Daily ward round on a ventilated patient with a central line, an arterial line and a urinary catheter on day 5
ABCDE
Run the bundle as a checklist on every round. The single most effective intervention is asking, out loud, whether each device is still needed today.
Central line → full barrier precautions and chlorhexidine skin preparation at insertion, ultrasound guidance, avoid the femoral site where practical, scrub the hub before every access, inspect the site daily, and remove the line the day it is no longer needed
Ventilator → head of bed 30–45°, daily sedation interruption with a spontaneous breathing trial, oral care with a toothbrush, subglottic secretion drainage where available, cuff pressure 20–30 cm H₂O, and no routine circuit changes
Urinary catheter → insert only for a genuine indication, keep the system closed and the bag below the bladder, and remove early. Do not treat asymptomatic bacteriuria — in pregnancy and before urological surgery are the exceptions
Surgical site and skin → antibiotic prophylaxis within 60 minutes of incision and stopped within 24 hours, normothermia and glycaemic control, clippers not razors, and daily chlorhexidine bathing in ICU
Stewardship and audit → review every antimicrobial at 48–72 hours against the cultures, set a stop date on the chart, and feed device-day infection rates back to the unit — measurement is what makes the bundle stick
Order set
- Daily device review: is each line, tube and catheter still needed?
- Sedation hold and spontaneous breathing trial
- Head of bed 30–45°
- Chlorhexidine bathing
- VTE and stress-ulcer prophylaxis review
- Antimicrobial review with a documented stop date
- Hand hygiene audit
Criteria
AdmitNot an admission diagnosis — a daily standard for every ICU and ward patient
ICUApplies to every ICU patient with an invasive device
DischargeDevices removed, prophylaxis rationalised, stop dates documented
Clinical detail — differentials, red flags, pitfalls, disposition
Red flags
- New erythema or pus at a line site
- New fever with no source in a patient with devices
- Rising ventilator requirement with new secretions
- A device nobody can justify
Differentials
- Catheter-related bloodstream infection
- Ventilator-associated pneumonia
- Catheter-associated urinary infection
- Surgical site infection
- Non-infective fever (drug, thrombosis, transfusion)
Common mistakes
- Treating asymptomatic bacteriuria
- Sending a culture from a colonised device instead of removing it
- Leaving a line in 'because it is working'
- Continuing surgical prophylaxis for days
- Running the bundle only when an audit is due
Disposition & follow-up
A daily process, not an event: the ward round checklist, the stop date and the device review are the intervention.
Discharge package
MedicationsAntimicrobial course completed with a documented stop date
Follow-upWound or line site review if a device was in place at discharge
LifestyleHand hygiene and wound care advice
Warning symptomsFever, redness, swelling or discharge at any site a device occupied
💊 Treatment detail — doses & preparation
Chlorhexidine 2%antiseptic
DoseSkin preparation before insertion; daily bathing in ICU
PreparationSingle-use applicators or wipes
MonitorSkin reaction; allow to dry fully before puncture
Surgical prophylaxisantimicrobial
DoseSingle dose within 60 min of incision, re-dosed for long procedures or major blood loss, stopped within 24 h
PreparationBy local formulary and allergy status
MonitorDo not extend for drains or lines
Stress ulcer prophylaxisPPI or H₂ blocker
DoseOnly for a genuine indication — ventilation, coagulopathy, shock — and reviewed daily
PreparationIV or enteral
MonitorStop when the indication resolves; PPIs are associated with C. difficile
📖 SHEA/IDSA compendium · Surviving Sepsis Campaign 2026 · ICU chapter 41 · Infection Prevention BundlesReviewed September 2026