Using a Bundle Approach to Improve Ventilator Care Processes and Reduce Ventilator-Associated Pneumonia (Field Study : Al-Basher Hospital )

1. Using a Bundle Approach to Improve Ventilator Care
Processes and Reduce Ventilator-Associated
Pneumonia (Field Study : Al-Basher Hospital )
By
Name: Gaith hasan mohedat
Supervisor: ahmad bataineh
UN – ID
20132023014
This proposal is submitted in partial fulfillment in success in
Feb 2016

2. 1.1 Introduction
In a recent integration of medical science and improvement work, intensive
care unit (ICU) staff, guided by faculty [including all authors] have considered a small
s (“ventilator bundle”) for patients on mechanicalbased intervention-set of evidence
ventilation. These interventions are as follows:
Peptic ulcer disease prophylaxis■
Deep vein thrombosis (DVT) prophylaxis■
Elevation of the head of the bed■
Sedation vacation■
Each of the four interventions is backed by medical evidence and
independently affects patient mortality and morbidity. Only elevation of the head of
the bed(Collard et.al ,2003) and sedation vacations, by reducing a patient’s length of
ventilation, has been shown to have an effect on outcomes forstay on mechanical
associated pneumonia (VAP)( Kollef,2004)-ventilator
A “bundle” of ventilator care processes (peptic ulcer disease prophylaxis,
, and a sedationdeep vein thrombosis prophylaxis, elevation of the head of the bed

3. associated pneumonia (VAP) rates, can-vacation), which may also reduce ventilator
serve as a focus for improvement strategies in intensive care units (ICUs). Between
lth careJuly 2002 and January 2004, teams of critical care clinicians from 61 hea
organizations participated in a collaborative on improving care in the ICU.
,2005)Resar(
inImplementing care bundles in clinical practice has been widely advocated
care unit (ICU) and is-mechanically ventilated patients admitted to an intensive
Fulbrookassociated pneumonia (VAP) (-associated with a reduced risk of ventilator
)Mooney,2003and
According to the above this paper is aimed to study how to improve
Associated Pneumonia by Using a-ilator Care Processes and Reduce VentilatorVent
Bundle Approach
Purpose of study1.2
A care bundle identifies a set of key interventions deriving from evidence-
based guidelines that, when implemented, are expected to improve patients’ health
outcomes (Crunden et.al,2005) The aim of care bundles is to improve health
outcomes by facilitating and promoting changes in patient care and to encourage
compliance.guideline

4. This paper aimed to examine the impact of adherence to ventilator-
associated pneumonia (VAP) bundle on the incidence of VAP in our intensive care
units by using bundle approach .
1.3 Problem statement and questions
The statement on the study problem can be formulated as this mais question
can the Bundle Approach usage improve Ventilator Care Processes and Reduce
Ventilator-Associated Pneumonia?
This question can be re-formulated in those main questions:
1. Why using VAP bundle in ICU?
2. Is using Bundle Approach usage improve Ventilator Care Processes?
3. Is Using Bundle Approach usage Reduce Ventilator-Associated Pneumonia?
1.4 Variable definition
1. Bundle approach (independent Variable) : IHI developed the concept of
“bundles” to help health care providers more reliably deliver the best possible care
for patients undergoing particular treatments with inherent risks. A bundle is a
structured way of improving the processes of care and patient outcomes: a small,
straightforward set of evidence-based practices — generally three to five — that,

5. when performed collectively and reliably, have been proven to improve patient
outcomes
2. Ventilator care (Dependent Variable) : A ventilator(VEN-til-a-tor)isamachine that
supportsbreathing.These machinesmainlyare usedinhospitals.Ventilators:
* Get oxygen into the lungs.
* Remove carbon dioxide from the body. (Carbon dioxide is a waste gas that can
be toxic.)
* help people breathe easier.
* Breathe for people who have lost all ability to breathe on their own.
3. VAP (Dependent Variable) is pneumonia that develops 48 hours or longer after
mechanical ventilation is given by means of an end tracheal tube or tracheotomy.
Ventilator-associated pneumonia (VAP) results from the invasion of the lower
respiratory tract and lung parenchyma by microorganisms.
1.5 Research models
Bundle approach
Ventilator care
Ventilator-associated
pneumonia (VAP)
(Independent Variable (Dependent Variable)

6. Figure (1) research Model
Source : developed by another
1.6 Research Hypothesis
H01: thesis is no significant statisticalimpact of bundle approach usage in improving
ventilator care at Al Basher hospital at level of (α≤0.03)
H02: thesis is no significant statisticalimpact of bundle approach usage in reducing
ventilator care Ventilator-associated pneumonia (VAP)at Al Basher hospital at level
of (α≤0.03)
1.7 Research design
Prospectively collected data were retrospectively examined from our Infection
Control Committee surveillance database of SICU patients over a 38-month period.
Cost of VAP was estimated at $30 000 per patient stay
2.0 literature review
In 2002, the IHI offered an improvement domain in critical care as part of its
IMPACT Network, a community of action-oriented organizations aiming to improve

7. health care. Between July 2002 and January 2004, teams of critical care clinicians
from 61 health care organizations attended face-to-face meetings with other
organizations. Every three months, teams that had recently joined the collaborative
first attended a half-day introductory course on the change concepts. On the basis of
the experience from a 2001 Idealized Redesign initiative for ICUs, all units were
encouraged implement a number of collaborative faculty-recommended
improvements, including the establishment of multidisciplinary rounds and daily
goals and the implementation of the ventilator bundle.
In 2001, the Institute for Healthcare Improvement (IHI) developed the “bundle”
concept in the context of an IHI and Voluntary Hospital Association (VHA) joint
initiative — Idealized Design of the Intensive Care Unit (IDICU) — involving 13
hospitals focused on improving critical care. The goal of the initiative was to improve
critical care processes to the highest levels of reliability, which would result in vastly
improved outcomes. The theory was that enhancing teamwork and communication
in multidisciplinary teams would create the necessary conditions for safe and reliable
care in the ICU. they focused on areas with potential for great harm and high cost,
and where the evidence base was strong.( Nolanet al ,2012)
While there were many changes the teams in the initiative worked toward
implementing, care of patients on ventilators and those who had central lines

8. became a strong focus, as it satisfied all of our criteria: the evidence for the clinical
changes was robust, and there was little or no controversy concerning their efficacy.
Further, teams would need to find new and better ways to work together to produce
reliable change and superior patient outcomes. We found that by using a “bundle”
— a small set of evidence-based interventions for a defined patient population and
care setting — the improvements in patient outcomes exceeded expectations of
both teams and faculty.
Thus began an innovative approach to improving care: the use of bundles. This white
paper describes the history, theory of change, design concepts, and outcomes
associated with the development and use of bundles over the past decade. We
reflect on what we have learned and make suggestions for further research and
implementation of the bundle approach to improving care.
3.1 Introduction
This chapter discusses the methods used in the study to answer the research
questions and test the hypotheses by several statistical methods. It is divided into
the following five sections: Study Methodology; Study Population and Sample; Study
Tools and Data Collection; Statistical Treatment; Reliability and Validity.
3.2 Study Methodology

9. This study used both descriptive and analytical analysis. Descriptive study includes
data collected from previous related works and literature review. These resources
were used to develop the theoretical model of this study. Furthermore, statistical
techniques were used for empirical analysis and a survey was designed to collect
data from the population of the study, who are ICU Pt with Ventilator at.
3.3 Study Population and Sample
Sampling is important as budget and time restrictions prevent study from surveying
the whole population. Sampling also gives higher truthfulness and fast result (Al-
Bakri, 2009).The population in the current research consists of ICU Pt with
collectedhave beensamples150about–Ventilator. This research chosen sample
can be used to represent the population. Given the large-Al basher hospitalfrom
population of the study, In order to increase sample size and statistical power, the
pilot study will also be the included as part of the final analysis.
3.4 Study Tools and Data Collection
This research of Using a Bundle Approach to Improve Ventilator Care
Processes and Reduce Ventilator-Associated Pneumonia is not very extensive
compared to the discussion of the effecting factors. Thus, to gain deeper

10. understanding of the related aspects in the hospitals, current research is conducted
with quantitative approaches to explore the impact Using a Bundle Approach to
Improve Ventilator Care Processes and Reduce Ventilator-Associated Pneumonia.
The overall VAP rates in our 2 ICUs were similar prior to the bundle program
and were comparable to the 50th percentile reported by the National Nosocomial
Infections Surveillance System28 for ICUs. The incidence of VAP decreased in each
ICU during the study period. The ER-ICU had a greater and more statistically
significant reduction in VAP compared with the SICU, which only approached
statistical significance. The VAP incidence at the SICU increased slightly during the
first year of the VAP bundle program but showed the greatest decrease during the
second year. The ER-ICU saw the greatest decrease in VAP during the third study
year. Combined VAP rates decreased during the study period and were statistically
significant This suggests a 67% risk reduction by the end of the study period.
The current research is conducted in these stages:
Stage 1. Literature review, examines the findings of other researchers and authors
who have extensive experience the field of study . This stage addresses a number of
different issues,
Stage 2. The quantitative approach includes the analyze of a sample. Also the

11. purpose of the survey is to produce quantitative descriptions of some aspects and
issues of the study population. The questionnaire has been developed based on the
literature review, and will be refined with results and information collected from the
previous stage of the research. The questionnaire focuses on Using a Bundle
Approach to Improve Ventilator Care Processes and Reduce Ventilator-Associated
Pneumonia The survey will be pre-tested for its validity and reliability. A pilot test
will be conducted to check the validity of the questionnaire, eliminate any
uncertainty, and make appropriate changes according to respondent‘s suggestions.
Stage 3. Data coding and analysis includes presentation, hypothesis testing, and
analysis of results. Various quantitative statistics of methods such as factor analysis,
analysis of variance and correlation will be employed on the survey data. The
application of several statistical techniques to test the relationships between
variables. Statistical Package for Social Science ‗SPSS‘ will be used to evaluate and
perform all the analysis to test the hypotheses.
3.5 Statistical Treatment
After collecting data from the returned responses, the researcher used the Statistical
Package for the Social Sciences SPSS (v19) to analyze the data. The researcher used

12. suitable Statistical treatment for each question and hypothesis from the following
tests:
- Cronbach Alpha (α) to test Reliability
- Percentage and Frequency to describe the sample.
- Arithmetic Mean and Standard Deviation to answer the study questions.
- T-test and using ANOVA table to measure the impact of the user characteristics⎫
on the usage and the usage level of the Portal
- Simple Linear and Multiple Regression analysis with (F) test
- Relative importance,
3.6 Validity and Reliability
(A) Validation
To test for survey clarity and coherency, a macro review covering all research
components was performed by academic reviewers - from Jordanian Universities -
specialized in Business, Information Technology and Statistics. Therefore, some
items were added based on their recommendations while some others were
modified. The survey was reviewed by a total of (8) academic reviewers and the
overall percentage of response which was 100%. Please see appendix ―B‖ for the

13. list of academic arbitrators.
(B) Reliability
To test the survey reliability, Cronbach Alpha (α) analysis was used to
measure internal consistency. A minimum acceptable level (Alpha ≥ 0.65) suggested
by (Revelle &Zinbarg, 2009) was adopted.
3.7 Procedure
After the IRB approval, the data collection process will, we will obtain the
written approval from the medical record of all hospital. The participants will be
selected after reviewing the patient’s files in the inpatient wards,. We will reach all
participants for this study through this setting. Any further explanation to
participant’s questions will take place in a private area.
The study tool will be attached with latter that’s include general information’s about
the study, required time to complete the data, consent form, the demographic form.
Collection process will need at least 4 months until we obtain eligible sample
Data Analysis
STATISTICAL ANALYSIS Differences in VAP rates were compared using the 2

14. test. Summary statistics are provided as annual VAP rate (VAP cases per 1000
ventilator days) with P value. Annual percentage of compliance was compared via
95% confidence intervals.
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