Patient safety bundles for critical care Richard H. Savel, MD, FCCM Montefiore Critical Care.

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Patient safety bundles for critical care Richard H. Savel, MD, FCCM Montefiore Critical Care

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Transcript of Patient safety bundles for critical care Richard H. Savel, MD, FCCM Montefiore Critical Care.

Page 1: Patient safety bundles for critical care Richard H. Savel, MD, FCCM Montefiore Critical Care.

Patient safety bundles for critical care

Richard H. Savel, MD, FCCMMontefiore Critical Care

Page 2: Patient safety bundles for critical care Richard H. Savel, MD, FCCM Montefiore Critical Care.

Bundles, According to the IHI:

• A "bundle" is a group of evidence-based care components for a given disease that, when executed together, may result in better outcomes than if implemented individually.

Page 3: Patient safety bundles for critical care Richard H. Savel, MD, FCCM Montefiore Critical Care.

Bundles, According to the IHI:

• In a bundle, the individual elements are built around best evidence-based practices.

• The science supporting the individual treatment strategies in a bundle is sufficiently mature such that implementation of the approach should be considered either best practice or a reasonable and generally accepted practice.

Page 4: Patient safety bundles for critical care Richard H. Savel, MD, FCCM Montefiore Critical Care.

IHI Critical Care Bundles

• Ventilator Bundle

• Central Line Bundle

• Severe Sepsis Bundles

Page 5: Patient safety bundles for critical care Richard H. Savel, MD, FCCM Montefiore Critical Care.

VAP BUNDLE

http://www.ihi.org/IHI/Topics/CriticalCare/IntensiveCare/Changes/ImplementtheVentilatorBundle.htm

Page 6: Patient safety bundles for critical care Richard H. Savel, MD, FCCM Montefiore Critical Care.

IHI patient safety bundles

• Ventilator-Associated Pneumonia (VAP)Bundle:

–DVT prophylaxis–GI prophylaxis–Head of bed (HOB) elevated to 30-45–Daily Sedation Vacation–Daily Spontaneous Breathing Trial

connected

Page 7: Patient safety bundles for critical care Richard H. Savel, MD, FCCM Montefiore Critical Care.

DVT prophylaxis: tips• Include deep venous prophylaxis as part of your ICU order admission set

and ventilator order set. Make application of prophylaxis the default value on the form.

• Include deep venous prophylaxis as an item for discussion on daily multidisciplinary rounds.

• Empower pharmacy to review orders for patients in the ICU to ensure that some form of deep venous prophylaxis is in place at all times on ICU patients.

• Post compliance with the intervention in a prominent place in your ICU to encourage change and motivate staff.

Page 8: Patient safety bundles for critical care Richard H. Savel, MD, FCCM Montefiore Critical Care.

GI prophylaxis: tips• Include peptic ulcer disease prophylaxis as part of your ICU

order admission set and ventilator order set. Make application of prophylaxis the default value on the form.

• Include peptic ulcer disease prophylaxis as an item for discussion on daily multidisciplinary rounds.

• Empower pharmacy to review orders for patients in the ICU to ensure that some form of peptic ulcer disease prophylaxis is in place at all times on ICU patients.

• Post compliance with the intervention in a prominent place in your ICU to encourage change and motivate staff.

Page 9: Patient safety bundles for critical care Richard H. Savel, MD, FCCM Montefiore Critical Care.

Head of Bed elevation: tips I• Implement a mechanism to ensure head-of-the-bed

elevation, such as including this intervention on nursing flow sheets and as a topic at multidisciplinary rounds.

• Create an environment where respiratory therapists work collaboratively with nursing to maintain head-of-the-bed elevation.

• Involve families in the process by educating them about the importance of head-of-the-bed elevation and encourage them to notify clinical personnel when the bed does not appear to be in the proper position.

Page 10: Patient safety bundles for critical care Richard H. Savel, MD, FCCM Montefiore Critical Care.

Head of Bed elevation: tips II

• Use visual cues so it is easy to identify when the bed is in the proper position, such as a line on the wall that can only be seen if the bed is below a 30-degree angle.

• Include this intervention on order sets for initiation and weaning of mechanical ventilation, delivery of tube feedings, and provision of oral care.

• Post compliance with the intervention in a prominent place in your ICU to encourage change and motivate staff.

Page 11: Patient safety bundles for critical care Richard H. Savel, MD, FCCM Montefiore Critical Care.

Daily sedation vacation/Spontaneous Breathing Trials: tips I

• Implement a protocol to lighten sedation daily at an appropriate time to assess for neurological readiness to extubate. – Include precautions to prevent self-extubation such

as increased monitoring and vigilance during the trial.

• Include a sedation vacation strategy in your overall plan to wean the patient from the ventilator– if you have a weaning protocol, add "sedation

vacation" to that strategy.

Page 12: Patient safety bundles for critical care Richard H. Savel, MD, FCCM Montefiore Critical Care.

Daily sedation vacation/Spontaneous Breathing Trials: tips II

• Assess that compliance is occurring each day on multidisciplinary rounds.

• Consider implementation of a sedation scale such as the Riker scale to avoid oversedation.

• Post compliance with the intervention in a prominent place in your ICU to encourage change and motivate staff.

Page 13: Patient safety bundles for critical care Richard H. Savel, MD, FCCM Montefiore Critical Care.

Central Line BUNDLE

http://www.ihi.org/IHI/Topics/CriticalCare/IntensiveCare/Changes/ImplementtheCentralLineBundle.htm

Page 14: Patient safety bundles for critical care Richard H. Savel, MD, FCCM Montefiore Critical Care.

IHI patient safety bundles

• Central line bundle:– Hand Hygiene – Maximal Barrier Precautions Upon Insertion – Chlorhexidine Skin Antisepsis – Optimal Catheter Site Selection, with Avoidance of

the Femoral Vein for Central Venous Access in Adult Patients

– Daily Review of Line Necessity with Prompt Removal of Unnecessary Lines

Page 15: Patient safety bundles for critical care Richard H. Savel, MD, FCCM Montefiore Critical Care.

Hand Hygiene: tips I• Empower nursing to enforce use of a central line

checklist to be sure all processes related to central line placement are executed for each line placement.

• Include hand hygiene as part of your checklist for central line placement.

• Keep soap/alcohol-based hand washing dispensers prominently placed and make universal precautions equipment, such as gloves, only available near hand sanitation equipment.

Page 16: Patient safety bundles for critical care Richard H. Savel, MD, FCCM Montefiore Critical Care.

Hand Hygiene: tips II• Post signs at the entry and exits to the patient room as

reminders.

• Initiate a campaign using posters including photos of celebrated hospital doctors/employees recommending hand washing.

• Create an environment where reminding each other about hand washing is encouraged.

• Signs often become "invisible" after just a few days. Try to alter them weekly or monthly (color, shape size).

Page 17: Patient safety bundles for critical care Richard H. Savel, MD, FCCM Montefiore Critical Care.

Maximal Barrier Precautions Upon Insertion: tips

• Empower nursing to enforce use of a central line checklist to be sure all processes related to central line placement are executed for each line placement.

• Include maximal barrier precautions as part of your checklist for central line placement.

• Keep equipment ready stocked in a cart for central line placement to avoid the difficulty of finding necessary equipment to institute maximal barrier precautions.

Page 18: Patient safety bundles for critical care Richard H. Savel, MD, FCCM Montefiore Critical Care.

Chlorhexidine skin antisepsis: tips• Empower nursing to enforce use of a central line checklist

to be sure all processes related to central line placement are executed for each line placement.

• Include Chlorhexidine antisepsis as part of your checklist for central line placement.

• Include Chlorhexidine antisepsis kits in carts storing central line equipment. Many central line kits include povidone-iodine kits and these must be avoided.

• Ensure that solution dries completely before an attempted line insertion.

Page 19: Patient safety bundles for critical care Richard H. Savel, MD, FCCM Montefiore Critical Care.

Optimal catheter site selection: tips

• Empower nursing to enforce use of a central line checklist to be sure all processes related to central line placement are executed for each line placement.

• Include optimal site selection as part of your checklist for central line placement with room for appropriate contraindications (e.g., bleeding risks).

Page 20: Patient safety bundles for critical care Richard H. Savel, MD, FCCM Montefiore Critical Care.

Daily review of Lines/Prompt removal: tips

• Empower nursing to enforce use of a central line checklist to be sure all processes related to central line placement are executed for each line placement.

• Include daily review of line necessity as part of your multidisciplinary rounds.

• Include assessment for removal of central lines as part of your daily goal sheets.

• Record time and date of line placement for record keeping purposes and evaluation by staff to aid in decision making.

Page 21: Patient safety bundles for critical care Richard H. Savel, MD, FCCM Montefiore Critical Care.

Severe Sepsis BUNDLES

http://www.ihi.org/IHI/Topics/CriticalCare/Sepsis/Changes/

Page 22: Patient safety bundles for critical care Richard H. Savel, MD, FCCM Montefiore Critical Care.

IHI severe sepsis bundles

• The sepsis resuscitation bundle

• The sepsis management bundle

Page 23: Patient safety bundles for critical care Richard H. Savel, MD, FCCM Montefiore Critical Care.

Sepsis resuscitation bundle

• describes seven tasks that should begin immediately, but must be accomplished within the first 6 hours of presentation for patients with severe sepsis or septic shock.

• Some items may not be completed if the clinical conditions described in the bundle do not prevail in a particular case, but clinicians should assess for them.

• The goal is to perform all indicated tasks 100 percent of the

time within the first 6 hours of identification of severe sepsis.

Page 24: Patient safety bundles for critical care Richard H. Savel, MD, FCCM Montefiore Critical Care.

Sepsis management bundle

• Lists four management goals.

• Efforts to accomplish these tasks should also begin immediately.

• These items may be completed within 24 hours of presentation for patients with severe sepsis or septic shock

Page 25: Patient safety bundles for critical care Richard H. Savel, MD, FCCM Montefiore Critical Care.

Sepsis resuscitation bundle: details• Serum lactate measured• Blood cultures obtained prior to antibiotic

administration• Improve time to broad-spectrum antibiotics• Treat hypotension and/or elevated lactate with

fluids• Apply vasopressors for ongoing hypotension• Maintain adequate central venous pressure• Maintain adequate central venous oxygen

saturation

Page 26: Patient safety bundles for critical care Richard H. Savel, MD, FCCM Montefiore Critical Care.

Sepsis management bundle: details

• Administer Low-Dose Steroids by a Standard Policy

• Administer Drotrecogin Alfa (Activated) by a Standard Policy

• Maintain Adequate Glycemic Control

• Prevent Excessive Inspiratory Plateau Pressures

Page 27: Patient safety bundles for critical care Richard H. Savel, MD, FCCM Montefiore Critical Care.

Critical Care Bundle: Conclusions

• Listed the contents of the IHI Critical Care bundles– VAP– Central Line– Severe Sepsis

Page 28: Patient safety bundles for critical care Richard H. Savel, MD, FCCM Montefiore Critical Care.

Critical Care Bundle: Conclusions

• More and more data that the use of these patient-safety bundles are associated with improved outcomes

• some clinicians disagree with the validity of the combined content

• Nevertheless, it is becoming part of standard practice for us to document our awareness of these national patient-safety initiatives

Page 29: Patient safety bundles for critical care Richard H. Savel, MD, FCCM Montefiore Critical Care.

END

• Questions?


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