welsh critical care improvement programme wccip report.pdf · following agreement upon the elements...

Welsh Critical Care Improvement ProgrammeFinal Report

Published by: - Christopher Hancock, Service Development Manager, Programme Lead Dr David Hope, Consultant Intensivist, Clinical Lead Dominique Bird, Senior Service Improvement Manager WCCIP NHS Trust Programme Managers National leadership and Innovations Agency for Healthcare Innovation House Bridgend Road Llanharan CF72 9RP Wales Phone (+44) 1443 233 333 www.nliah.wales.nhs.uk In association with the Welsh Assembly Government ISBN 1-905456-16-6 978-1-905456-16-1 © Crown Copyright 2007-10-24 Designed at Design Stage www.designstage.co.ukJune 2007

http://www.nliah.wales.nhs.uk/

http://www.designstage.co.uk/

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Contents

Introduction 3

Background 3

Collaborative Programme Methodology 4

Data collection strategy 6

Delivery Plan 8

Evaluation of the Collaborative Approach 9

Implementation of the Care Bundle Methodology ��

Clinical Engagement �3

Critical Success Factors �6

Appendix I �8

Appendix II 92

Appendix III 93

Appendix IV 96

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� Berenholtz, SM, Dorman, T, Ngo, K, Pronovost, PJ (2002) Qualitative review of intensive care unit quality indicators. Journal of Critical Care. �7: �2 - �5

IntroductionIn May 2006 the National Leadership and Innovation Agency for Healthcare (NLIAH) launched the Welsh Critical Care Improvement Programme (WCCIP). This report evaluates the programme at the conclusion of the first year.

The programme has had two aims: firstly, improvement in quality of critical care provision throughout Wales by the implementation of the Ventilator and Central Line Care Bundles and secondly, promotion and evaluation of a collaborative programme methodology as a means of developing and spreading best practice and fulfilling the NLIAH organisational development aim of embedding change management skills in the Welsh NHS.

BackgroundPatients receiving critical care are at risk of infection associated with prolonged ventilation and central line dwell time. There are significant costs associated with this risk both in financial and quality of care terms.

It has been suggested that by combining a number of evidence based interventions in a ‘care bundle’ and administering these interventions to every critical care patient on every day of their stay, these risks to the patient may be significantly reduced�.

Care bundles have been advocated by the Institute for Health Improvement (IHI) and Centre for Disease Control (CDC) in the US and have been promoted by the Modernisation Agency and Department of Health in the UK as ‘High Impact Changes’.

Prior to commencement of this programme the level one evidence supporting the Ventilator and Central Line Bundles was widely accepted by Welsh clinicians but although care bundles were in place in some critical care areas in Wales, there was no uniformity of definition or measure of application; this programme has worked towards standardisation of this otherwise disparate approach.

This programme has been implemented against a backdrop of huge change in Welsh critical care with the formation of three critical care networks in 2006-07, the publication of the Critical Care Quality Requirements (WAG 2006) and Healthcare Quality Improvement Programme (WAG 2007).


The events have been addressed by speakers from a variety of backgrounds including the director of the Intensive Care National Audit and Research Centre (ICNARC), the acting director of the Welsh Healthcare Associated Infection Programme (WHAIP), Policy Leads from the Welsh Assembly and a number of English critical care network managers and clinical leads.

Programme Manager TrainingThe Programme Managers carried a huge responsibility for the success of the programme and it was therefore considered vital that the programme be of benefit to their career and personal development. NLIAH has provided training in change skills, leadership, teambuilding and data handling as well as facilitating a forum for mutual support and sharing of experience.

Steering Group The WCCIP was conceived as part of a larger patient safety programme linked to the Healthcare Quality Improvement Programme (HQuIP). The strategic direction and high level decision making on the programme took place at the quarterly steering group meetings. The membership of the steering group is listed in appendix III.

Collaborative Programme MethodologyThe collaborative programme methodology originates from the work of the Institute for Healthcare Improvement in the USA when, in �996, they launched the ‘Breakthrough Series’ of quality improvement collaboratives.

A collaborative programme is a comprehensive way of creating specific improvements for patients based on evidence-based principles for spreading good practice using proven improvement techniques.

The programme methodology supports participating Improvement Teams in implementing changes by creating the time and opportunity for teams to reflect and discuss. Improvement teams then use a continuous method of improvement in which ideas for change are tested on a small scale. Results are analysed and either implemented or further refinements made to make the changes more effective. Changes are of an incremental nature, but the increments are very fast and expected to progress rapidly to wider and bigger change. The collaborative programme goes on to actively encourage spread and sustainability of the proven improvements.

A critical component of the collaborative methodology is sharing information and learning from each other’s experiences. Knowledge sharing provides powerful peer support and encouragement for continued modernisation. Case studies presented at learning workshops will provide an opportunity for improvement teams to see what changes others are making and decide whether those changes can be adopted or adapted to their own working practices.

Local Improvement TeamsThe improvement groups at a unit or Trust level were composed of clinical and executive leads as well as patient and therapies representation. They were led by Programme Managers, generally senior nurses who had taken the lead in training ICU staff. The teams implemented the programme locally, introducing innovation and collecting and processing the data.

Team Learning EventsFour national events were held from May 2006 to March 2007.These events have served to agree the bundle contents, inform on programme progress and national critical care policy, and decide the direction for the smaller local improvement groups.


Daily compliance for the unit for all eligible patients upon that unit was recorded on a chart similar to that below (figure 2).

VENTILATED CARE BUNDLE AUDIT FORM - UNIT

NETWORKTRUSTHOSPITALLEAD CONTACTDATE

Bed No. DVT Prophylaxis GU Prophylaxis Head Elevation (30 degrees)

Sedation Hold

Yes No Local Exclusion




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TOT%

DatabaseNLIAH developed and hosted a web based database, onto which the local Programme Managers entered the daily figures for number of eligible patients and number compliant thus giving a percentage rate.

The database then generated reports giving mean monthly compliance with the care bundles for each unit.

Figure 3: Screen Shot of Web-based Data Collection and Reporting Tool

Data collection strategy

Baseline DataA scoping exercise prior to the launch of the programme demonstrated that there was no national consensus on outcome measure definition, application or data collection. It was therefore considered of little use to attempt pre-programme baseline measurement of Average Length of Stay (ALoS), ventilator time or infection rates at a national level.

Instead, process data has been collected and analysed by daily measurement of individual patient, unit level and national compliance with the care bundles. Some units have also carried out their own baseline assessments and have continued to monitor outcome as well as process measures.

Bedside MonitoringThe systems for collection of the process data on compliance with the care bundles were developed by the individual units and therefore contain some variation in approach.

However, there are several common features. In all but one unit the system was paper based and relied upon the bedside nurse ensuring that a form, similar to that below (figure 1), was completed on a daily basis.

Bundle elements were ticked as completed, signed if not completed and reasons for exclusion from the bundle recorded.

Figure 1 – bedside ventilator compliance form

Yes No Clinical Exclusion

DVT Prophylaxis ✓

GU Prophylaxis ✓

Head Elevation - 30° ✓ ✓

Sedation Hold ✓

Bundle compliance was ‘all or nothing’ in that patients were only considered compliant if all elements of the bundles had either been performed or a reason had been given for not doing so.


Evaluation of the Collaborative ApproachThe collaborative programme methodology that was adopted for this programme was evaluated, as one of the aims of the programme itself, by the University of Glamorgan. The following section is an extract from the Executive Summary of that report:

The WCCIP had ambitious aims. Achieving significant change in clinical practice is never easy; to do so simultaneously across all Trusts in Wales, in a pre-determined timescale, with no ability to enforce change other than professional and managerial influence, and when the service is beset by numerous initiatives, is indeed ambitious. But it succeeded… this experience demonstrates that this sort of collaborative model, when appropriately led and resourced, is one which should prove adaptable to other similar clinical change tasks.

(See Executive Summary at Appendix II)

The WCCIP has been extremely well received with ‘buy in’ at CEO and clinical level from all Trusts in Wales. Participation in the programme has been genuinely multidisciplinary as evidenced by the numbers and diversity of background in attendance at the WCCIP events.

The feedback from these events and from the programme as a whole has been overwhelmingly positive. Critical care practice has reportedly been challenged, improved and standardised whilst clinicians report that the programme has empowered them to be innovative in introducing and managing change.

(See organisations reports at Appendix I)

Delivery Plan

The programme was planned with the following milestones:

�st Quarter – May 2006

• Establish Steering Group

• Programme Managers’ training

• Launch event

• Develop data collection toolkit.

2nd Quarter – September 2006

• 50% of all sites will have achieved >95% compliance with both care bundles during September.

• Learning event


3rd Quarter - December 2006

• 72% of all sites will have achieved >95% compliance with the two care bundles during December.

• Learning event


4th Quarter – March 2007

• 95% of all sites will achieve >95% compliance during March

• Closing event


• Draft evaluation report

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Implementation of the Care Bundle MethodologyFollowing agreement upon the elements of the care bundles, take up by intensive care units has been relatively quick. The following graph (figure 4) demonstrates that all eligible units were using the ventilator bundle and have continued to do so as of August 2006. As of March 2007 all units were using the CVC maintenance bundle.

Figure 4 – adoption of care bundles in Welsh ICUs

Care Bundle ComplianceCompliance with the care bundles that have been introduced as part of the programme has been calculated as a percentage at each site on each day of the programme and has been stored on an NLIAH hosted database.

As this compliance figure represents a reduction in adverse events due to omission of treatment it is suggested that it may be used as a proxy for quality improvement in critical care.

The mean all Wales compliance with these interventions reached 97.5% in March 2007 following a year of steady improvement from a low compliance position. By using this number as a surrogate it is suggested that quality improvement in Welsh critical care has been demonstrated.

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‘All Wales’ Care Bundle DefinitionsThe programme was launched in May 2006 at an event which was attended by approximately 80 delegates representing the medical, nursing and managerial workforce of every critical care unit in Wales. A similar number and mix of delegates have attended all events since the launch.

Following extensive consultation and debate at this event an ‘All Wales’ definition of the Ventilator Care Bundle was agreed. All fourteen critical care sites across Wales have adopted and implemented this Ventilator Care Bundle.

Elements of the Welsh Ventilator Care Bundle• Daily sedation rest

• Elevation of the head of the bed.

• DVT prophylaxis

• Peptic ulcer prophylaxis

A learning event was held in July at which all fourteen critical care sites and Velindre Cancer Centre were represented. Agreement was reached at this event to adopt two CVC bundles rather than the one advocated by the IHI. These bundles have now been implemented across all sites.

Elements of the Welsh Central Line Insertion Bundle• Wash hands before and after procedure: soap and water or alcohol-based agents.

• Use barrier precautions: gown and gloves must be worn; as much as possible of the patient should be covered with sterile drapes.

• Sterilise skin with chlorhexidine in alcohol and wait until the skin is dry.

• Avoid the femoral site unless it is the last resort.

Elements of the Welsh Central Line Maintenance Bundle• Review necessity of central line every day - and remove promptly if it is not

needed.

• TPN should be given via a separate line or a dedicated lumen.

• Access to line must be made using an aseptic technique.

• Entry site to be checked every day for signs of leakage or inflammation.

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Clinical EngagementMedical involvement has been a key element of the programme throughout planning and implementation. The Welsh Intensive Care Society as a whole, led by Chairman Dr Ian Greenway, has shown consistent support. The learning events have provided the opportunity for clinicians to meet and discuss the scientific and practical aspects of the bundles. This has resulted in consensus for national guidelines, process and outcome measures. Clinicians are generally enthused by the simple way that care bundles link theory to actual behaviours, resulting in benefits to patients. Collaboration with nurses, AHPs and managers from not only their own Trust, but from around the country, has been a positive experience for the doctors involved.

Dr Dave Hope – Programme Clinical Lead:

“Looking back at a year of the WCCIP one thing amazes me – how a simple idea can have so many consequences. Care bundles are easy: simply decide what you should be doing, then make sure you’re doing it every day on everybody that needs it. To actually achieve these goals turns out not to be straightforward however - several important things have got to happen first:

• Realisation that we are far from perfect

• Creation of a multidisciplinary group of motivated people

• Agreement on national clinical guidelines based on evidence

• Staff education on a large scale

• Implementation of a data collection and analysis system

• Detailed and prolonged feedback at local and national levels to improve practice

All of these steps have now been achieved and a new ‘quality improvement’ culture has been born in the process. This is a tribute to the enthusiasm and hard work of everyone involved in the Programme; it has been a pleasure and a privilege to play a part in the team.

There have been several positive spin-offs from our work already, including increased patient/carer involvement and linking up with efforts to reduce hospital acquired infections. Several areas outside of critical care are looking at our approach to see if it will work elsewhere. When I see the compliance rate graphs from around the country saying 95-100% compliant for this, that and the other I feel very proud. A huge number of patients are benefiting from improved standards of care as a direct result of our efforts. Next year will bring fresh challenges but I have every confidence that the team we have assembled are up to the task. Well done and thanks to everyone who has helped make it happen.”

Ventilator BundleVentilator bundle compliance rates for �3 of �4 (94%) critical care sites in March 2007 were greater than 95%.The aggregate national compliance has risen from 82% in June 2006 to 97% in March 2007 (figure 5).

Figure 5

Central Line BundleCentral line maintenance bundle compliance rates for �3 of �5 (87%) sites posting data in March 2007 were greater than 95%. The aggregate national compliance has risen from 26% in June 2006 to 98% in March 2007 (figure 6).

Figure 6

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Evaluation of Patient OutcomesThe outcome measures that have been advocated by the IHI are average length of stay (ALoS), average ventilated time, mortality and infection rates (Berenholtz et al, 2002). The scoping report had identified that there was no national consensus upon these measures and so evaluation of the programme at a national level using these measures has so far not been practicable.

It is possible that cultural and organisational differences between critical care in the US and UK will prevent a replication of the change in outcomes that has been suggested by the IHI although results from Conwy and Denbighshire, where care bundles have been in use for three years as part of the Safer Patient Initiative, demonstrate a reduction in mortality, non-clinical transfers and a 2.7 day reduction in ALoS.

The report from this Trust (Appendix I) however makes clear that changes in outcomes did not happen for eighteen months following the introduction of care bundles and that the ALoS figure only changed following the introduction of nurse led weaning. This suggests that it is not the care bundles in isolation that lead directly to changes in patient outcomes, but rather it is the re-evaluation and development of care systems that have come about as a result of the whole programme of improvement which are responsible.

Several units have experienced a reduction in the use of sedation which has been directly attributed to the ventilator care bundle. The value of this reduction has been estimated as 25% by UHW, 30% by Bronglais and £�8700 by North Glamorgan NHS Trust. Conwy and Denbighshire have experience a total pharmacy reduction on critical care items of £78587 since the introduction of care bundles.

Collaboration between WCCIP and WHAIP has been invaluable in developing critical care infection surveillance in Wales. It is expected that all ICUs in Wales will duplicate the UHW experience where, since the introduction of the central line care bundle, MRSA bacteraemias have been reduced by 50%.

Daily Process Audit A consequence of the daily audit that this programme has introduced is the realisation that interventions which had been assumed, by ICUs, to be standard practice were, in fact, subject to considerable variation.

Although, in this programme the target for compliance was greater than 95%, it appears likely that real change to the custom and practice of the ICU only becomes sustained when compliance has been stable at �00% for some time.

At what point the daily audit could be relaxed to a weekly or monthly regime with no resultant change in compliance is yet to be ascertained. There have been reports that suggest that a falsely high level of compliance may be attributed to the time of day that the audit takes place which suggests that, prior to reducing the frequency of audit, units should demonstrate high compliance rates at ‘spot’ audits at varying times during the day

The daily care bundle compliance has been shown to be very responsive to other changes in the workload and staffing of the units so it may be argued that it can be taken to act as a surrogate for the change process itself.

We believe that this frequent audit, rapid feedback model has huge potential for the introduction of change in a variety of clinical settings.


Ownership of ChangeThe collaborative approach NLIAH have taken to agreeing and implementing national bundles have ensured buy-in from all sites, clinicians, nursing and therapies staff prior to implementation. It is an often repeated axiom that for change to stick it must be owned by those affected by that change. There is ample evidence within the unit’s progress reports (Appendix I) that this is true. It may also be claimed though that the audit process to evaluate the change itself is also most effective when developed and owned by those participating.

Spread and Sustainability The collaborative approach of the programme has stimulated and provided a forum for national debate and has enabled the growth of networks and communities of practice. We believe that the collaborative methodology of the programme has been shown to be effective and will enable a national approach to other areas of critical care development in the coming years.

The second year of the programme will build upon the successes of this year to promote, support and evaluate a ‘whole hospital’ approach to improving patient safety through infection surveillance, dissemination of ‘bundle methodology’, adoption of sepsis bundles and implementation of a critical care outreach service. Participating Trusts will consolidate the ‘care bundle’ methodology that has been implemented through the WCCIP, creating further bundles and disseminate the process to areas outside the intensive care unit.

Collaboration with the Welsh Healthcare Associated Infection Programme (WHAIP) will continue and infection surveillance will be augmented to provide patient and organism specific data. Links to the Critical Care Networks will be strengthened and the newly appointed network managers will be invited to sit as members of the WCCIP Steering Group.

The estimated number of ICU admissions in Wales in 2005 was 8206 of which �9.7% were for severe sepsis (ICNARC 2006). Mortality for severe sepsis remains at 30-50% or up to 800 people in Welsh ICU’s annually and severe sepsis accounts for 46% of critical care bed days2. Effective treatment of severe sepsis therefore represents a considerable potential saving both in financial and mortality terms.

The programme will collaborate with the surviving sepsis campaign (SSC) in implementing the sepsis bundles within Welsh ICUs and, through development of the sepsis resuscitation bundle, it is intended that participants in this programme will collaborate with local training and education facilities in the consolidation and further development of existing systems for recognition and early appropriate treatment of critically ill patients. The Programme has already had a profound effect upon the organisation and delivery of critical care services in Wales and it is anticipated that it will continue to positively influence the quality of Welsh critical care in the future.

� Angus DC, Linde-Zwirble WT, Lidicker J, Clermont G, Carcillo J, Pinsky MR Epidemiology of severe sepsis in the United States: analysis of incidence, outcome and associated costs of care. Critical Care Medicine, 200�:29:�303-�0

Critical Success FactorsFollowing analysis of the organisation reports, the following critical success factors (CSF) have been identified as key to the success of local implementation of the Ventilator and Central Line Care Bundles.

Programme ManagersThroughout the programme it has been shown time and again that the most important factor in local success is the Programme Manager. These individuals have shown extraordinary determination and resilience in motivating their teams and introducing innovation. They have achieved this often in the absence of adequate funding and in some cases whilst having to overcome considerable resistance to change.

The Programme Manager training and study days have proved to be popular with the Programme Managers themselves as both a source of support and as a means of acquiring practical skills. Protected time to fulfil this role is invaluable and it is noticeable that sites where this role has not been backfilled have struggled at times in maintaining the momentum.

Local ChampionsClinical and managerial support for this programme locally has been essential to the successful implementation and sustainability of the care bundle approach. The programme has required substantial amounts of senior staff time in the planning, implementation and monitoring of the sustainability of the care bundles in the units, and without managerial and clinical support, this resource would not have been made available.

Patient InvolvementAt the outset of the programme, patient involvement was not common within critical care across Wales. Patient involvement on the National Steering Group has been key to ensuring the right questions were asked at key points in the programme, and has promoted local involvement of patients and carers on improvement teams. These teams have since stated that this is a key element of their success, as it provides a unique perspective which NHS staff often overlook and underestimate.

The steering group representative has now produced a pack which is intended as guidance for recruitment of a patient/carer representative on the local improvement team.

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Appendix I

Observation of clinical practice suggests that quality of patient care has improved-the use of longer acting sedation has now been reduced to a minimal. This has lead to a reduction in patients experiencing a sedation hangover. In addition there has been a reduction in the cost of sedation used per patient.

Central lines are now removed at least two days earlier than previously and many patients are managed without central lines.

Plans for the next year are to continue disseminate this work throughout the trust and build on this by monitoring our central line infection rates and our ventilator associated infection rate.

The tracheostomy care bundle has now been written this will initially commence in critical care and then be disseminated trust wide.

The Care Bundle approach has been seen to be a positive experience with very little resistance it has improved the equity of research based care given to patients.

As a Programme Manager it has been invaluable to have the support of my colleagues not only within the trust but also my fellow Programme Managers. We have been able to share experiences, resources and above all keep each other motivated.

Appendix I Organisations’ Progress Reports

Bro Morgannwg NHS Trust

Programme Manager: Julie Keill

Following the year long project to introduce the ventilation and central line care bundles both are now up and running well, with compliance rates improving steadily and are now �00%.

In addition theatres are running the central line insertion bundle and Casualty are due to commence the pre audit for the central line bundle.

The sepsis care bundle commenced in critical care. However, two study days were run for senior nurses across the trust to inform them of concept of care bundles with a view to taking the central line and sepsis care bundles out to the wards. These were well attended.

Feedback from senior nurses across the trust was that they wanted additional training on caring for central lines first, this was planned for February. Due to work load not all sessions were able to run and this work is continuing in May 07.

Coronary Care have shown a considerable interest in commencing the central line and sepsis care bundles. Therefore, work is currently underway with this.

There have been many positive aspects to this project the collaborative approach to clinical practice, the sharing of information and resources between clinical areas.

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Appendix IBACKGROUNDThe introduction of various care bundles into critical care has followed the work of the NHS Modernisation Agency’s project oncritical care outcomes, which was active only in England. A “care bundle” is simply a grouping together of individual careelements for particular treatments, such as ventilation, or symptoms or procedures. The elements are chosen because there isevidence to support their use in improving outcomes. Use of the elements can be easily audited so that feedback can beprovided and any problems in implementation identified. This means that we can check if what we think we do is what weactually do!

AIMSThe aim of the ventilatory care bundle is to use these elements to reduce ventilation associated complications such as pneumoniaand thromboembolism and to reduce the duration of ventilation. ALL elements of the bundle should be routine care for ALLpatients unless they are specifically excluded.

ELEMENTS OF THE BUNDLE30° head up positioning

This has been shown to reduce the incidence of microbiologically confirmed ventilator associated pneumonia from 23% to 5% when compared to supine positioning.1

DVT prophylaxisDVT is common in both medical and surgical patients in a critical care setting with rates of up to 56%. Prophylaxis can reduce this significantly.2

Gastric ulcer prophylaxisAll patients should be protected by ranitidine or omeprazole or enteral feed.

Avoidance of excessive sedationDuration of ventilation is known to be a risk factor for ventilator associated pneumonia. In all patients we should be aiming for a sedation score of 0 or 1. Use of sedation scores and protocols can reduce ventilator time.3

A daily sedation hold has been demonstrated to be a safe effective way of reducing duration of ventilation and ITU stay.4

There was NO increase in the incidence of accidental extubation.

WHAT NEXT?Data has been collected on our current use of the various care bundle elements. The 1st of December has been selected as thedate for the project to begin. ALL staff should then make every effort to ensure that this becomes routine care for ALL patients.Nursing staff should feel able to remind junior doctors if any of the prescribed elements have been overlooked.

INTRODUCTION OFVENTILATORY CARE BUNDLE

Julie Keill & Claire Farley

Critical Care Services, Princess of Wales Hospital, Bridgend

REFERENCES1. Drakolovic MB et al Lancet 1999 354(9193) :1851-8 Supine body position as a risk factor for nosocomial pneumonia inmechanically ventilated patients: a randomised control trial.2. Cook D et al Critical Care 2001 5(6): 336-42 Prevention and diagnosis of venous thromboembolism in critically ill patients:a Canadian survey.3. Brattebo G et al BMJ 2002 324: 1386-9 Effect of a scoring system and protocol for sedation on duration of patients’ needfor ventilator support in a surgical intensive care unit.4. Kress JP et al NEJM 2000 342(20): 1471-7 Daily interruption of sedative infusions in critically ill patients undergoingmechanical ventilation.

BACKGROUNDThe introduction of various care bundles into Critical Care has followed the work of the NHS Modernisation Agency project on

Critical Care outcomes which were active only in England. In partnership with the National Leadership and Innovations Agency

for Healthcare, a collaborative approach is now underway to introduce care bundles throughout Wales.

A care bundle is a grouping together of individual elements that have been proven through research to improve patient

care/outcomes.

AIMSThe aim of the central line care bundle is to reduce infection and complications to patients who need a central line. All elements

of the bundle should be routine care for ALL patients unless specifically excluded.

ELEMENTS OF CENTRAL LINE CARE BUNDLE

Central Line Insertion Bundle

Wash hands before and after procedure using 4% chlorexidine gluconate bactericidal skin cleanser and water or other alcohol-based agents

Use Maximal Barrier precautions: gown, gloves and drapes

Sterilise skin with Chlorhexidine and wait until the skin is dry

Use of jugular or subcalvian routes as preferred sites.

Central Line Maintenance Bundle

Review necessity of central line every day-and remove promply if it is not needed

TPN should be given via dedicated lumen.

Bionnectors on all ports no 3 way taps.

Access to line must be made using an aseptic technique.

Entry site to be checked every day for signs of leaking or inflammation

WHAT NEXT?Data has been collected on our current use of the various elements in the central line care bundle.

The 1st of August 2006 has been selected as the date for The Central Line Care Bundle to commence. All staff should then makeevery effort to ensure all elements of the central line care bundle become routine care for ALL patients.

There will be an ongoing teaching programme to inform staff about the care bundle. In addition there will be a study day on17th July 2006.

INTRODUCTION OF CENTRALLINE CARE BUNDLE

Julie Keill, Ashley John, Fiona Rogers, Jo HoldhamCritical Care Services Bro Morgannwg NHS Trust

REFERENCESMermel LA (2000) Prevention of intravascular catheter-related infections. Annals of Internal Medicine. Mar 7: 391-402.

Soufir L, Timsit JF, Mahe C, Regnier B, Chevret S (1999) Attributable morbidity and mortality of catheter-related septicaemiain critically ill patients: a matched, risk-adjusted, cohort study. Infection Control Hosp Epidemiol. June 20(6) : 396-401.

The National Institute for Clinical Excellence (2002) The effectiveness and cost-effectiveness of ultrasound locating devicesfor central venous access.


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Appendix I

Compliance to all four elements of greater than 95% was attained by July 2006 with �00% compliance achieved by September; this level of compliance has been maintained to date.

Various tools of data collection have been employed, with revisions made to accommodate lessons learned and improve efficiency. The biggest problem with ‘bundle’ implementation was found to be data collection by the senior nurses, with a 70% initial collection rate. After much motivation and the tenacity of the ‘bundle team’, we have achieved and maintained a collection rate of �00%.

Head Raised 30 degreesPatients have been traditionally nursed supine at Llandough; this was reinforced by the pre-audit which showed that one third of patients were nursed in this manner. Despite a big change in the culture of nursing patients supine, this intervention was accepted and adopted immediately producing greater than 95% compliance by July 2006. Auditing compliance for this (and the other bundle elements) at various times through the day, demonstrates that this element had been successfully adopted.

Sedation HoldIt was initially regarded to be the most difficult element to introduce: because the majority of critical care nurses felt that this intervention would increase patient anxiety levels, ICU psychosis and the risk of self extubations.

PDSA cycles were used to target this intervention, resulting in a resounding �00% compliance achieved by July 2006.

Initially the instigation of the sedation hold was ordered during the consultants ward round, but this has resulted in sedation holds commencing at �4.00hours for some patients during busy periods.

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Cardiff and Vale NHS Trust

Programme Manager (Llandough): Derek King

Programme Manager (University Hospital Wales): Nia Bromage and Lisa Evans

Llandough:

Llandough critical care comprises 5 commissioned level 3 beds and 4 level 2 beds, with one additional level 3 beds in times of need. We are a friendly department with a long tradition of implementing evidence based care.

When I was appointed Programme Manager in May 2006 I had a (very) basic understanding of the ‘care bundle’ conception, but did not appreciate the enormity of coordinating and implementing actual care bundles in practice. In this regard the expertise offered by NLIAH has been invaluable, especially in conjunction with the advice and support gained from the other Programme Managers.

The Ventilator Care BundleFollowing the May 2006 Programme Manager’s day and national learning event, we introduced a trial audit to ascertain current unit practice.

This demonstrated:Unexpected incidences of evidence based practice (as per bundle)Unexpected incidences where best practice was omitted.

From these surprising results an action plan was developed, this being implemented with the use of PDSA cycles. The ventilator care bundle was formally introduced in June 2006.

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Nov

embe

r

Dec

embe

r

Janu

ary

Febr

uary

Mar

ch

Cardiff & Vale NHS Trust: Llandough

0%10%20%30%40%50%60%70%80%90%

100%Vent Bundle

CVC Bundle


Appe

ndix

I


Appendix I

This demonstrated that practice was already of a high standard and highlighted 3 areas where improvements were required. A collaborative approach with our consultant staff was employed.

Barrier PrecautionsThough the use of sterile gown and gloves was already employed, the routine use of hat and mask was not general practice. These elements were quickly and easily adopted by the junior medical staff enabling �00% compliance by September 2006.

Skin Sterilisation.

Traditionally skin preparation was performed on our unit using Betadine alcoholic solution. However despite early concerns from the ‘Bundle Team’ about the uptake of chlorhexidine solution, this was quickly embraced and �00% compliance achieved and maintained since September 2006.

Access to Site using AsepsisThe pre-audit displays a very poor result for this element.

This was because we had not agreed on a protocol for drug/infusion administration via CVC locally. When protocols were established, �00% compliance was achieved and maintained.

0

120

100

80

60

40

20

Central Line Maintenance Bundle

%

Daily Review 100Dedicated TPN 100

Access to site 5

Site Check 100

Total Compliance 76.25

Pre

Audi

t

Sept

embe

r

Oct

ober

Nov

embe

r

Dec

embe

r

Janu

ary

Febr

uary

Mar

ch

To address this issue, we have implemented nurse led sedation hold at 08.30 hours according to guidelines agreed between the ‘bundle team’ and consultants. This change will now be closely monitored to determine its effects.

A large part of the critical care pharmacy budget is spent on sedation. With the successful introduction of the sedation hold we are currently considering a move from the more expensive propofol, as a sedation agent, to the more cost effective morphine / midazolam combination. This is because a daily sedation hold should limit the longer sedative effect of morphine and midazolam and enable considerable cost savings to be made.

Peptic Ulcer ProphylaxisThe pre-audit demonstrated that most of our case mix (93.7%) already received PU prophylaxis. We quickly achieved �00% compliance due mostly to the enthusiastic uptake of bundles by our consultant staff. These excellent compliance rates have been maintained with �00% compliance seen monthly.

Deep Vein Thrombosis ProphylaxisThree quarters of patients already received DVT prophylaxis at pre-audit. Again with the help of our consultants we have quickly (June 2006) achieved and maintained �00% compliance rates.

Central Line BundleFollowing on from the successful introduction of the Ventilator Care Bundle, in August 2006 a pre-audit was conducted to determine compliance with the proposed two central line bundles.

0

120

100

80

60

40

20

Central Line Insertion Bundle

%

HandwashBarrier

Skin Sterilisation

Femoral Avoidance

Total Compliance

Pre

Audi

t

Sept

embe

r

Oct

ober

Nov

embe

r

Dec

embe

r

Janu

ary

Febr

uary

Mar

ch


Appe

ndix

I


Appendix I

Ventilator Acquired Pneumonia (VAP) data is also inconclusive but this is based on limited data as VAP rates have not been previously collected (to give a baseline).

Catheter Related Bloodstream Infection rate pre bundle was 0 and remains at 0. Therefore no conclusive evidence is apparent at Llandough yet. However the introduction of infection surveillance has highlighted a need for us to be more vigilant in other areas of infection prevention and control.

Staff Views

‘Ventilator Care Bundles introduced into the intensive care setting have advantages for both patients and the NHS by reducing the incidence of ventilator acquired pneumonia for ventilated patients.

Introducing the bundles has been very easy in Llandough as this is a fairly small unit. It involves the standardisation of practice, which takes very little time to perform and have long term positive effects.

We as nurses must ensure patients are cared for in the most appropriate manner ensuring their health and safety.’

Marion Ross, Senior Staff Nurse

‘Excellent, ensures high standards of holistic care are implemented and maintained.

Bundles ensure that every patient is given the same care and opportunities in critical care, thus reducing inequalities in care. They provide a clear, concise method which is easy to follow.’

Jayne Kent, Staff Nurse

‘As newly qualified band 5 nurses, the care bundles have provided a useful structure to help us plan the care of our patient. They enable us to provide evidence based care ensuring the patient receives optimum treatment.’

Emily Taylor and Sian Evans, Junior Staff Nurses

However, a mini-audit on junior doctors (SHO and Registrar level) showed that none knew what a ‘Care Bundle’ was though all were implementing the elements of them.

Clearly some work still needs to be done!!

ResultsSince September 2006, compliance for all bundles has been maintained at �00%.

It has not been possible to show whether average length of stay or average ventilator time have been affected due to the introduction of the Care Bundles, due to the presence of long term patients over this period.

Average Length of stay and Ventilator time

0

2

4

6

8

10

12

14

16Average LOS (days)

Average Ventilator Time (days)

Mar

ch

Apr

il

May

June

July

Aug

ust

Sept

embe

r

Oct

ober

Nov

embe

r

Dec

embe

r

Janu

ary

VAP rates (per 1000 vent days)

0

5

10

15

20

25

30

35

40

45

50

May June July August September October November

VAP rates (per 1000 vent days)


Appe

ndix

I


Appendix I

University Hospital Wales:

I have been the deputy project manager since the introduction of the care bundles. My role has been small and one of a supportive role to the project manager. The project managers mid term report highlighted the vast amount of knowledge and skills that she had developed through the introduction of the care bundles. I myself would have to agree with her comments and feel that my skills have vastly increased due to the role that I had in ensuring the implementation of the care bundles and their daily compliance. My confidence and leadership skills have developed and I am able to challenge practice for the good of the patient, I feel comfortable in educating staff at all levels about care bundles and how they can benefit staff and patients. I have been able to develop links with our other unit on another site whilst increasing my links with more senior staff within the unit in which I work.

Overall, the introduction of the care bundles has had a positive effect on nursing and medical staff. Patient care has been standardised throughout the unit. The care bundles have given all staff the confidence to question practice. The ventilator care bundle has also given staff the awareness of having the patient head-up. As a unit, we have learnt that what we thought was head- up was not as head- up as we thought! Overall, our VAP rates and sedation costs have been reduced since the introduction of the care bundles.

The introduction of the CVC bundles has been easier to implement. These bundles have involved nurses at all levels. The nursing assistants who are aware of the bundles make up the packs. These packs consist of everything that the medics need to insert a CVC. The packs contain a sticky label; this label is then placed in the medical notes so that compliance can be monitored. Overall compliance is high as all the equipment is in the bag. The sticky label acts as a guide for the medic staff. Nurses have the confidence to question the practice of the medics due to the implementation of these bundles. All medical staff are aware of all the bundles due to education from medical and nursing staff of all grades. Bedside nurses have the confidence to question if the CVC is needed.

June

July

Augu

st

Sept

embe

r

Oct

ober

Nov

embe

r

Dec

embe

r

Janu

ary

Febr

uary

Mar

ch

Cardiff & Vale NHS Trust: UHW

0%10%20%30%40%50%60%70%80%90%

100%Vent Bundle

CVC Bundle

Unit BenefitsIntroduction of care bundles has helped highlight other areas where practice can be improved.

Introduction of Care bundles has helped foster better working relationships between nurses and consultants with regard to the introduction of new working new practices.

Introduction of a local Critical Care improvement program to evaluate current practices.

Generated an atmosphere of reflection and change amongst nursing staff

Developed new protocols and procedures as an off shoot of the current programme, e.g. introduction of a drug preparation protocol (amongst others) based on the best available evidence.

Personal HighsThe WCCIP has visited a turbulent plethora of emotive states upon me, some low, but a very many of them high.

Amongst the personal highs resulting from this programme:

Taking critical care outside the unit (Critical Care without walls!!).

Improved presentation skills

Learning (by my mistakes) to manage an ever increasing project, including developing leadership skills, time management (or lack of), negotiating skills, implementing audit etc.

Development of relationships with other Programme Managers and the staff at NLIAH

Experiencing the direct support of my Nursing managers, Nurse Consultant, Consultant staff, Clinical Director and the Chief Executive.

The FutureThere are no crystal balls at Llandough but the WCCIP has shown us that improvement to patient care can be made easily (small improvements have big benefits), cost effectively, and with associated benefits to staff members.

With these thoughts the ‘Bundle team’ have earmarked the following:

• Improved Infection Surveillance.

• The Introduction of the Sepsis Bundle.

• Dissemination and roll out of the CVC bundle to theatres and wards.

• Establishing and implementing a multidisciplinary approach to weaning and the development of a weaning protocol.


Appe

ndix

I


Appendix I

Cross-site practices have been standardised due to the implementation of these bundles and although there is still a lot of work to go, these bundles have been successful in starting the process. Links have been improved amongst nurses between these units.

The project manager keeps all staff up to date with the daily and monthly compliance rates; these are posted on our notice boards. Regular updates with the project manager give us time to reflect on the previous months work, discuss problems that we have encountered and share our successes.

The regular learning events have been successful. They have given me the opportunity to increase my knowledge locally, nationally and globally. I have been able to meet staff from other units at all levels. This has given me the confidence to meet staff I would not normally have the chance to meet and discuss care bundles. These learning events have given me the confidence to liaise with senior members of my own unit. The learning events have given everyone the chance to meet like-minded staff who have a keen interest in improving patient care and carrying the momentum of the care bundles forward. The learning events have given me an insight into new initiates from other units that can be taken forward on my own unit.

The Down SideOf course, there had to be a down side. Any new change can cause upset on a unit. The unit in which I work has many staff and many new doctors; this of course can cause many problems with the implementation of any change. The P.D.S.A. cycles have helped in managing change but they may have been ambitious. Our increased knowledge has led us to try smaller P.D.S.A. cycles. An ongoing problem has been data collection. When to collect the data, how to collect the data, who collects the data. Due to regular feedback from the staff on the unit, it has led us to look at ways to improve data collection. The learning events have shown that is a problem throughout most units. We are currently looking at a new format on how and when to collect data. Ensuring compliance is an ongoing problem i.e. ensuring the patient is head up, by utilising a P.D.S.A. cycle we are overcoming this problem. Managing data input with the constraints of the unit have proved difficult at times; a data input clerk would be invaluable.

The Future Selling the product! Encouraging staff to collect data efficiently and effectively. Keeping the momentum going. Regular feedback for medical and nursing staff. Embedding care bundles into the culture of Critical Care.


Appe

ndix

I


Appendix I

Carmarthenshire NHS Trust

Programme Manager: Sandra Miles

Since the interim report the care bundle team at Carmarthenshire NHS Trust, have continued to go from strength to strength. Compliance with the both ventilator and central line bundle remains >95% in ICU and HDU in West Wales General and Prince Phillip Hospital. To date we have been unable to show any reduction in average ventilation time or length of stay, however we feel that high level of compliance demonstrated in our bundle baseline audit may explain why this is the case.

On-going Projects:

• Development of a weaning and restraint guideline to support the ventilator bundle.

• Introduction of the central line insertion bundle to Accident and Emergency departments and theatre in WWGH and PPH.

• Development of a caesarian section care bundle in midwifery.

• Development by physiotherapist of a tracheostomy bundle for use on general wards.

The immediate future will see the introducing the sepsis care bundle to critical care and general wards throughout the Trust.

It has been a privilege and rewarding experience working both collaborative with staff within the Trust and throughout Wales. The project manager’s day’s were extremely valuable and provided much needed support and guidance throughout the whole programme. Locally, I feel that this programme has raised the profile of evidence-based care and the importance of audit amongst junior staff as well as the whole team critical care team. Overall the team and I look forward with enthusiasm to the challenges of the new objectives of the Welsh Critical Care Improvement Programme.

June

July

Augu

st

Sept

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r

Oct

ober

Nov

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r

Dec

embe

r

Janu

ary

Febr

uary

Mar

ch

Carmarthenshire NHS Trust

0%10%20%30%40%50%60%70%80%90%

100%Vent Bundle

CVC Bundle


Appe

ndix

I


Appendix I

Ca

rma

rth

en

shir

e N

HS

Tru

st -

2 s

ite

s:

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st W

ale

s G

en

era

l H

osp

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nc

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ip H

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ca

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ash

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undle

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100

90

80

70

60

50

40

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10 0

Centr

al Lin

e M

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D

ail

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evi

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of

Lin

e N

ec

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/de

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06

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007

Ja

n

100

90

80

70

60

50

40

30

20

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ct

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97%

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97%

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nth

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Se

pO

ct

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vD

ec

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n

100%

75%

100%

100%

100%

100

90

80

70

60

50

40

30

20

20 0

Deve

loped R

estr

ain

t G

uid

elines a

nd

Weanin

g P

roto

col

Medic

al

illu

stratio

n

Marilize d

u P

reez -

Clinic

al Lead P

hysio

thera

pis

t, S

andra

Miles -

Pro

fessio

nal D

evelo

pm

ent

Nurs

e for

Critical Care

, Critical Care

Directo

rate


Appe

ndix

I


Appendix I

Prior to starting the bundle it was decided to do a snapshot audit. The result of this audit was �00% compliance, which was extremely encouraging, as we had only just begun to look at sedation breaks. The ventilator care bundle was quickly introduced and implemented into our unit.

Sedation Expenditure in ICU

The sedation expenditure for the pre and post ventilator care bundle has reduced since the introduction of sedation breaks. The two main sedations used are Propofol and Morphine, we however do use Midazolam but our usage is extremely small. Our expenditure for 2006-07 on both Propofol and Morphine has had a 30% reduction this year. This figure is based on expenditure and no other parameters have been investigated except for patient numbers, which remain constant to the previous 2005-06. Other factors will however be looked at.

ALOS & ALVT

During the summer of 2006 we commenced an audit on our Average Length Of Stay (ALOS) and Average Length of Ventilated Time (ALVT). This revealed that our ALOS and ALVT were on average 3 days duration or below. However, during February of 2007 we had a long stay patient in Intensive Care which increased our figures to 6 days. Due to our small unit, any long stay patient can have a dramatic influence on out ALOS and ALVT.

PropofolMorphine

0

500

1000

1500

2000

2500

April 05 – March 06 April 06 – March 07

ALOSALVT

10

5

0

3.042.42

3.32.63

2.12.8

32.8

2.872.5

66.1

2.52

Sept Oct Nov Dec Jan Feb Mar

2.6

Ceredigion and Mid Wales NHS Trust

Programme Manager: Enfys James

The Critical Care Department at Ceredigion & Mid Wales NHS Trust consists of a total of 5 beds in a combined ITU/HDU unit at Bronglais General Hospital. The Welsh Critical Care Improvement programme set two main objectives for us to achieve within the �-year project. The objectives were to introduce two care bundles into the Critical Care setting. These were the ventilator care bundle and the central line care bundle. These bundles had been agreed and were evidence based. The all Wales compliance for these was set at 95%.

Critical Care Bundles was a concept that we had some knowledge of and concerns of how care bundles could be adapted to our unit. The Critical Care team was initially cautious regarding compliance, as a negative score would give us low scores, and that in turn would give us an overall low rate due to our small unit and low patient numbers compared to other units in Wales. However, following the first meeting by WCCCIP in February 2006, and the subsequent launch in May 2006, we commenced the Ventilator Care Bundles.

The Process

After the initial meeting, we adopted the paper version for the ventilator care bundle that had been shared with us in May. We arranged unit meetings, which was both poorly attended so we decided to one-to-one teaching and bedside discussions. After attending the learning event we decided to use the PDSA cycle (PLAN, DO, STUDY, ACT) and start small with one patient.

June

July

Augu

st

Sept

embe

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Oct

ober

Nov

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r

Dec

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Janu

ary

Febr

uary

Mar

ch

Ceredigion and Mid Wales NHS Trust

0%10%20%30%40%50%60%70%80%90%

100%Vent Bundle

CVC Bundle


Appe

ndix

I


Appendix I

Backg

rou

nd

•Wels

h C

ritica

l C

are

Im

pro

vem

en

t P

rogra

mm

e p

roje

ct

with

Na

tiona

l Lea

de

rsh

ip I

nno

va

tion

Age

ncy f

or

Hea

lth

ca

re

(NL

IAH

) to

im

ple

men

t C

are

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les in

critica

l ca

re

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tila

tor

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re B

und

le t

o b

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on

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l C

are

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ss W

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s-(

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r L

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, 2006

)

Pro

cess

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IAH

and

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ack to

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ith

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ria

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n ie

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rom

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nce

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ati

on

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ta c

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r co

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it t

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ase

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it info

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ata

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ta t

o b

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with

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ter

pro

gra

mm

e

Intr

od

ucti

on

of

Care

Bu

nd

les w

ith

in C

riti

cal

Care

Central Line Care Bundle (CVC)

The central line bundle was developed at the end of the project in 2007.Using a paper system we were able to pre-audit and review our practice. Our initial audit revealed a 94% compliance which was encouraging. Presently we are reviewing our local Trust policies with a view of some minor adjustments and looking to incorporating our Central Venous Catheter [CVC] surveillance data with the care bundle.

Personal DevelopmentDuring the past year both myself and my deputy Ann Humphreys have enjoyed this learning experience and by having a deputy the continuity of the project has been able to be at the forefront in our unit. The programme has enabled us to improve leadership and teaching skills. The learning events together with the Programme Managers days have been both informative and inspiring Communication has been one of the leading components in the success of these bundles not only in our unit but Trust and Wales wide. It is encouraging to know that the project will continue as it has now become an important link to standardising and improving care across Wales.

Future and Way ForwardThe maintenance and improvement in compliance will continue to be monitored closely to achieve 95% and above. The central venous catheter surveillance is to be adapted into the CVC bundle so as to reduce duplication and excessive paperwork, which will eventually be incorporated into the Intensive Care patient charts. The continuation of the Welsh Critical Care Improvement Programme means we will be able to continue to develop the Central Line insertion bundle to both Theatre and Accident and Emergency departments. The introduction of the Sepsis bundle will also be introduced in the near future.

Thank YouIt has been extremely rewarding to have been a part of this programme and the collaborative working with other units throughout Wales who have been a pleasure to work with.

May I take this opportunity to thank the Welsh Critical Care Improvement Programme team and Programme Managers throughout Wales. Personally, I would like to thank all members of our Critical Care team for all their hard work and enthusiasm over the last year.


Appe

ndix

I


Appendix I

Conwy and Denbighshire NHS Trust

Programme Managers: Linda Leech and Sue O’Keeffe

The Welsh Critical Care Improvement Programme’s (WCCIP) aim was to implement both the ventilator and central line bundles. At Conwy and Denbighshire the ventilator bundle had been in practice since July 2004 and the central line insertion bundle since January 2005.

The Trust was, and still is, involved in the first cohort of the Safer Patient Initiative (SPI). As part fulfilment for the SPI there was an expectation to implement both the ventilator and central line insertion bundle too. The initiative mandated that weekly monitoring of compliance and monthly outcome measures would be collated and reported.

Consequently, compliance of the bundles was already high and some tangible outcomes were beginning to be seen. What was a concern however was how the motivation and therefore compliance was going to be sustained?

The WCCIP provided the impetus to address two significant factors. Firstly, problems were beginning to emerge, especially in the ward environments, about the management of central lines post insertion and secondly, the excellent compliance with the current processes needed to be maintained.

June

July

Augu

st

Sept

embe

r

Oct

ober

Nov

embe

r

Dec

embe

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Janu

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Conwy and Denbighshire NHS Trust

0%10%20%30%40%50%60%70%80%90%

100%Vent Bundle

CVC Bundle

YMDDIRIEDOLAETH GIG CEREDIGION A CHANOLBARTH CYMRUCEREDIGION AND MID WALES NHS TRUST

Background1-year project with NLIAH to introduce two care bundles to all intensive

care departments throughout Wales

ProcessImplementation incorporated

PDSA – Plan, Do, Study & Actvia feedback to team through

meetings, bedside teaching andWCCIP meetings at Trust.

AuditBaseline audit completedwith 100% compliance.

Ventilator Care Bundlesimplemented

Evaluation

Clinical audit involved to supportdata analysis. Monthly unit

meetings with feedback to all staffregarding compliance. Further

monitoring and adjustmentsincorporated which developed into

standard practice of ventilatedpatients’ care

Central Venous CareBundles

Introduced using the sameprocess and incorporated with

Ventilator care bundles.

Central Venous CareBundles Implemented

Way Forward

Continuation of bundles with frequentmonitoring and feedback to all relevantstaff/Directorates. Introduction of othercare bundles within the Unit. Bundles

incorporated within the Intensive Care Unitthrough collaborative working with all

members of the Trust.


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Appendix I

There is less variability in the ALOS, both on ICU and on the ventilator. This denotes a more reliable process and a safer system.

The average length of time on the ventilator has also reduced by 2.7 days but interestingly, it was at the time of the implementation of the weaning and extubation guideline that variability finally ceased.

The number of tracheostomies performed has reduced significantly, from 22.5% to �2.�%. There is an assumption that this is in relation to the sedation break and exponential weaning.

AE

Jul-

02

Oct

-02

Jan-

03

Apr-

03

Jul-

03

Oct

-03

Jan-

04

Apr-

04

Jul-

04

Oct

-04

Jan-

05

Apr-

05

Jul-

05

Oct

-05

Jan-

06

Apr-

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Jul-

06

Oct

-06

-2

0

2

4

6

8

10

12

ALOSITU

Period

Indi

vidu

al V

alue

VCB CB

SB

Jul-

02

Oct

-02

Jan-

03

Apr-

03

Jul-

03

Oct

-03

Jan-

04

Apr-

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Jul-

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Oct

-04

Jan-

05

Apr-

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Jul-

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Oct

-05

Jan-

06

Apr-

06

Jul-

06

Oct

-06

-2

0

2

4

6

8

10

14

12

ALOS Mechanical ventilation

Period

Indi

vidu

al V

alue

VBCB

SB

Weaning guideline

Central Line Maintenance BundleThe central line maintenance bundle was implemented, initially on ICU, and is presently being PDSA’d on a surgical ward (where problems had been sited) and in the renal unit.

The central line maintenance monitoring form has been slightly modified for each clinical area but maintains the same format in order for it to be transferable.

Despite being involved in the SPI and consequent infection control data collection for some time, difficulties continue to be experienced around infection control data and matching any cultures to the patient’s clinical condition in a timely fashion. Infection control and the ICU team are working jointly to resolve these issues.

SustainabilityThe WCCIP has been pivotal in helping to maintain the sustainability of the two bundles compliance, especially because the practice development sister who originally implemented the bundles left ICU. Where compliance monitoring with the SPI had become much less frequent the demands of the WCCIP increased the monitoring frequency again and ensured that a ‘team approach’ involved all members of staff and promoted the sustainability by keeping the bundles profile high.

Where are we now?It is over 2 ½ years since the ventilator bundle was introduced into daily practice. Following on from its success the central line, sepsis and tracheostomy bundles have been implemented, a weaning and extubation guideline was designed and is utilised and daily goals are recorded during the multidisciplinary round.

Outcome data has been collated continuously but analysed at significant points post implementation e.g. six months, one year etc. Comparisons with previous equivalent time periods are also made to ‘compare ourselves against ourselves’. Our case-mix and staff have not changed significantly.

Two Years Post ImplementationWhat has been interesting is that change has not taken place overnight. Improvement has been a gradual process arguably, occurring where there has been a culture shift to enhanced partnership working.

The average length of stay (ALOS) on ICU has decreased by 2.7 days increasing the capacity for an additional 343 patients to be cared for in the ICU. Non-clinical transfers have reduced from seven to one and elective surgery cancellations, although still high, have reduced by �8.5%. Essentially, these level 2 and 3 patients are now being nursed in an environment appropriate to their needs. The severity of illness scoring, APACHE11, has not decreased despite the additional throughput; 17.3 vs. 17.4.


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Appendix I

Author: S O’Keeffe

901

1244

0200400600800

100012001400

No. of Patients in ICU

Pre Bundles

Post Bundles

22.50%

12.10%

0.00%

5.00%

10.00%

15.00%

20.00%

25.00%

%Pt.s with aTracheostomy

Pre BundlesPost Bundles

21.10%

17.10%

29%

24%

0.00%

5.00%

10.00%

15.00%

20.00%

25.00%

30.00%

ITU Mortality Hospital Mortality

Pre Bundles

Post Bundles

Two Years Post Critical Care BundlesWhat are the effects on our patients?

The Ventilator Bundle was implemented in August 2004. The Sepsis and Central line Bundles implemented in February and April 2005 respectively.

Patients no longer report nightmares or hallucinations, unlike their heavily sedated predecessors. Despite caring for 343 more patients in the post implementation period our pharmacy bill has decreased by £78587

The average length of mechanical ventilation has reduced by a mean of 2.7 days and the number of patient requiring a tracheostomy has almost halved, arguably because of their daily sedation breaks

The average length of stay on ICU has reduced from a mean of 5.6 days to 2.9 days – a reduction of a mean of 2.7 days despite matched apache scores: pre 17.3 post 17.4.

This reduction in length of stay has created extra capacity within the ICU and we have been able to accommodate an additional 343 patients in the two years post implementation

Patient mortality has decreased within the ICU and of those ICU patients who are discharged to the wards

ICU Average Length of Stay

0

2

4

6

8

10

12

14

16

18

Jul-0

2A

ug

-02

Se

p-0

2O

ct-02

No

v-02

De

c-02

Jan

-03

Fe

b-0

3M

ar-0

3A

pr-0

3M

ay-0

3Ju

n-0

3Ju

l-03

Au

g-0

3S

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-03

Oct-0

3N

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3D

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-04

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Jun

-04

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-04

Se

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pr-0

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Au

g-0

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-05

Oct-0

5N

ov-0

5D

ec-0

5Ja

n-0

6F

eb

-06

Ma

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Ap

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Jun

-06

Jul-0

6A

ug

-06

Se

p-0

6

Time Period

Day

s

Mean Length of Stay (days) Median Length of Stay (days) Stand deviation

high confidence low confidence Moving Average

VB – Aug 04SB – Feb 05 CLB – Aug 05

Pharmacy expenditure has decreased by £78,587 in total, compared to the previous two years. This equates to £2�4.40 per patient per episode. As yet an analysis has not been done to see where the reduction in costs is attributable to e.g. less sedation, fewer antibiotics or prompter conversion from intravenous medication or indeed, a combination of these factors.

Mortality has decreased too, from 2�% to �7% in ICU and 29% to 24% for those patient discharged from ICU to the wards. Sadly though, ventilator associated pneumonia rates and catheter related blood stream infection data was not collected prior to the implementation of the bundles. Therefore there is no ‘pre’ data to compare with.

It is known that bundles provide a ‘forcing function’ for teamwork. This has been exemplified throughout the last 2½ years with nurses empowered to question practices outside the norm but also with medical staff having the confidence, and competence, to relinquish some of their decision making roles.

At Conwy and Denbighshire NHS Trust, as elsewhere, bundles have provided the vehicle to fuse ‘best practice’ into everyday practice.

The ‘All Wales’ WCCIP has been hugely beneficial from a networking and collaborative learning perspective. Without this programme there would not have been the relationships built and learning shared. Thank you to all.


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Appendix I

Gwent Healthcare NHS Trust

Programme Manager (Nevill Hall): Sylvia Ireland

Programme Manager (Royal Gwent): Sarah Beuschel

Nevill Hall:

Care bundles have allowed a uniformity of care to be introduced where previously the practice of care varied dependant on consultant prescription. Clinical engagement has been a key element in the change process, with care bundles now routinely included for all admissions, approximately per year. A cohesive multidisciplinary approach led by myself and Dr Stephen Edwards (lead consultant), with all other consultants and the unit’s senior nurse enthusiastically committed to the programme from the start. The majority of the nursing team viewed care bundles as a helpful guide to practice ensuring evidence based holistic care. Care bundles are also seen as a reminder/ check list for all staff. A minority commented that care bundles would increase their paperwork, while perceiving an extra responsibility toward the patients during implementation. All nursing staff are encouraged to remind junior doctors of the bundle elements, especially those elements which are over looked.

The rotation of junior doctors has proved a challenge as occasionally care bundles have been viewed as an infringement of their clinical judgement. With consultant help and support I have managed to influence any reluctant junior doctors to fully accept care bundles as part of our care.

June

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Gwent Healthcare NHC Trust: Nevill Hall

0%10%20%30%40%50%60%70%80%90%

100%Vent Bundle

CVC Bundle

Improving Quality of Care to the Critically Ill via aImproving Quality of Care to the Critically Ill via aCare Bundle ApproachCare Bundle Approach

The average length of stay on the Intensive Care Unit has

decreased by 2.7 days from a mean of 5.6 days to 2.9 days despite matched APACHE 11 (severity of illness) scores:

pre 17.3 post 17.4. This means that all patients pre and post implementation are equally as ill – negating an

argument that the patients have been discharged quicker because they are less ill.

ALOS ITU

-2

0

2

4

6

8

10

12

Jul-0

2

Oct-0

2

Jan-

03

Apr-0

3

Jul-0

3

Oct-0

3

Jan-

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Apr-0

4

Jul-0

4

Oct-0

4

Jan-

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Apr-0

5

Jul-0

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Oct-0

5

Jan-

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Apr-0

6

Jul-0

6

Oct-0

6

Period

Indi

vidu

alV

alue

Results:

The reduction in length of stay has increased capacity by 29% allowing an additional 343 patients to be treated

in the Intensive Care Unit. The amount of cancelled elective surgery

and the number of patients transferred to other hospitals for

non-clinical reasons have also decreased.

21%

17%

29%

24%

0%

5%

10%

15%

20%

25%

30%

ICU Mortality and Hospital Mortality

Pre Bundles Post Bundles

The length of mechanical ventilation has also

reduced by a mean of 2.7 days, presumably because

the patients are less heavily sedated, unlike

their predecessors.

ALOS Mechanical ventilation

-2

0

2

4

6

8

10

12

14

Jul-0

2

Oct-0

2

Jan-

03

Apr-0

3

Jul-0

3

Oct-0

3

Jan-

04

Apr-0

4

Jul-0

4

Oct-0

4

Jan-

05

Apr-0

5

Jul-0

5

Oct-0

5

Jan-

06

Apr-0

6

Jul-0

6

Oct-0

6

Period

Indi

vidu

alV

alue

Mortality has also decreased in ICU from 21% to 17% in ICU and by 29% to 24% for those patients discharge from ICU to the wards.

This indicates that patients are not being discharged to the wards too early or that the volume of

patients for TLC has not increased

to createadditional capacity.

The pharmacy drugs expenditure decreased by £78,000 despite the

additional 343 patients cared for. This may be because patients are receiving

less sedation, are not requiring antibiotics for ventilator associated

pneumonias or because they are converting to oral or naso-gastric

medications from intravenous medications quicker.

The number of tracheostomies required and performed has fallen from 22.5% to

12% presumably because the reduced length of ventilation negates the need for

a tracheostomy to facilitate weaning. This reduces clinician times,

saves costs and most importantly avoids the patient body altering

procedure, risksand discomfort.

901

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0

200

400

600

800

1000

1200

1400

Total Number of Patients

Pre Bundles Post Bundles

Author: Sue OAuthor: Sue O’’Keeffe. Acting Head of ModernisationKeeffe. Acting Head of Modernisation –– with thanks to all the ICU teamwith thanks to all the ICU team

Conclusion:Implementation of bundles into

practice has ensured that, through consistent delivery of best practice,

patient process reliability has improved. This has subsequently improved outcomes

and quality of care. The implementation of bundles has been an excellent vehicle for

implementing evidenced-based practice and providing equity to all patients. The concept has also

enhanced team working and promoted a proactive approach to streamlining and improving patient care

Aims:Before implementation of the care bundles care of critically ill patients was adhoc, governed by individual preferences and not always evidenced-based. This often resulted in lack of continuity of care, staff dissatisfaction and delay in treatment regimes. The aim of implementing the ventilator, central line and sepsis bundles was to streamline care, execute evidenced-base practice and improve quality of care to the critically ill.

Methodology:Prior to implementation of the bundles an audit was undertaken

to provide a baseline measure of current practice. Each bundle was implemented using the Model for Improvement

and Plan Do Study Act (PDSA) methodology. This followed extensive multidisciplinary education,

both on the ethos of, and the research underpinning each element of the bundles. Initially auditing of

compliance was performed daily with immediate feedback given to staff.

Process and outcome data was displayed centrally

to encourage and motivate staff.VCBVCB

SBSBCVCBCVCB

VCBVCBSBSBCVCBCVCB

Discussion:The team very quickly recognised that patient care and treatment continuity were improved. This, in turn, increased motivation and compliance. Since implementation of the bundles over two years ago there have been some tangible results. Nursing staff who work on the ICU but also run the follow up clinic noticed that patients were not reporting nightmares or hallucinations unlike their predecessors who did not have a sedation break. They compared the timing of the introduction of the ventilator care bundle with the sedation break element and noticed a direct correlation.


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Appendix I

CVC BUNDLE INCLUDING VAS CATH / PICCO / PACING / CVC

HANDHYGIENE

& Chlorhexidine

skin prep

PLEASE TICK IF YES

MAXIMAL

BARRIER

PRECAUTIONS

PLEASE TICK IF YES

INSERTION INSERTION

DRESSING DRESSING

REMOVAL REMOVAL

Ventilator Bundle - Start Date March 2006As well as the four all Wales elements we at Nevill Hall include tight glucose control and a haemoglobin >7gm/dl. This allows continuity with the sepsis bundle.

During the first few weeks of this implementation it was identified that sedation scoring was not viewed as a priority by all nursing staff, therefore sedation holds were not being documented and managed appropriately. Individual audits of sedation scoring were carried out and staff given feedback with recommendations of regular sedation scoring for all patients based on their individual needs.

Sedation Scores/24 Hours

Patient One Admission: 07/08/2006 – �7/08/2006

Day � 2 3 4 5 6 7 8 9 �0

Sedation Score 5 9 9 2� 8 9 �0 8 6 9

0

5

10

15

20

25

1 2 3 4 5 6 7 8 9 10

Sedation ScoreDay

Seda

tion

Sco

re

Patient One

The NLIAH funding has allowed me to plan one day per week (dedicated care bundle time) to coordinate and implement the change towards care bundles with education and communication viewed as a priority. Verbal and written communication included one to one, and group teaching. I have attended all directorate and unit meetings during this year allowing me to feedback progress and inform every one of any changes, appropriate review and action has followed on from daily audits of compliance.

We now have five bundles in place ventilation, CVC, tracheostomy, renal and sepsis. Each care bundle started off as a sticker for the ITU chart and after two months was transferred in to the individualized patient care plan.

Planned Assessment of Condition / Needs Planned Care

(�) RESPIRATORY L N E Treatment Aims

VENTILATION CARE BUNDLE

YES NO N/A

Elevation of the head to the bed 35-45°

DVT prophylaxis

Peptic ulcer prophylaxis

Sedation hold

Assessment of readiness to wean

Tight glucose control

Haemoglobin >7g/l

Planned Assessment of Condition / Needs Planned Care

(2) CARDIOVASCULAR L N E Treatment Aims

TRACHEOSTOMY CARE BUNDLES (Please initial when filling in)

YES NO

PRN / 2 hourly suctioned at <200mmhg

2 Hourly checks on humidification

Dressing and tape changes PRN / 24 hourly checks

Tube patency / inner tube care PRN / 24 hourly checks


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Appendix I

Following on from teaching sessions on sedation holds the following algorithm has become part of our practice.

Sedation Holds in Ventilated Patients

IS SEDATION HOLD APPROPRIATE

Is the patient receiving a continuous infusion of sedatives?• Benzodiozepines• Opiates• Propofol

Is the patient receiving muscle relaxants?• FIO2 < 60%• Peep < �2.5cms H20• Reverse I:E ratio• Or is prone positioned

YES NO

Assess and document sedation score Reassess hours daily Continue hourly sedation score

Reduce patient activity i.e. avoid non-essential nursing care

Turn off sedationDO NOT TURN OFF ANALGESIA

Observe patient DO NOT LEAVE UNATTENDED

Assess and document sedation score

Sedation Scores/24 Hours (continued)

Patient 2 Admission: 09/08/2006 – �5/08/2006

Day � 2 3 4 5 6

Sedation Score 20 �0 �� 5 9 �7

Patient 3 Admission: �4/08/2006 – �5/08/2006

Day � 2

Sedation Score 9 0

0

5

10

15

20

25

1 2 3 4 5 6

Sedation ScoreDay

Seda

tion

Sco

re

Patient 2

0

2

4

6

8

10

2 5

Sedation ScoreDay

Seda

tion

Sco

re

Patient 3


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Appendix I

EXTUBATION GUIDELINES

The removal of an artificial airway from patients who have successfully been discontinued from ventilatory support should be based on an assessment of airway patency and the ability of the patient to protect their own airway

Patient fits the criteria for trial extubation as per weaning guidelines

YES

Exclusion Criteria• Facial injuries• Head injuries• GCS <8• Tracheostomy

• Check equipment and drugs for emergency re-intubation

• Inform patient• Stop feed/empty stomach• Sit patient up as

appropriate

IF NON NURSE LED

IF ANY YES

DR LED

Oxygen as previously administered or non – invasive support

Extubation technique• Suction and pharynx• Suction trachy / ETT• Deflate cuff• Ask patient to cough• Pull tube

Assess clinical signs of distress supported by ABG’s

* Reassure patient throughout

* Post extubation encourage patient to cough and deep breath

Optimal sedation score should be set on an individual patient basis daily.

Reassure the patient and maintain their safety, comfort and anxiety levels at all times.

Nurse-led weaning was introduced in March 2007 with unanimous backing from the Consultant. The proposed change was discussed with the Senior Nursing Team at their December monthly meeting, when the commencement date was set. The documentation and guidelines were explained in-depth within small groups across all grades.

In its’ infancy, problems have arisen and unfortunately, nurse-led weaning has not as yet been totally adopted. As a consequence the guidelines have not been piloted effectively therefore, it is proving difficult to ascertain the possible causes and whether changes will need to be made to its format. Early indications are that the written protocol is conservative compared to the clinical practice of our clinical body.

Building upon the nurse-led weaning it was identified that there was a natural progression to include a nurse-led extubation algorithm within the guidelines. Further teaching and promotion is indicated, to ensure nurse-led weaning can reach its full potential.

IS THE PATIENT HAEMODYNAMICALLY STABLE AND CALM?

Continue with sedation hold or restart at lower infusion rate to achieve an appropriate sedation score

Restart sedation in to achieve adequate sedation

YES NO

Assess and document sedation score hourly

Reassess if patient is appropriate for sedation hold in _ _ hours


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Appendix I

•FEEDBACK STARTDATE 03/06•IDENTIFY PROBLEMS•RE-PLAN•CARE PLAN CARDS•FEEDBACK•COMPLIANCE 96%

Care Bundle Across the Critical Care ContinuumIndividual Patient Care may Include One or all Care Bundles

Lead Nurse – Sylvia Ireland

Lead Consultant – Steve Edwards

Administration – Claire Hughes

SEPS

ISVE

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LATO

R

CENTR

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LINES

TRAC

HEO

STOMY

OUTREACH

•SURVIVING SEPSISCAMPAIGN•MDT CONTACTSREVIEW PRACTICE ITUTEACHING MAU, A&EITU, NURSEPRACTITIONERS

•TEACHING ITU / OUTREACH•FEEDBACK RE-PLAN•START DATE 10/05STICKERS•ELECTRONICDATA•A&E IMPLEMENTATION

•RE-PLAN DATACOLLECTIONTOOL•FEEDBACK•COMPLIANCE60-75%

•DECISION ON

ELEMENTS OF BUNDLE•REVIEW LITERATURE•IDENTIFY ELEMENTSOF BUNDLE•MDT CONTACTS•TEACHINGREVIEW•ITU PRACTICE•STICKERS•AUDIT TOOL

•REVIEW LITERATURE

•IDENTIFY ELEMENTS

OF BUNDLE•MDT CONTACTS•DECISION ON ELEMENTS•PRE IMPLEMENTATION•FEEDBACK•STICKERS

•START DATE 05/06•RE-PLAN•CARE PLAN• FEEDBACK•COMPLIANCE 86%

•STICKERS•START DATE 05/06•RE-PLAN•IDENTIFY PROBLEMS•FEEDBACK•COMPLIANCE 89%

•REVIEW LITERATURE•IDENTIFY ELEMENTSOF BUNDLE•DECISION ON ELEMENTS•PRE IMPLEMENTATION•FEEDBACK

Nevill Hall Hospital

Sepsis Bundle (To be acheived as soon as possible)Serum lactate measured.Blood cultures obtained prior to antibiotic administration.From the time of presentation, broad-spectrum antibiotics administered within 3 hours for

A/E admissions and 1 hour for ward admissions orexisting ITU patients.

20 ml/kg (minimum )of crystalloid (or colloid equivalent*) infusedInotropes for hypotension not responding to initial fluid resuscitation to maintainmean arterial pressure (MAP) > 65 mmAchieve central venous pressure (CVP) of > 8 mm Hg.Achieve central venous oxygen saturation (ScvO2) of > 70%.Synacthen test

Within 24 hoursLow-dose steroids* administered for septic shock in

accordance with a standardized ICU policy.Drotrecogin alfa (activated) XIGRIS considered andadministered in accordance with a standardized ICUpolicy.Glucose control maintained 4.4-6.1mmolsInspiratory plateau pressures maintained < 30 cm H2o for mechanically ventilatedpatients.

Ventilator bundleHead of the bed elevated 35-45% - except for nursing proceduresthis is for 24hoursDVT prophylaxis - clexane or if contraindicated TED stockin00.gsPeptic ulcer prophylaxis - ranitidine or omperazole even if enterallyfedSedation hold – every 24rs in the morning, between 09.00 -12.00hrsSedation scoring pre during and post hold.Remember to keep the patients analgised during the sedation holdDaily assessment of readiness to weanTight glucose control – aim 4.4 – 6.1 mmols, adjust actrapidaccordinglyHaemoglobin >7g/dl

CVC bundle (including vascaths, picco, temporary venous pacingHand Hygiene at all times especially during insertionAseptic technique during insertion, dressings and removal (use ofappropriate sterile drapes etc:)Use of ultra sound during insertion to achieve optimal positioningChlorhexidine skin preparationSite of line preferred site subclavian not internal jugular or femoralReplacement of lines in symptomatic patientsDaily assessment of CVP need and position? Inotropes? TPN? bolus of KCL etc:? CVP monitoring? Poor vascular access

Tracheostomy bundleSuction – 2hrly secretion checks and PRNsuctioningSafety equipment- All bedside equipmentemergency and specific tracheostomy needs tobe checked at the beginning of every shiftCuff pressures – Checked and documentedevery shift and as requiredHumidification – adequate appropriatehumidification, checked and documented 2hrlyTube patency/ inner tube care – tracheostomylumen patency to be checked for secretion build-up 2-4hrlyDressings and Tapes – These should bechanged at least every 24hrs

Future Plans

•Weaning / Extubation

•Nutrition Bundle RENAL / TPN

September 2005 – October 2006

CVC Bundle – Start Date May 2006This has been implemented with the empowerment of nursing staff and the support of consultants and has been relatively easy change to undertake. We already used one dedicated lumen for TPN; the only big change for us was to document the daily assessment of need.

Networking outside critical care into Accident & Emergency, Coronary Care and the general wards has allowed me to work closely with outreach and the nurse practitioners in the implementation of the sepsis bundle. This approach has increased the unit’s admissions of sepsis patients who were identified and resuscitated at ward level.

Sedation costs are now reviewed regularly although due to the increased use of remifentanyl our costs have not decreased.

We have seen an overall reduction in our length of stay; however this is not all due to care bundles and does include variances such as delayed discharges etc:

Compliance with all bundles remains constantly at 96-�00%

Personally I have grown in confidence during this year. I am now able to present to large audiences and teach on the Foundation in Critical Care (degree module) based at Gwent Healthcare. I now feel comfortable feeding back to all parts of the multidisciplinary team and regularly liaise with consultants outside critical care. My computer skills also have increased ten fold.

The success of the programme at Nevill Hall has been based upon my flexibility at working across directorate and professional boundaries. I have received support from my lead consultant, senior nurse and the rest of the critical care team. I have also been empowered by their belief in my ability to lead this project

This project at Nevill Hall has been facilitated by a small team of nurses (the bundle girls) who have taken on the task of the daily audits. I have also been supported by excellent administrative staff to who I would like to give special thanks.

Future Plans Start the next year with as much enthusiasm and commitment as this year

I plan to revisit all care bundles and reinforce teaching across all disciplines

Continue with nurse led weaning

Commence the mandatory infection surveillance

Work closely with outreach and implement the CVC bundle outside critical care into the general wards and theatres

Spend more time on the wards promoting the sepsis bundle


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Appendix I

Sedation expenditure is now inspected regularly to determine if there have been any improvements in cost. A reduction in cost is not evident as yet but it is a practice we will continue as it may be premature to establish an overall improvement.

The central line bundle has empowered members of staff, particularly on HDU which is a Surgical/ Medical led unit, to be able to ensure that central lines are not kept in for longer than is absolutely necessary. This now enables nursing staff to remove central lines without having to wait unnecessarily for a ward round or call back from the medical teams.

Total2525

20

15

10

5

0

Total

Changing score will improve compliance

Don’t know No Yes (blank)

Count of compliance

£70

£60

£50

£40

£30

£20

£10

£0

Sedation Costs/ Pt Days

Sedation Costs/ Pt Days

01/04/06 – 30/06/06 01/07/06 – 30/09/06 01/10/06 – 31/12/06 01/01/07 – 28/02/06

Royal Gwent:

The Welsh Critical Care Improvement Programme (WCCIP) has been an interesting and exciting project that has been an honour to be involved in.

The programme’s aims were to implement two care bundles, ventilator and central venous catheter with a greater than 95% compliance rate in every general intensive care unit across Wales.

This has been achieved in the Royal Gwent Hospital by hard work, a variety of change management techniques and dedication from the whole team and has been a resounding success. The two bundles are now in place and part of normal everyday practice, compliance is predominantly greater than 95% and any problems are identified and resolved.

However we have achieved so much more as a result of this programme:

A Critical Care Innovation Group now meets regularly between nursing and medical staff to discuss any proposed new initiatives and to establish views and hopefully a consensus on how to develop them.

A nurse led weaning protocol is now being implemented and modified to ensure it is a functional tool for all members of the multi disciplinary team.

Sedation scoring has been audited to establish why staff members were not completing the sedation forms and a questionnaire has highlighted a practical tool that the majority of staff are happy to use.

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Appendix I

WRITE PDSA TO START THEPROCESS OF IMPLEMENTATION

MEET THE NLIAH TEAM

1. Identify the job2. Meet the team involved3. Discuss the implications

PDSA Objective: Successful implementation of

ventilator care bundleDO : Presentation on education board.Teaching sessions, 2-3 days/week, when on duty

to explain rationale for implementation andprovide opportunity for feedback.Encourage ownership of the project.

RESULTS: Bundle and data collection tool inprocess of successful implementation. Members

of staff appear to be committed to the project.

CREATE OBJECTIVES1. Plan with manager2. Discuss with clinical team

19th April 2006 Commencement of Pre –

implementation audit to assess current practices.Assessment and validation of the data collection

tool. Analysis of data to identify educationalpriorities.Education of all members of the multi-disciplinary

team.12th June 2006Launch ventilator care bundle

Post- 12th June 2006Daily data collection – Completed by care bundle

team.Ongoing educationAnalyse compliance – aim for 100% compliance by

August 2006.

COMPLETE PRE-AUDIT

INFORM, EDUCATE AND INVOLVE THECRITICAL CARE STAFF

IMPLEMENT THE 1ST CARE BUNDLE.

VENTILATOR CARE BUNDLE

CHALLENGES:Maintain staff motivation – Commence compliance charts.Continue to collect data when programme manager notpresent – shift leaders taking responsibility.Consensus of aspects of CVC bundle – Multi disciplinaryInnovations group established.

PDSA TO IMPLEMENT 2ND CARE BUNDLECENTRAL VENOUS CATHETER (CVC) BUNDLEIMPLEMENTATION - NOVEMBER 2006.

PDSA Objective: Introduction of central linebundle

DO: Presentation on education board.Teaching sessions, 2-3 days/week from care

bundle team, to explain rationale forimplementation and provide opportunity forfeedback.

Encourage ownership of the project.RESULT: Members of staff appear to beinterested and supportive to the project. Need

to get microbiology on board.

A JOURNEY TO HIGH STANDARDS: ROYAL GWENT HOSPITALPersonal DevelopmentAs a result of WCCIP, I have developed an increased understanding of advancements outside of the critical care unit and Royal Gwent Hospital.

My presentation skills have improved considerably as a result of the training from the NLIAH staff. The progression of my poster presentations can be seen in the two posters I submitted for this programme. I also presented at the celebration event which was a challenge as I did not have the confidence previously.

My computer skills have improved dramatically since commencing this programme, with assistance from my manager I can now create an Excel spreadsheet and extract information from the spreadsheet, my PowerPoint and database skills have also progressed.

I also have an increased expertise in the process of change management and have discovered that there is a need to use different styles to be to achieve results. I have also realised the importance of sustainability and ownership to ensure that the change is permanent.

The formation of a critical care nurse network has been one of the greatest assets of this programme in my opinion. There has been a sharing of ideas, support network and ability to benchmark with other units. The sharing of protocols, databases, forms and paperwork has ensured that so much more has been standardised, not just the care bundles themselves.

I have a better appreciation of what is occurring outside of the Trust and Critical Care. I have become involved in infection surveillance on a much wider scale and am aware of the WHAIP, Welsh Assembly Government project.

Royal Gwent Hospital is part of the Safer Patient Initiative Project (phase 2) which is funded by the Institute for Healthcare Improvements (IHI) and it was beneficial to already have an understanding of the IHI prior to learning of our involvement.

Future DevelopmentsWe plan to cascade the central line bundle out to the wards with the support of the Outreach Team.

The weaning protocol will continue to be developed and the change management skills we have acquired can be used to achieve a working protocol.

The next bundle to implement on the critical care unit will be the management aspect of the sepsis bundle and once established to introduce it to the wards and A&E.

There will be a process of succession planning, whereby I will handover to someone who has the motivation and enthusiasm for care bundles, who is prepared to commit to the project could benefit from the support and expertise of NLIAH and being part of a network.

However I would hope to and want to continue to be an active and key member of this very successful project.

I would like to take this opportunity to thank everyone who supported me through the development of this programme. It certainly is not the final story.


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Appendix I

North East Wales NHS Trust

Programme Managers: Julie Ward-Jones and Tracey Harris

The past year has seen a resounding success within the North East Wales Trust (NEWT) with the implementation of the ventilator care bundle in ITU - with compliance figures consistently exceeding 95 %.

The Central Venous Catheter Care BundleThe CVC care bundle has been more complicated to implement due to its multi faceted elements i.e. two components and not just restricted to the critical care area. Baseline data showed that not all the elements were being complied with on a daily basis.

The decision was made early on to commence the insertion bundle in theatre, as this is where the majority of lines are inserted. Documentation has been a particular problem when capturing this information, so after many tests of change a form was devised so that it followed the patient from theatre through onto the unit and was completed once the line was removed.

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North East Wales NHS Trust

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Apri

l (2

wee

kpi

lot)

Jun-

06

Aug-

06

Oct

-06

Dec

-06

Feb-

07

Apr-

07

Jun-

07

Ventilator care bundle NEWT

80%85%90%95%

100%105%

Compliancepercentage

Target


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Appendix I

As part of our strategic framework to address this, the group have devised an action plan for overall delivery of the CVC care bundle:

THEATRES - The central venous catheter care bundle has been introduced to Theatres since November 2006.

CORONARY CARE UNIT/MHDU - The Coronary Care Unit began implementation of the process in February 2007 following education delivery. The acute medical physician is a keen champion for this process.

RENAL UNIT – The renal unit have shown considerable interest in the education programme for the CVC care bundle and teaching sessions are being planned for May 07 with a view to implementing the bundle for acute line insertion of renal lines and general ward maintenance.

ACCIDENT AND EMERGENCY – A+E are currently looking at a pre-audit analysis of CVC insertion and educational sessions will begin with casualty staff in June 07.

TRUST WIDE - a trust-wide programme for the central venous catheter maintenance bundle will follow this.

Length of Stay

Length of stay has shown very little decrease that can be contributed to the care bundle process – since the commencement of the care bundles there have been elements of long stay patients and the variable case mix e.g. trauma, post operative, medical and surgical emergencies.

Ventilated patients admitted to ICU/HDU 1st January 2005 – 31st December 2006 ICU/HDU average of stay on the unit

Month and Number of Admissions

Aver

age

leng

th o

f st

ay o

n un

it (

days

)

20

Jan0

5–13

Pts

Feb0

5–17

Pts

Mar

05–2

4Pts

Apr0

5–19

Pts

May

05–1

6Pts

Jun0

5–19

Pts

Jul0

5–16

Pts

Aug0

5–20

Pts

Sep0

5–21

Pts

Oct

05–2

0Pts

Nov

05–1

9Pts

Dec

05–2

0Pts

Jan0

6–14

Pts

Feb0

6–14

Pts

Mar

06–1

7Pts

Apr0

6–17

Pts

May

06–2

1Pts

Jun0

6–18

Pts

Jul0

6–19

Pts

Aug0

6–22

Pts

Sep0

6–18

Pts

Oct

06–1

7Pts

Nov

06–1

6Pts

Dec

06–1

7Pts

18

16

12

10

8

6

4

2

0

14

After considerable work on staff education by the practice development nurse, and feedback to staff and project board we have now improved our compliance rate and are looking at spreading the bundle to outside the unit and theatre, into the general wards and A+E.

Further progress has been made on the introduction of all in one packs for the insertion of CVC lines and discussions are taking place with pharmacy with regards to Chlorhexidine 2%.

Coronary Care and the Medical High Dependency Units have shown a considerable interest in commencing the central line and sepsis care bundles.

Both units have been using the CVC care bundle since February 2007 following a large scale education and awareness raising exercise delivered by the practice development nurse and anaesthetic consultant. Initial teething problems with spreading the bundle have been investigated and the latest March figures for compliance with the CVC maintenance bundle have showed a significant improvement – 97%.

To assist in the implementation of the spread of the CVC care bundle outside of the critical care area, the clinical lead for the programme, Dr Campbell Edmondson established a ‘Vascular Access Group’. This group brought representatives from critical care, theatres, coronary care/MHDU, renal unit and A+E. The representatives consisted of medical, nursing and managerial staff.

Vascular Access Group

The overall aim of the group is to ensure equity and fairness for all patients who require a CVC. This involved those patients who may not be cared for within the critical care area.

Sept-06 Oct-06 Nov-06 Dec-06 Jan-07 Feb-07 Mar-07

CVC Compliance Rates

0%

20%

40%

60%

80%

100%

Daily maintenance monthly complianceLine insertion monthly compliance

Target compliance

Documentation‘test of change’

Baseline data Commenced incoronary care


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Appendix I

Educatedstaff

Developedguidelines, elementsand local exclusions

for the CVC care bundle

Developed audit

documentationImplemented CVC care bundle and

auditcompliance

Changed the audit form again and again

and again……following feedback

from staff

Collected data from Pathology to inform infection

surveillance

Critical care bundles…the story so far.

Continued to work as a team

Brought more people on board

Along the way we have…….

…the story continues with the Sepsis care bundle

The CVC care bundle

• infection surveillance link nursing sister• theatre staff• Coronary Care staff.

Central venous catheters (CVC’s) provide vascular access, which is essential within the critical care setting. Their use does however put patients at risk from local and systemic complications. The use of these catheters is associated with both mechanical and infective complications. In critical care the catheter is often manipulated several times a day. It may be in situ for an extensive length of time and patients can subsequently be colonised with hospital – acquired organisms. This ‘Care Bundle’ has two main areas to it: insertion and maintenance (to include line necessity review).This bundle commenced at the beginning of November 2006 and again will be audited against compliance with all elements of both areas.

The Ventilator Care Bundle

80%

85%

90%

95%

100%

105%

April (2week pilot)

May-06 Jun-06 Jul-06 Aug-06 Sep-06

compliance percentage target

•Continues to show above 95% compliance rate.•Practice Development Nurse progressing with ‘Nurse led weaning’policy.

This will be continued to be monitored as a measure not only for the Trust but WCCIP and the Safer Patient Initiative.

There has been a lack of consensus on what constitutes a ventilator-associated pneumonia and therefore no baseline data exists. Current work with the Safer Patient Initiative will hopefully overcome the issues with definition.

Barriers, Breakthroughs & Learning

BARRIERS Initial clinical engagement was slow but with the assistance of a clinical champion in the form of our clinical lead the situation has improved as the programme has developed.

Documentation – As is often the case, documentation continues to be a major issue. However with the careful use of tools and techniques (e.g. PDSA methodology) we have been able to overcome this barrier in many areas.

BREAK-THROUGHS

Continuous feedback to critical care staff and the improvement of compliance rates especially those of the ventilator care bundle have contributed towards the motivation for clinicians to engage in the process and thus reducing many of the barriers.

Networking between Trusts and other departments has been invaluable. It is essential for us as a group that this continues.

The programme for NEWT has now moved from ‘Project focused’ to being our ‘core business’.

LEARNING It has been clearly evident that the value of giving feedback to all staff at each stage of the project is invaluable.

Many of the processes that have been utilised were in place before commencement of the SPI 2 initiative, which has stood us in good stead for contributing to this initiative.

Next StepsIn addition to these strategies it is envisioned that the dissemination of improvement efforts will continue throughout the Trust. In order to enhance this we aim to continue monitoring central line infection rates and VAP in conjunction with SPI 2. Overall, new and revisited initiatives will include:

NURSE LED WEANING POLICY - Prior to the WCCIP the development of a weaning protocol was well underway, following ratification from the Directorate Management Team we aim to begin the implementation of the guidelines in August 2007 this will add considerable support to the ventilator bundle.

WHAIP – to support of infection surveillance by utilising the CVC care bundle.

Teamwork has been a vital element for the success of the programme as well as the dedication and commitment to quality patient care through the use of the care bundles.


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Appendix I

The Ventilator Care BundleA baseline audit of compliance with the ventilator care bundle from the beginning of April revealed consistent use of DVT prophylaxis and GU prophylaxis, variable practice with head elevation, but no provision for daily sedation interruption.

Even though a more gradual introduction was advised, it was decided to implement the whole of the ventilator care bundle simultaneously on May 22nd 2006, as the intensive care unit was quiet with only four ventilated patients during the first week.

The ventilator care bundle was rapidly and successfully implemented due to a combination of initial low bed occupancy which allowed for ease of introduction and the empowerment of nursing staff in ensuring overall compliance facilitated by an already existing desire to change and improve the use of sedation.

A three-month period was planned for the exclusive implementation of the ventilator care bundle before introducing the central venous catheter care bundles.

The Central Venous Catheter (CVC) Care BundleAfter conducting a baseline audit of compliance with the CVC maintenance care bundle in July and August 2006, it was clear that compliance was low in terms of aseptic lumen access, use of a dedicated TPN lumen and daily assessment of catheter need.

A baseline audit of catheter insertion was not conducted but the elements of the care bundle were already established as standard practice.

Following two weeks of designing revised and new documentation, education and awareness through presentations and discussion with staff, the central venous catheter care bundles were implemented in full on 4th September 2006.

The CVC care bundles were again rapidly and successfully implemented through empowerment of nursing staff, and a progression of the care bundle concept which had already delivered visible benefits.

Data CollectionThe concept of daily collection of detailed audit data was a new experience for everyone at North Glamorgan Intensive Care Unit. The original documentation has been revised several times during the year due to increase of data and to improve ease of use.

At the outset of the programme, it was agreed that the senior nurse in charge of the unit each day would have responsibility for overseeing practice and recording the daily compliance data. This has proved to be very successful in improving practice at the bedside and ensuring that compliance with data collection has been consistently �00% throughout the year.

North Glamorgan NHS Trust

Programme Manager: Vincent Espley

I was appointed as the Trust Programme Manager for the Welsh Critical Care Improvement Programme (WCCIP) at the end of April 2006, with the task of organising, co-ordinating and managing the implementation of the care bundles.

A Trust project board comprising the Clinical Director for Intensive Care, Head of Planning, Director of Nursing for Surgery and Clinical Nurse Manager for Intensive Care had already been involved in the initial planning of the programme, with funding of £�0,000 allocated to the trust from NLIAH.

Having attended the first Programme Manager day and the National Launch event on May 9th and 10th respectively, I formulated a project plan with the first two weeks taken up by design and production of programme documentation, an awareness programme throughout the Intensive Care Unit to gain agreement from anaesthetic staff, and education of nursing staff using Powerpoint presentations and discussion.

A local improvement team of my senior nurse colleagues in the Intensive Care Unit was also formed to assist me in implementing and sustaining the programme.

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North Glamorgan NHS Trust

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CVC Bundle


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Appendix I

Below are the results of data audit of average length of ventilator time and average length of stay for the period May 2006 – March 2007.

The graph demonstrates a distinct correlation between the average length of ventilator time and average length of stay.

There is a marked reduction in average length of ventilator time in June following the introduction of the ventilator care bundle.

The figures for average length of stay were heavily influenced by the delayed discharge of numerous patients during the summer/autumn of 2006, with the hospital wards being generally busier than normal for the time of year.

During the same period, the unit had an unusually high number of critically ill septic patients resulting in increased ventilator time.

The expected winter variation is clearly apparent, with the intensive care unit working at a relentlessly high occupancy since December 2006.

The patient case mix during the winter has also seen high numbers of critically ill, chronically sick patients who have been admitted with pneumonia and/or sepsis and subsequent renal failure, necessitating prolonged periods of ventilation and intensive care.

The audit of ventilator-associated pneumonia and catheter-related bloodstream infection rates over the past year is ongoing, and as such, no figures are currently available.

This is mainly attributable to the considerable time constraints involved in combining the roles of WCCIP Programme Manager and clinically based Ward Manager.

May June July Aug Sept Oct Nov Dec Jan Feb Mar

10

8

6

4

2

0

Average Length of Ventilator Time vs. Average Length of Stay

ALOSAVLT

Below are the results of data audit of ventilator and central venous catheter care bundle compliance for the period April 2006 – March 2007.

The ventilator care bundle graph demonstrates 0% compliance at the baseline audit in April 2006; prior to implementation of the care bundle, primarily due to lack of a protocol for daily sedation interruption.

Considering the fact that the ventilator care bundle was implemented towards the end of May, compliance was already up to 50%.

In June, compliance had reached 94%, and from July onward the programme target compliance of greater than 95% has been consistently achieved, with �00% compliance from November 2006 to March 2007.

Compliance with the central venous catheter maintenance bundle was at 26% in July 2006 during the baseline audit, rising to 92% during August through a programme of awareness and education.

The central venous catheter care bundle graph also shows consistently high compliance figures for insertion from the implementation date.

Since September 2006, the target compliance rate for both bundles has been achieved, with �00% compliance from October 2006 to March 2007.

Care Bundle Compliance April 06 - March 07

Ventilator Care Bundle CVC Insertion Bundle CVC Maintenance Bundle

1009080706050403020100

April May June July Aug Sept Oct Nov Dec Jan Feb Mar


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Appendix I

Team DevelopmentAt a local level, empowering nursing staff to implement change and sustain improvement through WCCIP has been a significant development, and has proved what can be achieved in a relatively small timescale.

The culture of challenging traditional medical and nursing practice through evidence-based research is a development undoubtedly accelerated by the methodology of this programme.

An intensive care forum was established early in the programme to ensure regular meetings between senior anaesthetic staff, myself and the clinical nurse manager, with the intention of driving forward change together through discussion and protocol development. Unfortunately, organisation of these meetings has been problematic, but hopefully can be resolved this year.

With the requirement for regular audit regarding ventilator-associated pneumonia and bloodstream infections, and the forthcoming surveillance programme, there has been a considerable improvement in the working relationship between intensive care and the infection control department.

Patient CareThe care bundles have provided standardised, consistent, evidence-based care for all patients who are ventilated and/or have a central venous catheter, using guidelines which have been widely accepted locally and nationally.

The traditional culture of over-sedation was broken very quickly, and has led to many more patients being managed on ventilators with little or no sedation. In addition, and when appropriate, patients are generally weaned from ventilators more quickly.

The programme has coincided with a trust policy regarding central venous catheter insertion, which ensures medical staff receive training during their induction process. Intensive Care, Accident and Emergency and Coronary Care now have ultrasound devices for guidance during catheter insertion, and ward patients requiring central venous catheters have the procedure performed in a theatre anaesthetic room.

In the Intensive Care Unit, greater attention is paid to aseptic access of central venous catheters, a dedicated lumen for TPN is now general practice, and regular assessment of need has resulted in early removal.

Financial BenefitsThere has been a considerable impact on intensive care pharmacy expenditure at North Glamorgan NHS Trust when comparing April 2005-06 with April 2006-07, following the implementation of the Welsh Critical Care Improvement Programme.

Programme SuccessesThe first year of the Welsh Critical Care Improvement Programme has been an undoubted success at North Glamorgan NHS Trust, for me personally, for the intensive care staff as a whole, and ultimately for the many patients who have required intensive care over the past twelve months.

Personal and Professional DevelopmentWCCIP has provided me with a first opportunity in project management, with local responsibility for planning, organising, co-ordinating and managing a significant national improvement project in critical care. This has been accompanied by further development of skills in presentation and report writing as well as a raised personal profile within the trust.

As a member and contributor to an all-Wales Programme Manager network in critical care, my knowledge and awareness of National and Strategic Health Policy both generally and in relation to critical care has increased significantly.

I have participated in the strategic decision process through membership of a critical care working group examining the future of critical care services in the local area, and have recently been nominated as the trust critical care representative for the Intravenous Devices Group for Welsh Health Supplies Contracts.

National CollaborativeThis year has resulted, for the first time, in the successful formation of an all-Wales network of critical care nurses, having a common goal and the desire to work together and provide support to promote positive change and improvement nationally.

The Programme Manager days have proved to be an invaluable forum for the excellent training provided by NLIAH, sharing experiences and ideas throughout the year, and as a means of support and encouragement, which has been greatly appreciated.

The Learning Events have provided an opportunity to introduce colleagues to the context of WCCIP outside the local units, to put an all-Wales perspective on the programme, and to meet critical care colleagues both professionally and socially.


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Appendix I

The programme has been very much nurse-led in terms of organisation, teamwork and improvement at the bedside, and has been successful due to a desire to improve patient care, willingness to embrace positive change with visible results, and perseverance to maintain high standards through difficult circumstances.

The Future of Care Bundles at North Glamorgan NHS TrustThe Welsh Critical Care Improvement Programme moves into a second phase in April 2007, with a proposed third phase in April 2008 as part of the Welsh Assembly quality agenda.

The first objective is to consolidate and continue the work of the ventilator and central venous catheter care bundles within the Intensive Care Unit.

The central venous catheter care bundle will hopefully be introduced to Theatres, Accident and Emergency, and Coronary Care Unit early this year, with initial contact between myself and senior colleagues in these areas encouraging. This will be followed by a trust-wide programme for the central venous catheter maintenance bundle.

The forthcoming Welsh Healthcare Associated Infection Programme (WHAIP) of surveillance for central venous catheters will provide feedback on infection rates.

Preparation work is under way to introduce the Surviving Sepsis Campaign care bundles into the intensive care unit, prior to a proposed trust-wide programme.

It is hoped to involve the Infusion Devices and Resuscitation Teams in the next phase of the programme, as they have already expressed an interest in care bundles, and have access to staff across the trust through training.

The improvement team in Intensive Care will be expanded this year, with the possibility of introducing other care bundles for the management of tracheostomies, nutrition, head injury and renal failure.

Personal ThanksTo Dave Hope, Chris Hancock, Dominique Bird and the NLIAH team for the leadership, organisation, training, support and encouragement they have provided during the past year.

To Noel Rowley, Lead Nurse at Morriston NHS Trust, for the database he allowed me to use and adapt, which has been invaluable in collecting compliance information.

To my colleagues at North Glamorgan NHS Trust, for their co-operation, understanding, perseverance and skill in making the first year of this programme successful and enjoyable to lead.

The ventilator care bundle has directly impacted on the costs of Midazolam and Morphine, the principal sedative agents used for ventilated patients:

Midazolam expenditure has been reduced by 4�%

Morphine expenditure has been reduced by 35%

Propofol expenditure has been unchanged

Xigris (Drotrecogin alpha) expenditure has been reduced by 33%

It must be noted that Xigris cost reduction is also attributable to factors other than the introduction of care bundles, namely patient eligibility according to treatment criteria.

However, patient numbers, case mix and consideration were considered comparable.

The total cost saving for the above drugs alone has been £�8,700 in the past year.

The total funding received by North Glamorgan NHS Trust in April 2006 was £�0,000.

The actual programme expenditure for the period April 2006-07 was £4002.79, or £6485.95 accounting for the theoretical cover of staff hours at the Learning Events.

SummaryThe Welsh Critical Care Improvement Programme evolved at an ideal time at North Glamorgan NHS Trust Intensive Care Unit, as it provided the means to deal with several patient care issues already being questioned and examined.

The care bundles have proved to be a simple, cost-effective, achievable and sustainable means to provide evidence-based best treatment to intensive care patients.

Sedation Costs 2005 – 2007

Midazolam Morphine

Ann

ual Ex

pend

itur

e £5,000

£4,000

£3,000

£2,000

£1,000

£0

April 2005-06 April 2006-07


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Appendix I

North West Wales NHS Trust

Programme Manager: Suzie Wilson

The Care Bundle approach was not an entirely new concept to ITU at Ysbyty Gwynedd in March 2006 when the programme started; in theory we already had the ventilator and sepsis care bundles running. However, an audit at the beginning of the year demonstrated poor compliance. The challenge was to convince the ITU team of the benefits to the patients so that we were compliant as near to 100% of the time as possible, to stop patients slipping through the net.

The first step was to form a strategic team involving as many members of the multidisciplinary team as possible. We had participation from nurses, physios, anaesthetists, dietician, pharmacy, infection control, outreach, audit department, modernisation department and a patient representative. The large team has improved communication between different members of the MD team and also meant that care bundles have had a high profile within the hospital.

The Ventilator Care BundleAn education programme was started that aimed to target every single anaesthetist and nurse within the department which involved formal teaching, bedside discussions, coming in on night duty to teach the night staff and doing talks at doctors meetings. A page for the hospital intranet was developed and a resource file made for every bed space.

To assist with communication we also started a daily ward round between anaesthetic team and nursing staff. A daily multidisciplinary ward round was agreed to in principle but has proven impractical at present.

Prescribing DVT and stress ulcer prophylaxis was readily accepted; the sticking points were 30 degrees head up and sedation holds. Better compliance has been achieved by education and persistence.

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CVC Bundle

PPrrooggrraammmmee MMaannaaggeerr


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Appendix I

Pembrokeshire and Derwen NHS Trust

Programme Manager: Linda Horswill

In May 2006 Pembs & Derwen joined the Welsh Critical Care Improvement Programme along with fourteen other critical care sites across Wales. This report reflects on our Unit’s achievements over the last year, the progress we are making and how we plan to sustain the improvements made.

At the start of the programme within our intensive care unit most of the medical and nursing staff had no pre-existing knowledge of care bundles and also the nursing staff had little experience of clinical audit. A project team was established and clear aims and objectives were set using the PDSA cycle format. A baseline audit was undertaken, simple audit tools were developed and a programme of education commenced.

Our aim at the start of the programme was to implement the ventilator and central line bundle and meet the set target compliance of 95% or above on a consistent basis.

The ventilator care bundle was implemented in July 2006. Initially there was some confusion and inconsistency around the sedation element of the ventilator bundle but with further clarification this has long since been resolved and as a result we are consistently achieving 95% and above compliance and this is encouraging.

In addition the ventilator weaning policy, which had previously been introduced into the Unit, but rarely used, was now revised and implemented again as a natural progression to the sedation element of the ventilator bundle.

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Pembrokeshire & Derwen NHS Trust

00.10.20.30.40.50.60.70.80.9 Vent Bundle

CVC Bundle

1

To complement the ventilator care bundle a nurse led weaning protocol was developed (with the help of Swansea) with the aim of reducing average ventilator time. This has been a big cultural change as traditionally nurses on the unit have not adjusted ventilator settings.

The Central Line Care BundleOnce we had achieved good compliance levels with the ventilator bundle we tackled the central line maintenance bundle. The main change to practice was early central line removal. This was surprisingly well received and the only negative feedback was from the night nurse practitioners who complained that they kept being called to the wards to insert venflons on ex ITU patients who were no longer being discharged with central lines. The average dwell time for central lines has been reduced by approximately 2 days. The insertion part of the bundle has just been started, the delay being due to having a drape and insertion pack being specially made for us as we had neither. We continue to monitor central line infections with the hope of trying to reduce them now that the bundle has been started.

The Sepsis Care BundleThe sepsis maintenance bundle was already implemented, and compliance with every element has been good except for tight glucose control. This is an area that we want to concentrate on in the coming year. A&E are in the early stages of implementing the sepsis resuscitation bundle, with support from ITU.

Taking Care Bundles to the WardsWe have a roll out programme for the wards to implement the central line bundle. Feedback from the first ward is very encouraging, where medical and nursing staff think that bundles are a great idea and are very keen to get started.

Benefits of the ProgrammeAlthough at NWW we have not been able to demonstrate a reduction in ventilator time or length of stay by implementing care bundles, the unit has benefited greatly from involvement with the programme.

Nurses now practice with more autonomy as they are able to wean and remove central lines without consulting medical staff.

Data collection and infection surveillance has become a normal part of the unit’s activity

We are more aware of developments on a national level and have been able to borrow ideas from other hospitals

Patients receive evidence based care

On a personal level, I have learned a great deal about change management and improved presentation skills. I would like to thank NLIAH and all the Programme Managers for their support and the enthusiasm from all on ITU at Ysbyty Gwynedd.


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Appendix I

Central Line Compliance

Coping with ChangeAs with any culture change it takes time for any new change process to become an established norm. Since the beginning of this year the ventilator and central line care bundles have become fairly well established and clinical audit of the practice is now much more routine.

Future PlansWork is already underway on our next objective, which is to implement the sepsis bundle, and it is envisaged that the central line bundle will be disseminated to theatres, A&E and some of the medical and surgical wards in the near future. Further projects will be to introduce other bundles, such as, tracheostomy, enteral feeding and tight blood glucose control.

EvaluationIntuitively care bundles feel right, and local audits and evaluations are beginning to demonstrate the benefits. In our own unit information sharing and working collaboratively with other critical care staff across Wales has been a positive and rewarding experience. Nursing staff have an increased awareness of audit, data analysis and infection control surveillance, and each individual patient’s care bundle encourages communication between anaesthetists and nursing staff. Since implementing care bundles in our unit we have seen a change in our nursing practice and we welcome the improvements to the quality of care we now deliver.

The project team at Pembs & Derwen would like to thank NLIAH and all those involved with the WCCIP for their support and enthusiasm throughout the duration of the programme. We feel proud of our achievements over this last year and look to continue with the same enthusiasm and commitment in the future.

% Compliance

% Compliance100.5

100

99.5

99

98.5

98

97.5

97

96.5

96

95.5Dec-06 Jan-07 Feb-07 Mar-07 Apr-07

Ventilator Compliance

The central line bundle was implemented in December 2006 and was generally well supported particularly from members of the junior anaesthetic team. It encouraged us to look at our infection control practices. Our compliance for this bundle is also 95% and above. Infection surveillance is to be introduced into the Unit, which will help us to monitor our performance.

Central Line Insertion Compliance

% Compliance

% Compliance100

90

80

70

60

50

40

30

20

10

0

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06

Aug

-06

Sep-

06

Oct

-06

Nov

-06

Dec

-06

Jan-

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-07

Apr

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% Compliance

% Compliance100

9080

70

60

50

40

30

20

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0Dec-06 Jan-07 Feb-07 Mar-07 Apr-07


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Appendix I

Project TeamLinda Horswill Project Manager

Dr. R Griffiths Lead Clinician

Alison Howells Sister

Julie Wickland Sister

Juddah David physiotherapist

Dr Kanakaraj anaesthetics

Dr Ranjan anaesthetists

Dr Chandra anaesthetists

Sue Richards specialist nurse infection control


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Appendix I

Feb

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Pontypridd and Rhondda NHS Trust

Programme Manager: Andrew Hermon

The programme has now been running for one year within the Critical Care Unit at the Royal Glamorgan Hospital. The two care bundles that were implemented by the Welsh Critical Care Programme in March 06, Respiratory and CVC have now been successfully integrated into the working practices of the Critical Care Unit at the Royal Glamorgan Hospital.

Initial problems to start with of providing the staff with training and education of the care bundles have now been resolved after the building of a very good team within the department who are committed to the implementation of the initiative.

There has also been the development of releasing a member of staff to chase up the care bundle data and input it into the computerized database so that gives the department and the Welsh Critical Care Programme how well the care bundles are progressing.

There was also a development of a new initiative to comply with the Central Line bundle which has meant a complete change of practice of how intravenous drugs are given at the bedside within the ITU and HDU. This initiative will now coincide with the ICU surveillance for Central Venous Catheter associated infections and looking at how that practice change has improved related infections.

The work that has been done within the department has been very progressive over the year and it is exciting to see how the care bundles have been taken on and utilized for the benefit of the patient. The Programme Manager has found the work and implementation of the care bundles very difficult initially but progressively over the year this has steadily improved as more staff have been keen to take part in the initiative.

From the utilization of the respiratory care bundle and allowing the patient a sedation break there has been a small reduction in the amount of usage of propofol and alfentanyl.

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Pontypridd & Rhondda NHS Trust

00.10.20.30.40.50.60.70.80.9 Vent Bundle

CVC Bundle

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Appendix I

Ventilator Care BundleThe Ventilator Care Bundle, launched as part of the WCCIP, was introduced with the Basic Care Bundle. Both these bundles are now a part of each nurse’s daily routine. The checking of cuff pressure every shift was included as an extra component in addition to those agreed by the WCCIP. Even though this was not included in the National Care Bundle, we felt it’s importance was significant enough to include as a local variation within the Ventilator Care Bundle.

Central Line Care BundleThe Central Line Care Bundles were introduced to the Critical Care Department during autumn 2006. The purpose of this bundle was to standardise the insertion of central lines and ensure daily maintenance of the central lines. The infection data, i.e. catheter related blood stream infection rates, are collected and monitored in co-ordination with the Welsh Associated Infection Programme (WHAIP). Data collection with this bundle has been inconsistent, possibly due to the large number of nursing and medical staff needed to educate regarding the bundle. The geography of the two sites is difficult to monitor. By the time data is required for the national surveillance, it is hoped staff will be more familiar in completing the forms.

Weaning ProtocolA nurse led weaning protocol has been developed, piloted and is now implemented into the department. This is intended to reduce the length of time patients are on ventilators.

Swansea NHS Trust Improvement GroupAn improvement group was set up within the Trust to look at areas of practice through use of the Care Bundles and ensure patients receive high standards of care at all times. The group’s memberships include the following:

Noel Rowley, Lead Nurse

Dave Hope, Consultant

Linda Reid, Head of Modernisation

Liz Savage, Patient / Public Representative

Anne Houghton, Lead Nurse

Bethan James, Practice Development Nurse

Tracy Owen, Sister

Karen James, Physiotherapist

Harri Jones, Consultant

Swansea NHS Trust

Programme Managers: Noel Rowley & Bethan James

The Critical Care Department at Swansea NHS Trust consists of a total of 26 beds, �8 beds in Morriston Hospital and 8 beds in Singleton Hospital.

Care Bundles was a concept familiar to the Critical Care Department in Swansea before the launch of the Welsh Critical Care Improvement Programme, (WCCIP). During 2004, we had previously piloted a system of data collection in relation to Care Bundles involving a computerised system, which was unsuccessful due to its complexity. Following the first meeting of the WCCIP in February 2006, a far simpler version of data collection was implemented using a paper audit tool. This was described by colleagues at the launch and had been successful within their areas.

Swansea NHS Trust - Launch In March 2006, the ‘All Wales Journey’ was commenced in Swansea NHS Trust with the implementation of a Basic Care Bundle and a Ventilator Bundle. Early introduction allowed more time to establish the concept of Care Bundles and identify any problems prior to the National launch. A poster was devised to summarise our actions.

Basic Care BundleThe introduction of the Basic Care Bundle was devised by the Critical Care Department in Swansea to ensure all patients, ventilated or not, received standardised interventions. These included DVT prophylaxis, tight glucose control, feeding protocol and administration of Folic Acid.

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Swansea NHS Trust

0%10%20%30%40%50%60%70%80%90%

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CVC Bundle


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Appendix I

I have been asked to collaborate on two specific projects:

• a survey to assess the level of relatives satisfaction with communication with ITU staff.

• the revision of the written information about ITU given to the relatives of new patients.

I have also met with Moyra Griffiths, Patient Experience Manager, initially to discuss training for representatives like me, which does not at present exist, and then to discuss any other ways in which I can be of help. She will keep me informed of future initiatives and meetings, including those of the Editorial Board and audits of different departments.

I have to achieve a delicate balance between asking questions which can stimulate a different way of thinking and interfering in clinical discussions. I hope to gain confidence in this role.

I would also like to receive training and discuss our role with other public/patient representatives in Swansea NHS Trust and nationally.”

Elizabeth Savage 30.03.2007

The FutureOur aims for the future

• To increase the care bundle compliance above 95 %.

• To implement a system to enter data directly onto a computer at the bedside.

• To introduce nurse led extubation within the weaning protocol.

• To improve on the multi-disciplinary reviews for our long term patients, facilitated by the use of the continuity of care forms.

• To feedback on the relatives survey on patient communication and satisfaction.

• To implement the severe sepsis bundle, linking in with an outreach service to allow early recognition and treatment of septic patients on the wards.

The team in Swansea NHS Trust would like to thank everybody for their help and support in the project and look forward to another successful year.

The purpose of the group is to look at areas of practice and if required to implement changes in the way we work. The Care Bundle data is analysed and changes are made to strive for �00% compliance. Our target is to ensure each patient receives all the interventions they require every day. The group meets every three months.

As a result of the group, there have been benefits in improved continuity of care for long term patients, with better liaison between medical staff, nurses and the physiotherapists regarding rehabilitation. A multi-disciplinary policy was drawn up which involved standardising bedside folders and regular discussion of long stay patients at our weekly multi-disciplinary meetings.

Each patient over ten days would be allocated a designated lead consultant, nurse and physiotherapist whose role is to co-ordinate and communicate the overall care of the patient. The consultant’s timetables were reviewed to maximise continuity of patient care. It was agreed that the consultant admitting the patient would be allocated as their lead consultant. The nurses were allocated depending on their experience and availability over the following few weeks. All multi-trauma patients were included in the programme immediately.

Communications between the multi-disciplinary team with patients and relatives has been addressed with the help of our patient/ public representative. Written information in the form of patient leaflets have been updated and now distributed to relatives when patients are admitted to the Unit. A survey of relatives’ satisfaction and communication needs is currently being undertaken.

A valued member of the group is Liz Savage our Patient/ Public representative. Liz has attended all our meetings and has written a short summary of her involvement within the group:

“My involvement in this programme started as a result of a meeting with Noel Rowley to discuss a problem experienced in the nursing care of my mother while in ITU during summer 2006. I was asked to attend the Improvement Group meeting held on October 25th 2006 and have attended the two subsequent meetings.

I am very aware of my limited knowledge and experience of hospital procedures and medical and nursing terminology so I prefer to listen to discussions and only make a contribution, ask a question or give a point of view when the subject is relevant to the general public and relatives of patients in particular. However, my experience as a teacher has afforded me some understanding of how public organisations work.

All members of the group have been supportive, welcoming and professional and are open to my opinions, willing to listen as well as explain.


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Appendix I

Trained the practitioners involved in the placement of the catheters concerning the elements of the bundle that had to be implemented.

Trust wide information sharing, ensuring that staff were aware of the project.

Devised a spread sheet in the CVC insertion clinic where data could be entered after each placement with a clear indication on the exclusions taken.

Patient RepresentativeA patient representative was involved from the onset and expressed his views from the patients’ perspective.

What change came about as a result of this project?The bundle has improved our practice in general in that we now use full body draping and pay more attention to the preferred site for placement. Chlorhexidine solution is now used for all CVC placements.

ResultsThere was a �00% compliance rate from the onset and this was maintained throughout.

The FutureWe aim to introduce further bundles into our practice in Velindre, namely the sepsis bundle which will be adapted to non-critically ill patients. Our CVC infection surveillance will take place along side the bundle.

Velindre NHS Trust

Programme Manager: Meinir Hughes

Velindre NHS Trust is based in Cardiff and provides specialist services at a local, regional and all Wales level. The Trust comprises of many Divisions, one being Velindre Cancer Centre. The Cancer Centre specialises in the care of patients with cancer and is committed to ensuring quality standards of care for our patients.

The Cancer Centre does not have a critical care unit within the hospital and our involvement in the Critical Care Improvement Programme was to introduce one care bundle into our daily practice. There are many Care Bundles being introduced into the critical care settings throughout Wales as a result of this project, however due to our patient group we could only implement the CVC Insertion Bundle at Velindre Cancer Centre.

Around 400 PICCs are placed annually in Velindre and �00 Hickman catheters. Both devices are crucial in the treatment of our patients to accommodate the delivery of intravenous therapy. The CVC insertion bundle was successfully introduced into the PICC and Hickman placement clinics in May 2006 and has been successful throughout the year.

How did we go about it?The team involved: Doctor, Senior Nurse, Intravenous Access Specialist and patient representative collectively agreed on the process and the way to implement the project.

Wrote an information document to inform the relevant practitioners of the concept of Care Bundles.

Amended the bundle to include our own local exclusions.

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Velindre NHS Trust

0%10%20%30%40%50%60%70%80%90%

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Appendix III

Executive Summary from Programme EvaluationIn order to gain insight into the impact of the collaborative approach telephone interviews were held to capture Senior Nurse, Sister, Charge Nurse and medical views of the programme. Face to face interviews were held with the Programme Lead and Clinical Lead to establish their roles. All relevant documentation was reviewed and an extended focus group held with key Trust staff involved in the implementation of the programme.

Strengths of the Approach NLIAH has achieved successful collaboration through empowerment and ownership by making this a clinician led initiative which provided clinical credibility, understanding of the issues and motivation to succeed. It seems that collaboration is the key to successful implementation of change. Failure to incorporate it within the WCCIP could have resulted in the ultimate rejection of this opportunity to improve care delivery for adult critical care patients.

Many of those involved in the Programme argued that the greatest single achievement was the creation in every Trust of a culture which valued routine monitoring of selected key aspects of service delivery, and acting on data generated therapy.

• Compliance figures for September 2006 show that Trusts achieved around 90% compliance for the care bundles with only one Trust falling below this. This is representative of the success of the WCCIP approach.

• The impact of the fact that care bundles are here to stay has assisted in gaining co-operation of all involved. The care bundles are seen as a means to achieving best practice, quality and standards of nursing/ medical care for patients and for these agreed standards to be met regardless of which Critical Care Unit the patient is admitted to in Wales.

• The work of the local Programme Managers was a key factor in ensuring professional engagement, and their own clinical credibility was central to this.

• Integration into practice required the ability to overcome resistance from some doctors and nurses through discussion, debate and education. There will always be some debate over the quality of evidence used to change practice and incorporated within the care bundles, but a key point with the WCCIP is that the care bundles will evolve and require review if new evidence is identified.

Appendix III

Janet Atwell-Thomas Head of CGSDU and Specialist Advisor, WAG

Geoff Bell Patient Representative, Pontypridd & Rhondda NHS Trust

Dominique Bird Senior Service Development, NLIAH

Steve Bowden Senior Pharmacist, UHW, Cardiff & Vale NHS Trust

Alan Brace LHB Chief Executives Carmarthenshire LHB

Wendy Chatham Director of the Quality, Standards and Safety Improvement Directorate, WAG

Peggy Edwards (for Julie Rix) – NPSA

Dr Bruce Ferguson Trust Representative, Medical Director, Bro Morgannwg NHS Trust

Dr Jonathon Gray Wales Centre for Health

Chris Hancock Programme Lead, WCCIP

Dr Gill Hastings Assistant Director, The Health Foundation

Dr David Hope Clinical Lead, WCCIP

Judyth Jenkins Welsh Therapies Advisory Committee

Dr Robin Mann Informing Healthcare

Winnie Mugambo Nutrition Nurse, UHW

Sue O’Keeffe Nursing Lead, WCCIP

Denise Richards Nursing Officer, WAG

Dr David Salter Acting Chief Medical Officer, WAG

Glyn Smith Community Health Councils

Alan Willson Director, Service Development, NLIAH

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II Appendix II

The membership of the Welsh Critical Care Improvement Programme steering group was as follows:

Hugh Ross (Chair) Chief Executive Cardiff and Vale NHS Trust


The collaborative methodology of the WCCIP has provided a stimulus for an All Wales approach and national debate with the growth of Critical Care Networks and an integrated approach to care bundles in clinical practice. It is envisaged that the WCCIP has set in motion a foundation for an open culture of sharing and learning on an All Wales basis and that this process will continue with future developments such as the implementation of the Sepsis Care Bundle and identification and dissemination of new care bundles as the process evolves.

Recommendations • It was noted that better use could be made of the Local Improvement Groups

to facilitate and negotiate the needs of Programme Managers and logistics of delivery. This could also improve the perceived gap regarding Trust Executives and management engagement in the process.

• Time for the Programme Managers needs to be protected at one day per week and that their roles should not be seen as having someone extra on duty to rely on if it gets busy. Appropriate PR and marketing needs to be implemented in conjunction with the start of the programme so that the public and NHS Trusts have access to key developments using flyers, websites and Trust intranet and bulletins.

• Patient Involvement: A patient representative enables the service user perspective to be captured and considered when reviewing changes, standards and quality of service.

�. This needs to be viewed in the context of Trust wide PPI strategy as this is a common problem for all Trusts.

2. Time to build the infrastructure to identify and support patients involved in this and to sustain this.

3. In terms of WCCIP this process was the starting point and requires time to develop.

Evaluation of the improvement project should run simultaneously with the project commencement to capture the relevant data throughout the project

University of Glamorgan, Cheryl Phillips, Senior Lecturer, March 2007

Appendix III

• This has been a clinician led initiative which has been invaluable in terms of motivation, understanding the issues and credibility.

• The way in which Programme Managers tackled the business of targets through peer pressure and consensus is to be acknowledged.

• The monitoring and corrective action decided locally by the people concerned seems to have created a culture where people own the problem and solve it without outside intervention.

The WCCIP has put into place a process that viewed differently is action learning and they have done this successfully.

Weaknesses • The Learning events, used as a forum for discussion, sharing and networking, were

mis-fitted and therefore off putting, resulting in poor representation from Trusts despite Programme Managers efforts to encourage attendance.

• Programme Managers need to be assured of dedicated and protected time for their role as they have relied on using their own time to achieve goals.

• Resources such as early implementation of PR and marketing processes in future improvement programmes are necessary to avoid missed opportunities to highlight what has been done.

• Databases and web site need improvement in terms of unity of databases used, accessibility and reliability and to be user friendly.

• More patient representation in Trusts Local Improvement Groups is required to reflect the valuable perspective they can bring to service delivery and improvement issues.

Evidence of outcomes to show we are making a difference is required, but proof of effectiveness through ongoing monitoring of process and outcomes is hard to substantiate. There are compliance details which may reflect clinical engagement, but Trusts want to see proof of patient outcomes not just the process.

Conclusion The WCCIP had ambitious aims. Achieving significant change in clinical practice is never easy; to do so simultaneously across all Trusts in Wales, in a pre-determined timescale, with no ability to enforce change other than professional and managerial influence, and when the service is beset by numerous initiatives, is indeed ambitious. But it succeeded. The analysis set out in this report identifies the key reasons for the Programme’s success, and those (relatively minor) issues which should be addressed before any roll-out or other similar initiatives are attempted. Most importantly, this experience demonstrates that this sort of collaborative model, when appropriately led and resourced, is one which should prove adaptable to other similar clinical change tasks.

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Appendix IV

Risks AnalysisEarly on in the programme NLIAH conducted a risk analysis to ensure countermeasures were in place early enough to reduce the impact of the identified risks. Presented below is an analysis of how this process has been managed to date:

Risk Countermeasure Results

Level of data collection required and lack of local dedicated data resources within units

NLIAH provided sites with funding allocations to set up data collection processes and potentially back-fill staff

Where this resource has been used efficiently, data collection has assisted the programme locally

Lack of nationally agreed definitions for elements of data analysis – e.g. some outcome measures

Programme worked closely with national team developing minimum data set

Programme’s objectives are to increase compliance with bundles. Data not being used to benchmark. Local teams continue to monitor their own progress in outcome measures

Potential duplication/conflict with aims of the Critical Care Networks to be established at the end of the programme

Continued close working with WAG and the advisory group established to inform the development of the Critical Care Networks

Findings from this programme have fed into the establishment of the Critical Care Networks

Disengagement of the Welsh Intensive Care Society (WICS) if programme seen as target-driven, top down approach

Clinical Lead appointed due to previous appointment as Chair of WICS, and detailed experience of the bundle approach. Collaborative approach used to ensure national support for way ahead

Collaborative approach has been evaluated and will be used to inform the design of future NLIAH programmes, as it has shown to increase engagement and local support

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