High Impact Interventions Care bundles

1
High Impact Interventions(Care bundles)

• Janice Stevens
• Department of Health

2
Infectionhappens!
INFECTION IS INTOLERABLE
3
Quality and Safety

• Infection is a key quality indicator
• Safety issue
• Risk factors
• hand hygiene
• aseptic technique
• antibiotic practices
• wound/catheter care
• technical competence

4
Questions

• How do you know if you are delivering good
  quality care ?
• How do you define it?
• How do you measure it?
• How do you improve it?
• How do you demonstrate you are delivering it?

5
Answer..
But why?

• Care Bundles High Impact Interventions

6
Clinical Practice

• Real reductions will not be achieved unless staff
  do the right things every time
• Often mismatch between intention and action!
• Having done the training doesnt assure
  competence
• Staff too embarrassed to ask questions about
  something so basic!!
• Often elements of practice carried out but rarely
  all

7
Wouldnt it be good if

• We could demonstrate easily how and why we are
  improving
• It was easy to do
• We had a way of feeding back to our team
• We were clear about which bits of a care process
  can cause infection
• Patients didnt get infections therefore no
  needless pain, suffering, extended stay, anxiety

8
Outcome.

• ALL patients receive the best
  care/treatment,
• based on evidence or logic,
• 100 of the time
• Lancet series, March April 2004 MRSA article
  BMJ, 17th July 2004

9
But we do that already

• If you always do what youve always done
• You will always get what youve always got!

10
Audit blight!

• Audit has its place but
• Quarterly audits will rarely result in
  significant improvement
• Audit loop not often closed
• Focus often missing

11

• Audit research
• Outcomes
• Larger numbers
• Statistical significance
• Longer timescales

• Bundles
• Process measures
• Small numbers
• Focus on compliance
• Fast feedback action

12
What is it?

• A systematic method of measuring and improving
  clinical care processes
• based on groups of care elements for particular
  diagnoses and procedures

13
Renal Dialysis Catheter Care (2C)

• ELEMENTS
• No routine replacement
• Catheter type
• Insertion site
• Alcoholic chlorohexidine used
• HII 1 (gown gloves etc)

14
Compliance

• Measure each element provides focus for
  improvement
• Simple it either happened or it didnt
• How often is each element performed every time?
• Goal every element performed every time

15
Reliability comparisons

• Aircraft checks
• Food industry
• Drug rounds

16
Keep it simple

• Team effort
• Peer observation
• Self review
• Do it as often as possible
• Use run charts
• Feedback often and agree actions

17
Charting performance - Run Charts
18
How to

• Sell to team
• Train to use tool
• Small scale testing (PDSA)
• Communicate, communicate, communicate
• Use formal and informal ways of feeding back
  results
• Make results visible
• Celebrate successes

19

Sustainability - Factors

• Clear responsibility for change
• Change Champions
• Communication involvement
• Pace sequence, demonstrate benefits
• Meets patient needs
• Change is measured/monitored
• Team work is encouraged

20

• Continuous improvement a priority
• Those affected committed to success
• Teams have skill and knowledge
• Focus is long term
• Vision, purpose priorities goals clear
• Difficult issues are confronted

21
We are what we repeatedly do. Excellence then is
not an act, but a habit
Aristotle
22
Inpatient safety Series

• Bion JF, Heffner JE. Challenges in the care of
  the critically ill. Lancet 2004 363970-977.
• Pronovost PJ, Nolan T, Zeger S, et al. How can
  clinicians measure safety and quality in acute
  care? Lancet 2004 363 1061-67
• Lilford R, Mohammed AM, Spieglehalter N, et al.
  Use and misuse of process and outcome data in
  managing performance of acute medical care
  avoiding institutional stigma. Lancet 2004
  3631224-30
• Cook DJ, Montori VM, McMullin JP, et al.
  Improving patients' safety locally
• Changing clinician behaviour. Lancet 2004 363
  2151-62
• Angus DC, Black N. Improving care of the
  critically ill
• Institutional and health-care system processes.
  Lancet 2004 3631314-20

23
Other articles

• Fulbrook P, Mooney S.(2003) Care Bundles in
  critical care a practical approach to evidence
  based practice. Nursing in Critical Care 2003
  8(6) 249-255
• Dellinger RP et al. Surviving Sepsis Campaign.
  Crit Care Med 2004 32 (3) 858-873
• Biant LC, Teare EL et al. Eradication of MRSA by
  ring fencing of elective orthopaedic beds. BMJ
  2004 329149-51
• Mant J Hicks N, Detecting differences in quality
  of care the sensitivity of measures of process
  and outcome in treating acute myocardial
  infarction. BMJ 1995 311793-796
• Berenholtz SM, Dorman T, Ngo K, Provonost PJ.
  Qualitative review of intensive care unit quality
  indicators. Journal of Critical Care 2002 17(1)
  12-15
• Websites www.ihi.org, www.nip.dk