ICU uses 'bundles' to make huge improvements
Initiatives spurred by IHI collaborative
The ICU at Baptist Memorial Hospital in Desoto, MS, has reduced its rate of ventilator-associated pneumonias (VAPs) from 7.6% to 0.73%, has had only three in the last 24 months, and at one point went 14 months without any. Its urinary tract infection rate has gone from 5.7% to virtually zero, with only one infection in the last two years.
How did they do it? By employing a technique called bundling. "A bundle," explains Darla G. Belt, RN, director of quality review services, "is a grouping of best practices that have been individually proven to improve quality in a certain area."
What the staff operate on are not protocols per se, but a certain group of steps proven to be successful if done consistently over a period of time for the same population, adds Belt.
Learning from IHI
Belt first learned about bundles when Baptist Memorial participated in the Institute for Health-care Improvement's (IHI) ICU collaborative about six years ago. "Then, a year later, we came back to another convention where they talked about bundles and we got very deeply involved," she recalls. "We began assembling benchmarking data, and now, we may be the first facility to have benchmarked for five years of bundles."
What attracted Belt to the technique? "It really made sense to us," she says. "We were in the process of trying to change our whole organizational culture and mindset around nosocomial infections." In the past, she notes, these infections were considered things that naturally happened in the ICU. "We tried to change our mindset so that they were not considered a natural part of ICU practice but events that generally could be prevented."
After identifying the first three initiatives — central-line infections, VAPs, and urinary tract infections — "We took the steps outlined by IHI," says Belt.
So, for example, the central-line infection bundle has six major steps:
- MD and all staff assisting with insertion must disinfect hands before procedure.
- MD must wear mask, sterile gown, sterile gloves, and cap.
- All personnel assisting with procedure must wear gloves and mask. Patient also should don mask.
- Prep site with Chlorhex prep stick.
- Drape site with sterile drape.
- Dress site immediately with CVC (central venous catheter) sterile dressing kit and apply bio-patch medicated disc to site.
Although there was an outline provided, the staff had to make adjustments for their specific needs. For example, notes Belt, since a maximum barrier was required, they had to not only train the nursing staff but also had to provide an accessible protective gear package. "We started with a cart, but you had to go get that, so we came up with a package of everything that was needed in central line sterilization and placed it in readily accessible areas wherever patients might have a central line," she says.
Working with staff
Since bundling represented an entirely new concept for the staff, it was important for them to adapt the new technique to their regular practices. "For example, we had already been doing multidisciplinary rounds," notes Belt. "There would be a meeting every morning at 10 involving anyone who had anything to do with the patient, such as the charge nurse, the intensivist, the patient's nurse, the dietitian, and so forth. So, bundles maintenance became part of that rounding."
The maintenance involved verification that all steps were current and correctly met. "If they are not, the rounding team does education right on the spot with staff," says Belt. "That is led by the intensivist."
The key steps to follow in order to ensure success, says Belt, are education, accessibility, and daily monitoring to ensure compliance. "For example, in VAP you have to make sure the bed is at 30 degrees. There is a mercury-based ballast that can show the angle, but it's not that easily visible. So, we put large red arrows on the wall to show the correct level."
Mouth care, she continues, must be done every two hours. "The charge nurses make the assignments as to who will do the care; consistency is the absolute key," she notes.
The bottom line, says Belt, is that the mission must be transmitted to the entire staff. "A quality leader's job is never done until the medical staff and the line staff can stand up and speak for organizational quality with the same effectiveness that you can," she asserts.
A replicable process
Belt says you don't have to have a certain type of facility or be of a certain size to successfully implement bundling. "I absolutely believe any sort of facility can provide this level of care; it is not restricted by budget or staff size," she observes.
For every such project she takes on, says Belt, she tries to make a business case.
"For example, we've been able to reduce length of stay by two days," she says. "Any expense incurred from purchasing the silver-coated catheters we needed, for example, is more than offset by the decrease in the reduction in the number of costly antibiotics given and days in the hospital."
Having demonstrated such success in the ICU, Belt was able to expand the bundling techniques to the entire facility a couple of years ago. "Anywhere there is a central line, or a Foley catheter, staff is expected to follow the steps," she says. "They look every day to see when the line or catheter is ready to come out; the sooner, the better. And we now conduct multidisciplinary rounds on the med/surg unit."
The ICU at Baptist Memorial Hospital in Desoto, MS, has reduced its rate of ventilator-associated pneumonias (VAPs) from 7.6% to 0.73%, has had only three in the last 24 months...You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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