ICU Bundle Checklist

#ICU Bundle

Ventilator
? Spontaneous Awakening Trial (SAT)
= turn off sedation
? Spontaneous Breathing Trial (SBT)
= Place patient on Pressure Support 5/5
- Perform SAT & SBT concurrently if able
- Contraindications to SAT/SBT include FiO2 > 50%, PEEP > 8, O2 sat < 90%, pH < 7.30, SBP < 90 or MAP < 60, paralysis, intracranial pressure >15, concern for significant bleeding
? If ARDS: goal Vt 4-6 cc/kg of ideal body weight (calculated by height), plateau pressure < 30
? Head of bed at >30 degrees
? Oral care is ordered

Sedation / Delirium
? Ask: Is patient delirious (CAM+)?
? Review med list for any deliriogenic medications and discontinue/change where possible
? Define RASS goal
? Record QTc daily, consider changing medications if QTc > 500

Restraints
? Ask: Are restraints needed?
? Sign necessary restraint orders
? Discuss barriers to removing restraint orders

Mobility
? Consult PT for early mobility
- Contraindications include: deep sedation, paralysis

Pressure Ulcers
? Ask: Are pressure ulcers present? Is a wound care consult needed?
? Discuss whether any changes are needed to ulcer management plan

DVT prophylaxis
? Review patient’s current DVT prophylaxis orders and adjust if needed
- Contraindications to LMWH DVT ppx include AKI (switch to UFH TID), clinically significant bleeding (hold pharmacologic), platelet count < 30K (hold pharmacologic)
- Add sequential compression boots if holding pharmacologic prophylaxis

GI / Nutrition
? Famotidine 20mg IV BID in intubated patients; Pantoprazole 20-40mg IV daily if history of GERD or GI bleed
? Review nutrition, consult nutrition if not already done. While awaiting nutrition input, start enteral nutrition:
- In most patients, Osmolite 1.5 @10mL/hr, advance by 20mL Q6h to goal 50mL/hr
- If renal failure and high K or phos: Nepro @ 10mL/hr, advance by 10mL Q6h to goal 40mL/hr
- MVI with minerals daily
- thiamine 100mg daily x3 days
- folate 1mg daily x 3 days
? Ask: Is bowel regimen adequate? Make changes if necessary.
? Review glucose range over past 48h and insulin regimen, adjust regimen if needed.
- Goal glucose range is 70-180

Tubes / Lines / Drains
? List all tubes / lines / drains and discuss if any can be removed or should be changed

Patient / Family Communication
? Discuss if patient has healthcare making capacity - if not, activate healthcare proxy
? Update families by phone
- Suggest RN update at least daily
- MD update Q3 days, with any significant clinical change, or per family request

Disposition
? Discuss anticipated dispo, barriers to dispo

Code Status
? Review current code status, discuss if goals of care are realistic with prognosis - if not, discuss with patient / family

Abbreviations:
SAT = Spontaneous Awakening Trial
SBT = Spontaneous Breathing Trial
CAM = Confusion Assessment Method
RASS = Richmond Agitation and Sedation Scale