Are Care Bundles Helpful Or Hindrance In Critical Care Medicine?

Components of care bundles

Part 1 Are ‘care bundles’ (example sepsis or other) helpful or a hindrance?

A care bundle refers to a collection of interventions that result in a more effective outcome when used together than when the interventions are delivered independently; this represents more progress compared to a non-structured method. Care bundles can be utilised to guarantee the minimum standard of care has been delivered; they are able to be used as an audit tool to evaluate how interventions are provided however, the effectiveness of performing individual interventions is unable to be assessed. Through the use of Care bundles, evidence reviews and altering clinical care guidelines should be encouraged, prompting education of staff in best practice. Further explanation regarding care bundles was given by( Berenholtz and team) to measure quality of care. Based on their research, interventions were applied to show how morbidity and mortality can be prevented and avoided. . It is evident from this method that there are two significant forms of care bundles to focus on: (i) the interventions themselves and (ii) the processes of care delivery. Consequently, the care bundle is also seen as a valuable tool for audit and quality assurance. Therefore, it is known as a popular management and clinical tool.

The sepsis care bundle is part of the international Surviving Sepsis campaign, and it is the most commonly used bundle (Deborah L Horner 2012). Bundles shaped a significant part of the ‘100 000 Lives Programme’ (2004) and the ‘5 Million Lives Campaign’ (2006)in  several clinical situations. Within critical care medicine, these comprised of but were not limited to: sepsis, cardiac, and respiratory failure. Internationally, bundles have also been strongly endorsed within critical care; the Surviving Sepsis campaign would be strong example. This international initiative intended to plan and implement a care bundle method to increase the rates of survival from severe sepsis by 25%. All of the above mentioned care bundles have been very successful and this has resulted in increased interest in intensive care bundles for the management of a broader range of circumstances in the future.( Berenholtz SM,  Dorman T,  Ngo K,  Pronovost PJ2002)

Components of care bundles

Group of 3–5 evidence-based interventions relating to a specific ailment or event in patient care should able to implement together.

Should be followed for every patient at all times

Able to be used to assess evidence based practice

Every step able to be audited, that is, done/not done/local exclusion

Benefits of Care Bundles

Bundle should only receive compliance once all interventions are completed or if a step is excluded for pre-defined reasons.

Care bundles are helpful or hindrance

In order to evaluate the effectiveness of care bundles, the elements of fundamental theory needs to be considered and whether it is proved in practice. To start, it is a requirement in the care bundle method that all patients in a specified group receive all elements of required care; this is expected to increase the overall level of care. It is grounded on the assumption that an unvarying procedure to deliver evidence-based ‘high impact’ interventions should decrease unjustified dissimilarities in care. Unrecognized omissions of clinical care should be prevented, resulting of human error or local differences in practice, which should decrease morbidity and mortality. (Deborah L Horner 2012).  

This process encompasses staff education in best practice.

Direct benefit to the patient

Shorter intensive care unit stay

Decreased financial cost

Improve resource utilization, and therefore, benefit to other patients outside the scope of the care bundle

In summary, it is evident that there is a strong case for extensive employment of care bundles in critical care medicine. Numerous reports in the literature have evaluated the success and efficiency of critical care bundles; where these have been applied with a high degree of compliance. In conclusion, that care bundles have been shown to be effective and are here to stay.

Part 2

The following discussion with fellow students and the feedback from work place practices in use of care bundles in intensive care unit (ICU) proved greater patient recovery rates, reduced complications and reduced length of stay in ICU. The theory behind care bundles is that when several evidence?based interventions are grouped together in a single protocol implementation, it will enhance a speedy recovery for patients. Commonly used bundles in ICU are ventilator care bundles (elevation of the head of the bed to between 30° and 45° , daily ‘sedation interruption’, assessment of readiness to extubate, peptic ulcer disease prophylaxis and venous thromboembolism prophylaxis), Line bundles, catheter care bundles and sepsis care bundles (Bouadma L, 2010).

Bouadma and colleagues mentioned the incidence of ventilator-associated pneumonia was reduced by 51% over a two-year period after introducing a ventilator care bundle. Key elements of the bundle included hand hygiene, use of gown and gloves while performing interventions, adoption of a semi-recumbent position (30° head-up tilt), meticulous attention to correct tracheal cuff pressure, elimination of unnecessary placement of nasogastric tubes, care to avoid gastric distension, good oral hygiene, and avoidance of tracheal suctioning other than when essential.

The most important and widely accepted care bundle in intensive care unit is the Surviving Sepsis. It consists of resuscitation and ongoing care components including monitoring serum lactate levels, taking blood cultures before giving antibiotics, Broad-spectrum antibiotics given within three hours of A&E admission and within one hour of non-A&E admission, treating hypotension and/or elevated lactate with fluids, giving vasopressors for hypotension not responding to initial fluid resuscitation to keep mean arterial pressure >65 mm Hg , Keep CVP>8 mm Hg ,Low-dose iv. hydrocortisone for 7 days (200–300 mg day−1 in 3–4 divided doses or continuous infusion) in patients with refractory low arterial pressure, despite adequate fluid and vasopressors and also commence glucose control if blood sugar level >10 mmol litre (FAuthor, 2013).

Levy and colleagues evaluated the effectiveness of the surviving sepsis guideline. Compliance with the management bundle improved from 18.4% to 36.1% (Levy MM, 2010). An online audit published by Lagan and colleagues in August 2008 suggested that 96% of the units were using a ventilator care bundle and 68% of those units achieved 80% or better compliance (Lagan S, 2011).

FAST HUG is the implementation of collective interventions/ clinical practice for caring for critically ill patients in various intensive care units worldwide and is a part of many care bundles. It aids in fast recovery, reduces complications and reduces length of stay in intensive care units. It includes early start of feeding, adequate analgesia, appropriate Sedation and sedation hold, thrombo-prophylaxis, head-of-bed angle, Ulcer prophylaxis and Glucose control; it was proposed to highlight key aspects of care that should be considered at least daily for all ICU patients. Regularly reviewing these elements enhances safety and patient care in ICU units (Bouadma L).

Care bundles have proven to be effective in improving clinical outcomes. It is important to know that the best strategies to implement in clinical setting. There are many reports in the literature evaluating the success and effectiveness of critical care bundles, implemented with a high degree of compliance, there have been associated reductions in morbidity and mortality. To have been effective and are here to stay. It remains the responsibility of the critical care community to further develop, refine, and update bundles in the light of evolving clinical evidence as well as continue with research evidences and adapt best practices to the intensive care units.

Components of care bundles

PART 1

Are ‘care bundles’ (example sepsis or other) helpful or a hindrance?

Care bundle can be defined as a set of different types of interventions that results in providing more effective output when being utilized together in comparison to when each of these types of  interventions are delivered in an independent manner. This approach helps in providing better outcome to a non-structured procedure. Care bundles can be used so that the Healthcare professionals can provide a guarantee that minimum number of standards of care have been maintained and delivered. Many of the researchers have also considered utilizing care bundles as an audit tool that helps in evaluation of the ways by which interventions are provided. However till date the effectiveness of performing individual interventions has not  been able to be assessed successfully. with the proper utilization of the care bundles, Health Care Industries can encourage reviews of evidences as well as altering of different clinical care guidelines so that they can successfully prompt education of the staff in providing the best quality care to patients. Many of the researchers have put forward explanation to understand the quality of care provided by the care bundles. They have put forward many researches through which interventions were tested to show whether they are successful in preventing morbidity and mortality of patients ( Berenholtz and team). It is evident from the method that two important forms of care bundles are there that the Healthcare professionals can focus on. The first one is the interventions themselves and the second one is the processes of care delivery. Many of the researchers also see the care bundle as a valuable tool for audit as well as quality assurance. Therefore, it can be referred to as a popular management as well as clinical tools

One of the most commonly used care bundle is the sepsis care bundle and it is a part of the international Surviving Sepsis Campaign. Bundles have become one of the most important parts of the 100000 Live Program and the 5 Million Life Campaign in 2006 in varieties of clinical situations. Within the domain of Critical Care medicine the set of care bundles are seen to B comprising of sepsis, cardiac as well as respiratory failure but they are not limited to this domain is only. The surviving sepsis campaign was a very good example that can be cited here. This was an international initiative that was mainly intending for effective planning and implementation of care bundle method that help in the increasing of the rates of the number of survival of people suffering from severe sepsis by an amount which is near bout 25% (Berenholtz SM,  Dorman T,  Ngo K,  Pronovost PJ2002). The already mentioned care bundles have been found to be extremely successful and therefore they have increased the interest of their use by different professionals in Intensive Care bundles mainly for managing of broader as well as various range of circumstances in the times of the future

Benefits of Care Bundles

Components of care bundles:

The main components of the care bundles are comprising of a group of 3 to 5 evidence based interventions that relate to a specific type of ailment as well as an event in care of the patient and they should be able to be implemented together while providing care. These interventions should be followed for every patient at all possible time and should be able to be used for perfect assessment of evidence-based practices. The care bundle should be such that every step should be able to be audited in the three categories of done, not done and local exclamation. Bundle should only receive compliance once all the interventions are completed or if a step is excluded for predefined reasons.

Care bundles are helpful or hindrance:

It is very important to evaluate that whether the care bundles are effective or not and for that two important steps need to be taken. The first step is   considering the elements of the various types of fundamental theory needs as well as to prove whether it is effective in practice or not. Researchers have stated that it is indeed one of the most important requirements in the carer bundle that every of the patient in a specified group should be receiving all elements of required care. This overall results in an increase in the level of care. Researchers have clearly stated that the concept is mainly based on the assumption that that an unvarying procedure for the delivering of evidence-based high impact interventions which will in turn decrease unjustified dissimilarity in care (Deborah L Horner 2012). In order to decrease the mobility and mortality, different types of unrecognized omissions of clinical care as well as human error or local differences in practice was taken. This has a number of benefits as this process helps in encompassing staff education in best of the practices and has direct benefit to the patient. They also help in shorter Intensive Care Unit stay and thereby decrease financial cost. It also helps in improvement of the resource utilization that in turn benefits the other patients outside the scope of care bundles.

From the above discussion, it becomes clear that there is a strong base for the extensive incorporation of care bundles in the critical care medicine. Different types of researchers have evaluated the success as well as the efficiency of critical care bundles. In such articles there have been a high degree of compliance found along with the care manuals. Therefore, we one can conclude that care bundles have shown effective outcomes and have the potential to become more successful in the future.

Examples of Care Bundles in Intensive Care Unit

References:

1 Continuing Education in Anaesthesia Critical Care & Pain, Volume 12, Issue 4, 1 August 2012, Pages 199–202, https://doi.org/10.1093/bjaceaccp/mks021

Published: 09 May 2012

2. BerenholtzSM,  Dorman T,  Ngo K,  Pronovost PJ. Qualitative review of intensive care unit quality indicators, J CritCare , 2002, vol. 17 (pg. 1-12) https://doi.org/10.1053/jcrc.2002.33035
3. Patient Safety First Critical Care Interventions Available from https://www.patientsafetyfirst.nhs.uk/Content.aspx?path=/interventions/Criticalcare/ (accessed 23 August 2011)

PART 2

Discussions were conducted with fellow students. After the discussion,  their feedback were taken from workplace practices on the utilization of care bundles in Intensive Care units. This proved that greater patient recovery rates were associated with Effective utilization of care bundles. Reduce complications as well as reduce length of stay in the ICU were also effective outcomes. The main theory that was found to reside behind the use of care bundle is that when an large number of evidence based interventions are put together and grouped, so that a single protocol implementation can be carried out, it results in better enhancement of the patient health as well as speedy recovery of this patient. One of the commonly used type of the bundles in the ICU is the ventilator care bundles. It mainly includes elevation of the head of the bed two angles between the range of about 30 and 45 degree. It also included daily sedation interruption assessment of the readiness for the successdul extubation as well as  peptic ulcer disease, venous thromboembolism prophylaxis as well as peptic ulcer disease prophylaxis. Some other examples are line bundles catheter bundles as well as sepsis care bundles (Bouadma L, 2010).

Analysis of a study showed that after introducing a ventilation care bundle, the incidence of one type of pneumonia was the ventilator-associated pneumonia and was seen to undergo reduction by 51% over a period of 2 years. Some of the elements of the bundle comprise of proper hand hygiene, use of gowns as well as gloves during the performance of the interventions, effective adoption and management of semi recumbent position. It also involve meticulous attention to different correct tracheal cuff pressure, good oral hygiene, elimination of  unnecessary placement of nasogastric tube, effective care for providing gastric distention, good oral hygiene as well as to avoid that brachial functioning other than when essential.

Surviving sepsis is one of the most significant as well as widely accepted care bundles in Intensive Care Unit. This is mainly seem to be comprising of the reservation as well as ongoing care components that incorporate effective monitoring of the serum lactate levels. It also involves taking of blood cultures mainly in the time before the giving of various antibiotics, as well as broad spectrum antibiotics that have to be given within 3 hours of A and E admission. They should be also given within 1 hour of non A and E admission with effective treatment of hypotension as well as elevated lactate level with Fluids (FAuthor, 2013). It is also seen to comprise of vasopressors for hypotension not responding to initial fluid resuscitation. This helps to keep the mean arterial pressure greater than 65 millimeter of mercury. He also helps to keep the cvp greater than 8 millimeter of Mercury and has low dose like hydrocortisone for 7 days. This is mainly done in clients who suffer from refractory low atrial pressure despite the adequate fluid as well as vasopressors. Glucose control is commenced If the blood sugar level is greater than 10 mmol/litre (Lagan S, 2011).

Effectiveness of the Surviving Sepsis guideline

Researchers such as Levy and colleagues have conducted evaluation of the effectiveness of the surviving sepsis guidelines. It was seen that compliance with the management bundle had shown steady improvement from the time of 18.4% to 36.1%. Researchers like Lagan and his colleagues had published an online audit in the year 2008 in the month of August with suggested the 96% of the units  were using ventilator care bundles and 68% of those units were seen to achieve 84% as well as better compliance.

FAST HUG can be defined as the implementation of a collection of interventions as well as clinical practices for proper caring of critically ill patients who are residing in Intensive Care units worldwide. It was also made a part of many care bundles and mainly helps in providing faster recovery and reduction of the complications as well as length of stay of the patients in ICU. This is mainly seen to include a number of aspects like early start of feeding, appropriate sedation and sedation hold, adequate analgesia, head of bed angle, thrombo-prophylaxis, ulcer prophylaxis as well as glucose control. Regularly reviewing these elements mainly helps in enhancement of the safety as well as well as quality care of the patient in ICU unit

Care design seems to have proven to be effective in improvement of the clinical outcomes. It is significant for every healthcare professional to know the best Strategies for implementing in clinical care.  a number of reports  in Literature have been provided which has helped to evaluate the success as well as effectiveness of critical care bundles  along with implementation with a high degree of compliance. It has been found that they have been considerate reductions in morbidity and mortality of patients. Therefore, it remains a responsibility of Critical Care community for the development refining and updating the bundles by taking help through properly evolving different types of clinical evidence and thereby to continue with research evidences and adopt best practices for Intensive Care units

References:

1  FAuthor: P Fulbrook, RN, MSc, PGDE, BSc (Hons), Clinical Reader in Critical Care, Institute of Health & Community Studies, Bournemouth University, Bournemouth, Dorset; S Mooney, RN, MSc, PGDip, Consultant Nurse in Critical Care, Dorset County Hospital, Dorchester, Dorset ... Less ASTHUG for intubated and ventilated patients intensive care units  practiced in worldwide.

2 BouadmaL,  Mourvillier B,  Deiler V, et al. A multifaceted program to prevent ventilator-associated pneumonia: impact on compliance with preventive measures, Crit Care Med, 2010, vol. 38 (pg. 789-96) https://doi.org/10.1097/CCM.0b013e3181ce21af

3 . Levy MM,  Dellinger RP,  Townsend SR, et al. The Surviving Sepsis Campaign: results of an international guideline-based performance improvement program targeting severe sepsis, Intensive Care Med , 2010, vol. 36 (pg. 222-31) https://doi.org/10.1007/s00134-009-1738-3

4 Lagan S. National Care bundles audit Available from https://www.midtrentccn.nhs.uk/service-improvement/care-bundles (accessed 2 April 2018)