Key Elements Of Vent Bundle Terry Clemmer MD Vicki Spuhler RN MS

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 1. ↠ The science behind the bundle is so well established that it should be considered standard of care.

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.

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

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

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

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

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

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

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

Successes – all or none compliance –reduced VAP –reduced LOS on ventilator Barriers – all or none compliance –reduced VAP –reduced LOS on ventilator

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

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.

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

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?

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.