Ventilator Bundles

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Ventilator Bundles

• David Gourley, BS, RRT
• Director of Cardiopulmonary Services
• Chilton Memorial Hospital
• Pompton Plains, New Jersey

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Ventilator Bundles

• Concept of a bundle
• Several elements done simultaneously
• Consistently result in better outcomes
• Greater quality than elements done independently
• Systems must ensure all elements applied to all
  patients
• Limit bundle elements

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Ventilator Bundle Performance Improvement

• What we can accomplish?
• To achieve greater than 95 on the ventilator
  bundle.
• How will we know that a change is an improvement?
• Monitor percent of ventilator patients receiving
  all five bundle elements

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Ventilator Bundle Performance Improvement

• What changes can we make that will result in
  improvement?
• Improve education by distributing a FACT SHEET
• Hold in-services for bedside providers
• Improve communication among providers by using
  the DAILY GOALS SHEET during rounds in the ICU.

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Ventilator Bundle Performance Improvement

• What changes can we make that will result in
  improvement? (cont.)
• Create independent redundancy to insure that
  patients receive the processes of care included
  in the ventilator bundle.
• Conduct glucose control rounds where you review a
  patient who is on the protocol

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Ventilator Bundle Elements

• HOB elevation
• Appropriate DVT prophylaxis
• Appropriate PUD prophylaxis
• Appropriate sedation
• Assessment of readiness to extubate

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HOB Elevation

• HOB elevated greater than 30 degrees
• Reduces frequency and risk of nosocomial
  pneumonia
• Simple, no-cost intervention
• Incidence of aspirations reduced 30
• Vent and ICU LOS reduced

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Appropriate DVT Prophylaxis

• Thromboprophylaxis effective in preventing DVT
• Multiple methods of thromboprophylaxis
• Unfractionated heparin
• Heparin
• Mechanical prophylaxis (TED hose, sequential
  compression)
• Baseline incidence of DVT at 30

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Appropriate PUD Prophylaxis

• Reduces risk of upper GI bleeding
• Risk increased in
• Mechanical ventilation greater than 48 hours
• Coagulopathy
• No specific therapy

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Appropriate Sedation

• Daily interruption decreases vent LOS
• Vent LOS reduced by 33
• ICU LOS reduced by 35
• Hold sedation daily until patient can follow
  commands

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Assessment of Readiness to Extubate

• Reduce vent LOS, complications, and ICU costs
• Daily screening of respiratory function
• Spontaneous breathing trials
• Vent LOS reduced by 1.5 days
• Reduced self extubation, reintubation, trach,
  prolonged mechanical ventilation
• No baseline data

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Systems of Independent redundancy

• To incorporate multiple independent triggers into
  the existing system and
• improve compliance with the vent bundle
• Add triggers to the charting system to query the
  RN/respiratory therapist when documenting
• Is HOB elevated 30 degrees?
• Is patient receiving DVT prophylaxis

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Systems of Independent redundancy

• Monitor performance for the ventilator bundle
• Print a run chart of performance for vent bundle
  over time.
• Plan meeting with team
• Evaluate opportunities to further improve
  performance

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Fact Sheet

• Head of bed (HOB) elevation greater than 30
  degrees reduces the frequency and risk for
  nosocomial pneumonia compared to supine position.
• The use of thromboprophylaxis is effective for
  preventing deep venous thrombosis (DVT).
• The use of peptic ulcer disease (PUD) prophylaxis
  reduces the risk of upper gastrointestinal
  bleeding.

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Fact Sheet
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Additional Elements for Future Implementation

• Appropriate Glucose Control
• Intensive insulin therapy
• Maintain blood glucose less than 110 mg/deciliter
• Decrease morbidity and morality
• Gastric Decontamination
• Reduce colonization with resistant gram negative
  aerobic bacteria
• Reduce ICU and hospital mortality

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Ventilator Bundles

• Ventilator bundles and performance improvement
• Elements of a ventilator bundle
• Systems of independent redundancy
• Fact Sheet
• Additional elements for future implementation