequently than every 48 hours. Install filters, e.g. heat-moisture exchangers with filters (HMEF) on the expiratory and inspiratory ends of the ventilator to prevent contamination 2. Endotracheal suction catheters Closed suction catheters that incorporate a protective sleeve do not need to be changed every 24 hours. Studies have demonstrated these can safely be used on the same patient until the device is contaminated or malfunctions. More often, disposable suction catheters are used for respiratory tract suctioning. This device should be discarded after each use or may be used maximum for up to 6 hours on the same patient. The water used for flushing the catheter after each suction must be sterile and changed every time. Alternatively: Nursing staff and attendants must disinfect their hands properly

before and after each use. Suction catheters must not be shared between patients. Intensive Care Unit 64 Table 6: Reprocessing & patient care practices for specialized equipment in the intensive care unit (ICU) - (Continued) Equipment and patient-care articles Reprocessing Method 3. Endotracheal tubes These may be recycled after thorough cleaning and autoclaving. Disposable endotracheal tubes are available but are more expensive than recyclable ones. 4. Ambu-bags These are used for resuscitation. Ambu-bags are extremely difficult to disinfect and become contaminated very quickly: Heat is the most reliable method of disinfection; 2% glutaraldehyde is a less acceptable method. The bags must be rinsed thoroughly in sterile water after immersion in glutaraldehyde. This will reduce the risk of chemical irritation, which can itself precipitate respiratory infection. 5. Oxygen delivery masks These can be disposable or reusable; Wash thoroughly. Soak in alcohol for 10 minutes or soak in chlorine (500 ppm), rinse, dry and store.. 6. Suction and drainage bottles These are usually disposable, with a self-sealing inner container held in a clear plastic outer container. Non-disposable bottles: Before buying a system, ensure that the outer container can be heatdisinfected or autoclaved. Non-disposable bottles: Must be changed every 24 hours (or sooner if full). The contents may be emptied down the toilet. Must be rinsed and autoclaved. If sterilizing facilities are not available, wash thoroughly, dry and perform high level disinfection. Recyclable connector tubing should be cleaned thoroughly and sterilized. The system must be closed and risk to staff from body fluids should be minimal. Do not leave fluids standing in suction bottles. 7. Resuscitaires

 Disconnect all connections. Wash thoroughly with a soft brush and autoclave. Intensive Care Unit 65 Environmental Cleaning Daily Cleaning must be done daily with the hospital approved cleaner. All surfaces must be wiped with a damp cloth to remove dust and dirt; Cleaner/disinfectants should be identified by the IC- team and used as indicated. High level disinfectants (HLD) are not used for environmental cleaning. Cleaner/disinfectants should be kept closed when not in use. Terminal When patients are discharged from the unit, a thorough cleaning of the bed and bedside equipment must be completed before admitting new patients. Scheduled A total cleaning of all areas, including the store clean and soiled storage areas , should be done at least every 1-2 weeks. Separate mops, and cleaning utensils should be used for cleaning of the unit. Cleaning equipment should be wiped and properly stored when not in use. 15

Endotracheal Suction Catheters

Oropharyngeal, tracheal, and endotracheal suction are methods of clearing secretions by the application of negative pressure via either a yankauer sucker (oropharyngeal) or an appropriately sized tracheal suction catheter (tracheal/endotracheal). This procedure may be required in an emergency situation or as part of a patients planned care. It is important to remember that: The purpose of performing oral suction is to maintain oral hygiene and comfort for the patient or to remove blood and vomit in an emergency situation. The purpose of tracheal/endotracheal suction is to remove pulmonary secretions in patients who are unable to cough and clear their own secretions

effectively. The patient may be fully conscious or have an impaired conscious level. Secretions are cleared from these patients airways in order to maintain airway patency, to prevent atelectasis secondary to blockage of smaller airways (Royal Free Hampstead NHS Trust 1999), and to ensure that adequate gas exchange (particularly oxygenation) occurs. Closed suction catheters that incorporate a protective sleeve do not need to be changed every 24 hours. Studies have demonstrated these can safely be used on the same patient until the device is contaminated or malfunctions. More often, disposable suction catheters are used for respiratory tract suctioning. This device should be discarded after each use or may be used maximum for up to 6 hours on the same patient. The water used for flushing the catheter after each suction must be sterile and changed every time. Alternatively: Nursing staff and attendants must disinfect their hands properly before and after each use. Suction catheters must not be shared between patients.