Key Elements Of Vent Bundle Terry Clemmer MD Vicki Spuhler RN MS

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Key Elements Of Vent BundleTerry Clemmer
MDVicki Spuhler RN MS
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What is a bundle?

• ?A grouping of best practices with respect to a
  disease process that individually improve care,
  but when applied together result in substantially
  greater improvement
• ? The science behind the bundle is so well
  established that it should be considered standard
  of care.

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What is a Bundle?

• Bundle elements are dichotomous and compliance
  can be measured
• yes/no answers.
• Bundles eschew the piecemeal application of
  proven therapies in favor of an all or none
  approach.

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Vent Bundle

• HOB elevated 30 degrees
• DVT prophylaxis
• Gastric ulcer prophylaxis
• Sedation vacation
• Daily readiness to wean
• Other potential additions
• Oral Care protocol
• Mobility protocol

Change
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Vent Bundle

• HOB elevated 30 degrees
• Why?
• Reduces potential for aspiration
• Potential to improve ventilation
• Identified issues and concerns
• Is it comfortable for the patient?
• Causes the patient to slide down in bed
• Potential for skin shearing
• Anectdotal experience
• Patients do not complain of discomfort
• No significant documented increase in skin
  breakdown

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Vent Bundle

• DVT Prophylaxis
• Why?
• Reduces potential for clot formation
• Reduces potential for pulmonary emboli
• Identified issues and concerns
• None- well accepted therapy
• Anecdotal experience
• If using scds- assure they are on the patient
  not on the floor

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Vent Bundle

• Gastric Ulcer prophylaxis
• Why?
• Reduces acid production in stomach
• Reduces potential for severe lung injury related
  to aspiration
• Identified issues and concerns
• None- well accepted therapy
• Anecdotal experience
• None significant

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Vent Bundle

• Sedation Vacation
• Why?
• Has been demonstrated to reduce overall patient
  sedation
• Promotes early weaning
• Potential to increase time to extubation
• Identified issues and concerns
• Increases potential for self extubation
• Increases potential for patient pain and anxiety
• Increases episodes of desaturation
• Anecdotal experience
• Promotes early extubation
• No significant increase in pt. self extubation

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Vent Bundle

• Daily readiness to wean
• Why?
• Brings weaning potential to the fore front of
  vent management
• Entices discussion and teases out teaching that
  will strengthen the knowledge and understanding
  of both MD and RN/RT.
• Will generate the need for a weaning protocol if
  one does not already exist
• Identified issues and concerns
• Involvement of RT and MD are essential
• Anecdotal experiences
• Decreases time on ventilators overall

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Other potential additions to Vent Bundle

• Oral Care
• Why?
• Has been demonstrated to reduce colonization in
  the oral pharynx
• Has been demonstrated to reduce the secretions
  that accumulate above the ET tube cuff
• Assumption (lacks evidence)-reduces potential for
  VAP
• Mobility
• Why?
• Improves patient strength
• Reduces potential for deconditioning
• Increases potential for early extubation

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• Successes
• all or none compliance
• reduced VAP
• reduced LOS on ventilator
• Barriers
• all or none compliance
• reduced VAP
• reduced LOS on ventilator

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Tips for successful tests of change

• Stay one cycle ahead
• PDSA
• Scale down the scope of the test
• Test on one patient
• Test with one MDs patients
• Test on one shift
• Pick willing volunteers
• Work with those who want to work with you
• Look for the early adopters

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Tips for successful tests of change

• Avoid the need for consensus, buy-in, or
  political solutions
• Choose changes that do not require a long process
  of approval
• Work with what you can influence
• Nurses- dont start with a process that is MD
  driven or MD controlled- look for your piece of
  influence within that process.

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Tips for successful tests of change

• Dont reinvent the Wheel
• Try modifying someone elses work.
• Pick easy changes to try
• Avoid technical slow downs
• Computer programming

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Tips for successful tests of change

• Reflect on the results of every change
• There are no failed tests of change
• Ask yourself
• What did we think would happen?
• What did happen?
• Where there unintended consequences?
• What was the best thing about this test?
• What was the worst thing about this test?
• What should we do next?

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Tips for successful tests of change

• Be prepared to end the test of a change
• If the test shows that a change or a series of
  changes is not leading to improvement- STOP IT!
• Go back to the last improvement and revamp your
  next test.