Importance of infection control in ICU
Ventilator-associated Pneumonia definition and bundles, Central line-associated infection and its bundles and foley's catheter-associated infection and its bundles
this presentation in reference to CDC and IMO
Prevention of Central Line Associated Blood Stream Infection (CLABSI )[compa...drnahla
Infection Control Guidelines for Prevention of Central Line Associated Blood Stream Infection (CLABSI )
Dr. NAHLA ABDEL KADERوMD, PhD.
INFECTION CONTROL CONSULTANT, MOH
INFECTION CONTROL CBAHI SURVEYOR
Infection Control Director, KKH.
A "bundle" is a
group of evidence-based care components
for a given disease that, when executed together, may result in better outcomes than if implemented individually.
Central Venous Catheter Care- A Nursing skill Tse Sona
- Shared on the request of al the delegates who attended and those who couldn't attend the webinar on "CVC care- A Nursing Skill'' due to limited seats. I hope it will be helpful to all
Importance of infection control in ICU
Ventilator-associated Pneumonia definition and bundles, Central line-associated infection and its bundles and foley's catheter-associated infection and its bundles
this presentation in reference to CDC and IMO
Prevention of Central Line Associated Blood Stream Infection (CLABSI )[compa...drnahla
Infection Control Guidelines for Prevention of Central Line Associated Blood Stream Infection (CLABSI )
Dr. NAHLA ABDEL KADERوMD, PhD.
INFECTION CONTROL CONSULTANT, MOH
INFECTION CONTROL CBAHI SURVEYOR
Infection Control Director, KKH.
A "bundle" is a
group of evidence-based care components
for a given disease that, when executed together, may result in better outcomes than if implemented individually.
Central Venous Catheter Care- A Nursing skill Tse Sona
- Shared on the request of al the delegates who attended and those who couldn't attend the webinar on "CVC care- A Nursing Skill'' due to limited seats. I hope it will be helpful to all
Catheter-associated Urinary Tract Infections (CAUTI)
A urinary tract infection (UTI) is the most common type of healthcare-associated infection reported to the National Healthcare Safety Network (NHSN). Among UTIs acquired in the hospital, approximately 75% are associated with a urinary catheter, which is a tube inserted into the bladder through the urethra to drain urine. Between 15-25% of hospitalized patients receive urinary catheters during their hospital stay. The most important risk factor for developing a catheter-associated UTI (CAUTI) is prolonged use of the urinary catheter. Therefore, catheters should only be used for appropriate indications and should be removed as soon as they are no longer needed.
Introduction to the Visual Infusion Phlebitis (VIP) scoreivteam
The Visual Infusion Phlebitis score is a standardised approach to monitoring peripheral IV catheter sites.
The fact that it encourages site observation means that it also has an impact on other peripheral IV catheter problems such as dislodgement, infiltration and infection.
The innovation of this tool is the recognition of the visual nature of peripheral IV problems and the subsequent benefits of a visual tool to identify these issues early.
As health care workers we have a duty of care to monitor the condition of a patients IV site.
Failure to monitor IV sites is seen as failure in duty of care.
The VIP score is internationally acknowledged as a proven standardised tool for the monitoring of peripheral IV catheter sites.
Infection control guidelines for Prevention of Peripheral Venous Catheter (PV...drnahla
Infection Control Guidelines for Prevention of Peripheral Venous Catheter (PVC) Associated Infections
Dr. NAHLA ABDEL KADERوMD, PhD.
INFECTION CONTROL CONSULTANT, MOH
INFECTION CONTROL CBAHI SURVEYOR
Infection Control Director, KKH.
NABH : National Accreditation Board for Hospitals & Healthcare Providers - guidelines for sterlity protocols, care of poly-trauma cases and hospital waste management
Central-Line-Associated Bloodstream Infections (CLABSI) pause a major health problem in hospitalized patients. This disease is associated with people with a central line/tube inserted through the skin into the large vein, which can be used to give medicines, fluids, nutrients, or blood products to patients in critical conditions. The disease occurs when microbes enter through the central line invading the bloodstream.
Catheter-associated Urinary Tract Infections (CAUTI)
A urinary tract infection (UTI) is the most common type of healthcare-associated infection reported to the National Healthcare Safety Network (NHSN). Among UTIs acquired in the hospital, approximately 75% are associated with a urinary catheter, which is a tube inserted into the bladder through the urethra to drain urine. Between 15-25% of hospitalized patients receive urinary catheters during their hospital stay. The most important risk factor for developing a catheter-associated UTI (CAUTI) is prolonged use of the urinary catheter. Therefore, catheters should only be used for appropriate indications and should be removed as soon as they are no longer needed.
Introduction to the Visual Infusion Phlebitis (VIP) scoreivteam
The Visual Infusion Phlebitis score is a standardised approach to monitoring peripheral IV catheter sites.
The fact that it encourages site observation means that it also has an impact on other peripheral IV catheter problems such as dislodgement, infiltration and infection.
The innovation of this tool is the recognition of the visual nature of peripheral IV problems and the subsequent benefits of a visual tool to identify these issues early.
As health care workers we have a duty of care to monitor the condition of a patients IV site.
Failure to monitor IV sites is seen as failure in duty of care.
The VIP score is internationally acknowledged as a proven standardised tool for the monitoring of peripheral IV catheter sites.
Infection control guidelines for Prevention of Peripheral Venous Catheter (PV...drnahla
Infection Control Guidelines for Prevention of Peripheral Venous Catheter (PVC) Associated Infections
Dr. NAHLA ABDEL KADERوMD, PhD.
INFECTION CONTROL CONSULTANT, MOH
INFECTION CONTROL CBAHI SURVEYOR
Infection Control Director, KKH.
NABH : National Accreditation Board for Hospitals & Healthcare Providers - guidelines for sterlity protocols, care of poly-trauma cases and hospital waste management
Central-Line-Associated Bloodstream Infections (CLABSI) pause a major health problem in hospitalized patients. This disease is associated with people with a central line/tube inserted through the skin into the large vein, which can be used to give medicines, fluids, nutrients, or blood products to patients in critical conditions. The disease occurs when microbes enter through the central line invading the bloodstream.
PCA is neither “ one size fits all “ or a “ set and forget “ therapy
An Anesthesiologist style ……….
no fixed dose of drug fits all patient
make patient analgesia and take care
predictors of mortality in mechanically ventilated patients using APACHE II a...Raj Mehta
A study to evaluate predictors of mortality in mechanically ventilated patients by using APACHE II and SAPS II scoring systems in adult ICU of AIIMS, New Delhi.
Presention on the Computerised real time automatic SAPS APACHE and SOFA score Calculation and display system implemented at JPNA Trauma Centre, AIIMS, New Delhi
Severity of illness scoring systems have been developed to evaluate delivery of care and provide prediction of outcome of groups of critically ill patients who are admitted to the intensive care units. This prediction is achieved by collating routinely measured data specific to the patient. This article reviews the various commonly used ICU scoring systems, the characteristics of the ideal scoring system, the various methods used for validating the scoring systems.
Patient control epidural analgesia Al Razi hospital KuwaitFarah Jafri
This is the Patient Controlled Epidural Analgesia protocol at Al Razi Hospital. This presentation was done before initiating the PCEA as a pain control modality in the hospital.
After discovering a lapse in documentation for PCAs in the Operating Room I created a short RN education inservice to correct this. Here is a presentation of my findings.
January-February 2016 • Vol. 25/No. 1 17
CPT (R) Gwendolyn Godlock, MS-PSL, BSN, RN, AN, CPHQ, is Field Representative Nurse
Surveyor, The Joint Commission, Oakbrook, Terrace, IL.
CPT Mollie Christiansen, BSN, RN, AN, CMSRN, is Clinical Nurse Officer in Charge, Burn
Progressive Care Unit, United States Army Institute of Surgical Research, Joint Base San
Antonio Fort Sam Houston, TX.
COL Laura Feider, PhD, RN, is Dean, School of Nursing Science and Chief, Department of
Nursing Science, Army Medical Department Center and School, Health Readiness Center of
Excellence, Joint Base San Antonio Fort Sam Houston, TX.
Acknowledgments: The team would like to thank nursing leaders COL (R) Sheri Howell, for-
mer Deputy Commander of Nursing and Chief of Staff; and COL Richard Evans, Assistant
Deputy Chief Army Nurse Corps, for their support. A special acknowledgment for the former
Chief, Medical Nursing Section, COL Vivian Harris, who remained a staunch supporter, advo-
cate, and cheerleader, the Medical Section nursing staff, and the Center for Nursing Science
and Clinical Inquiry.
Note: The view(s) expressed herein are those of the authors and do not reflect the official policy
or position of Brooke Army Medical Center, the U.S. Army Medical Department, the U.S. Army
Office of the Surgeon General, the Department of the Army, Department of Defense, or the U.S.
Government.
Implementation of an Evidence-Based
Patient Safety Team to Prevent Falls
in Inpatient Medical Units
T
he Centers for Medicare &
Medicaid Services identified
falls as a preventable health
care acquired condition (DuPree,
Fritz-Campiz, & Musheno, 2014). A
large portion of the medical-surgical
inpatient population is aging, and
therefore at high risk for falls (Boltz,
Capezuti, Wagner, Rosen berg, &
Secic, 2013). Falls have physical and
emotional implications for patients,
as well as increased financial costs for
facilities. Nationally, medical units
have the highest rates of falls
(Bouldin et al., 2013). Most notably,
falls can cause significant injuries
resulting in increased length of stay,
unexpected surgeries, and even death
(Williams, Szekendi, & Thomas,
2014). Historically medical-surgical
nurses care for a mix of complex
patients with an array of comorbidi-
ties and patient needs (Carter &
Burnette, 2011).
Literature Review
The literature search was limited
to keyword searches on falls, team-
work, patient safety, nursing, hourly
rounding, and communication. Data -
bases included PubMed, EBSCO,
Agency for Healthcare Research and
Quality, CINAHL, and The Joint
Commission for years 2008-2014.
Use of fall prevention teams was an
emerging evidence-based practice
(EBP) intervention to decrease the
incidence of inpatient falls (Graham,
2012). Consistently, the evidence
demonstrated ineffective communi-
cation, situation awareness, team-
work, assessment, hourly rounding,
and environmental challenges as key
factors related to preventable inpa-
tient falls.
Collectively, research.
2021-2022 NTTAP Webinar: Fundamentals of Comprehensive CareCHC Connecticut
Join us as we discuss the core concepts of team-based care and introduce elements of team-based care that builds upon these basics to support your teams in advancing their capability to provide satisfying and effective care to complex patient populations. .
We will be joined by Margaret Flinter, Senior Vice President/Clinical Director for Community Health Center, Inc., and both Thomas Bodenheimer, MD, Physician and Founding Director, and Rachel Willard Grace, Director, from the Center for Excellence in Primary Care.
Meeting the challenge together... delivering care in the most appropriate set...NHS Improvement
Meeting the challenge together... delivering care in the most appropriate setting (October 2008). This document has been designed to support the pilot sites (now starting to test new ideas working with partners in primary care and social care) but will also be of interest to other organisations attempting to reform inpatient care (Published October 2008).
4-Continuous Quality Improvement (CQI) is defined by the Americabartholomeocoombs
4-Continuous Quality Improvement (CQI) is defined by the American Society for Quality (ASQ) as “a philosophy and attitude for analyzing capabilities and processes and improving them repeatedly to achieve customer satisfaction”. (Huber 292) CQI is something that is relevant to all nurses as we all need to be responsible for continual improvement at work. As professionals we should always have this as a top priority. There are many challenges in the workplace, and by looking for ways to improve, we are constantly learning and growing as a profession, this is a large piece of evidence-based practice, which is something we all hold as a standard in healthcare today.
An example of how I would apply CQI in my current position working as a nurse circulator in the operating room, is to ensure that the time out procedure is followed every single case I circulate. This is important as we often get complacent in rules and regulations, as do surgeons that we are trying to keep happy as they are customers just as much as our patients are.
I had circulated a case with another nurse during orientation in which not all implants for a total knee replacement were in the room. I was not notified of this until after the case started, the patient was anesthetized, and time out had been completed though this requirement was not stated/asked. Later the rep for the implants then stated the implants were in route from another location. This is unacceptable, and I am glad that I was still in orientation at the time this occurred as it was a great learning experience for me. I learned how to write an incident report that day, and why the time out procedure is so important.
Resources
Huber, Diane.
Leadership and Nursing Care Management, 5th Edition
. Saunders, 10/2013. VitalBook file.
5-Health care delivery requires structure (staff, education, equipment, prospective data collection), and process (policies, procedure, protocols), which when integrated provide a system (programs, organizations, cultures) leading to outcomes (patient safety, quality, satisfaction). An effective health care system has all of these elements – structure, process, system, and patient outcomes in a framework of continuous quality improvement, or CQI (Kronich et al., 2015).
The purpose of QCI is to improve health care by identifying problems, implementing and monitoring corrective action and evaluating its effectiveness. Hospitals use a specific process to find areas in the health care delivery system that need improvement. When an area has been found, staff develop and implement strategies for improvement. General areas that are being studied include access to care, continuity of care, the intake process upon admission, emergency care, and adverse patient events, including all deaths (National Commission on Correctional Care, 2018).
In my previous position, working as a NICU RN, we initially did not use two RN’s to verify the content in the TPN-bags for each patient. Shortly after I ...
A review of the total knee replacement pathway: Integrated care is quality careApollo Hospitals
A Total Knee Replacement (TKR) Pathway (adapted from the Credit Valley Hospital, Canada) is in place at the Apollo Health city facility since 2011. We re-visited the pathway design and the priority grid that led to its adaptation. We analyzed the data with the aim to analyze repetitive and unique trends and evaluate the performance of the pathway. Even with the increased volume the patient satisfaction rose from 56% at the time of pathway implementation to 77% at the end of the evaluation period of 45 months. The Average Length of Stay reduced by 27% from 7.94 to 5.78 days (the difference between the initial and final recorded values), in the same evaluation time period. The methodology of evaluation of the pathway was adapted from the Leuven Clinical Pathway Compass 5 way approach.
THE 10 STRATEGIC POINTS FOR THE PROSPECTUS,21THE 10 STRATEGIC P.docxtodd801
THE 10 STRATEGIC POINTS FOR THE PROSPECTUS, 21
THE 10 STRATEGIC POINTS FOR THE PROSPECTUS, 28
DPI Project Milestone:10 Strategic Points for the Prospectus, Proposal, and Direct Practice Improvement Project
Running head: THE 10 STRATEGIC POINTS FOR THE PROSPECTUS, 1
The 10 Strategic Points for the Prospectus, Proposal, and Direct Practice Improvement Project
The 10 Strategic Points
Broad Topic Area
1. Broad Topic Area:
The topic taken into consideration is the Central Line-Associated Bloodstream Infections (CLABSIs) and prevention
Introduction
2. Introduction
· The paper is an analysis of the CLABSIs infection and how best the infection can be prevented or even eliminated among patients.
· The infection is characterized by a catheter gaining entry into the bloodstream, greatly affecting either the inferior or the superior vena cava or the vessels of the neck.
· The location of the catheter makes entry of pathogens into the bloodstream very occasional. Patients thus become sick easily.
· The risk factors associated with the infection can result from the healthcare provider and also the patients and include; contamination on insertion, the skin flora of the patient, non-intact dressing, poor nutrition, position of the central line, poor patient and healthcare provider hygiene.
· Symptoms include redness, swelling, discharge at the central line exit, fever, chills, respiratory distress, and altered cognitive state.
· The infection can be prevented, through monitoring of the patients for any signs and symptoms, ensuring proper hygiene practices, and keeping patients educated about management of their central line.
· The paper gives all these information in detail, why there is a need to address Central line-associated bloodstream infections (CLABSIs) and how best the infection can be handled both by the health care givers and the patients.
Literature Review
3. Literature Review:
1. Primary points basis four sections in the Literature Review:
a. Background of the problem/gap:
· Researchers have dedicated numerous efforts towards the cause and the probable symptoms related to Central line-associated bloodstream infections (CLABSIs) that one needs to be on the look-out for.
· Attention has thus been shifted from the different measures to prevent the occurrence of the infection among patients.
· There arises an urgency to intervene and develop effective measures to curtail the incidence of CLABSIs.
· The use of proper hand hygiene and skin aseptic techniques over the insertion site is necessary for preventing microbial infections
· The nurses need to have the significant knowledge associated with evidence-based practices for the Central line-associated bloodstream infections (CLABSIs), their attitude towards the guidelines and the utilization of the hygienic measures for the Central Venous Catheter (CVC) patients.
b. Theoretical foundations (models and theories to be the foundation for the project)
· The efficacy of training of nu.
Adult survivorship: from concept to innovationNHS Improvement
The National Cancer Survivorship Initiative (NCSI) is a partnership between the Department of Health, Macmillan Cancer Support and NHS Improvement. As part of this initiative, NHS Improvement is testing approaches to care and support that ensures that we are moving to a position of not only supporting recovery from their disease, but also their future health and wellbeing through sustaining that recovery. During the last few years a proof of principle has been established which if transferable from the test sites to other organisations will begin the process of spread across the NHS and provide national risk stratified effective pathways for breast, colorectal and prostate cancers.
1. Using Care Bundles to
Improve Health Care Quality
Abdel latif M. Marini, BSN, MSN, CPHQ
Resar R, Griffin FA, Haraden C, Nolan TW. Using Care Bundles to Improve Health Care Quality. IHI Innovation Series
white paper. Cambridge, Massachusetts: Institute for Healthcare Improvement; 2012. (Available on www.IHI.org)
2. Innovative approach to improving care: the use of
bundles.
• This white paper describes the
development and use of bundles over the
past decade including :
– The history,
– Theory of change,
– Design concepts,
– Outcomes,
– Reflection and suggestions for further
research
3. Pretest
The concept of ‘care bundles’ was developed by the:
A- Institute for Healthcare Improvement IHI
B- Voluntary Hospital Association (VHA)
C- Scottish Patient Safety Programme
D- A & B
Ideally, a care bundle should:
A- Be for a specific population in one location,
B- comprising a set of 5 to 10 practices,
C- focus on what the best care should be
D- All of the Above
4. Definition of a Bundle
• A small set of evidence-based interventions for
a defined patient segment/population and
care setting that, when implemented together,
will result in significantly better outcomes
than when implemented individually.
5.
6. Origins of the Bundle Approach to Improving Care
• 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.
7.
8. The First Two Bundles
IHI Ventilator Bundle
• 1. Elevation of the head of the bed
to between 30 and 45 degrees
• 2. Daily “sedation vacations” and
assessment of readiness to extubate
• 3. Peptic ulcer disease (PUD)
prophylaxis
• 4. Deep venous thrombosis (DVT)
prophylaxis
• (Note: A fifth bundle element,
“Daily oral care with chlorhexidine,”
was added in 2010.)
IHI Central Line Bundle
• 1. Hand hygiene
• 2. Maximal barrier precautions
• 3. Chlorhexidine skin antisepsis
• 4. Optimal catheter site selection,
with avoidance of using the femoral
vein for central venous access in
adult patients
• 5. Daily review of line necessity,
with prompt removal of
unnecessary lines
9. “All-or-None” Measurement
• They measured compliance with the
bundles by checking
documentation of adherence to all
elements of the bundle.
• This measurement technique for
bundles — called “all-or-none”
measurement — focused attention
on the importance of delivering all
elements of the bundle to the
patient, unless medically
contraindicated.
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.
10. Prediction….
• Most clinicians in the participating IDICU initiative
hospitals assumed that the bundle elements were being
reliably performed on their patients.
• Initial data: 10-20 % compliance at best!!
• ↑motivation to change processes in their critical care
units to improve their reliability rates.
11. What did they do ?
• They focused on teamwork and communication in ensuring
reliable and consistent care to improve compliance rates ensued.
• Reliable process re-design and implementation + several months
of reaching high levels of all-or-none compliance with the
Ventilator Bundle elements, both faculty and teams were
surprised to observe ↓ in VAP.
• High levels of compliance with the Central Line Bundle => ↓
CLABSI
• These reductions in the incidence of VAP and CLABSI spurred
the further development and refinement of the bundle concept.
12. Elements of success
• First, in both cases: participating clinicians agreed that
there was sufficient medical evidence supporting each
individual element in the bundle to recommend that it can
be applied to most, if not all, patients.
• Second, the list of elements included in the bundle was
short — no more than five.
13. Message learnt
• The bundles were not intended to be comprehensive
care; rather, they were developed to test a theory —
that is, when compliance is measured for a core set of
accepted elements of care for a clinical process, the
necessary teamwork and cooperation required will
result in high levels of sustained performance
[reliability] not observed when working to improve
individual elements.
14. Bundle Design Guidelines
The bundle has three to five interventions (elements), with strong clinician agreement.
Each bundle element is relatively independent.
The bundle is used with a defined patient population in one location.
The multidisciplinary care team develops the bundle.
Bundle elements should be descriptive rather than prescriptive, to allow for local customization
and appropriate clinical judgment.
Compliance with bundles is measured using all-or-none measurement, with a goal of 95 % or >
15. The bundle has three to five interventions
(elements), with strong clinician agreement.
• The goal of the bundle approach is to pull together the short list of
interventions and treatments that are already recommended and that
are generally accepted in national guidelines and by local consensus of
clinicians as being appropriate care for the population of focus.
• Including only those elements that most clinicians accept as being
applicable to most patients in the population allows the team to move
forward with improvement, rather than spend time debating the
validity of the elements.
• Moreover, as the number of bundle elements increases, it becomes
mathematically more difficult to achieve high compliance with the all-
or-none measure.
• Since the intent is neither to create a comprehensive care protocol nor
to include elements that vary in their applicability to individual
patients, using three to five bundle elements is most successful.
16. Each bundle element is relatively independent.
• The bundle is designed so that if one of the elements of care
is not implemented for a patient, it should not affect
whether other bundle elements are implemented.
For example, in the Central Line Bundle, if the central line
insertion site was not cleansed with chlorhexidine (one of the
bundle elements), the remaining four Central Line Bundle
elements still could be implemented.
17. The bundle is used with a defined patient population
in one location.
• The bundle is most successfully applied to a discrete patient population
in a defined location — for example, patients on ventilators in the ICU.
For example, the bundle approach was tested in an IHI Collaborative on perioperative safety,
using the surgical site infection (SSI) prevention measures . These measures cross multiple
geographic areas — the preoperative holding area, the OR, PACU, and the postoperative ward —
and occur at different times in the perioperative process. There were often at least 4 different
teams involved, one or more from each geographic area, who rarely came in contact with each
other. Although teams were able to improve the individual elements of care that occurred in their
respective areas, the bundle approach was less successful.
• If a particular type of harm (e.g., sepsis) occurs in more than one
location, develop a bundle for each location and design good handoffs.
For example, there are two Sepsis Bundles — one for management of septic patients in the
emergency department, and another for management of septic patients in the ICU.
18. The multidisciplinary care team develops the
bundle.
• Communication and teamwork are fundamental to the
success of a bundle.
• Having bundles developed by care teams with members
from many disciplines will improve the likelihood of the
bundle’s acceptance and success.
19. Bundle elements should be descriptive rather than prescriptive, to
allow for local customization and appropriate clinical judgment.
• In some cases, the science or generally accepted opinion may
support a general care element, but the care element could be
implemented in several ways or have varying interpretations. For
example, the DVT and PUD prophylaxis elements of the
Ventilator Bundle do not specify the type of prophylaxis.
• Local clinicians will determine the appropriate form for their
patient population and care setting.
• Bundles elements must be applied sensibly; they should never be
forced when clinically inappropriate, and there should always be
an “opt out” choice.
• All exceptions should be documented in the patient record so
that all members of the care team are aware of the rationale.
20. Compliance with bundles is measured using all-or-none
measurement, with a goal of 95 percent or greater.
• Compliance with bundles is measured by documentation of
adherence to all elements of the bundle using a simple “yes” or “no.” If
all elements have been accomplished, or if an element was
documented as medically contraindicated (with the goal that all care
team members know the rationale for exceptions, which may change
over time), the bundle is counted as complete for that patient. If any
of the elements are absent in the documentation, the bundle is
incomplete (no “partial credit” is given).
• The percentage of all-or-none compliance for a bundle always focuses
on a patient population (e.g., the percentage of patients on ventilators
in the ICU who received all bundle elements, or had documentation of
contraindications). This all-or-none measurement approach for
bundles focuses attention on the importance of delivering all
elements of the bundle to the patient, unless medically
contraindicated.
21. Theory of Change:
Why Do Bundles Produce Better Outcomes?
• 1. Bundles change the assumption that evidence-based care
is being delivered reliably.
• 2. Bundles promote awareness that the entire care team
must work together in a system designed for reliability.
• 3. Bundles promote the use of improvement methods to
redesign care processes.
22. 1. Bundles change the assumption that evidence-based
care is being delivered reliably.
• If each of five bundle elements is delivered at 90 percent
reliability, then the bundle is delivered at 59 percent
reliability, as bundle reliability is the product of each
element’s reliability (90% x 90% x 90% x 90% x 90%).
• Typically, most clinicians assume that the bundle elements
are being reliably performed on their patients. However,
when they collect their initial data, they are often surprised
at the low levels of all-or-none bundle compliance, with
some ICUs finding reliability levels of 10 to 20 percent.
23. 2. Bundles promote awareness that the entire care team
must work together in a system designed for reliability.
• Teams that have achieved high levels of bundle compliance
and concomitant improved outcomes did so through
working as a team in new ways:
– using specific daily goals developed by the team and patient
– multidisciplinary rounds where the bundle elements are discussed
and checked
– debriefs at the end of the day to reflect on compliance and to plan
ongoing improvements.
24. 3. Bundles promote the use of improvement
methods to redesign care processes.
• In the original bundle development work, teams used the Model for Improvement
– What are we trying to accomplish?
The aim of using bundles is to reduce harm and improve care for the patient through improving the
reliability of care processes.
– How will we know the change is an improvement?
Two measures: all-or-none bundle compliance and improved patient outcomes.
– What changes can we make that will result in improvement?
Several changes are listed above — daily goals, multidisciplinary rounds, and debriefing; in addition,
effective changes include the use of checklists, standardization, and co-location of resources (e.g.,
the central line equipment cart).
• Teams then test the changes using the Plan-Do-Study-Act (PDSA) cycle iteratively to learn
and to refine the changes until they are able to produce reliable processes that lead to
improved outcomes.
25. Evolution of Bundles Designed in IHI Initiatives
• Central Line Bundle and Ventilator Bundle
• Severe Sepsis Bundles and Perinatal Care Bundles
26. Evolution: Central Line Bundle and Ventilator Bundle
• The first bundles developed in IHI initiatives, the Central Line
Bundle and the Ventilator Bundle, were used subsequently in
IHI’s critical care initiative in the IMPACT network starting in
July 2002.
• Both the Central Line Bundle and the Ventilator Bundle were
included as key interventions in IHI’s 100,000 Lives Campaign
and 5 Million Lives Campaign.
• Over 4,000 US hospitals participated in the Campaigns between
2006 and 2008. Those hospitals were surveyed in 2007 about
results following bundle implementation; 65 hospitals reported
going one year or more without a VAP in an ICU setting, and 35
hospitals reported six months or more of no CLABSI in at least
one intensive care unit.
27. Evolution: Central Line Bundle and Ventilator Bundle
• The Scottish Patient Safety Programme, launched in 2007 in
collaboration with IHI, included the Central Line Bundle and the
Ventilator Bundle; hospitals in Scotland recently published
significant reductions in VAP after implementing the Ventilator
Bundle.
• Two recently published studies reported on retrospective review
of CLABSI, VAP, and compliance with the bundles from surveyed
hospitals participating in the Centers for Disease Control and
Prevention National Health Safety Network. Both studies found
that only when Central Line Bundle and Ventilator Bundle
compliance were sustained at 95 percent or higher were
decreases in the associated infections (CLABSI and VAP
respectively) observed; further, they found that both having a
bundle policy and monitoring compliance were required to
achieve reductions in infections.
30. Evolution: Severe Sepsis Bundles and Perinatal
Care Bundles
• The bundle concept has been applied in other clinical areas,
including sepsis, which has also led to reported
improvements in outcomes.
• Other bundles currently being tested within IHI initiatives
include the Perinatal Elective Induction and Augmentation
Bundles.
31. Conclusion
• The use of bundles of care interventions as an approach to
improving the reliability of care received by patients and
preventing certain serious clinical outcomes has been
demonstrated successfully for nearly ten years, with a growing
body of published results in medical journals.
• Success is related to more than simply “doing a bundle.”
Implementing a bundle with high reliability requires redesign of
work processes, communication strategies, and infrastructure,
along with sustained measurement and vigilance.
• Bundles are neither “magic bullets” nor comprehensive care for
any condition or patient situation; rather, they are one strategy
among many that hospitals must implement in order to prevent
serious complications in their patients — and save lives.
32. Conclusion- Take Home Message
• It is important for future bundles to be tested since, not all
clinical topics lend themselves to this approach.
• To ensure optimal support from clinicians, bundle
developers should always remember to select elements that
are supported by evidence.
• Finally, it is worth reiterating that a bundle itself does not
improve care; rather, improvement is a result of the
strategies taken by the team to redesign work, communicate
better, and work more effectively toward achieving patient
goals.
Editor's Notes
Harms associated with both ventilators and central lines were commonly identified using the IHI ICU Adverse Event Trigger Tool, which teams used to identify and track harm.
care of patients on ventilators and those who had central lines 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.
It is important to note that the elements of the Ventilator Bundle were not designed to reduce
ventilator-associated pneumonia (VAP) specifically or solely. Rather, our intent was to design
processes for reliably providing care that prevents certain serious adverse events (such as gastritis and
DVT) associated with the care of a patient on mechanical ventilation. (For this reason, we called it
the “Ventilator Bundle” — not the “VAP Bundle.”)
However, when they collected their initial data, they were surprised at the low levels of all-or-none compliance,
with some ICUs finding 10 percent to 20 percent compliance at best. Participants and faculty were thus motivated to change processes in their
critical care units to improve their reliability rates. It is important to note that measuring compliance
with each bundle element, as well as all-or-none compliance, is the first step in building a reliable system.
reductions in central line-associated bloodstream infections (CLABSI) after teams also achieved high levels of compliance with the Central Line Bundle, which was less surprising given that all elements of the bundle were designed to reduce central line infections.
Involving care teams that physically work together in the same location with a defined patient population allows for strategies to achieve all-or-none bundle compliance that are not always transferable when multiple teams across locations are involved.
Teams can use many methods to improve process reliability and outcomes.
Examples of such changes included use of checklists, revising
the structure and process of daily multidisciplinary rounds, and use of daily goal sheets.
Examples of such changes included use of checklists, revising
the structure and process of daily multidisciplinary rounds, and use of daily goal sheets.
Two publications have noted decreases in hospital mortality and length of stay associated with implementation of one or both Sepsis Bundles.
A subsequent study also reported on mortality reductions and estimated that 47 lives were saved in the hospital’s first year after implementation of the Severe Sepsis Bundles and a savings of over $1 million for the hospital..Bundles, like all clinical work, need to change as the evidence to support them changes. With regard to the current Sepsis Bundles, the use of drotrecogin alpha has been eliminated as subsequent clinical trials found it ineffective