- Email: [email protected]
Implementing quality initiatives using a bundled approach
Intensive and Critical Care Nursing (2011) 27, 117—120
available at www.sciencedirect.com
journal homepage: www.elsevier.com/iccn
INTERNATIONAL RESEARCH SERIES
Implementing quality initiatives using a bundled approach Deborah Dawson a,∗, Ruth Endacott b a b
St. George’s Hospital NHS Trust, London, United Kingdom School of Nursing and Midwifery, University of Plymouth, United Kingdom
Accepted 29 March 2011
KEYWORDS Care bundle; International; Quality improvement; Multidisciplinary
Summary Critical care has been criticised for its inconsistency in implementing and evaluating evidence based practice both at national and international level. A review of the critical care literature by Berenholtz et al. (2002) identified interventions that might help prevent morbidity or mortality in the intensive care unit; from this four elements were developed into the initial ventilator care bundle. The aim of this bundle was to improve the quality of care for mechanically ventilated patients by improving compliance with relevant evidence based practice; implementation of this or an adapted cluster of interventions has been shown consistently to reduce the incidence of ventilator-associated pneumonias across countries. There are now numerous care bundles and the bundle approach to quality improvement has been proven to be effective across a number of problems, international boundaries and in a wide variety of ICU’s. The bundle approach recognises that core clinical interventions, are not always consistently applied across all appropriate patients, the range of interventions within a bundle tackles the problem from a variety of different angles. Other strengths include its adaptability to the wide variety of environments and working practices of intensive care units across the world. The bundle and the method of implementation can be adapted to suit individual teams and units; however, this can also be a weakness of this approach as it limits comparability across centres. The bundle approach to quality improvement requires significant multidisciplinary engagement and resources to be effective. © 2011 Elsevier Ltd. All rights reserved.
Introduction Critical care has been criticised for its inconsistency in implementing and evaluating evidence based practice both
∗
Corresponding author. Tel.: +44 208 725 3129. E-mail address: [email protected] (D. Dawson).
at national and international level (Audit Commission, 1999; Thomson et al., 2000). Berenholtz et al. (2002) assessed 35 years of critical care literature to identify interventions that might prevent morbidity or mortality in the intensive care unit (ICU). This review identified six evidence-based process measures including: effective assessment of pain, appropriate use of blood transfusions, prevention of ventilator associated pneumonia, appropriate sedation, appropriate peptic ulcer prevention, and appropriate deep vein thrombosis prophylaxis. The latter four elements were developed
0964-3397/$ — see front matter © 2011 Elsevier Ltd. All rights reserved. doi:10.1016/j.iccn.2011.03.006
118 into the initial ventilator care bundle published by the Institute of Healthcare Improvement (http://www.IHI.org) with an aim to improve the quality of care for mechanically ventilated patients by improving compliance with relevant evidence based practice. Each of these practices was based on one or more published studies, which if implemented individually should benefit the patient. Kress et al. (2000) found that a daily interruption of sedative infusions decreased the duration of mechanical ventilation (4.9/7.3 days; p = 0.004) and length of stay (6.4/9.9 days; p = 0.02) compared with a control group who did not routinely receive an interruption of their sedation. A systematic review of the literature by Attia et al. (2001) concluded that low dose subcutaneous heparin reduced the rate of deep vein thrombosis in ICU patients by 50% compared with no prophylaxis. Cook et al. (1994) identified an increased risk for upper gastrointestinal bleeding in the mechanically ventilated patient (odds ratio 15.6) and thus the requirement for stress ulcer prophylaxis. In this study the mortality rate in patients who suffered a clinically significant bleed was 48.5% compared with 9.1% for all other patients (p < 0.001) (Cook et al., 1994). Supine positioning and the length of time a mechanically ventilated patient remained in this position were identified as individual risk factors for aspiration of gastric contents in two studies (Drakulovic et al., 1999; Torres et al., 1992). They concluded that positioning a mechanically ventilated patient in a >30◦ semi-recumbent position reduced this risk. Despite only one element of the bundle being directly related to a reduction in ventilator associated pneumonia — the >30◦ head of bed elevation — implementation of this or an adapted cluster of interventions has been shown consistently to reduce the incidence of ventilator-associated pneumonias across countries (Al-Tawfiq and Abed, 2010; Blamoun et al., 2009; Bonello et al., 2008; Hawe et al., 2009; Resar et al., 2005; Unahalekhaka et al., 2007; Youngquist et al., 2007). As can be seen from the range of publications, the care bundles concept initiated by the ventilator care bundle, has been internationally adopted and widely adapted. There are numerous care bundles; many aim to reduce device related infection such as ventilator acquired pneumonia (VAP), central venous catheter blood stream infection (CVC-BSI), catheter related urinary tract infection, antibiotic related infection such as clostridium difficile (c.diff) or are pathway related including weaning from mechanical ventilation and the sepsis resuscitation and management care bundles.
Strengths of the care bundle approach There are numerous prospective observational studies that identify a positive relationship between patient outcomes and adherence to a care bundle (Hawe et al., 2009; Levy et al., 2010; Muto et al., 2007; Pronovost et al., 2006; Resar et al., 2005). Hawe et al. (2009) introduced a locally identified bundle of six interventions for the prevention of VAP. This included semi recumbent positioning, oral anti-sepsis, sub-glottic suctioning, daily sedation breaks, daily assessment of readiness to wean and tubing management. Compliance with the complete bundle (0 vs. 54%) and a reduction in VAP rates (19.17 vs.
D. Dawson, R. Endacott 7.5/1000 ventilator days) occurred following a nine month ‘active’ period of implementation. The Surviving Sepsis Campaign (http://www.survivingsepsis.org) published their most recent results in 2010 demonstrating an improved compliance over two years with the resuscitation bundle of 10.9% vs. 31.3% (p < 0.0001) and 18.4% vs. 36.1% (p = 0.008) for the management bundle, with an adjusted hospital mortality reduction of 5.4% (95% CI 2.5—8.4%) for the same period (Levy et al., 2010). An outbreak of c.diff. promoted the development of a c.diff. infection control bundle consisting of education, increased and early case finding methodologies, expanded infection control measures, development of a c.diff. management team and targeted antimicrobial management (Muto et al., 2007). These interventions successfully reduced the rate of c.diff. from 7.2 infections/1000 hospital discharges in 2000 to 3.0/1000 hospital discharges in 2006 (p < 0.001). A highly publicised study (Pronovost et al., 2006) now adapted by the National Patient Safety Agency (NPSA) for use across England (http://www.nrls.npsa.nhs.uk/matchingmichigan) demonstrated a mean reduction across 103 ICU’s in Michigan, United States from 7.7 CVC-BSI/1000 dwell days at baseline to 1.4 at 18 months (p < 0.002). Resar et al. (2005) demonstrated that implementation of the ventilator care bundle across 35 ICU’s reduced VAP rates from 5.5 to 2.7 per 1000 ventilator days. They report that units with the highest rates of compliance with all aspects of the ventilator care bundle, as described earlier, demonstrated the greatest reduction. It appears that the bundle approach is more effective than clinical guidelines (Robb, 2010) possibly because guidelines may be seen as advisory and care bundles are mandatory, although the content of each step in the bundle may vary: ‘‘. . .a set of steps that experts believe are critical, but in many cases the clinical values attached to each step are locally defined or may change over time based on evolving research and the experiences of users’’ (Institute for Healthcare and Improvement, 2004). From an international perspective, the care bundle approach therefore allows the bundle to be implemented without being constrained by local restrictions, such as staffing or interprofessional roles. The aim of a bundle is to change the underpinning philosophy of practice without dictating the precise nature of the intervention; they rely on accumulated evidence packaged together, which support multidisciplinary teams (MDT) to put research evidence or expert opinion if there is no research evidence, into practice. The bundle approach recognises that core clinical interventions, are not always consistently applied across all appropriate patients (Masterson, 2009) and can be a driver to improve the reliability of the delivery of evidence based care (Marwick and Davey, 2009). The range of interventions within a bundle tackles the problem from a variety of different angles; this might include the use of new devices, an education programme, new ways of caring for the patient and multi rather than unidisciplinary team involvement (Institute for Healthcare and Improvement, 2010). Commonly, the bundled approach requires technical and adaptive change (Pronovost et al., 2006). Technical elements might include the use of a new type of product such as a silver-coated central venous line or closed system urinary catheter and drainage bag, the introduction of an audit, an education package, or the
Implementing quality initiatives use of a dedicated central line insertion trolley. Adaptive change describes the alteration in individual and collective behaviour as a result of experience; in the case of care bundles, a method of measuring these changes might include examining the importance professionals place on individual infection control measures before and after the introduction of technical changes. This flexible approach allows individual units or teams to assess the evidence and decide which interventions are suitable for their individual patient groups or possible in their service/team. For example, Hawe et al. (2009) included the use of sub-glottic suctioning in their VAP bundle, for many reasons these specialised endotracheal tubes may not be available in all units or in all countries. However, if following successful implementation of the other five elements there was no reduction in VAP, this might then provide an argument for specialised tubes to be made available. Alternatively, the use of a >30◦ semi-recumbent position would not be appropriate in most patients with suspected or proven spinal or pelvic injuries, therefore this element would not be measured in those patients. Having identified the bundle, a stepwise approach to implementation, with sustained education of all staff, avoiding overloading staff with many new initiatives at the same time, may help improve adherence and thus improve results (Bhutta et al., 2007). To maintain best practice over time there is a need to revisit the evidence to ensure the most recent is utilised. Equally important is the need to maintain education and feedback to all participants to sustain their interest and compliance with all the interventions.
Challenges of the care bundle The flexibility of the bundle approach requires consensus across the multidisciplinary team (MDT); confusion in care will arise if individuals or professional groups are managing the patient in differing ways. This agreement is not only required to decide that a care bundle approach is to be used to manage an identified problem but also to agree the components and application of that bundle. This generally requires a maturity in the team leading and providing care that may not be achievable in all units, however, a lack of multidisciplinary involvement may limit the successful implementation of a bundled approach to care. Even where this approach is possible and multidisciplinary team working is sufficiently advanced, implementing care bundles will require substantial resources to initiate and review practice and to achieve and maintain adherence. Rello (2002) suggests that adherence amongst medical staff is affected by disagreement with how individual studies are interpreted, despite this the level of that evidence does not appear to be linked to adherence. To be effective bundles need to be based on excellent supporting evidence (Masterson, 2009), however, the success of the bundle approach has lead to less robust evidence being combined, reducing the reliability of the process. For nursing staff non-adherence is most commonly influenced by patient related factors such as the fear of causing discomfort or other adverse events (Ricart et al., 2003). Both staff groups suggest that a lack of resources will diminish adherence (Rello, 2002; Ricart et al., 2003).
119 To ensure that practice remains current, the evidence supporting the individual components of a care bundle require regular review (Finfer, 2010). Levy et al. (2010) report of the outcomes of the sepsis care bundles originally published in 2004 (Dellinger et al., 2004), but updated to include new evidence in 2008 (Dellinger et al., 2008). Latterly this has been updated again to include the latest guidance on glycaemic control following the NICE-SUGAR trial results (Finfer et al., 2009). For the sepsis care bundles this has been achieved by consensus between a large group of individuals and an organisation, however, expending similar resource is not possible in most units. Therefore internationally or nationally agreed consensus describing the elements of a bundle should provide an attractive opportunity for individual units. Despite this the reported compliance with all elements of the sepsis care bundles at the end of the study period was just 31.3% for the resuscitation bundle and 36.1% for the management bundle, with individual elements varying from 24.3% for ScvO2 > 70% to 83.8% for plateau pressure control (Levy et al., 2010). This suggests that either some elements posed a greater challenge for those implementing the bundle or there remained a lack of agreement with the evidence as presented. Added to this tailoring the care bundle either before implementation or during implementation makes it difficult to compare outcomes between study sites. To mitigate the potential problems posed by the bundle approach to quality improvement there is a need for continuous active engagement with the full ICU MDT. This is best achieved by identifying a problem that is considered important enough to put in the necessary resources, that can hold the interest of the MDT and to set goals that are challenging but achievable. The project will require clear leadership and a clear documented plan to maintain intensity and consistency over time. Cook (2003) reports the requirement for clarity when implementing new practices. Firstly the need to identify exactly what is to be done and secondly who is responsible for getting it done. Education will need to be developed and delivered to a sufficient quantity of staff, usually greater than 80% to ensure uptake, this education will need to be repeated for new and novice staff and repeated to maintain momentum. This can be achieved through informal and formal education sessions, but also via visible reminders such as posters and newsletters. Clear and auditable standards must be applied to each element of a bundle, for example is a >30◦ head of bed elevation to be measured using an angle finder or by eye. If a measuring tool is used, are the staff trained in its use and if an observational method is utilised, has the unit measured rater reliability? To understand compliance and outcome, a baseline followed by regular audit is required; these data could be used to motivate staff in elements where they are achieving success, but also to identify areas that require further work. These can be fed back to the team to identify why these elements are less easily achieved and how they can be improved.
Conclusion The bundle approach to quality improvement has been proven to be effective across a number of problems, international boundaries and in a wide variety of ICU’s. The
120 bundle and the method of implementation can be adapted to suit individual team and units; however, this can also be a weakness of this approach as it limits comparability across centres. Having decided that a problem requires addressing, this approach requires a motivated multidisciplinary team to initiate the bundle, implement change, to achieve and maintain adherence and to review and update the bundle and processes.
References Al-Tawfiq J, Abed M. Decreasing ventilator-associated pneumonia in adult intensive care units using the Institute for healthcare improvement bundle Am. J Infect Control 2010;38(7):552—6. Attia J, Ray J, Cook D, Douketis J, Ginsberg J, Geerts W. Deep vein thrombosis and its prevention in critical ill adults. Arch Intern Med 2001;161:1268—79. Audit Commission. Critical to success: the place of efficient and effective critical care services within the acute hospital. London: The Audit Commission; 1999. Berenholtz S, Dorman T, Ngo K, Pronovost P. Qualitative review of intensive care unit quality indicators. J Crit Care 2002;17(1): 1—15. Blamoun J, Alfakir M, Rella ME, Wojcik JM, Solis RA, Anees Khan M, et al. Efficacy of an expanded ventilator bundle for the reduction of ventilator-associated pneumonia in the medical intensive care unit. Am J Infect Control 2009;37:172—5. Bonello RS, Fletcher CE, Becker WK, Clutter KL, Arjes SL, Cook JJ, et al. An intensive care unit quality improvement collaborative in nine Department of Veterans Affairs Hospitals: reducing ventilator-associated pneumonia and catheter-related bloodstream infection rates. Jt Comm J Qual Patient Saf 2008;34:639—45. Bhutta A, Gilliam C, Honeycutt M, Schexnayder S, Green J, Moss M, et al. Reduction in bloodstream infections associated with catheters in paediatric intensive care unit: stepwise approach. BMJ 2007;334:362—5. Cook D. Moving toward evidence based practice. Respir Care 2003;48(9):859—68. Cook D, Fuller H, Guyatt G, Marshall J, Leasa D, Hall R, et al. Risk factors for gastrointestinal bleeding in critically Ill patients New England. J Med 1994;330:377—81. Dellinger R, Carlet J, Masur H, Gerlach H, Calandra T, Cohen J, et al. Surviving Sepsis Campaign Management Guidelines Committee Surviving Sepsis Campaign and guidelines for management of severe sepsis and septic shock. Crit Care Med 2004;32:858—73. Dellinger R, Levy M, Carlet J, Bion J, Parker M, Jaeschke R, et al. International Surviving Sepsis Campaign Guidelines Committee; American Association of Critical-Care Nurses; American College of Chest Physicians; American College of Emergency Physicians; Canadian Critical Care Society; European Society of Clinical Microbiology and Infectious Diseases; European Society of Intensive Care Medicine; European Respiratory Society; International Sepsis Forum; Japanese Association for Acute Medicine; Japanese Society of Intensive Care Medicine; Society of Critical Care Medicine; Society of Hospital Medicine; Surgical Infection Society; World Federation of Societies of Intensive and Critical Care Medicine. Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock. Crit Care Med 2008;36(January (1)):296—327. Erratum in: Crit Care Med 2008;36(April (4)):1394—6. Drakulovic MB, Torres A, Bauer TT, Nicolas JM, Nogué S, Ferrer M. Supine body position as a risk factor for nosocomial pneumonia
D. Dawson, R. Endacott in mechanically ventilated patients: a randomised trial. Lancet 1999;354(9193):851—1858. Finfer S. The surviving sepsis campaign: robust evaluation and high-quality primary research is still needed. Int Care Med 2010;36:187—9. Finfer S, Chittock DR, Su SY, Blair D, Foster D, Dhingra V, et al. Intensive versus conventional glucose control in critically ill patients. N Engl J Med 2009;360(13):1283—97. Hawe CS, Ellis KS, Cairns CJ, Longmate A. Reduction of ventilator associated pneumonia: active versus passive guideline implementation. Intensive Care Med 2009;35:1180—6. Institute for Healthcare Improvement; 2004. Bundle up for safety available at: http://www.ihi.org/IHI/Topics/CriticalCare/ IntensiveCare/ImprovementStories/BundleUpforSafety.htm. Institute for Healthcare Improvement; 2010. Available at: http://ihi.org/IHI/Topics/CriticalCare/IntensiveCare/ ImprovementStories/WhatIsaBundle.htm [accessed 20.11.10]. Kress J, Pohlman A, O’Connor M, Hall J. Daily interruption of sedative infusions in critically ill patients undergoing mechanical ventilation. N Engl J Med 2000;342:1471—7. Levy M, Dellinger R, Townsend S, Linde-Zwirble W, Marshall J, Bion J, et al. The Surviving Sepsis Campaign: results of an international guideline-based performance improvement program targeting severe sepsis. Intensive Care Med 2010;36:222—31. Marwick C, Davey P. Care bundles: the holy grail of infectious risk management in hospital? Curr Opin Infect Dis 2009;22(4): 364—9. Masterson R. Sepsis care bundles and clinicians. Int Care Med 2009;35:1149—51. Muto A, Blank M, March J, Vergis E, O’Leary M, Shutt K, et al. Control of an outbreak of infection with the hypervirulent clostridium difficile BI strain in a University Hospital using a comprehensive ‘‘bundle’’ approach. Clin Infect Dis 2007;45(10):1266—73. Rello J. Changing physicians behaviour in the intensive care unit. Crit Care Med 2002;30(11):2593—4. Ricart M, Lorente C, Diaz E, Kollef M, Rello J. Nursing adherence with evidence-based guidelines for preventing ventilator-associated pneumonia. Crit Care Med 2003;21(11):2693—6. Pronovost P, Needham D, Berenholtz S, Sinopoli D, Chu H, Cosgrove S, et al. An Intervention to Decrease CatheterRelated Bloodstream Infections in the ICU. N Engl J Med 2006;355(26):2725—32. Resar R, Provonost P, Haraden C, Simmonds T, Nolan T. Using a bundle approach to improve ventilator care processes and reduce ventilator associated pneumonia. Jt Comm J Qual Patient Saf 2005;31(5):243—8. Robb E. Using care bundles to reduce in-hospital mortality: quantitative survey. BMJ 2010;340:c1234. Thomson P, Angus N, Scott J. Building a framework for getting evidence into critical care education and practice. Intensive Crit Care Nurs 2000;16:164—74. Torres A, Serra-atlles J, Ros E, Piera C, Puig de la Bellacasa J, Cobos A, et al. Pulmonary aspiration of gastric contents in patients receiving mechanical ventilation: the effect of body position. Ann Intern Med 1992;116:540—3. Unahalekhaka A, Jamulitrat S, Chongsuvivatwong V, Øvretveit J. Using a collaborative to reduce ventilator-associated pneumonia in Thailand. Jt Comm J Qual Patient Saf 2007;33: 387—94. Youngquist P, Carroll M, Farber M, Macy D, Madrid P, Ronning J, et al. Implementing a ventilator bundle in a community hospital. Jt Comm J Qual Patient Saf 2007;33:219—25.
available at www.sciencedirect.com
journal homepage: www.elsevier.com/iccn
INTERNATIONAL RESEARCH SERIES
Implementing quality initiatives using a bundled approach Deborah Dawson a,∗, Ruth Endacott b a b
St. George’s Hospital NHS Trust, London, United Kingdom School of Nursing and Midwifery, University of Plymouth, United Kingdom
Accepted 29 March 2011
KEYWORDS Care bundle; International; Quality improvement; Multidisciplinary
Summary Critical care has been criticised for its inconsistency in implementing and evaluating evidence based practice both at national and international level. A review of the critical care literature by Berenholtz et al. (2002) identified interventions that might help prevent morbidity or mortality in the intensive care unit; from this four elements were developed into the initial ventilator care bundle. The aim of this bundle was to improve the quality of care for mechanically ventilated patients by improving compliance with relevant evidence based practice; implementation of this or an adapted cluster of interventions has been shown consistently to reduce the incidence of ventilator-associated pneumonias across countries. There are now numerous care bundles and the bundle approach to quality improvement has been proven to be effective across a number of problems, international boundaries and in a wide variety of ICU’s. The bundle approach recognises that core clinical interventions, are not always consistently applied across all appropriate patients, the range of interventions within a bundle tackles the problem from a variety of different angles. Other strengths include its adaptability to the wide variety of environments and working practices of intensive care units across the world. The bundle and the method of implementation can be adapted to suit individual teams and units; however, this can also be a weakness of this approach as it limits comparability across centres. The bundle approach to quality improvement requires significant multidisciplinary engagement and resources to be effective. © 2011 Elsevier Ltd. All rights reserved.
Introduction Critical care has been criticised for its inconsistency in implementing and evaluating evidence based practice both
∗
Corresponding author. Tel.: +44 208 725 3129. E-mail address: [email protected] (D. Dawson).
at national and international level (Audit Commission, 1999; Thomson et al., 2000). Berenholtz et al. (2002) assessed 35 years of critical care literature to identify interventions that might prevent morbidity or mortality in the intensive care unit (ICU). This review identified six evidence-based process measures including: effective assessment of pain, appropriate use of blood transfusions, prevention of ventilator associated pneumonia, appropriate sedation, appropriate peptic ulcer prevention, and appropriate deep vein thrombosis prophylaxis. The latter four elements were developed
0964-3397/$ — see front matter © 2011 Elsevier Ltd. All rights reserved. doi:10.1016/j.iccn.2011.03.006
118 into the initial ventilator care bundle published by the Institute of Healthcare Improvement (http://www.IHI.org) with an aim to improve the quality of care for mechanically ventilated patients by improving compliance with relevant evidence based practice. Each of these practices was based on one or more published studies, which if implemented individually should benefit the patient. Kress et al. (2000) found that a daily interruption of sedative infusions decreased the duration of mechanical ventilation (4.9/7.3 days; p = 0.004) and length of stay (6.4/9.9 days; p = 0.02) compared with a control group who did not routinely receive an interruption of their sedation. A systematic review of the literature by Attia et al. (2001) concluded that low dose subcutaneous heparin reduced the rate of deep vein thrombosis in ICU patients by 50% compared with no prophylaxis. Cook et al. (1994) identified an increased risk for upper gastrointestinal bleeding in the mechanically ventilated patient (odds ratio 15.6) and thus the requirement for stress ulcer prophylaxis. In this study the mortality rate in patients who suffered a clinically significant bleed was 48.5% compared with 9.1% for all other patients (p < 0.001) (Cook et al., 1994). Supine positioning and the length of time a mechanically ventilated patient remained in this position were identified as individual risk factors for aspiration of gastric contents in two studies (Drakulovic et al., 1999; Torres et al., 1992). They concluded that positioning a mechanically ventilated patient in a >30◦ semi-recumbent position reduced this risk. Despite only one element of the bundle being directly related to a reduction in ventilator associated pneumonia — the >30◦ head of bed elevation — implementation of this or an adapted cluster of interventions has been shown consistently to reduce the incidence of ventilator-associated pneumonias across countries (Al-Tawfiq and Abed, 2010; Blamoun et al., 2009; Bonello et al., 2008; Hawe et al., 2009; Resar et al., 2005; Unahalekhaka et al., 2007; Youngquist et al., 2007). As can be seen from the range of publications, the care bundles concept initiated by the ventilator care bundle, has been internationally adopted and widely adapted. There are numerous care bundles; many aim to reduce device related infection such as ventilator acquired pneumonia (VAP), central venous catheter blood stream infection (CVC-BSI), catheter related urinary tract infection, antibiotic related infection such as clostridium difficile (c.diff) or are pathway related including weaning from mechanical ventilation and the sepsis resuscitation and management care bundles.
Strengths of the care bundle approach There are numerous prospective observational studies that identify a positive relationship between patient outcomes and adherence to a care bundle (Hawe et al., 2009; Levy et al., 2010; Muto et al., 2007; Pronovost et al., 2006; Resar et al., 2005). Hawe et al. (2009) introduced a locally identified bundle of six interventions for the prevention of VAP. This included semi recumbent positioning, oral anti-sepsis, sub-glottic suctioning, daily sedation breaks, daily assessment of readiness to wean and tubing management. Compliance with the complete bundle (0 vs. 54%) and a reduction in VAP rates (19.17 vs.
D. Dawson, R. Endacott 7.5/1000 ventilator days) occurred following a nine month ‘active’ period of implementation. The Surviving Sepsis Campaign (http://www.survivingsepsis.org) published their most recent results in 2010 demonstrating an improved compliance over two years with the resuscitation bundle of 10.9% vs. 31.3% (p < 0.0001) and 18.4% vs. 36.1% (p = 0.008) for the management bundle, with an adjusted hospital mortality reduction of 5.4% (95% CI 2.5—8.4%) for the same period (Levy et al., 2010). An outbreak of c.diff. promoted the development of a c.diff. infection control bundle consisting of education, increased and early case finding methodologies, expanded infection control measures, development of a c.diff. management team and targeted antimicrobial management (Muto et al., 2007). These interventions successfully reduced the rate of c.diff. from 7.2 infections/1000 hospital discharges in 2000 to 3.0/1000 hospital discharges in 2006 (p < 0.001). A highly publicised study (Pronovost et al., 2006) now adapted by the National Patient Safety Agency (NPSA) for use across England (http://www.nrls.npsa.nhs.uk/matchingmichigan) demonstrated a mean reduction across 103 ICU’s in Michigan, United States from 7.7 CVC-BSI/1000 dwell days at baseline to 1.4 at 18 months (p < 0.002). Resar et al. (2005) demonstrated that implementation of the ventilator care bundle across 35 ICU’s reduced VAP rates from 5.5 to 2.7 per 1000 ventilator days. They report that units with the highest rates of compliance with all aspects of the ventilator care bundle, as described earlier, demonstrated the greatest reduction. It appears that the bundle approach is more effective than clinical guidelines (Robb, 2010) possibly because guidelines may be seen as advisory and care bundles are mandatory, although the content of each step in the bundle may vary: ‘‘. . .a set of steps that experts believe are critical, but in many cases the clinical values attached to each step are locally defined or may change over time based on evolving research and the experiences of users’’ (Institute for Healthcare and Improvement, 2004). From an international perspective, the care bundle approach therefore allows the bundle to be implemented without being constrained by local restrictions, such as staffing or interprofessional roles. The aim of a bundle is to change the underpinning philosophy of practice without dictating the precise nature of the intervention; they rely on accumulated evidence packaged together, which support multidisciplinary teams (MDT) to put research evidence or expert opinion if there is no research evidence, into practice. The bundle approach recognises that core clinical interventions, are not always consistently applied across all appropriate patients (Masterson, 2009) and can be a driver to improve the reliability of the delivery of evidence based care (Marwick and Davey, 2009). The range of interventions within a bundle tackles the problem from a variety of different angles; this might include the use of new devices, an education programme, new ways of caring for the patient and multi rather than unidisciplinary team involvement (Institute for Healthcare and Improvement, 2010). Commonly, the bundled approach requires technical and adaptive change (Pronovost et al., 2006). Technical elements might include the use of a new type of product such as a silver-coated central venous line or closed system urinary catheter and drainage bag, the introduction of an audit, an education package, or the
Implementing quality initiatives use of a dedicated central line insertion trolley. Adaptive change describes the alteration in individual and collective behaviour as a result of experience; in the case of care bundles, a method of measuring these changes might include examining the importance professionals place on individual infection control measures before and after the introduction of technical changes. This flexible approach allows individual units or teams to assess the evidence and decide which interventions are suitable for their individual patient groups or possible in their service/team. For example, Hawe et al. (2009) included the use of sub-glottic suctioning in their VAP bundle, for many reasons these specialised endotracheal tubes may not be available in all units or in all countries. However, if following successful implementation of the other five elements there was no reduction in VAP, this might then provide an argument for specialised tubes to be made available. Alternatively, the use of a >30◦ semi-recumbent position would not be appropriate in most patients with suspected or proven spinal or pelvic injuries, therefore this element would not be measured in those patients. Having identified the bundle, a stepwise approach to implementation, with sustained education of all staff, avoiding overloading staff with many new initiatives at the same time, may help improve adherence and thus improve results (Bhutta et al., 2007). To maintain best practice over time there is a need to revisit the evidence to ensure the most recent is utilised. Equally important is the need to maintain education and feedback to all participants to sustain their interest and compliance with all the interventions.
Challenges of the care bundle The flexibility of the bundle approach requires consensus across the multidisciplinary team (MDT); confusion in care will arise if individuals or professional groups are managing the patient in differing ways. This agreement is not only required to decide that a care bundle approach is to be used to manage an identified problem but also to agree the components and application of that bundle. This generally requires a maturity in the team leading and providing care that may not be achievable in all units, however, a lack of multidisciplinary involvement may limit the successful implementation of a bundled approach to care. Even where this approach is possible and multidisciplinary team working is sufficiently advanced, implementing care bundles will require substantial resources to initiate and review practice and to achieve and maintain adherence. Rello (2002) suggests that adherence amongst medical staff is affected by disagreement with how individual studies are interpreted, despite this the level of that evidence does not appear to be linked to adherence. To be effective bundles need to be based on excellent supporting evidence (Masterson, 2009), however, the success of the bundle approach has lead to less robust evidence being combined, reducing the reliability of the process. For nursing staff non-adherence is most commonly influenced by patient related factors such as the fear of causing discomfort or other adverse events (Ricart et al., 2003). Both staff groups suggest that a lack of resources will diminish adherence (Rello, 2002; Ricart et al., 2003).
119 To ensure that practice remains current, the evidence supporting the individual components of a care bundle require regular review (Finfer, 2010). Levy et al. (2010) report of the outcomes of the sepsis care bundles originally published in 2004 (Dellinger et al., 2004), but updated to include new evidence in 2008 (Dellinger et al., 2008). Latterly this has been updated again to include the latest guidance on glycaemic control following the NICE-SUGAR trial results (Finfer et al., 2009). For the sepsis care bundles this has been achieved by consensus between a large group of individuals and an organisation, however, expending similar resource is not possible in most units. Therefore internationally or nationally agreed consensus describing the elements of a bundle should provide an attractive opportunity for individual units. Despite this the reported compliance with all elements of the sepsis care bundles at the end of the study period was just 31.3% for the resuscitation bundle and 36.1% for the management bundle, with individual elements varying from 24.3% for ScvO2 > 70% to 83.8% for plateau pressure control (Levy et al., 2010). This suggests that either some elements posed a greater challenge for those implementing the bundle or there remained a lack of agreement with the evidence as presented. Added to this tailoring the care bundle either before implementation or during implementation makes it difficult to compare outcomes between study sites. To mitigate the potential problems posed by the bundle approach to quality improvement there is a need for continuous active engagement with the full ICU MDT. This is best achieved by identifying a problem that is considered important enough to put in the necessary resources, that can hold the interest of the MDT and to set goals that are challenging but achievable. The project will require clear leadership and a clear documented plan to maintain intensity and consistency over time. Cook (2003) reports the requirement for clarity when implementing new practices. Firstly the need to identify exactly what is to be done and secondly who is responsible for getting it done. Education will need to be developed and delivered to a sufficient quantity of staff, usually greater than 80% to ensure uptake, this education will need to be repeated for new and novice staff and repeated to maintain momentum. This can be achieved through informal and formal education sessions, but also via visible reminders such as posters and newsletters. Clear and auditable standards must be applied to each element of a bundle, for example is a >30◦ head of bed elevation to be measured using an angle finder or by eye. If a measuring tool is used, are the staff trained in its use and if an observational method is utilised, has the unit measured rater reliability? To understand compliance and outcome, a baseline followed by regular audit is required; these data could be used to motivate staff in elements where they are achieving success, but also to identify areas that require further work. These can be fed back to the team to identify why these elements are less easily achieved and how they can be improved.
Conclusion The bundle approach to quality improvement has been proven to be effective across a number of problems, international boundaries and in a wide variety of ICU’s. The
120 bundle and the method of implementation can be adapted to suit individual team and units; however, this can also be a weakness of this approach as it limits comparability across centres. Having decided that a problem requires addressing, this approach requires a motivated multidisciplinary team to initiate the bundle, implement change, to achieve and maintain adherence and to review and update the bundle and processes.
References Al-Tawfiq J, Abed M. Decreasing ventilator-associated pneumonia in adult intensive care units using the Institute for healthcare improvement bundle Am. J Infect Control 2010;38(7):552—6. Attia J, Ray J, Cook D, Douketis J, Ginsberg J, Geerts W. Deep vein thrombosis and its prevention in critical ill adults. Arch Intern Med 2001;161:1268—79. Audit Commission. Critical to success: the place of efficient and effective critical care services within the acute hospital. London: The Audit Commission; 1999. Berenholtz S, Dorman T, Ngo K, Pronovost P. Qualitative review of intensive care unit quality indicators. J Crit Care 2002;17(1): 1—15. Blamoun J, Alfakir M, Rella ME, Wojcik JM, Solis RA, Anees Khan M, et al. Efficacy of an expanded ventilator bundle for the reduction of ventilator-associated pneumonia in the medical intensive care unit. Am J Infect Control 2009;37:172—5. Bonello RS, Fletcher CE, Becker WK, Clutter KL, Arjes SL, Cook JJ, et al. An intensive care unit quality improvement collaborative in nine Department of Veterans Affairs Hospitals: reducing ventilator-associated pneumonia and catheter-related bloodstream infection rates. Jt Comm J Qual Patient Saf 2008;34:639—45. Bhutta A, Gilliam C, Honeycutt M, Schexnayder S, Green J, Moss M, et al. Reduction in bloodstream infections associated with catheters in paediatric intensive care unit: stepwise approach. BMJ 2007;334:362—5. Cook D. Moving toward evidence based practice. Respir Care 2003;48(9):859—68. Cook D, Fuller H, Guyatt G, Marshall J, Leasa D, Hall R, et al. Risk factors for gastrointestinal bleeding in critically Ill patients New England. J Med 1994;330:377—81. Dellinger R, Carlet J, Masur H, Gerlach H, Calandra T, Cohen J, et al. Surviving Sepsis Campaign Management Guidelines Committee Surviving Sepsis Campaign and guidelines for management of severe sepsis and septic shock. Crit Care Med 2004;32:858—73. Dellinger R, Levy M, Carlet J, Bion J, Parker M, Jaeschke R, et al. International Surviving Sepsis Campaign Guidelines Committee; American Association of Critical-Care Nurses; American College of Chest Physicians; American College of Emergency Physicians; Canadian Critical Care Society; European Society of Clinical Microbiology and Infectious Diseases; European Society of Intensive Care Medicine; European Respiratory Society; International Sepsis Forum; Japanese Association for Acute Medicine; Japanese Society of Intensive Care Medicine; Society of Critical Care Medicine; Society of Hospital Medicine; Surgical Infection Society; World Federation of Societies of Intensive and Critical Care Medicine. Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock. Crit Care Med 2008;36(January (1)):296—327. Erratum in: Crit Care Med 2008;36(April (4)):1394—6. Drakulovic MB, Torres A, Bauer TT, Nicolas JM, Nogué S, Ferrer M. Supine body position as a risk factor for nosocomial pneumonia
D. Dawson, R. Endacott in mechanically ventilated patients: a randomised trial. Lancet 1999;354(9193):851—1858. Finfer S. The surviving sepsis campaign: robust evaluation and high-quality primary research is still needed. Int Care Med 2010;36:187—9. Finfer S, Chittock DR, Su SY, Blair D, Foster D, Dhingra V, et al. Intensive versus conventional glucose control in critically ill patients. N Engl J Med 2009;360(13):1283—97. Hawe CS, Ellis KS, Cairns CJ, Longmate A. Reduction of ventilator associated pneumonia: active versus passive guideline implementation. Intensive Care Med 2009;35:1180—6. Institute for Healthcare Improvement; 2004. Bundle up for safety available at: http://www.ihi.org/IHI/Topics/CriticalCare/ IntensiveCare/ImprovementStories/BundleUpforSafety.htm. Institute for Healthcare Improvement; 2010. Available at: http://ihi.org/IHI/Topics/CriticalCare/IntensiveCare/ ImprovementStories/WhatIsaBundle.htm [accessed 20.11.10]. Kress J, Pohlman A, O’Connor M, Hall J. Daily interruption of sedative infusions in critically ill patients undergoing mechanical ventilation. N Engl J Med 2000;342:1471—7. Levy M, Dellinger R, Townsend S, Linde-Zwirble W, Marshall J, Bion J, et al. The Surviving Sepsis Campaign: results of an international guideline-based performance improvement program targeting severe sepsis. Intensive Care Med 2010;36:222—31. Marwick C, Davey P. Care bundles: the holy grail of infectious risk management in hospital? Curr Opin Infect Dis 2009;22(4): 364—9. Masterson R. Sepsis care bundles and clinicians. Int Care Med 2009;35:1149—51. Muto A, Blank M, March J, Vergis E, O’Leary M, Shutt K, et al. Control of an outbreak of infection with the hypervirulent clostridium difficile BI strain in a University Hospital using a comprehensive ‘‘bundle’’ approach. Clin Infect Dis 2007;45(10):1266—73. Rello J. Changing physicians behaviour in the intensive care unit. Crit Care Med 2002;30(11):2593—4. Ricart M, Lorente C, Diaz E, Kollef M, Rello J. Nursing adherence with evidence-based guidelines for preventing ventilator-associated pneumonia. Crit Care Med 2003;21(11):2693—6. Pronovost P, Needham D, Berenholtz S, Sinopoli D, Chu H, Cosgrove S, et al. An Intervention to Decrease CatheterRelated Bloodstream Infections in the ICU. N Engl J Med 2006;355(26):2725—32. Resar R, Provonost P, Haraden C, Simmonds T, Nolan T. Using a bundle approach to improve ventilator care processes and reduce ventilator associated pneumonia. Jt Comm J Qual Patient Saf 2005;31(5):243—8. Robb E. Using care bundles to reduce in-hospital mortality: quantitative survey. BMJ 2010;340:c1234. Thomson P, Angus N, Scott J. Building a framework for getting evidence into critical care education and practice. Intensive Crit Care Nurs 2000;16:164—74. Torres A, Serra-atlles J, Ros E, Piera C, Puig de la Bellacasa J, Cobos A, et al. Pulmonary aspiration of gastric contents in patients receiving mechanical ventilation: the effect of body position. Ann Intern Med 1992;116:540—3. Unahalekhaka A, Jamulitrat S, Chongsuvivatwong V, Øvretveit J. Using a collaborative to reduce ventilator-associated pneumonia in Thailand. Jt Comm J Qual Patient Saf 2007;33: 387—94. Youngquist P, Carroll M, Farber M, Macy D, Madrid P, Ronning J, et al. Implementing a ventilator bundle in a community hospital. Jt Comm J Qual Patient Saf 2007;33:219—25.