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What is a bundle?

What is a bundle?. ↠ A grouping of best practices with respect to a disease process that individually improve care, but when applied together result in substantially greater improvement ↠ The science behind the bundle is so well established that it should be considered standard of care.

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What is a bundle?

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  1. What is a bundle? • ↠A grouping of best practices with respect to a disease process that individually improve care, but when applied together result in substantially greater improvement • ↠ The science behind the bundle is so well established that it should be considered standard of care.

  2. What is a Bundle? Bundle elements are dichotomous and compliance can be measured: yes/no answers. Bundles eschew the piecemeal application of proven therapies in favor of an “all or none” approach.

  3. Vent Bundle • HOB elevated 30 degrees • DVT prophylaxis • Gastric ulcer prophylaxis • Sedation vacation • Daily readiness to wean • Other potential additions • Oral Care protocol • Mobility protocol Change

  4. Vent Bundle • HOB elevated 30 degrees • Why? • Reduces potential for aspiration • Potential to improve ventilation • Identified issues and concerns • Is it comfortable for the patient? • Causes the patient to slide down in bed • Potential for skin shearing • Anectdotal experience • Patients do not complain of discomfort • No significant documented increase in skin breakdown

  5. Vent Bundle • DVT Prophylaxis • Why? • Reduces potential for clot formation • Reduces potential for pulmonary emboli • Identified issues and concerns • None- well accepted therapy • Anecdotal experience • If using scd’s- assure they are on the patient not on the floor

  6. Vent Bundle • Gastric Ulcer prophylaxis • Why? • Reduces acid production in stomach • Reduces potential for severe lung injury related to aspiration • Identified issues and concerns • None- well accepted therapy • Anecdotal experience • None significant

  7. Vent Bundle • Sedation Vacation • Why? • Has been demonstrated to reduce overall patient sedation • Promotes early weaning • Potential to increase time to extubation • Identified issues and concerns • Increases potential for self extubation • Increases potential for patient pain and anxiety • Increases episodes of desaturation • Anecdotal experience • Promotes early extubation • No significant increase in pt. self extubation

  8. Vent Bundle • Daily readiness to wean • Why? • Brings weaning potential to the fore front of vent management • Entices discussion and teases out teaching that will strengthen the knowledge and understanding of both MD and RN/RT. • Will generate the need for a weaning protocol if one does not already exist • Identified issues and concerns • Involvement of RT and MD are essential • Anecdotal experiences • Decreases time on ventilators overall

  9. Other potential additions to Vent Bundle • Oral Care • Why? • Has been demonstrated to reduce colonization in the oral pharynx • Has been demonstrated to reduce the secretions that accumulate above the ET tube cuff • Assumption (lacks evidence)-reduces potential for VAP • Mobility • Why? • Improves patient strength • Reduces potential for deconditioning • Increases potential for early extubation

  10. Successes • all or none compliance • reduced VAP • reduced LOS on ventilator Barriers • all or none compliance • reduced VAP • reduced LOS on ventilator

  11. Tips for successful tests of change • Stay one cycle ahead • PDSA • Scale down the scope of the test • Test on one patient • Test with one MD’s patients • Test on one shift • Pick willing volunteers • Work with those who want to work with you • Look for the early adopters

  12. Tips for successful tests of change • Avoid the need for consensus, buy-in, or political solutions • Choose changes that do not require a long process of approval • Work with what you can influence Nurses- don’t start with a process that is MD driven or MD controlled- look for your piece of influence within that process.

  13. Tips for successful tests of change • Don’t reinvent the Wheel • Try modifying someone else’s work. • Pick easy changes to try • Avoid technical slow downs • Computer programming

  14. Tips for successful tests of change • Reflect on the results of every change • There are no failed tests of change • Ask yourself • What did we think would happen? • What did happen? • Where there unintended consequences? • What was the best thing about this test? • What was the worst thing about this test? • What should we do next?

  15. Tips for successful tests of change • Be prepared to end the test of a change • If the test shows that a change or a series of changes is not leading to improvement- STOP IT! • Go back to the last improvement and revamp your next test.

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