social ‎cognitive ‎theory ‎(bandura ‎ ‎theory)

History.Definition of care bundles.Goals of using care bundles.Characteristics of care bundles. Element of bundle care.

Types of care bundles in ICU.

Ventilator bundle.Central venous catheter care bundle.Sepsis bundles.Eternal feeding bundle.Skin bundle.Urinary Catheter Care Bundle.Surgical site.IV bundle.ABCDEF bundle

IntroductionCare “bundles” are simple sets of evidence-based practices that, when implemented collectively, improve the reliability of their delivery and improve patient outcomes. A number of specific bundles are available that can be implemented at healthcare facilities in resource-limited settings. These packages of care contribute to infection prevention, reduce unnecessary antibiotic prescribing, and may limit the development of antibiotic resistance in healthcare facilitiesHistory

Care bundles were first developed over 20 yrs. ago. They have been used in a number of different medical and surgical specialties and have been used particularly extensively in cardiology.

Interest in the application of care bundles to critical care developed in the late 1990s and early years of this century. This was fuelled by the publication of an early goal-directed therapy study in the treatment of severe sepsis and septic shock. Although this study is now considered controversial, it generated much interest at the time because the apparent improvement in outcomes it demonstrated came about as the result of implementation of a protocol involving a number of distinct elements which could be regarded as (or in a more general sense, delivered as) a care bundle.Bundles formed a key part of the ‘100 000 Lives Program’ (2004) and the ‘5 Million Lives Campaign’ (2006) introduced by the Institute for Healthcare Improvement. These were aimed at increasing patient safety and improving quality of care in a variety of clinical conditions. In critical care medicine, these included sepsis, cardiac, and respiratory failure. On the international scene, bundles have also been strongly promoted in critical care. A key example of this is the Surviving Sepsis campaign. This international collaborative initiative aimed to design and implement a care bundle approach to improve survival from severe sepsis by 25% by the year 2009. The success of all three care bundle programmers described above has led to further enthusiasm and interest in intensive care bundles for the management of a wider range of conditions in the future.(Jan owen,FRCA,Robjohn).Definition:

·         It is a set of interventions that, when used together, significantly improve patient outcomes. Multidisciplinary teams work to deliver the best possible care supported by evidence-based research and practices, with the ultimate outcome of improving patient care. (Mc carron,kim MS ,CRNP ) .

 

·        A bundle is a structured way of improving the processes of care and patient outcomes: a small, straightforward set of evidence-based practices — generally three to five — that, when performed collectively and reliably, have been proven to improve patient outcomes.

 

v Goals of using care bundles

§  Promote consistency in the management of clinical conditions using evidence-based practices.

§  Improved outcomes and decreased complications.

§  Accountability.

§  Delivery of best practice.

§  Reduction of unwarranted clinical variation.

§  Efficient use of resources.

§  Improve patient care.

§  Prevent avoidable mortality.

§  Reduce length of stay and/or complications.

§  Job satisfaction.

 

·        Characteristics of a Bundle

·        Collection of practices or processes.

·        With approximate time and space characteristics.

·        Best practices based on existing level 1 or 2 research evidence –“standard of care”.

·        Individual component improves care, but when applied together result in even greater improvement.

·        Bundle components are dichotomous: yes/no answers.

·        Bundle compliance measured as “all or none emphasis initially on process rather than outcome.

·        Eventual endpoint is outcome Improvement.

 

Element of bundle care

·        A care bundle consists of a group of (usually) between three and five evidence-based interventions.

·        Care bundles require continuous re-evaluation and periodic updating. Interventions are grouped together in this way, on the assumption that the interventions, when executed together, result in better outcomes than would be the case if they were implemented individually.

·        Each intervention should be widely accepted as good practice in its own right, and widely applicable.

·        A key principle of care bundles is that there should be a high level of adherence to all components. In essence, unless there is a clear reason for clinical variance, all elements should be implemented in every patient 100% of the time.

·        The audit of care bundles assesses the delivery of interventions, rather than how well these are performed.

·        Most elements of care bundles used in critical care are delivered within the critical care environment. For bundles to deliver maximum effectiveness, it may be necessary to commence them before the patient reaches the critical care unit and to continue them out with the critical care environment. This can include periods of patient transfer to other clinical care environments such as the operating theatre or radiology suite, or after final discharge or step down from the critical care unit. (Jan owen,FRCA,Robjohn).

 

Types of care bundles

§  Ventilator bundle.

§  Central venous catheter care bundle.§  Sepsis bundles.§  Eternal feeding bundle.§  Skin bundle.§  Urinary Catheter Care Bundle.§  IV line.§  ABCDEF bundle.   

The bundle was created to prevent complications associated with mechanical ventilation, specifically ventilator-associated pneumonia (VAP). This hospital-acquired pulmonary infection develops more than 48 hours following intubation and may be prevented or delayed using specific interventions.

 

The ventilator bundle comprises five core components:

·       Elevating the head of the bed between 30 and 45 degrees

Elevation of the head of the bed is an integral part of the ventilator bundle and has been correlated with reduction in the rate of ventilator-associated pneumonia. The recommended elevation is 30-45 degrees.

While it is not immediately clear whether the intervention aids in the prevention of ventilator-associated pneumonia by decreasing the risk of aspiration of gastrointestinal contents or oropharyngeal and nasopharyngeal secretions, this was the main reason for the initial recommendation.

 

·        Daily “sedation interruption” and daily assessment of readiness to extubate

For the purpose of assessing whether the patient can breathe independently of the ventilator.

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·       Administering medications to prevent gastric ulceration

Patients with respiratory failure have an increased risk of “stress ulcers” and associated gastrointestinal (GI) bleeding. Medications that reduce gastric acidity have been shown to protect such patients from the development of peptic ulcer and GI bleeding.

 

·       Administering deep vein prophylaxis

Patients with respiratory failure have an increased risk of DVT. Treatment with anticoagulants has been shown to reduce this risk.

While it is unclear if there is any association with decreasing rates of ventilator acquired pneumonia, but when applied as a package of interventions for ventilator care, the rate of pneumonia decreases precipitously.

 

·       Daily Oral Care with Chlorhexidine

Dental plaque develops in patients that are mechanically ventilated because of the lack of mechanical chewing and the absence of saliva, which minimizes the development of biofilm on the teeth. Dental plaque can be a significant reservoir for potential respiratory pathogens that cause ventilator-associated pneumonia (VAP). 0.12% Chlorhexidine antiseptic has long been approved as an inhibitor of dental plaque formation and gingivitis.

 

These interventions should be implemented together with standard precautions (hand hygiene and use of gloves when handling respiratory secretions) as well as adequate disinfection and maintenance of equipment and devices.21 Other components of the VAP bundle may include:

• Utilization of endotracheal tubes with subglottic secretion drainage (only for patients ventilated for longer than 24 hours).

 

·       Care of tube

·        Maintain level of water in humifier.

·        Do not routinely change ventilator circuits; change when visibly soiled or a mechanical malfunction has occurred.

·        Change closed in-line suction catheter every 72 hours.

 

·        Change the heat, moisture exchange filter (HMEF) every 48 hours.

·        Periodically drain and discard condensation in tubing of the mechanical ventilation circuit.

 

v Central venous catheter care bundle

Central lines are used commonly in intensive care units (ICUs) and in non ICU populations such as dialysis units, intraoperatively, and oncology patients.

Most hospital-acquired bloodstream infections are associated with a central line. Central line associated blood steam infection   (CLABSIs)  are responsible for excess mortality and morbidity, prolonged hospital stays, and increased costs. CLABSI incidence is higher in low income countries.

The central line bundle comprises the following components:Insertion Bundle:

·        Insert central venous catheter as need.

·        Assess skin site.

·        Assess level of consciousness of patient.  

·        Maximal sterile barrier precautions (surgical mask, sterile gloves, cap, sterile gown, and large sterile drape).

·        Skin cleaning with alcohol-based chlorhexidine (rather than iodine).

·        Dedicated staff for central line insertion, and competency training/assessment.

·        Avoiding central line insertion into the femoral vein. The femoral site is associated with greater risk of infection in adults

·        Standardized insertion packs.

·        Availability of insertion guidelines (including indications for central line use) and use of checklists with trained observers.

·        Use of ultrasound guidance for insertion of internal jugular lines.

·        CXR after insertion.

Maintenance Bundle:

·        Daily review of central line necessity.

·        Prompt removal of unnecessary lines.

·        Check patency of C.V.C (central venous Cather).

·        Disinfection prior to manipulation of the line.

·        Daily chlorhexidine washes (in ICU, patients > 2 months).

·        Disinfect catheter hubs, ports, connectors, etc., before using the catheter.

·        Change dressings and disinfect site with alcohol-based chlorhexidine every 24 hours (change earlier if soiled).

 

These activities need to be integrated in a multi-modal approach including hand hygiene, clinician and nurse education.

 

Sepsis bundles

Sepsis is the fourth biggest killer disease in the world. A protocoled manner of managing sepsis has been shown to reduce mortality. The sepsis bundles were developed by Sepsis Campaign, an international forum convened to examine the effect of sepsis, severe sepsis, and septic shock. The two bundles are the sepsis resuscitation bundle and the sepsis management bundle.

 

The sepsis management bundle consists of interventions that must be performed within 24 hours of the diagnosis of severe sepsis or septic shock.

 These interventions include:

 

·       Administer Low Dose Steroid by a standard Policy.

Intravenous hydrocortisone (200-300 mg/hour) preferably as a continuous infusion or in 3-4 divided doses for 7 days is suggested for adult patients with septic shock in whom blood pressure is refractory to fluid resuscitation and vasopressor therapy.

·       Maintain adequate glycemic control

Present recommendation is to use a protocoled approach to blood glucose management of patients in ICU with severe sepsis. Intravenous insulin infusion should be started when two consecutive blood glucose level is 180 mg/dl or more.

  

·        Prevent excessive Inspiratory Plateau pressure.

     Present recommendations for septic patients on mechanical ventilation are to target a tidal volume of 6 ml/kg of predicted body weight in patients with different severity of acute respiratory distress syndrome.

 

·       Administering recombinant human active protein C, according to a stander ICU policy.

The resuscitation bundle is a set of evidence-based interventions delivered within 6 hours of recognition of severe sepsis:

ü Measuring Lactate levels. Hyperlactatemia due to anaerobic metabolism and tissue hypo perfusion is usually present in severe sepsis and septic shock and is an important prognostic marker.

ü

 

ü Improve time to broad spectrum antibiotics.

     Every hour delay of starting empirical broad spectrum antibiotic increases mortality in severe sepsis and shock.

 

ü Treat hypotension. All patients of sepsis presenting with hypotension, should be aggressively resuscitated with fluids. Recent surviving sepsis guidelines recommend crystalloid resuscitation over colloids. An initial fluid challenge of 1000 ml of crystalloid (normal saline or Ringers solution) to achieve a minimum of 30 ml/kg of fluid should be given in the first 4-6 hours.

 

ü Apply vasopressors for ongoing hypotension when an appropriate fluid challenge fails

    To restore an adequate arterial pressure and organ perfusion therapy with vasopressor agents. Current recommendation for the choice of vasopressor is intravenous norepinephrine infusion titrated to an appropriate Mean Arterial Pressure.

 

ü Maintain adequate Central Venous Pressure

  Early goal directed therapy for resuscitating severe sepsis patients have an essential component of continuing fluid resuscitation to achieve a CVP of 8-10 mm Hg in non-mechanically ventilated patient.

 

Eternal feeding bundle (nasogastric tube, gastrostomy tube).

Enteral Nutrition Therapy (ENT) plays a key role in the state of intense lipid and protein catabolism, also called metabolic response to stress, a common state in the critically ill patient, mainly present in the acute phase of the disease. This metabolic reaction is considered physiological, because it is through protein mobilization that the injury repair and energy supply occur for the maintenance of organic functions.

However, the nutritional depletion in intensive care leads to a negative clinical outcome, because it changes the tissue composition and the function of organs and structures, impairs the immune response, compromises the healing process, predisposes individuals to nosocomial infections, increases the incidence of pressure ulcers, and thereby results in greater morbidity and mortality in the intensive care unit (ICU).

ü Before insertion:-         Assess indication of insertion.-         Assess doctor order.-         Assess level of consciousness.-         Assess trial of oral feeding.-         Assess site of insertion.ü After insertion·        Position must be checked post insertion through :Ø Aspiration gastric content.Ø Air auscultation.Ø PH test.Ø Radiological check ·        Position checks each shift, before feeding.·        Check feeding formula.·     Irrigate tube with 30cm water after feeding   .·       Avoid change position after feeding.·       Avoid suction after feeding. Skin bundle    The SKIN Bundle was developed in 2004 at St Vincent’s Medical Centre, a 528-bed hospital in Florida, US. It was introduced in Wales in 2009 through Transforming Care, a ward-based programmer for Wales that aimed to improve patient care by reducing pressure ulcer.

 

Pressure ulcer prevention bundle (SSKIN)

ü Skin:

Skin inspection and assessment should occur once during each shift in the ICU, or more frequently in patients.

 

ü Surface·        Select correct mattress according to Trust guidelines·        Use a pressure reducing cushion when sat up in a chair·        Do not use multiple layers under patient·        Keep sheets free of wrinkles, ensure top sheet not tight over feet

·       

·        Check air-mattress/cushion and power box for faults at each repositioning·        Reassess pressure ulcer risk and equipment requirements dailyü Keep Moving·        Reposition patient every 2- hrs. when in bed (minimum every 4 hours)·        Shift patients' weight at least every 2 hours if in chair.·        Document position changes on repositioning chart.·        Inspect skin and document at every position change, or once every 24 hours if patient moves unaided in nursing notes.ü Incontinence·        Offer toileting assistance regularly according to individual need.·        For patients with intractable incontinence use well-fitting continence products. Wash skin daily and when visibly soiled·        Do not use oil based creams with continence products.ü Nutrition·        Complete Nutritional Risk Assessment.·        Ensure optimal nutritional intake.·        Keep patient well hydrated.

 

 

Urinary Catheter Care Bundle

Nurses are expected to take a key role in implementing the bladder bundle, given that the insertion, care, and maintenance of the indwelling catheter falls most often on nursing personnel.

 

ü Avoiding the use of urinary catheters by considering alternative methods for urine collection. Methods include: condom, intermittent catheterization.

ü Assess doctor order.

ü Assess patient need for catheter.

ü  Using an aseptic technique for insertion and proper maintenance after insertion.

·         Hand hygiene (Immediately before and after).

·        Clean the urethral meatus, With sterile normal saline or sterile water

·        Sterile, closed drainage system

 

ü  Following evidence-based guidelines and implementing catheter insertion policies at the institution.

ü Daily intake and out chart.

ü Daily assessment of the presence and need for indwelling urinary catheters.

·        Need to closely monitor urine output in unstable patients.

·        To assist perineal wound care.

·        Document Date, catheter size.

·        Change folly catheter after 14 day.

 

Bundle for the prevention of surgical site infection (SSI)

 SSIs are infections of the incision or organ or space that occur after surgery.

ü Administration of parenteral antibiotic prophylaxis.

·          Antibiotic prophylaxis should be administered within 60 minutes prior to incision, including for Cesarean section.

·        Re-dosing is recommended for prolonged procedures and in patients with major blood loss or excessive burn.

ü Patients should be washed with soap or an antiseptic agent within a night prior to surgery.

ü Hair removal at incision site.

ü Use alcohol-based disinfectant for skin preparation in the operating room.

ü Assessment to wound for sings and symptoms of infection.

I.V line bundle

ü Assess need for I.V line.

ü Assess site

ü Assess I.V line size.

ü Check place and patency of I.V line.

ü Dress I.V line with document date and time.

ü Change dressing daily.

ü Assess skin for signs and symptoms of inflammation.

ü Change I.V line every 3 days.

 ABCDEF bundle :

Ø Assess, prevent and mange pain.

§  Assessment of pain is the first step before administering pain relief.

§  IV opioids should be considered as the first-line drug class of choice for non-neuropathic pain.

§  Relaxation and/or distraction techniques.

§  Massage/touch.

§  Music therapy.

§  Both Spontaneous Awakening Trials (SAT) and Spontaneous Breathing Trials (SBT).

§  To enable successful implementation of SATs and SBTs, it is important to create an inter professional team.

§  Depth and quality of sedation should be routinely assessed in all ICU patients.

§  The SBT safety screen includes evaluation of the need for ventilator support; this helps facilitate ventilation weaning and decreases reintubation rates.

 

Ø Choice of Analgesia and Sedation

 

§  Patients should be routinely assessed for pain.

§  Nonpharmacological strategies play an important role in managing pain .

§  IV opioids should be considered first-line analgesics for the treatment of non-neuropathic pain.

 

Ø Delirium: Assess, Prevent and Manage

Delirium is identified by the following key features:

-         Disturbance in attention and awareness

-         Disturbance in cognition (e.g., memory, disorientation, language, and perception)

-         Development over a short period of time and tendency to fluctuate during the day.

§  Routinely monitor for delirium in all adult ICU patients.

-         Confusion Assessment Method for the ICU (CAM-ICU).

-         Intensive Care Delirium Screening Checklist (ICDSC).

§  Stop (consider sedatives, review medications and plan to reduce drug exposure)

§  THINK (Toxic situations, Hypoxemia, Infection/nosocomial sepsis, Immobilization, , K+ or other electrolyte disturbances)

§  Medicate (guideline suggests non benzodiazepine sedatives.

 

Ø Early Mobility and Exercise

  

Step 2: Initiate bed exercise. Watch the patient, watch the monitor, and watch the lines. 

Step 3: Sit the patient on the edge of the bed. Assess for pain and orthostatic blood pressure.

Step 4: Assist seated patient in standing.

Step 5: Initiate walking. Keep a chair close to the patient. Utilize aides, volunteers and students to push chair and intravenous poles.

Step 6: Seat and rest the patient as needed.

  

Ø Family Engagement and Empowerment.

·        Keeping patients and families informed

·        Actively involving patients and families in decision-making

·        Actively involving patients and families in self-management

·        Providing both physical comfort and emotional support to patient and families

·        Maintaining a clear understanding of patients’ concepts of illness and cultural beliefs.