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ICU Bundles

Prevention bundles for sedation, ventilators, lines, catheters, clots and skin, plus isolation by organism

Reviewed by Alex G, BSN, RN, CEN, CCRN, CMC, NREMT-P · From the Reference tab of the app

ICU Liberation (ABCDEF) bundle

SCCM bundle built on PADIS 2018: each letter at the bedside

A: Assess, prevent, manage pain	Self-report 0–10, or CPOT (over 2) or BPS (over 5) if the patient cannot report; treat pain first and rescore after each dose
B: Both SAT and SBT	Daily safety screens; stop sedation (SAT), then a breathing trial (SBT) if awake; a failed SAT restarts at half the dose (ABC 2008)
C: Choice of analgesia and sedation	Analgesia first; light sedation, RASS −2 to +1 (PADIS 2018); propofol or dexmedetomidine over benzodiazepines
D: Delirium: assess, prevent, manage	CAM-ICU or ICDSC (4 or more) each shift; reorient, glasses, hearing aids, sleep, mobility; antipsychotics not routine
E: Early mobility and exercise	Daily progressive activity, from sitting to walking, once a safety screen passes; match intensity to the patient (TEAM 2022)
F: Family engagement and empowerment	Open visiting, family on rounds and in care, early goals-of-care talks; less family anxiety, depression and PTSD (PICS-F)

Daily check

Pain scored and treated before any sedative
SAT screen passed and sedation stopped, or the reason it was not documented
SBT screen and trial with the respiratory therapist
Sedation target set and actual RASS documented
CAM-ICU or ICDSC done; causes of delirium looked for
Mobility level reached today recorded
Family updated or present on rounds

Doing every element was linked to lower 7-day mortality (adjusted HR 0.32) and less delirium, coma, restraint and ICU readmission (Pun 2019, 15,226 adults, observational).

VAP and VAE prevention

SHEA/IDSA/APIC 2022 practices and the CDC ventilator-associated event tiers

Essential practices, every day (SHEA 2022)

Head of bed 30–45° unless contraindicated
Light sedation; avoid benzodiazepines where possible
Paired SAT and SBT; HFNC or NIV to avoid intubation or reintubation when suitable
Toothbrushing; no chlorhexidine oral care
Early exercise and mobilization
Early enteral rather than parenteral nutrition
Circuit changed only when visibly soiled or malfunctioning

Beyond the essentials

Additional (SHEA 2022)	Subglottic suction tube if likely ventilated over 48–72 h; early tracheostomy; post-pyloric feeds if gastric intolerance and aspiration risk
Not for VAP prevention	Chlorhexidine oral care, probiotics, silver-coated tubes, automated cuff control; SUP and residual checks do not prevent VAP

VAE tiers (CDC NHSN 2026)

Baseline	Adults ventilated 4 days or more: 2 or more days of stable or falling daily minimum PEEP or FiO₂ (lowest held over 1 h)
VAC	Then daily minimum PEEP up 3 cm H₂O or more, or FiO₂ up 0.20 or more, for 2 or more days; PEEP 0–5 counts as 5
IVAC	VAC plus temperature over 38 or under 36 °C, or WBC 12,000 or more or 4,000 or less, plus a new antimicrobial for 4 or more days
PVAP	IVAC plus a quantitative respiratory culture, purulent secretions with an organism, or a positive pleural, Legionella or viral test

VAE is surveillance, not a bedside diagnosis: most VACs turn out to be pneumonia, ARDS, atelectasis or pulmonary edema.

Central line care

CLABSI prevention after insertion: bathing, hubs, dressings, tubing, daily review

After insertion (SHEA 2022, CDC 2011)

Chlorhexidine bath	Daily for ICU patients over 2 months old with 2% CHG cloths; not on the face or mucous membranes; no rinsing
Scrub the hub	Every access: CHG-alcohol (preferred) or 70% alcohol with friction for at least 5 s, then let dry; or antiseptic caps
Transparent dressing	CHG dressing with site care at least every 7 days; sooner if damp, loose or soiled
Gauze dressing	Every 2 days, sooner if damp, loose or soiled; for an oozing site or sweaty skin
Tubing	Continuous sets every 96 h to 7 days; blood or lipids within 24 h; propofol every 12 h (label)
Needleless connectors	Change with the administration set; no benefit from changing more often than every 72 h (CDC 2011)
Daily review	Is every line still needed? Remove it the day it is not; no scheduled line changes
Emergency-placed line	Replace within 48 h when sterile technique could not be ensured (CDC 2011)

Suspected line infection: paired blood cultures from the line and a peripheral vein before antibiotics; growth from the line 2 h or more earlier implicates it (IDSA 2009).

Urinary catheters

CAUTI prevention: indications, nurse-driven removal and maintenance (SHEA 2022)

Appropriate indications

Acute retention: scanned residual over 500 mL, or over 300 mL with bladder pain or fullness
Hourly urine output that is changing therapy (resuscitation, diuresis, pressor titration)
Selected surgery; a catheter placed only for a long case comes out at the end of it
Healing an open pressure injury or skin graft in selected incontinent patients
Comfort at the end of life, if the patient wants it
CDC 2009 also lists prolonged immobilization (unstable spine, pelvic fractures)
Not indications: incontinence, convenience, ICU status alone, a urine sample from someone who can void

Nurse-driven removal

Each day, check the catheter against the indication list
No indication left: remove it under the protocol and document
After surgery: remove as soon as possible, ideally within 24 h (CDC 2009)
Watch for voiding; bladder scan if none by the protocol time or with discomfort
Retention: intermittent catheterization before a new Foley; external catheter for incontinence

Maintenance

Closed system: never disconnect the catheter from the tubing
Bag below the bladder and off the floor; tubing free of kinks and dependent loops
Empty into a clean container for each patient; the spout never touches it
Secure the catheter against traction; smallest workable size
Routine meatal hygiene with soap and water; no antiseptic cleaning (CDC 2009 advises against it; SHEA 2022: unresolved)
No scheduled catheter or bag changes and no routine irrigation
Culture only for fever, altered mental status or new sepsis with no other source, flank pain, acute hematuria or new pelvic discomfort
Sample from the disinfected port, never the bag; cloudy or smelly urine or pyuria alone is no reason to culture

Daily ICU prophylaxis

VTE and stress ulcer prophylaxis, head of bed, glucose

VTE prophylaxis

Enoxaparin	40 mg SC daily; 30 mg daily if CrCl under 30; trauma often 30 mg every 12 h; BMI 40 or more often 40 mg every 12 h
Heparin (UFH) SC	5,000 units every 8–12 h; for severe kidney failure or when a procedure is near
Choice (ASH 2018)	LMWH over UFH in critical illness; the drug alone, since adding compression devices did not help (PREVENT 2019)
Compression only	Intermittent pneumatic compression while anticoagulants are unsafe; start the drug as soon as bleeding risk allows
Hold or delay	Active bleeding, platelets under about 50,000; spontaneous ICH: start 24–48 h after onset once stable; SAH: once the aneurysm is secured
Epidural catheter	Prophylactic enoxaparin at least 12 h before placement or removal; next dose at least 4 h after removal (ASRA 2018)
HIT history	No heparin of any kind, flushes included; fondaparinux 2.5 mg SC daily if CrCl 30 or more and weight 50 kg or more

Stress ulcer prophylaxis (SCCM/ASHP 2024)

At risk	Coagulopathy, shock, chronic liver disease, neurocritical illness; REVISE 2024: pantoprazole cut bleeding on the ventilator (1.0% vs 3.5%)
Pantoprazole	Prophylaxis: 40 mg IV or enteral once daily; famotidine 20 mg twice daily is an equal choice (halve it at CrCl under 50)
Not needed	Low-risk patients who are enterally fed; acid suppression adds pneumonia and C. difficile risk
Stop	When the risk factor resolves, and before ICU transfer, unless another indication (recent bleed, esophagitis) remains

Every patient, every day

Head of bed	30–45° when ventilated or tube-fed unless contraindicated; 30° meets both the VAP and the skin (shear) goals
Glucose	140–180 mg/dL; start insulin at persistent 180 or more (ADA 2026); the 81–108 target raised deaths (NICE-SUGAR 2009)
Hypoglycemia	Under 70 mg/dL: stop the insulin, give D50 12.5–25 g IV per protocol, recheck in 15 min

FAST HUGS BID: feeding, analgesia, sedation, thromboprophylaxis, head of bed, ulcer prophylaxis, glucose, spontaneous breathing trial, bowels, indwelling lines, de-escalation.

Pressure injury

Braden bands, NPIAP stages, device injuries, turning and surfaces

Braden scale (6–23; lower is worse)

Subscales	Sensory perception, moisture, activity, mobility, nutrition (1–4 each); friction and shear (1–3)
19–23	Not at risk; reassess per policy and with any change
15–18	Mild risk: start prevention (turning, heels, moisture, nutrition)
13–14	Moderate risk
10–12	High risk
9 or less	Very high risk

NPIAP stages (2016)

Stage 1	Intact skin with non-blanchable redness (may look different in dark skin); purple or maroon suggests deep tissue injury
Stage 2	Partial thickness: pink, moist dermis or a serum blister; no fat, slough or eschar. Not for moisture damage or skin tears
Stage 3	Full thickness skin loss with fat visible; may have slough, eschar, undermining or tunneling; no fascia, muscle or bone
Stage 4	Full thickness skin and tissue loss with fascia, muscle, tendon, ligament, cartilage or bone exposed or palpable
Unstageable	Full thickness loss hidden by slough or eschar; leave stable dry eschar on a heel or ischemic limb in place
Deep tissue (DTPI)	Persistent non-blanchable deep red, maroon or purple area, or a blood-filled blister; may open fast
Device-related	Takes the shape of the device and is staged the same way; injury on mucous membranes is not staged

Prevention

Devices	ETT, NG, NIV mask, collar, SpO₂ probe, tubing: pad, rotate and lift; check under them at least twice daily, more with edema
Turning	Individualized, often every 2 h; 30° side tilt; small shifts if unstable; float heels fully off the bed
Head of bed	As low as allowed, to limit shear; 30° meets the VAP minimum in ventilated patients
Support surface	High-specification foam for anyone at risk; alternating pressure or low-air-loss for high risk or an existing injury
Prophylactic dressing	Silicone multilayer foam on sacrum and heels in at-risk patients (2019 international guideline)
Moisture and nutrition	Prompt incontinence care, barrier product; with an injury and malnutrition risk: 30–35 kcal/kg and protein 1.25–1.5 g/kg a day

Do not reverse-stage: a healing stage 4 stays a healing stage 4. Moisture damage, skin tears and burns are not pressure injuries.

Isolation precautions

Precaution type, room and PPE by organism (CDC 2007 guideline with updates)

Precaution types

Standard	Every patient: hand hygiene, PPE for the expected exposure, respiratory hygiene, safe injections
Contact	Gown and gloves on entry, off before leaving; private room or cohort; dedicated stethoscope and BP cuff
Contact (enteric)	Contact PPE plus soap-and-water hand washing, sporicidal (bleach) cleaning and a dedicated toilet or commode
Droplet	Surgical mask on entry; private room, or beds 3 ft apart with the curtain drawn; mask the patient to move
Airborne	Fit-tested N95 or PAPR before entry; AIIR (negative pressure, 12 air changes/h new, 6 older), door closed; mask the patient to move

Respiratory spread

Tuberculosis, pulmonary or laryngeal	Airborne: AIIR and N95; until improving on therapy with 3 negative AFB smears, or TB is ruled out
Measles	Airborne: AIIR; N95 for all staff, immune or not; until 4 days after rash onset (whole illness if immunocompromised)
Varicella, disseminated zoster	Airborne plus contact: AIIR, N95, gown, gloves; immune staff preferred; until all lesions are dry and crusted
Localized zoster	Standard with lesions covered if immunocompetent; airborne plus contact if immunocompromised until dissemination is ruled out
Influenza	Droplet for 7 days or until 24 h after symptoms end, whichever is longer; aerosol procedures: N95, gown, gloves, eye protection
COVID-19	N95, gown, gloves, eye protection; single room, door shut, AIIR for AGPs; 10 days, up to 20 if severe; test-based end if immunocompromised
Meningococcus	Droplet until 24 h of effective antibiotics; prophylaxis for staff with unmasked airway exposure (intubation, suctioning)
Pertussis	Droplet until 5 days of effective antibiotics; private room preferred

Contact spread

MRSA	Contact (SHEA 2022; a hospital may modify after a risk assessment); ICU decolonization: daily CHG bath plus 5 days of nasal mupirocin
VRE	Contact per hospital policy; dedicated equipment; thorough daily and discharge cleaning
CRE	Contact; single room and dedicated equipment; flag the chart and warn the receiving unit at transfer
Candida auris	Contact for the whole stay (colonization persists); single room; EPA List P disinfectant, since quaternary ammonium alone fails
C. difficile	Contact (enteric) from suspicion, before the result, until at least 48 h after diarrhea stops (IDSA/SHEA 2017); soap and water; bleach
Norovirus	Contact (enteric); mask and eye protection if vomit may splash; soap and water; bleach; until 48 h after symptoms end
Scabies	Contact until 24 h after effective treatment; crusted scabies is far more contagious: private room, treat exposed staff per policy

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