Bundle Science and the Ventilator Bundle

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Bundle Science and the Ventilator Bundle

• Roger Resar MD
• Mayo Health System
• Senior Fellow IHI
• March 2005

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History of the Bundle

• Challenging the teams in the IHI Idealized Design
  of the ICU Collaborative
• Development of the all or none measurement
• Observation of VAP reduction
• Evaluation of the change strategy

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BundleA grouping of failure
mode processes (bundle elements) with approximate
time and space characteristics that when done
collectively can have an enhanced affect on an
outcome
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Bundle Science

• Each element requires solid science that is
  essentially non refutable
• The tasks must relate in time and space
• A minimal number is required
• All or none is the measurement
• Outcomes are a by product of the process change
  and will depend on subsequent science

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Learning From Implementing the Vent Bundle

• The demand for the all or none measurement
  drove change in the unit in an unpredictable
  positive way
• Bundles and their elements facilitate identifying
  failures in design
• Failures can be actively used to redesign the
  process
• Improved outcomes are a by product and not the
  initial goal

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Process for Bundle Development

• Review the evidence for appropriate care
  (guidelines)
• Identify the important failure modes
• Define the bundle elements from a gap analysis of
  defect rates
• Bundle the elements based on tasks carried out
  with similar time and space characteristics

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Bundle Theories

• 1-(Don Berwick) The bundling causes a
  synergistic affect and then gives you a positive
  interaction and outcome
• 2-(Roger) The bundles are individually high level
  science. Done together they build teamwork and
  accomplish more than individual elements alone
• 3-(Tom Nolan) Task design in time and space
  related to logic flow. The logic flow allows for
  human factors to achieve high reliability (Dinner
  party story sauce, vcr and coffee)
•  

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Healthcare Reliability Terminology(Different
from the mathematical)

• Unstable process Failure in greater than 20 of
  opportunities
• 10-1 80 or 90 percent success. 1 or 2 failures
  out of 10 opportunities
• 10-2 5 failures or less out of 100
  opportunities
• 10-3 5 failures or less out of 1000
  opportunities
• 10-4 5 failures or less out of 10,000
  opportunities

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Premises IHI Innovation Team
For service system failures without immediate
catastrophic consequences

• 10-1 performance indicates no articulated common
  process
• 10-2 performance indicates processes with medium
  to high variation
• 10-3 performance indicates a well designed
  system with low variation and cooperative
  relationships

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Ventilator Bundle

• Head of bed elevation
• Sedation vacation
• DVT prophylaxis
• PUD prophylaxis

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Intent, Vigilance and Hard Work 10-1
Performanceto 10-2 transitionLevel 1

• Standardization (mostly structure)
• Personal check lists
• Working harder next time
• Feedback of information
• Awareness and training

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Human Factors and Reliability Science 10-2
Performance to 10-3 transitionLevel 2

• Decision aids and reminders built into the system
• Desired action the default(based on evidence)
• Redundancy
• Takes advantage of habits and patterns
• Standardization of process

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Ventilator Bundle Data

• 35 units (academic, community, surgical, med surg
  etc)
• Greater than 20 improvement in adherence to the
  ventilator bundle
• 44 improvement in VAP

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VAP Facts

• VAP occurs in up to 15 of ventilated patients
  (Craven)
• Mortality rate for VAP 46(Ibrahim)
• Prolonged mechanical ventilation associated with
  VAP(Kress)
• VAP guidelines published (Dodek)
• VAP guidelines not implemented reliably(Rello)

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Sedation Vacation

• Must not be medically contraindicated
• Implies waking patient to level of ability to
  follow commands
• Implies once every 24 hours
• Does not dictate method or drugs

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Elevation of Head of Bed

• Must not be medically contraindicated
• Does not demand a given degree of elevation but
  greater than 30 degrees (literature suggests 45
  degrees best) Drakulovic
• Does not demand 100 but an acceptable percent
  determined by the unit
• Measurement at least once a day but more often
  preferred

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PUD Prophylaxis

• Element does not dictate which agent to be used
  (although sucralfate probably best) Cook

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DVT Prophylaxis

• Element Does not dictate which methodology to use

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Work of Rene Almaberti
Increasing safety margins
No limit in performance
Becoming team player
Excessive autonomy of actors
Accepting to become equivalent actors
Craftman s attitude
Accepting to endorse residual risk
Ego-centered safety protections, vertical
conflicts
Accepting to question the success and to change
strategies
Loss of visibility of risk, froozing actions
Fatal Iatrogenic adverse events
Blood transfusion
Anesthesiology ASA1
Medical risk (total)
Cardiac Surgery Patient ASA 3-5
No system beyond this point
Hymalaya mountaineering
Chartered Flight
Civil Aviation
Railways (France)
Microlight or helicopters spreading activity
Road Safety
Nuclear Industry
Chemical Industry (total)
Fatal risk
10-2
10-3
10-4
10-5
10-6
Very unsafe
Ultra safe
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Tips to Implementing the Ventilator Bundle

• Start multidisciplinary rounds
• Document daily goals
• Build redundancy into the processes
• Rely on mid level providers as much as possible
• Test on all shifts before you settle on a
  finished design

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Tips for Measurement

• Start with simple measures (one time measurement
  of HOB)
• Sample 5 patients 7 AM each morning
• Have the team do the measurement
• Employ the use of run charts over time with
  appropriate annotation
• Do not do 100 measurement
• Insist on all or none measurement

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