Bundle Health: Spread the Wealth

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Bundle Health Spread the Wealth

• Carol Wynne, MSN, RN, CCRN
• Improvement Advisor
• Hackensack University Medical Center

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What is a Bundle?

• Websters definition
• a group of things fastened together for
  convenient handling

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Institute for Healthcare Improvement

• Group of interventions related to a disease that
  when instituted together give better outcomes
  than when done individually.
• Roger Resar, MD

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A bundle is..

• Small and straightforward
• Group of best practices
• Scientifically grounded
• Protocol based
• Executed collectively and reliably
• Forcing functions
• All or nothing indicator

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Public Reporting Projects are bundles.

• Projects
• AMI10 indicators
• Heart Failure 4 indicators
• Pneumonia 7 indicators
• SIP 3 indicators

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Ventilator Bundle

• DVT Prophylaxis
• HOB gt 30 degrees elevation
• PUD Prophylaxis
• Daily Sedation Vacation
• Daily Assessment of Readiness to Wean
• Mouth Care Q 2hr

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Central Line Bundle

• Hand-Washing
• Optimal Insertion Site
• Full Barrier Protection
• Prepare Skin with Antiseptic/Detergent
  Chlorhexidine 2 in 70 Isopropyl Alcohol
• Daily Maintenance
• Daily Review of Necessity
• Early Removal
• Optional antibiotic impregnated catheter in
  select populations

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Severe Sepsis Bundle

• 6-Hour (Initial) Bundle
• Serum lactate measured
• Blood culture obtained prior to antibiotic
  administration
• Broad-spectrum antibiotics administered within 3
  hours of presentation
• Initial fluid resuscitation with 20-30 ml/kg/hr
  of crystalloid or saline per estimated kg of body
  weight (SBP lt 90, MAP lt 70, lactate gt 4mmol/L
• Measure CVP and ScVO2 or SVO2 in septic shock
• Vasopressors for persistent hypotension (after
  initial fluid resuscitation)

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Severe Sepsis Bundle

• 24 Hour (Maintenance) Bundle
• Glucose control maintained
• Cosyntropin stimulation test perfored with
  appropriate steroids given per protocol
• Drotrecogin alfa (activated) administered within
  guidelines
• Adoption of a lung protective strategy with
  plateau pressures lt 30 cmH2O for mechanically
  ventilated patients.

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Back to Basics..

• Forming team
• Model for Improvement
• Develop Reliable Processes
• Measurement
• Communication and Feedback

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Team Members

• Team Leader
• Clinical Expertise
• Quality Staff
• Day-to-day Manager
• Front-line Staff
• The right people at the time

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Model for Improvement
What are we trying to
accomplish?
How will we know that a
change is an improvement?
What change can we make that
will result in improvement?
Act
Plan
Study
Do
From Associates in Process Improvement
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The PDSA Cycle
Act
Plan

• Objective
• Questions and
• predictions (why)
• Plan to carry out
• the cycle (who,
• what, where, when)

• What changes
• are to be made?
• Next cycle?

Study
Do

• Complete the
• analysis of the data
• Compare data to
• predictions
• Summarize what
• was learned

• Carry out the plan
• Document problems
• and unexpected
• observations
• Begin analysis
• of the data

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Repeated Use of the PDSA Cycle
Changes That Result in Improvement
DATA
Implementation of Change
Wide-Scale Tests of Change
Follow-up Tests
Hunches Theories Ideas
Very Small Scale Test
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Overall Aim More than one test of change at a
time
Specific Test Cycles
One Test
Another Component Test
Separate Component
Another Component
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Design Reliable Care

• Standardize Care
• Scripted processes
• Protocols
• Order Sets

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Protocols

• Redundancies and reminders built in
• Decreases variance in practice
• Defaults require justification
• Increases reliability
• Makes it easy to do the right thing

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Aim Decrease time on ventilator by providing
daily sedation vacation
Decrease time on ventilator with daily sedation
vacation on all patients
DATA
Cycle 5 MDR
Cycle 4 Set default on Order Set
Cycle 3
RT Extubation Assessment Form
Overuse of sedation resulting in increase time on
ventilator
Cycle 2
Staff Education (Change culture)
Cycle 1 Development of Order Set
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Overall Aim Decrease Ventilator Time in MICU
Specific Test Cycles
Extubation Readiness Assessment
Sedation Vacation
Weaning Protocol
HOB elevated 30 degrees
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2005 MICU Vent LOS
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Measurement

• Process measures
• Maintain 95 compliance on bundles
• Outcome measures
• Infection rates

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Communication

• General publications
• Postings, flyers, newsletters
• Small group interaction
• Unit level, team meetings
• Interactive activities
• Email, conference calls
• Face-to-face
• One-to-one, mentoring

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Planning for Spread.

• Leadership involvement
• Strategy
• Social System local culture
• Communication Plan
• Measurement and Feedback System

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Basic Themes for Innovations

• Bundle Science
• Reliability Science
• Change Theory

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Leadership Involvement

• Strategic alignment
• Executive responsibility
• Day-to-day Manager

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Bundle Science

• Identifying most important actions
• Must dos
• Performed together, consistently
• Every patient, every time
• Highly reliable process
• You can count on it
• Service Guarantee
• Its on time or its on us
• Will achieve the desired result
• delighting the patient

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Spread Strategy

• Target population
• Successful pilot site
• Key players
• Plan
• Communication
• Reward and recognition
• Resources

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Overall Aim Decrease VAP in the ICUs utilizing
Ventilator Bundle
Specific Test Cycles
CCU Sister unit
MICU pilot unit
SICU
CSICU
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Social System

• Key Communicators
• Communities of practice
• Front-line staff concerns
• Tools and methods

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Spread Aim To decrease VAP in the SICU by
Utilizing the Ventilator Bundle
Decrease in VAP in SICU
DATA
Cycle 5 Bundle Compliance
Cycle 4 Weaning Protocol
Cycle 3
Extubation Readiness
Ventilator bundle to be implemented in the SICU
to decrease VAP
Cycle 2
PUD Prophylaxis
Cycle 1 Change Packet
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Communication Plan

• Raise awareness
• Non-punitive
• Comparative data
• Internal
• External

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Organizational Structure
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Proposed Organizational Structure
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Measurement Feedback

• Outcomes
• Spread rate Timeline
• Data collection
• Close the loop

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Vent Bundle Reliability
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CL Bundle Reliability
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VAP Rate
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CLBSI Rate
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Reliability Science Perfect Care

• Have your patients received their bundle of joy?

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Three Tier Design Strategy

• Prevent Design the system to prevent failure
  initially with standardization
• Identify Design process to make failures
  visible
• Mitigate Critical failure mode function, enables
  to identify critical failure and then redesign

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Transition from 10-1 to 10-2
PerformanceLevel 1(designing basic failure
prevention)

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

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Transition from 10-2 to 10-3 Performance
Level 2(designing sophisticated failure
prevention, basic failure identification and
mitigation)

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

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Vent Bundle Reliability
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Utilized the Critical failure mode function to
discover process failure decrease in vent
bundle compliance

• Defect Sedation vacation component
  (segmentation) of vent bundle
• Reason Vacation default lost in CPOE conversion
  of order set
• Redesign CPOE order set reformatted to include
  sedation vacation default

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Improving Reliability

• Sedation Vacation Bundle Component
• Reformat Order Set for CPOE (10 -1)
• Address sedation on MDR (10 -2 )
• Educate RT on sedation medications (10 -2 )
• Incorporate sedation medication on extubation
  assessment tool for RT (10 -2 )

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Business Case

• VAP 40,000
• CLBSI 29,000
• Money Saved

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Develop Own Bundles

• CABG Bundle
• SIP 1,2,3
• Hair Removal
• Glycemic Control (POD 12)
• Future
• Patient Satisfaction

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UTI BUNDLE

• Foley Strapped to Leg
• Foley Bag Below Bed
• Daily Review for Necessity
• Clarity of Urine

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CATS Decrease Surgical Site Infection
Hair Removal If
hair must be removed from the surgical site,
clippers are the best option. Never use a razor.
Clippers Antibiotics Temperature Sugar
Prophylactic Antibiotic
Antibiotics consistent with national guidelines
should be administered within 1 hour of incision
time and discontinued within 24 hours, in most
cases.
Normothermia
Colorectal surgery patients should be
normothermic (96.8-100.4F) within the first hour
of surgery.
Glucose Control
Cardiac surgery patients should have controlled 6
a.m. serum glucose (200 mg/dl) on postoperative
Day 1 and Day 2.
www.medqic.org www.hsag.com
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To Sustain Improvement..

• Frontline engagement
• Standardized processes
• Reliable plan
• Organizational learning
• Change process
• Clear Communication

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Identified Barriers/Failures

• Change in administration/management
• Lack of crisp plan
• Lack of accountability
• Spread too quickly

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Found Helpful

• Road trips
• Bring in experts from other departments
• Collaborative IHI
• Connect with Best Practice Organizations

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Lessons Learned

• Keep the patient in the center
• Question the status quo
• Steal shamelessly
• Keep it simple (KISS)
• Beware of the local culture
• Avoid technical slow downs
• Continuously learn
• Spread with caution

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• Bundle up for Safety!

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• Questions?

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References

• Institute for Healthcare Improvement, Boston,
• Massachusetts
• Gladwell, M. The Tipping Point. Boston Mass
• Little, Brown and Company 2000
• Langley J, Nolan K, Nolan T, Norman, C, Provost
  L. The Improvement Guide. San Frsancisco
  Jossey-Bass 1996
• Rogers E. Diffusion of Innovations. New York
  The Free Press, 1995