Intensive and Critical Care Nursing (2011) 27, 117—120

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INTERNATIONAL RESEARCH SERIES

Implementing quality initiatives using abundled approach

Deborah Dawsona,∗, Ruth Endacottb

a St. George’s Hospital NHS Trust, London, United Kingdomb School of Nursing and Midwifery, University of Plymouth, United Kingdom

Accepted 29 March 2011

KEYWORDSCare bundle;International;Quality improvement;Multidisciplinary

Summary Critical care has been criticised for its inconsistency in implementing and evalua-ting evidence based practice both at national and international level. A review of the criticalcare literature by Berenholtz et al. (2002) identified interventions that might help prevent mor-bidity or mortality in the intensive care unit; from this four elements were developed into theinitial ventilator care bundle. The aim of this bundle was to improve the quality of care formechanically ventilated patients by improving compliance with relevant evidence based prac-tice; implementation of this or an adapted cluster of interventions has been shown consistentlyto reduce the incidence of ventilator-associated pneumonias across countries. There are nownumerous care bundles and the bundle approach to quality improvement has been proven to beeffective across a number of problems, international boundaries and in a wide variety of ICU’s.

The bundle approach recognises that core clinical interventions, are not always consistentlyapplied across all appropriate patients, the range of interventions within a bundle tackles theproblem from a variety of different angles. Other strengths include its adaptability to the widevariety of environments and working practices of intensive care units across the world. The

bundle and the method of implementation can be adapted to suit individual teams and units;however, this can also be a weakness of this approach as it limits comparability across centres.The bundle approach to quality improvement requires significant multidisciplinary engagementand resources to be effective.

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Introduction

Critical care has been criticised for its inconsistency inimplementing and evaluating evidence based practice both

∗ Corresponding author. Tel.: +44 208 725 3129.E-mail address: deborah.dawson@stgeorges.nhs.uk

(D. Dawson).

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0964-3397/$ — see front matter © 2011 Elsevier Ltd. All rights reserved.doi:10.1016/j.iccn.2011.03.006

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t national and international level (Audit Commission, 1999;homson et al., 2000). Berenholtz et al. (2002) assessed 35ears of critical care literature to identify interventions thatight prevent morbidity or mortality in the intensive care

nit (ICU). This review identified six evidence-based processeasures including: effective assessment of pain, appro-

riate use of blood transfusions, prevention of ventilatorssociated pneumonia, appropriate sedation, appropriateeptic ulcer prevention, and appropriate deep vein throm-osis prophylaxis. The latter four elements were developed

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nto the initial ventilator care bundle published by the Insti-ute of Healthcare Improvement (http://www.IHI.org) withn aim to improve the quality of care for mechanicallyentilated patients by improving compliance with relevantvidence based practice.

Each of these practices was based on one or moreublished studies, which if implemented individually shouldenefit the patient. Kress et al. (2000) found that a dailynterruption of sedative infusions decreased the duration ofechanical ventilation (4.9/7.3 days; p = 0.004) and length

f stay (6.4/9.9 days; p = 0.02) compared with a controlroup who did not routinely receive an interruption of theiredation. A systematic review of the literature by Attia et al.2001) concluded that low dose subcutaneous heparin redu-ed the rate of deep vein thrombosis in ICU patients by 50%ompared with no prophylaxis. Cook et al. (1994) identi-ed an increased risk for upper gastrointestinal bleeding inhe mechanically ventilated patient (odds ratio 15.6) andhus the requirement for stress ulcer prophylaxis. In thistudy the mortality rate in patients who suffered a clini-ally significant bleed was 48.5% compared with 9.1% forll other patients (p < 0.001) (Cook et al., 1994). Supineositioning and the length of time a mechanically venti-ated patient remained in this position were identified asndividual risk factors for aspiration of gastric contents inwo studies (Drakulovic et al., 1999; Torres et al., 1992).hey concluded that positioning a mechanically ventilatedatient in a >30◦ semi-recumbent position reduced this risk.

Despite only one element of the bundle being directlyelated to a reduction in ventilator associated pneumonia

the >30◦ head of bed elevation — implementation ofhis or an adapted cluster of interventions has been shownonsistently to reduce the incidence of ventilator-associatedneumonias across countries (Al-Tawfiq and Abed, 2010;lamoun et al., 2009; Bonello et al., 2008; Hawe et al., 2009;esar et al., 2005; Unahalekhaka et al., 2007; Youngquistt al., 2007). As can be seen from the range of publications,he care bundles concept initiated by the ventilator careundle, has been internationally adopted and widely adap-ed. There are numerous care bundles; many aim to reduceevice related infection such as ventilator acquired pneu-onia (VAP), central venous catheter blood stream infection

CVC-BSI), catheter related urinary tract infection, antibio-ic related infection such as clostridium difficile (c.diff)r are pathway related including weaning from mechani-al ventilation and the sepsis resuscitation and managementare bundles.

trengths of the care bundle approach

here are numerous prospective observational studies thatdentify a positive relationship between patient outcomesnd adherence to a care bundle (Hawe et al., 2009;evy et al., 2010; Muto et al., 2007; Pronovost et al.,006; Resar et al., 2005). Hawe et al. (2009) introdu-ed a locally identified bundle of six interventions forhe prevention of VAP. This included semi recumbent

ositioning, oral anti-sepsis, sub-glottic suctioning, dailyedation breaks, daily assessment of readiness to weannd tubing management. Compliance with the completeundle (0 vs. 54%) and a reduction in VAP rates (19.17 vs.

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D. Dawson, R. Endacott

.5/1000 ventilator days) occurred following a nine monthactive’ period of implementation. The Surviving Sepsisampaign (http://www.survivingsepsis.org) published theirost recent results in 2010 demonstrating an improved com-liance over two years with the resuscitation bundle of0.9% vs. 31.3% (p < 0.0001) and 18.4% vs. 36.1% (p = 0.008)or the management bundle, with an adjusted hospital mor-ality reduction of 5.4% (95% CI 2.5—8.4%) for the sameeriod (Levy et al., 2010).

An outbreak of c.diff. promoted the development ofc.diff. infection control bundle consisting of education,

ncreased and early case finding methodologies, expandednfection control measures, development of a c.diff. mana-ement team and targeted antimicrobial management (Mutot al., 2007). These interventions successfully reduced theate of c.diff. from 7.2 infections/1000 hospital dischargesn 2000 to 3.0/1000 hospital discharges in 2006 (p < 0.001). Aighly publicised study (Pronovost et al., 2006) now adaptedy the National Patient Safety Agency (NPSA) for use acrossngland (http://www.nrls.npsa.nhs.uk/matchingmichigan)emonstrated a mean reduction across 103 ICU’s in Michi-an, United States from 7.7 CVC-BSI/1000 dwell days ataseline to 1.4 at 18 months (p < 0.002). Resar et al. (2005)emonstrated that implementation of the ventilator careundle across 35 ICU’s reduced VAP rates from 5.5 to 2.7er 1000 ventilator days. They report that units with theighest rates of compliance with all aspects of the venti-ator care bundle, as described earlier, demonstrated thereatest reduction. It appears that the bundle approach isore effective than clinical guidelines (Robb, 2010) possi-ly because guidelines may be seen as advisory and careundles are mandatory, although the content of each step inhe bundle may vary: ‘‘. . .a set of steps that experts believere critical, but in many cases the clinical values attachedo each step are locally defined or may change over timeased on evolving research and the experiences of users’’Institute for Healthcare and Improvement, 2004). From annternational perspective, the care bundle approach there-ore allows the bundle to be implemented without beingonstrained by local restrictions, such as staffing or inter-rofessional roles.

The aim of a bundle is to change the underpinning philo-ophy of practice without dictating the precise nature of thentervention; they rely on accumulated evidence packagedogether, which support multidisciplinary teams (MDT) to putesearch evidence or expert opinion if there is no researchvidence, into practice. The bundle approach recogniseshat core clinical interventions, are not always consis-ently applied across all appropriate patients (Masterson,009) and can be a driver to improve the reliability ofhe delivery of evidence based care (Marwick and Davey,009). The range of interventions within a bundle tackleshe problem from a variety of different angles; this mightnclude the use of new devices, an education programme,ew ways of caring for the patient and multi rather thannidisciplinary team involvement (Institute for Healthcarend Improvement, 2010). Commonly, the bundled approachequires technical and adaptive change (Pronovost et al.,

006). Technical elements might include the use of a newype of product such as a silver-coated central venous liner closed system urinary catheter and drainage bag, thentroduction of an audit, an education package, or the

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Implementing quality initiatives

use of a dedicated central line insertion trolley. Adaptivechange describes the alteration in individual and collec-tive behaviour as a result of experience; in the case ofcare bundles, a method of measuring these changes mightinclude examining the importance professionals place onindividual infection control measures before and after theintroduction of technical changes. This flexible approachallows individual units or teams to assess the evidence anddecide which interventions are suitable for their indivi-dual patient groups or possible in their service/team. Forexample, Hawe et al. (2009) included the use of sub-glotticsuctioning in their VAP bundle, for many reasons these spe-cialised endotracheal tubes may not be available in all unitsor in all countries. However, if following successful imple-mentation of the other five elements there was no reductionin VAP, this might then provide an argument for speciali-sed tubes to be made available. Alternatively, the use ofa >30◦ semi-recumbent position would not be appropriatein most patients with suspected or proven spinal or pel-vic injuries, therefore this element would not be measuredin those patients. Having identified the bundle, a stepwiseapproach to implementation, with sustained education ofall staff, avoiding overloading staff with many new initia-tives at the same time, may help improve adherence andthus improve results (Bhutta et al., 2007). To maintain bestpractice over time there is a need to revisit the evidenceto ensure the most recent is utilised. Equally important isthe need to maintain education and feedback to all partici-pants to sustain their interest and compliance with all theinterventions.

Challenges of the care bundle

The flexibility of the bundle approach requires consensusacross the multidisciplinary team (MDT); confusion in carewill arise if individuals or professional groups are managingthe patient in differing ways. This agreement is not onlyrequired to decide that a care bundle approach is to beused to manage an identified problem but also to agree thecomponents and application of that bundle. This generallyrequires a maturity in the team leading and providing carethat may not be achievable in all units, however, a lackof multidisciplinary involvement may limit the successfulimplementation of a bundled approach to care. Even wherethis approach is possible and multidisciplinary team wor-king is sufficiently advanced, implementing care bundles willrequire substantial resources to initiate and review practiceand to achieve and maintain adherence. Rello (2002) sug-gests that adherence amongst medical staff is affected bydisagreement with how individual studies are interpreted,despite this the level of that evidence does not appear tobe linked to adherence. To be effective bundles need to bebased on excellent supporting evidence (Masterson, 2009),however, the success of the bundle approach has lead to lessrobust evidence being combined, reducing the reliability ofthe process. For nursing staff non-adherence is most com-

monly influenced by patient related factors such as the fearof causing discomfort or other adverse events (Ricart et al.,2003). Both staff groups suggest that a lack of resources willdiminish adherence (Rello, 2002; Ricart et al., 2003).

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To ensure that practice remains current, the evidenceupporting the individual components of a care bundleequire regular review (Finfer, 2010). Levy et al. (2010)eport of the outcomes of the sepsis care bundles origi-ally published in 2004 (Dellinger et al., 2004), but updatedo include new evidence in 2008 (Dellinger et al., 2008).atterly this has been updated again to include the latestuidance on glycaemic control following the NICE-SUGARrial results (Finfer et al., 2009). For the sepsis care bundleshis has been achieved by consensus between a large groupf individuals and an organisation, however, expendingimilar resource is not possible in most units. Thereforenternationally or nationally agreed consensus describinghe elements of a bundle should provide an attractivepportunity for individual units. Despite this the reportedompliance with all elements of the sepsis care bundles athe end of the study period was just 31.3% for the resusci-ation bundle and 36.1% for the management bundle, withndividual elements varying from 24.3% for ScvO2 > 70% to3.8% for plateau pressure control (Levy et al., 2010). Thisuggests that either some elements posed a greater chal-enge for those implementing the bundle or there remainedlack of agreement with the evidence as presented. Added

o this tailoring the care bundle either before implementa-ion or during implementation makes it difficult to compareutcomes between study sites.

To mitigate the potential problems posed by the bundlepproach to quality improvement there is a need for conti-uous active engagement with the full ICU MDT. This is bestchieved by identifying a problem that is considered impor-ant enough to put in the necessary resources, that can holdhe interest of the MDT and to set goals that are challengingut achievable. The project will require clear leadershipnd a clear documented plan to maintain intensity andonsistency over time. Cook (2003) reports the requirementor clarity when implementing new practices. Firstly theeed to identify exactly what is to be done and secondlyho is responsible for getting it done. Education will need

o be developed and delivered to a sufficient quantity oftaff, usually greater than 80% to ensure uptake, this edu-ation will need to be repeated for new and novice staffnd repeated to maintain momentum. This can be achievedhrough informal and formal education sessions, but also viaisible reminders such as posters and newsletters. Clear anduditable standards must be applied to each element of aundle, for example is a >30◦ head of bed elevation to beeasured using an angle finder or by eye. If a measuring tool

s used, are the staff trained in its use and if an observationalethod is utilised, has the unit measured rater reliability? To

nderstand compliance and outcome, a baseline followed byegular audit is required; these data could be used to moti-ate staff in elements where they are achieving success, butlso to identify areas that require further work. These cane fed back to the team to identify why these elements areess easily achieved and how they can be improved.

onclusion

he bundle approach to quality improvement has beenroven to be effective across a number of problems, inter-ational boundaries and in a wide variety of ICU’s. The

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undle and the method of implementation can be adaptedo suit individual team and units; however, this can also beweakness of this approach as it limits comparability acrossentres. Having decided that a problem requires addressing,his approach requires a motivated multidisciplinary teamo initiate the bundle, implement change, to achieve andaintain adherence and to review and update the bundle

nd processes.

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