Improving Quality of Care via the Care Bundle Approach

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Improving Quality of Care via the Care Bundle
Approach

• Sue OKeeffe
• Acting Head of Modernisation
• Conwy Denbighshire NHS Trust

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• Conwy and Denbighshire NHS Trust is located in a
  picturesque rural setting between the mountains
  and the sea serving a varied population with high
  percentage of elderly patients.
• Approximately 900 beds and over 5500 staff.
• The organisation runs nine hospital sites within
  a twenty-mile radius covering the Acute,
  Community Mental Health services.

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Conwy and Denbighshire NHS Trust (YGC)

• Six ICU (level 3) beds and two HDU (level 2) beds
• ICU case-mix is general but includes a regional
  Maxillo-facial service
• Demographic is predominately elderly
• Summer caseload is equally as busy as the winter.

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What is a care bundle?

• A series of interventions relating to a treatment
  or intervention
• Ventilator bundle
• Central line bundle
• Tracheostomy bundle. Etc
• When implemented together will achieve
  significantly better outcomes than when
  implemented individually (IHI 2005)

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Why Use Care Bundles?

• A way of reducing the gap between research and
  practice in clinical areas
• A method of translating best practice into
  practice
• Promotes evidenced-based change
• Reduces variability
• unit to unit
• clinician to clinician

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Improving Quality of Care?
Measure quality not assumptions
Based on solid science
All or none- Avoids piecemeal application
Best practices applied together
Improved Quality of Care
Improved clinical outcomes e.g. ALOS, Mortality
Reduced adverse events e.g. VAP, CRBSI, PE
Reduced variability - Increased throughput
Increased patient satisfaction
Cultural change- Improved team working
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Why did we do them?

• Gap analysis showed
• Staff lacked knowledge of existence of protocols
• Lack of understanding of the research
  underpinning guidelines and protocols
• Guidelines often written in a language not
  conducive to ease of use
• Therefore frustrations for all
• Practicetheory gap and ad hoc treatment regimes
• Improve quality of care/patient safety,
  consistently

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The Adoption/Innovation Curve
Forget everybody over here they wont help!
Pick somebody on this side who wants to help
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How to do it?

• Decide what elements to include
• Remember KISS
• Write guidelines then translate into useable
  language
• Nursing staff love flow charts!!
• Educate, Educate, Educate
• Consider how staff will document compliance and
  make it user friendly

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PDSA cycle

• 1. Plan
• What needs to be done?
• 2. Do
• Have a go
• 3. Study
• Look at what happened
• 4. Act
• Decide how successful it was

Act
Plan
Study
Do
Very Small Scale Test
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Repeated Use of the PDSA Cycle
Changes That Result in Improvement
Model for Improvement
What are we trying to
accomplish?
How will we know that a
A
P
change is an improvement?
S
D
What change can we make that
will result in improvement?
DATA
D
S
Implementation of Change
P
A
e.g. all
A
P
S
Wide-Scale Tests of Change
D
Hunches Theories Ideas
A
P
e.g. 35 patients
S
D
Follow-up Tests
e.g. adapt monitoring chart-1pt
Very Small Scale Test
e.g. strict blood glucose monitoring-1 pt.
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The Spread
S P R E A D
1
3
5
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Ventilator Bundle _at_ YGC

• Head elevation (gt300) (Lancet 19992541851-8)
• DVT prophylaxis (CritCareMed 200230772)
• Gastric ulceration prophylaxis (NEJM 1998338
  791-97)
• Sedation holds sedation vacation (Kress et
  al, NEJM 20003421471-7)
• Tight insulin control
• Transfusion guideline
• Low tidal volumes (6ml/kg)
• In the absence of medical contra-indications

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Ventilator Care Bundle

•  
•  
•  
•  

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Barriers Breakthroughs

• Medical ideas cookbook medicine
• All or nothing compliance
• Fear of hypoglycaemias
• HOB gt300
• Independent redundancy

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CVC Sepsis Bundles

• CVC Bundle implemented in January 05
• Sepsis Bundle implemented February 05
• Promote proactive care of treatments
• Empowered nursing staff to commence treatment or
  question practices outside the norm
• Encourage joint working
• Streamlined processes of care

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Daily Review of Line Necessity If all the answers
are No please remove central line
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(No Transcript)
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Auditing

• Audit process measures.
• Will have an effect on outcomes
• Provide immediate feedback to staff
• Require constant updating
• Hawthorn effect.?beneficial in initial phase
• Change times of auditing e.g. audit day night
  duty

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Auditing

• .and outcome measures
• ALOS, ALOMV, mortality, VAP, CRBSI etc
• Compare yourselves against yourselves
• Remember less obvious outcome measures
• Cost benefit realisation
• These ultimately convey impact empower staff to
  effect change

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ALOS decreased by a mean of 2.7 days
VCB
CVCB
SB
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Number of Patients
APACHE Pre 17.3 Post 17.4
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ALOS Mechanical Ventilation
decreased by a mean 2.7 days
VCB
CVCB
SB
Weaning guideline
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Drugs Expenditure
Reduction of 78,587
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Drugs Expenditure

• This equates to a reduction of 214.40 per
  patient episode
• 315
• 422
• ?cause
• Sedation
• Antibiotics
• Oral / NG usage

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Percutaneous Tracheostomies
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Mortality
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Other Outcome Measures

• Non-clinical transfers
• 7 vs. 1
• Cancelled elective surgery
• Reduced by 22

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Anecdotal?

• Fewer nightmares and hallucinations
• Reported by patients at follow-up clinic
• Less (patient) agitation
• Patients get better quicker
• No long term patients

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Summary

• Implementation requires will, ideas and
  execution
• Enhances teamworking streamlines care
• Empowers staff to question practices outside the
  norm
• Improves processes of care
• And therefore patient outcomes
• Improves quality of patient care

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Any Questions?