icu bundles

8/4/2019 Icu Bundles

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ICU Interventions to Improve

Care


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Why This Talk?

Quality improvement is rewarding

Change culture

Reasons for reluctance

Dont believe the data Bundles are not necessary

Do not want to be told how to practice medicine

Inconvenient

Too much time Too many mandates and protocols already

Will be used to punish physicians if not incorporated


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ICU Bundles

A "bundle" is a group of interventionsrelated to a disease process that, whenexecuted together, result in better

outcomes than when implementedindividually.

www.ihi.org.


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ICU Checklist / Goal Sheet

Checklists serve as a daily reminder to aset tasks or processes that improve thedelivery of care but are not necessarilylinked or bundled together


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Why bundles and checklists?

Ensures best medicine is applied withcomplete consistency

The consistent application of establishedbest practices leads to improved outcomesand decreased complications

Accountability


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ICU Interventions

Ventilator Bundle

Central Line Bundle

Sepsis Bundle*

Multidisciplinary rounds

Daily Checklist / Goal sheet

Glucose Control*

Sedation/analgesia

Delirium


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Ventilator Bundle

Elevation of the Head of the Bed

Daily interruption of sedation andassessment of readiness to wean

Peptic Ulcer Disease Prophylaxis

Deep Venous Thrombosis Prophylaxis

Daily Oral Care with Chlorhexidine


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Results of Implementation

After institution of ventilator bundle VAPrates decreased from 2.7 - 8.2 per 1000MV days to 0.0 - 3.3 per 1000 MV days.

Benefis Medical Center


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Ventilator Bundle Tips

Daily interruption of sedation protocol

Coordinate interruption of sedation withweaning protocol

Use of validated sedation scale Incorporate other ICU staff

Use visual cues

Standardized order sets

Checklists / multidisciplinary rounds


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Central Line Bundle

Appropriate hand hygiene

Chlorhexidine skin prep

Maximal barriers for central line insertion Subclavian vein placement is preferred

site

Review lines daily and removeunnecessary catheters

MMWR 2002;51(No. RR-10):1-36


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Improvement

1500 ICU months and 300,000 catheter-daysduring the sustainability period were reported

Mean rate of catheter-related bloodstream

infections Baseline; 7.7 per 1000 catheter-days

16-18 months; 1.4 per 1000 catheter-days

34-36 months; 1.1 per 1000 catheter-days N Engl J Med2006; 355:2725

BMJ2010 Feb 4; 340:c309


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Tips

Rigorous staff education

Central line checklist

Keep all necessary equipment in an easily

accessible cart Empower nursing to enforce use of a central line

checklist

Include daily review of line as part of

multidisciplinary rounds and daily goals sheet Easy to find record of date and time of

placement


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Central Line Checklist


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Prevention of Catheter Infections

Antiseptic- or antibiotic-impregnated CVC

Anti-infective lock

Chlorhexidine-impregnated spongedressing


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Sedation and Analgesia

Protocol-directed sedation

Use of validated sedation scale

Bolus doses of benzodiazepines instead ofa continuous infusion

Sedatives with a short duration of action

Daily interruption of sedation (DIS) alsoreferred to as spontaneous awakeningtrials


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Daily Interruption of SedationBenefits

Decrease ventilator days

Decrease LOS ICU and Hospital

Decrease complication, i.e. VAP Decreased medication complications

Decreased delirium

Decreased cost of care


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Barriers and Tips

Barriers

Lack of nursing acceptance

Time constraints

Perceived patient safety Long-term psychological sequelae

Tips

Education

Involve nursing and support staff in development ofprotocols

Success breeds success


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No sedation

A Protocol of No Sedation For Critically Ill PatientsReceiving Mechanical Ventilation: A Randomized Trial

Strom T, Martinussen T, Toft P Lancet. 2010;375:475-480

140 mechanically ventilated adult patients randomized in

an unblinded manner to receive either no sedation orsedation

Patients in both groups received intravenous morphineas needed for analgesia

No sedation had significantly more days withoutventilation (13.8 days vs 9.6 days), shorter stay in theintensive care unit and in the hospital

Agitated delirium and haloperidol use were morefrequent in the no sedation group


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Early ICU Mobility

Decreases time on ventilator Decreases LOS ICU Decreases LOS hospital

Decreased delirium Decreased use of benzodiazepines andnarcotics

Improves functional ability at time of discharge

Improved feeling of wellbeing (standardizedquestionnaires) Safe: no difference in complications


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Data

Early activity is feasible and safe in respiratory failure patients Crit Care Med 2007;35:139

Early exercise in critically ill patients enhance short-term functional recovery Crit Care Med 2009; 37:2499

Early intensive care unit mobility therapy in the treatment of acuterespiratory failure Crit Care Med 2008; 36:2238

Needham DM, et al. Early physical medicine and rehabilitation for patientswith acute respiratory failure: A quality improvement project. Arch Phys Med Rehabil. 2010; 91:536-542

Early intensive care unit mobility therapy in the treatment of acuterespiratory failure

Critical Care Med 2008, 36: 2238 Early physiotherapy in the intensive care unit

Respir Med 2005; 99:1096


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Early Intensive Care Unit Mobility Therapy inthe Treatment of Acute Respiratory Failure

Statistically more likely to have physical therapy, have therapyinitiated in ICU, and have more PT sessions

First out of bed; usual care 11.3 days vs protocol 5 days (p=0.001)

Decreased ICU LOS; 8.1 days vs 7.6 days. (p =0.084)

Decreased hospital LOS 17 days vs 14.9 days (p = 0.048)

Hospital costs: Usual care Protocol

Team salaries $6805 $7309

Cost per PT $44,302 $41,142

Proportion of protocol patients at each level

Level 1; 26.7% Level 2; 7.3% Level 3; 10.9% Level 4; 55.1%

Crit Care Med 2008; Vol 36:p 2238

Th P t l


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Therapy ProtocolCrit Care Med 2008; Vol 36:p 2238


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Mobility Tips

Protocol for sedation with daily interruption of thesedation

Develop safety-related guidelines regarding

when patients were considered eligible formobility and who determines eligibility

Coordination between the nurse, respiratorytherapy, and therapist

Appropriate staffing of therapists Consider early physiatrist consults for patients

with anticipated prolonged ICU stays


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Delirium

Risk factors

Patient: old age, alcoholism, impairedhearing, impaired vision, HTN, depression,

smoking, baseline cognitive impairment Critical illness: acidosis, anemia, sepsis/fever,

hypotension

Preventable: Medication, sleep disturbance,immobilization


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Delirium

Assessment of delirium in the ICU

Intensive care delirium screening checklist(ICDSC)

Confusion assessment method for the ICU(CAM-ICU)

Minimizing risk factors where possible

Sedation protocols and sedation holds


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Delerium

Sedation and analgesia medication

Sleep deprivation

Immobilization


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Delerium and sedation in the intensive care unit:Survey of behaviours and attitudes of 1384

healthcare professionals

71% use sedation protocol

76% written policy on spontaneousawakening trial (SATs)

44% practice SATs on more than half ofdays

59% screen for delirium

33% use a specific screening tool Crit Care Med 2009; 37:825


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Foley Catheters

Remove foley catheter as soon aspossible

Securement device

Reminder systems may reduce catheter-associated urinary infections (CAUTIs)

52% decrease in the rate of CAUTIs and a

37% reduction in the mean duration ofcatheterization

Clin Infect Dis. 2010;51:550-560


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Multidisciplinary Rounds

Coordinate care between all care givers

Discuss plans and required staff toimplement plans

Discuss bundles and checklists Culture change

Saves providers time

Save on multiple pages Incorporates the family into the team.


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Multidisciplinary Rounds

Physician (team leader) Nurse Respiratory therapy Pharmacy Representative physical therapy, occupational

therapy, speech therapy, and rehab coordinator Dietician

Social worker / discharge planner Palliative care coordinator Individual designated to document


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Rounds Tips

Multiple models

Implement slowly

Consider adding family when ready Considerate of time


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Checklist / Goal Sheet

Checklist: reminder to evaluate a limitednumber of specific medical interventions,preventative measures, bundles and

processes to improve consistency of care

Goal sheet: outlines the goals of themedical therapy defined by the

multispecialty team to be completed thatday


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Daily Checklist / Goal Sheet

Decrease errors of omission, createreliable and reproducible evaluations,improve quality standards and use of best

practices Facilitate communication

Integrate the multiple other bundles and

care processes required in the ICU


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Checklist / Goal Sheet


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Room to improve

Barriers

Relapses

Need for repetitive education Staff

Doctors

Everyone needs to buy-in


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Starting the Process

Identify and prioritize the projects

Create a multidisciplinary team

Enlist all stakeholders to identify the potential barriers,opportunities, and resources for the project and help find

appropriate solutions Prepare the project and build support

Create data collection and reporting system to provideaccurate baseline data and document improvement.

Introduce strategies to change clinician behavior andcreate the change that will produce improvement

Continue to reevaluate and change as necessary


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Starting the Process

Champions

Continuous education

Direct feedback on success Change in culture


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HELP

Institute for Healthcare Improvement

WWW.IHI.ORG

Society of Critical Care Medicine ParagonQualitity Improvement

WWW.SCCM.ORG
http://www.ihi.org/http://www.ihi.org/

icu bundles

Documents