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Bundle Science and the Ventilator Bundle

History of the Bundle. Challenging the teams in the IHI Idealized Design of the ICU CollaborativeDevelopment of the

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Bundle Science and the Ventilator Bundle

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    1. Bundle Science and the Ventilator Bundle Roger Resar MD Mayo Health System Senior Fellow IHI March 2005

    2. History of the Bundle Challenging the teams in the IHI Idealized Design of the ICU Collaborative Development of the “all or none” measurement Observation of VAP reduction Evaluation of the change strategy

    3. Bundle A grouping of failure mode processes (bundle elements) with approximate time and space characteristics that when done collectively can have an enhanced affect on an outcome

    4. Bundle Science Each element requires solid science that is essentially non refutable The tasks must relate in time and space A minimal number is required All or none is the measurement Outcomes are a by product of the process change and will depend on subsequent science

    5. Learning From Implementing the Vent Bundle The demand for the “all or none” measurement drove change in the unit in an unpredictable positive way Bundles and their elements facilitate identifying failures in design Failures can be actively used to redesign the process Improved outcomes are a by product and not the initial goal

    6. Process for Bundle Development Review the evidence for appropriate care (guidelines) Identify the important failure modes Define the bundle elements from a gap analysis of defect rates Bundle the elements based on tasks carried out with similar time and space characteristics

    7. Bundle Theories 1-(Don Berwick) The bundling causes a synergistic affect and then gives you a positive interaction and outcome 2-(Roger) The bundles are individually high level science. Done together they build teamwork and accomplish more than individual elements alone 3-(Tom Nolan) Task design in time and space related to logic flow. The logic flow allows for human factors to achieve high reliability (Dinner party story sauce, vcr and coffee)  

    8. Healthcare Reliability Terminology (Different from the mathematical) Unstable process: Failure in greater than 20% of opportunities 10-1: 80 or 90 percent success. 1 or 2 failures out of 10 opportunities 10-2: 5 failures or less out of 100 opportunities 10-3: 5 failures or less out of 1000 opportunities 10-4: 5 failures or less out of 10,000 opportunities

    9. Premises – IHI Innovation Team 10-1 performance indicates no articulated common process 10-2 performance indicates processes with medium to high variation 10-3 performance indicates a well designed system with low variation and cooperative relationships

    10. Ventilator Bundle Head of bed elevation Sedation vacation DVT prophylaxis PUD prophylaxis

    11. Intent, Vigilance and Hard Work: 10-1 Performance to 10-2 transition Level 1 Standardization (mostly structure) Personal check lists Working harder next time Feedback of information Awareness and training

    12. Human Factors and Reliability Science: 10-2 Performance to 10-3 transition Level 2 Decision aids and reminders built into the system Desired action the default(based on evidence) Redundancy Takes advantage of habits and patterns Standardization of process

    15. Ventilator Bundle Data 35 units (academic, community, surgical, med surg etc) Greater than 20% improvement in adherence to the ventilator bundle 44% improvement in VAP

    17. VAP Facts VAP occurs in up to 15% of ventilated patients (Craven) Mortality rate for VAP 46%(Ibrahim) Prolonged mechanical ventilation associated with VAP(Kress) VAP guidelines published (Dodek) VAP guidelines not implemented reliably(Rello)

    18. Sedation Vacation Must not be medically contraindicated Implies waking patient to level of ability to follow commands Implies once every 24 hours Does not dictate method or drugs

    19. Elevation of Head of Bed Must not be medically contraindicated Does not demand a given degree of elevation but greater than 30 degrees (literature suggests 45 degrees best) Drakulovic Does not demand 100% but an acceptable percent determined by the unit Measurement at least once a day but more often preferred

    20. PUD Prophylaxis Element does not dictate which agent to be used (although sucralfate probably best) Cook

    21. DVT Prophylaxis Element Does not dictate which methodology to use

    23. Tips to Implementing the Ventilator Bundle Start multidisciplinary rounds Document daily goals Build redundancy into the processes Rely on mid level providers as much as possible Test on all shifts before you settle on a finished design

    24. Tips for Measurement Start with simple measures (one time measurement of HOB) Sample 5 patients 7 AM each morning Have the team do the measurement Employ the use of run charts over time with appropriate annotation Do not do 100% measurement Insist on all or none measurement

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