SCCM Resource Library-Science of Critical Care Bundles: Create, Implement, Evaluate

Video Transcription

Hi, and welcome to our presentation today on the science of critical care bundles. My name is Brenda Punn from Vanderbilt University Medical Center, and I'm really excited today  for all that we're going to learn about creating, implementing, and evaluating bundles. Good afternoon, my name is John Devlin, and I'm excited to start off this session today  focused on the science of critical care bundles. I'm going to be focusing on bundle creation. Here are my disclosures. So what is a bundle?  Well, it's defined by the Institute for Healthcare Improvement, which really invented the concept of quality improvement bundles more than 15 years ago.  They define a bundle as a structured way of improving the processes of care and patient outcomes.  Bundles are a small, straightforward set of evidence-based practices, usually no more than three to five elements or interventions that when performed collectively and reliably  have been proven to improve patient outcomes. What makes a bundle so special? Well, the power of a bundle comes from not only just the body of science supporting a  bundle element intervention, but also the method by which it's executed. Generally, bundle elements usually aren't new.  They're often well-established best practices, but generally in many ICUs, they're often not performed uniformly, making treatment unreliable and at times idiosyncratic.  Bundles will tie the changes together in a package of interventions that people know they must be followed for every patient in the ICU every single time.  Some of the summary of key elements of any care bundle, as I already noted, generally three to five evidence-based interventions related to a particular condition in critically  old adults or an event in patient care that when executed together resulted in a better outcome than if implemented individually.  A particular condition might be ventilator-associated pneumonia or sepsis or an event across a patient care.  A good example that we'll be spending some time in our session today is the ABCDF bundle. As I already noted, each intervention should be widely accepted as good practice and widely  applicable, should be adhered to for every patient 100% of the time, can be used to measure evidence-based practice.  But remembering when we're measuring bundles, as Brighton and Michelle are going to be talking about, we're really looking at efficacy and bundle compliance.  We're not trying to redo randomized control efficacy studies. Each step should be able to be audited, that it's either done or not done, realizing there  could be some local exclusions. Audit should focus on organizational aspects of performing the intervention in terms of  the interprofessional team and who does what and when this is done and the frequency by  which it's done rather than how well the intervention performed. Generally only compliance with a bundle should be easily measured when an intervention is  completed or a step is excluded for a predefined reason. Again, just to highlight some of the key points, this is sort of a cohesive unit of clinical change.  If only two or four elements of a bundle are delivered to a patient, outcomes will definitely not be optimized.  All clinical changes generally should always be based on randomized control evidence or strong cohort data showing that this is best practices.  There really shouldn't be a debate among the ICU team or different physicians or clinicians on why a bundle element is included.  As I already noted, completion of each bundle element should be a clear yes, no. But generally bundle changes should occur in the same time and space continuum.  For example, the surviving sepsis bundles are in the context of additional sepsis recognition and the order of bundle elements are often important.  I'd like to go through some of the process steps in designing a care bundle. The first thing is to identify that you probably have a care problem and not following best  practices in your ICU or in a group of ICUs. This can be based on published systematic reviews, tools such as IHI's adverse event trigger tool, or an analysis of own patient data.  Helping to define the problem can be informed by a comprehensive literature review. It's then time to start thinking about an evaluation of the literature.  This is going to be the primary literature with a large focus on large randomized control studies.  It's also important at the same time, of course, to identify and review pertinent practice guidelines.  When looking at the bundle elements, and we're going to spend some time later about what are good bundle elements and what aren't, it's important to select elements relative  to the identified problem from randomized control studies and or practice guidelines or both.  If a grade process is important, unless only practice guideline recommendations developed  with grade, I would like to suggest that most bundles are not just based on practice guideline recommendation. The next step is creating a bundle in a draft form.  It's important to evaluate does your draft bundle meet IHI requirements, some of the things we talked about a few minutes ago.  It's important that it be reviewed potentially by experts in the field. Certainly it should be reviewed by clinicians in your ICU or work across your health system.  I tell you, it probably would be good to get some feedback from patients and families. If there's questions raised, it's important to go back and refine the bundle elements.  Once your draft bundle is finalized, the next step is to do some pilot testing in a small number of ICU patients.  This could really identify potential risks and barriers to the bundle for being implemented.  It's a really good way to evaluate feasibility, ease of use, clinician comfort, and the potential effectiveness of relative outcomes.  These could be simple things like is it done, isn't it done, things like length of ICU stay, etc.  It's also important to be thinking about unexpected barriers or risks that could come up throughout the ICU and things like reliability of potential interventions if there's a lack  of clarity in the bundle elements. If there's things that maybe appeared safe in a randomized control study where there  was close monitoring, but appear maybe not to be safe, or there's concerns about safety or feasibility during the pilot testing might require some revision to elements, and then  certainly there might be issues with barriers.  I'd like to spend a little bit of time as I think Brendan, Michelle will be talking about is the ADAPT bundle, because this is where, this is what I certainly have the most  experience with. This is a bundle that's been well-established in real care practice around the world.  It's a bundle, and I'm not going to spend too much time about this, but it's a bundle that's had some iterations and revisions, and we're going to talk about bundle revisions  at the end of the presentation. For example, the C element, which currently is choice of NLG's incineration, was coordination for SAT and SBTs.  The family engagement and empowerment bundle element was added after the other bundle elements were fairly well-established.  What I'd like to do is focus on delirium, because I think there's some interesting things with respect to delirium, how these elements were defined, how they're measured, and how  the 2018 and the 2013 pain agitation delirium guidelines informed the development of these elements.  The mandatory element in the D bundle of the ADAPT bundle is to routinely monitor for delirium  in all ICU patients using either the confusion-assessed method for the ICU or the intensive care delirium screening checklist. I think this is fairly widespread in many ICUs.  Suggested elements are looking for possible causes of delirium. These are modifiable risk factors that might be evolving in a patient, like a new onset  of sepsis or dehydration, or it could be the administration of a new delirogenic medication. Usually this is best operationalized using the THINK or Dr. Dre approach.  The other suggested elements are to optimize non-pharmacologic delirium mitigation strategies and avoid routinely administering medications to prevent or treat delirium.  It's important with these suggested elements that these aren't the measurable elements that are used when people are looking at compliance.  I think it's important to take a step back and look at how practice guidelines are developed, and there's some limitations as the sole informers for bundles.  Practice guidelines are somewhat selective in the PICO questions, and these are the actionable  questions that they develop in terms of the actual intervention, the comparison, the outcomes. HAD-IS, for example, had a fairly important focus on post-ICU outcomes.  If there's not evidence that have been published with these outcomes or on the way a particular intervention is defined, it might not be possible to make a recommendation.  Practice grading is obviously critical in developing rigorous guideline recommendations,  but in some cases, it certainly puts a bias on randomized control studies, which are important.  But again, for things like, for example, delirium screening, and we'll talk about an example in a minute, there might not be always the perfect randomized control study with the  high quality of evidence to guide a bundle element recommendation. There's certainly inherent barriers to making strong recommendations.  A lot of recommendations end up being conditional. We'll talk about the differences in just a second.  There's variable evidence of decision considerations, and these can sometimes be applied in many different ways.  This is where the section panel members are around the virtual table looking at the evidence  and then thinking about things like cost, feasibility, resource use, any potential downsides or benefits, and this is where they're going to be formulating their recommendations.  And then lastly, guidelines take at least four, if not longer, years to develop. So often they're outdated in terms of the pertinent recommendations and PICO questions  that are being answered and certainly the evidence that's available, and it's really hard to update these.  So it's really important, again, to certainly use guidelines when they're available, but it's important to have other evidence from rigorous literature searches to help advise  and support the development of bundles. So this is just one example with our PAD guidelines that I chaired, and Brendan and Michelle played a key role in.  Only two of our 37 PAD recommendations are rated as strong. And so when you start getting into conditional recommendations, these are harder recommendations to use in bundles.  So a strong recommendation applies to almost all patients, but anybody that's read our PAD guidelines will notice that we often have sort of subgroups of patients that we've refined  their recommendation to or certain patient conditions or preferences. Generally, supporting evidence in strong recommendations is very, very high quality, which is not going  to change. The evidence isn't going to change the recommendation, but conditional recommendations are often  small, sometimes a flawed randomized control study, and it could be easy for one large  new randomized control study to change the evidence profile. Certainly benefits clearly outweigh burdens with strong recommendations.  Conditional recommendations might be a little bit more close. And when we're looking at performance and quality indicators, which obviously is critical  for bundle development, they can be readily adapted in most healthcare systems. But conditional recommendations, again, there's going to be some debate at the bedside about  whether to deliver these things. So in the PAD guidelines, we asked the question, should we assess for delirium using a valid  tool versus not performing this assessment with a valid tool and critically ill adults? We focused on an effective using any assessment tool versus no assessment tool.  We found that early assessment with a assessment tool led to quicker identification, potentially  correcting etiologies, and treatment effectiveness assessments, but we actually didn't find the  perfect randomized study suggesting that evaluating patients rigorously with a CAM ICU or the ICDS-C had a huge difference in patient outcome.  But that said, when you step back, what are the risks with the delirium screening and the benefits are substantial.  So we made a good practice statement suggesting that critically ill adults should be regularly assessed for delirium using a valid tool.  And so for the A to F bundle, it's most commonly evaluated, the use of the or compliance with the delirium bundle element is whether the patient received was assessed for delirium  twice in a 24-hour period. One thing, looking at some of the suggested recommendations in the PAD guidelines, we  asked should a multi-component strategy be used versus not being used to reduce or shorten delirium?  So this interestingly, the way we looked at this PICO guideline, actually the A to F bundle  use is a multi-component non-pharmacological intervention, and this is what we recommended. And certainly other components of this are important, including reducing modifiable risk  factors, optimizing sleep, mobility, hearing, and vision. But this is a conditional recommendation, so it doesn't mean that every one of these  patients, for example, should be optimized sleep or have hearing or vision or other cognitive interventions, but as a group, this definitely does improve outcome.  And then looking at medications, we asked should a pharmacologic agent be used to prevent delirium in all critically ill adults?  And we made a recommendation not to use Haldol, 18-point psychotics, Dex, statins, or ketamine to prevent delirium in all critically ill adults.  So there's not a role for this to be used routinely, but there might be a patient that, you know, based on, for example, a randomized control study that I published a couple years  ago that nocturnal Dex may actually reduce delirium. So there could be select patients where this would be used, but it's not a recommendation  that would be routinely used in all patients. So it shouldn't be a mandatory bundle element.  And then looking at delirium treatment, should a pharmacologic agent be used to treat delirium in all critically ill adults?  And we, in the PAG guidelines, we suggested not routinely using haloperidol or atypical antipsychotics, again, a conditional recommendation. The key thing is routinely.  So there could be patients that are managed with the A to F bundle who have delirium and  have, you know, bothersome symptoms that maybe would warrant pharmacologic treatment, generally that don't respond to non-pharmacologic interventions.  This could be, you know, non-pain-related agitation, fear, hallucinations. So maybe a short course of an antipsychotic would be beneficial in these patients, but  this shouldn't really be a mandatory part of the, you know, A to F, the D component of the A to F bundle because we want to be judicious and selective in our use of antipsychotics.  The last point I wanted to raise is just a few points about bundle refinement. This should be a continual process.  Important to update bundle elements is new level one randomized control evidence. This guideline recommendation to become available, as I noted before, most, you know, guidelines  are four to five years old as soon as they're published. It's important to continue to think about and refine how the ICU interprofessional team  can optimize bundle implementation elements and, you know, be clear on which ICU team members are accountable for each bundle element.  And I think, you know, Brenda and Michelle are going to talk a lot more about this.  It's important not to build into the bundle a lot of exceptions for different ICU populations.  Again, as I've kind of noted before, if there's a bundle element that doesn't really fit for  most ICU populations or only a select few, it probably doesn't really belong in the bundle. It's also important to avoid diluting the bundle by adding, you know, other quality  improvement goals that are not strongly evidence-based. This is a lot of, you know, things that we might include in an ICU checklist.  So it doesn't mean that checklists aren't good, but generally checklist items would not be incorporated in the bundle itself.  But certainly a checklist item could be, you know, was the bundle completed? Also, it's important to, you know, not expand the bundle to too many new areas, even if  it's a somewhat related clinical focus, particularly if, you know, there's not rigorous evidence to do things.  You might want to think about developing a second bundle or even sort of not really practice guidelines or bundles, but maybe some clinician suggestions about how to manage things.  So one thing that, you know, has come up the last couple of years is sleep. You know, sleep is an evolving area in practice. We know it's important.  There's certainly non-pharmacologic things we can do in an effort to improve sleep that generally reduce delirium, simply because sleep is so hard to evaluate its quality in  patients. And there was actually quite a bit of discussion within SCCM and our guideline group about  including, you know, refining the A to F bundle and adding a G component for good sleep, but we decided not to.  It doesn't mean this isn't going to happen in the future, but right now we feel with sleep that there's just not the evidence and practice direction that should be a mandatory  bundle element, but it doesn't mean that people can't be making change in their individual ICUs with respect to sleep.  So I thank you very much for your attention and I'll turn you over to our other, to Michelle and Brenda. Thank you. Hi, I'm Brenda Punn with Vanderbilt University Medical Center.  Today I'm going to be speaking on how to implement a bundle in the critical care setting. I have no disclosures for this talk.  So let's just dive right in and look at what the bundle specifically that we're going to focus on in this presentation is the A to F bundle.  There are so many different bundles that we use in the critical care setting and I want to spend most of this talk really focused on this bundle because if you can implement  this one, you can implement anything in your setting. And you can see here that it's got many pieces and that involves a big team.  And so the first thing that I will say with implementing a bundle is it really involves a team.  So the first step in successful implementation is gathering that team together and really thinking about an interprofessional group.  That this really needs to involve every person that will be involved in any aspect of completing this bundle. And you can start with the patient and work your way outward.  That nursing, medical, OT, PT, pharmacy, respiratory, social workers, other people that are in your system, and most importantly, don't forget patient and family.  So when you create a team or some steering committee or whatever you want to call it, you want to make sure that it includes someone from all of these different stakeholders that  would be able to comment on how changes or decisions would impact their particular position. And then once you have that group together, your first step is really to say what do you  already do? None of the things in this bundle are new. We've been doing many of them for years and it's just packaging them in a different way.  And so it's first establish what do you already do? What do you do successfully? What needs improvement?  And a gap analysis is a great way to start this, of saying here are the things we should be doing, checking off and marking off the things that you already do.  Reviewing each component and seeing it in action. We sometimes call this walking the walk. So attend rounds, that going through rounds, spend a day in the life of the patient to  see what things get done, what doesn't get done. Interview the stakeholders for each of the elements and say what works with this, what doesn't work.  Be sure to ask about the process as well as the documentation pieces of it. Identify barriers and keep a running list of those.  Many will overlap for the different elements in the bundle. And then measure your performance. How are you doing with what you already do? Are you doing it well?  Are there any pieces that you're knocking it out of the park with and there's some pieces that aren't even off the ground? And really you need to be able to visually see this.  The Society of Critical Care Medicine has made a minimum data set that's free to use and you can input your data into an Excel sheet that you download on your computer and  you keep your data locally and that Excel sheet already creates graphs for you to be able to track and see how you're doing. Great way to mark where you're starting.  This ICU Liberation book has an excellent gap analysis in it and this is just a screenshot of the very beginning of it, but it's a great comprehensive list of the different elements  in this bundle to be able to say do we do this, do we not do that? And now for the rest of the talk, that's really the foundation.  Get a group together, figure out where you're starting from. Now I want to talk about the different steps in this implementation process.  We're going to talk about engaging, educating, executing, and evaluating. So the four E's of implementation here. And we're going to, let's just start now with engaging.  So the first step is to engage the heart and the mind of all of your stakeholders, everyone that will be involved here.  Over the course of my work, I've found that this is really powerful to do when we connect these interventions and assessments that are in the A to F bundle with what happens from  the patient's perspective and especially the long-term trajectories and outcomes that improve. Sometimes we can give the updates of if we do this, it will decrease length of stay,  get them off the ventilator, get them out of the ICU. But really when we hear from the patient what their life is like and how hard it is  when they're having cognitive problems or physical problems in long-term survivorship, it helps to motivate us to do the best practices that could prevent that.  So when we think of post, and I suggest teaching about post-intensive care syndrome, and that that's your goal is to prevent it.  The best way we know to prevent it is to use the A to F bundle. And in practice, regularly, every patient, every day, get patient testimonies. Get from your own patients.  That's so powerful to find patients and family members that are willing to tell their stories  in unit board meetings or on a Zoom conference, there's an opportunity for them to tell what is life like, to paint the picture.  There are tons of videos online, and I've just shared a picture here of some that are on our ICU delirium website. You also might need to engage the purse strings.  And so when some of these interventions, you might be asking for resources or personnel or changing of things within your unit, that you'll have to ask higher-ups and management  and executives for those resources. You want to share about those outcomes that are saved, but you also wanna share about the money that's saved.  And I cited this paper here by Jean Shea and the folks at Montefiore looking at the implementation, the full bundle implementation versus partial bundle implementation.  And you can see that they did find those usual outcomes improved, but they also were able to report a 24% reduction in ICU costs and a 30% reduction in overall hospital costs.  That can be a really powerful tool to engage to get the resources that you need from your management.  So the next step is education. And I'm a firm believer that the first step of education with this bundle is to educate about the bundle, this idea, this package, the big picture.  You can see from this poster,  this particular institution put a whole poster based on just about the bundle, that it has these different elements. This is what A and B and C and D and E and F stand for.  These are the things that we're gonna be doing. And as they focused in the implementation, when they're executing it on the different elements, they highlighted those on this poster  so that all along everybody could see the big picture that this part they were working on, this zoom in part they were working on was part of something bigger.  And I think that that really helps to communicate that the A element really is connected to the B element and the B element influences the E element  and F element influences everything. And so it's really important to change your language, start talking about the A to F bundle, start talking about the ICU liberation bundle  as it's also called. Put it in the whole unit, in your documentation, in posters, in patient family education, then you can work on the individual elements.  So you can see this is an example of a rounding tool that's used at one university and they've divided up the different pieces per element and the data that's there.  Now, most of you will have these elements in your rounding tools or your scripts that you're using, but they specifically put the element letter  beside each section that it pertains to. Another hospital that I've worked with, they created, this is their patient care brochure that they hand to all family members  when they come into the ICU. And you can see if you kind of zoom in there on the, looking at the picture on the right, that they have explained to families  that this is a basic care that we provide our patients have to do with these bundles. So then you're ready to execute. So try it, zoom into a specific element  whichever one that you need to work on first, start with easy wins and work through PDSA cycles. Plan it, do it, do it on some easy win people,  don't try to mobilize your sickest patient on the very first time you try to mobilize somebody, go for the less sick patients, go for the healthiest ventilator patient you got.  You need your team to see easy wins, to see the process working, and then review, adjust your protocols, adjust your process, and then start all over again in the process.  And then a really key component is evaluating. And I think that we've got to be able to track our performance and display that, display it to your staff and be able to give it  to those in authority over you that are making decisions about things. Review this at team meetings, set goals, and look for trends and celebrate their successes.  Cake and cookies go a long way in celebration.  And then one of the things I like to talk about in terms of goals is sure our ultimate goal is every patient every day, 100%, but there's some goals along the way  that we want to reach to and celebrate. And so you might set what I call progressive goals or relative goals. And an example might be in two months,  we want to improve 20% from where we are in every element. Or in a month, we want to improve on a specific element. Or in three months, we want to improve 30%  in our overall compliance, that the patient's getting all elements of the bundle. When we look at those trends and we see that we're in the 80 to 85% rate of compliance,  we will see that's when we're really getting to adoption, that this has become a part of the water that we drink here. So that's also a great goal to shoot for  and to celebrate when you get there.  Look for trends in your goals. And I just put this early mobility tracking here and that you can see from January, there was an improvement up about almost 20% here.  And you can see that's pretty sustained for the next three months. And so in this situation, I'd say, wow, we see improvement and we want to celebrate that improvement,  but why can't we get any better than this? And what's the deeper dive I need to take to figure out what might be there keeping us  from really achieving better improvement in these areas? Some of the frequent barriers are the electronic health records. Things are getting documented in weird places.  Or one member may not see the same screen that another member has. Maybe some people are uncomfortable with the safety criteria. And so there's some people consistently  they're not mobilizing or not doing the other things. And so really diving into what's the issue here and do we need to change the safety criteria  or do you need to change the education and the feeling around those to help give people more confidence there? Maybe there's some coordination difficulties happening  that you might be able to switch up the process with.  Insufficient staffing, insufficient equipment, that maybe having a designated area for certain equipment would really facilitate things. Other environmental factors going on,  like a global pandemic. Different things happen that really get in the way of our implementation and being able to track and look at these trends can help us  take those deeper dives and to ask the questions to figure out which ones apply.  So in summary, when we're talking about bundles and specifically I'm looking at the A to F bundle but this really applies to any bundle is you wanna create that team.  You'll wanna see where you're starting from, what's your baseline and have some way to track that. Epic and Cerner are both diligently working  with the Society of Critical Care Medicine and this is great news right now that they're working to build in the A to F bundle and Epic already has it,  Cerner's got it on a couple platforms and so that they will be able to readily produce these types of dashboards for us to track how we're doing in these elements.  Once we can track it, we see a baseline and we're starting the actual implementation, we gotta engage the hearts. There has to be a so what,  that people care that they are motivated to do this. Educate them that the overall bundle is the goal. This big picture that these, you can't walk a deeply sedated patient.  So they go together and we've gotta be thinking about them in tandem. We need to execute it, just do it, try it out, don't refine the protocol to death,  get a protocol and try it on a couple patients. Rework it, fix the kinks, try it again, trial and trial, trial, trial and adjust as you need.  And then lastly, evaluating, track how you're going,  celebrate, be able to show your team and your superiors how you're progressing here and identify the things you need to keep moving up the chart. So I'm gonna wrap up here,  but if you have questions that don't get answered here, then please feel free to reach out to me at this email address or through our website.  I'd be happy to help you in whatever way that I can be of assistance to help you be a success in implementing this bundle at your institution.  Thanks. Good afternoon, everybody. First, I'd like to take the opportunity to thank you for giving me the opportunity to present at this year's scientific conference.  Also, I really would like to take a moment to thank all the direct care providers for all the tremendous amount of work that they're doing during this most incredibly  challenging time. Not only do we have the attempt of the coup, but of course, the terrible pandemic. The amount of stress and fatigue  that all of you are experiencing is beyond worrisome. I really do hope that you are taking some time to take care of your own personal health and wellbeing.  And please know, please know, that there are many of us that are really committed to ensuring that your efforts during this time aren't going to be forgotten.  Finally, I'd also like to thank Drs. Pun and Dr. Devlin for the tremendous job they did with their presentation on how to create and implement the bundle.  My name is Michelle Ballas, and I'm currently an associate professor at The Ohio State University College of Nursing in their Center of Healthy Aging,  Self-Management and Complex Care. Here are my disclosures.  What I plan to do in this presentation is to pose a series of questions. These questions will ask you to reflect on your past implementation, bundle implementation efforts,  and also suggest evidence-based ways of improving the entire implementation process. We're going to start with question one. And that question is, was the evidence-based practice  was the evidence-based practice you tried to implement really worth the effort? Now, I know this kind of sounds like a crazy question, doesn't it?  But consider this quote by my fellow Omahaian, I don't even know if that's the correct term, but by Warren Buffett. What the human being is best at doing  is interpreting all new information so that their prior conclusions remain intact. Now, think about that for a minute. Has anyone ever found it difficult  to convince their colleagues to change one of their antiquated practices? Come on, admit it. I think we all have things that drive us crazy.  My extreme personal irritants currently include the continued use of antipsychotics and Benadryl with older adults. Why is it so hard to change other people's practice?  As this figure illustrates, an overwhelming amount of objective facts, you see that on the left there, and or clinical experience, so what you're seeing as you practice,  will do very little to change people's personal beliefs.  This is called confirmation bias, kind of technical term, but confirmation bias is the tendency to interpret new evidence as confirming  of one's existing beliefs or existing theories. So example, the belief that anyone on mechanical ventilation needs to be kept deeply sedated. Someone might firmly believe that,  and any new study that comes out that might in some way support that belief is taken in as confirmation for what they believed in the first place.  Overcoming confirmation bias is super hard, but the good news is it's not impossible. There are evidence-based strategies, believe it or not,  that can be used to address this common challenge, the bundle implementation, and we'll touch upon some of those strategies shortly. But I digress just a little bit.  Let's get back to the first question. So was the evidence-based practice you try to implement worth the effort? I really believe, I truly believe that the first step  in evaluating whether any implementation is worth it is to, it comes down to, what is the evidence supporting the intervention?  Now, there's a ton of ways you can assess evidence-based, whether or not the strength of evidence, right? So whether or not it's suitable to be implemented into clinical practice.  And really looking at the level of evidence for the projects that you're trying to implement is important. There are so many things we would love to change in clinical practice.  Whether or not it's worth the effort to implement is another question that really should be derived, as we're seeing throughout this pandemic,  that really should be focused and based in science. While the level of evidence is important, there's also other things that you need to consider  when evaluating implementation efforts, right? So is that evidence-based practice applicable to your population? Were the trials done with the people that you care for?  Could the evidence-based practice be adapted or tailored in such a way that would work in your unit? And here's the important part. Will it work in your unit without being adapted?  Meaning, could you use it as the evidence suggests you should use it?  Or if you do try to change the evidence to fit your unit's culture, will the evidence-based practice lose its effectiveness? Tweaking evidence has risk.  And one of those risks is if that evidence is tweaked too much, it may not work anymore. So important question.  Is the evidence-based practice congruent with what your organization is focused on right now? So is it an organizational priority  or is it congruent with other quality and safety initiatives that you're having in your unit or in your organization at that time?  Again, that's a really important question to ask. Is now the time that you want to invest implementation efforts? Probably not the ideal time right now  to be investing in a lot of this process if you don't even have enough intensive care unit beds to, or enough staff to care for the critically ill.  How do the people that you practice with  deem the evidence-based practice? Do you anticipate that there's gonna be a lot of resistance to adopting that practice? What are the advantages of implementing the practice?  Would an alternative solution be a little bit better? How difficult will it be? Is it gonna take a lot of time, treasure, and talent to get this move through?  And finally, what are the costs? When we think about costs, we often think about, well, if we use this evidence-based practice, we're gonna save X amount of dollars.  Very important consideration. So thinking about the cost of your return on investment. If you do this, how much money are you gonna save?  But other costs need to be considered as well, right? So what are the costs with the actual practice? What are the costs associated with all the time and training  that you're gonna need to do in terms of getting that practice into everyday care?  Next question, and I'm pretty sure Dr. Pun touched upon this in her presentation, but did you perform an implementation needs assessment  before you tried to implement this program into practice? Did you do an assessment? Do you have the people that you need to do it? Do you have people in terms of the adopters,  meaning who are the clinical decision makers that really believe this needs to be an initiative that has to be implemented? Who are the people that are gonna actually implement  and do that practice? And also, do you have those champions or the maintainers? Who's the one who's going to be responsible  for making sure that this practice gets into everyday care and stays that way, maintaining it? Is the environment set up in a way conducive to the practice?  And finally, again, those resources. Do you have that managerial support? Do you have the time for the implementation efforts  to plan the implementation efforts and to carry them out? And also the compensation for that time and effort that's needed?  Long question here. Did you create program-specific adoption and implementation outcomes? Did you make performance objectives? Did you make a good assessment  of what are the determinants or change objectives? And we're gonna break that down with an example in just a second. So in terms of adoption and implementation outcomes,  we need to have outcomes that are specific for each person who will be adopting,  implementing, or maintaining the evidence-based practice. So if there's multiple disciplines involved, like with the ABCDF bundle,  each one of those disciplines may have their own adoption and implementation outcomes.  Identifying those outcomes is pretty straightforward, right? And I'll give you an example again in a couple of slides, but we're simply gonna state who's involved,  what they're gonna do, and what the expected outcome is.  In terms of performance objectives, performance objectives are the specific steps, right, that people must do in order to achieve the outcome that you set.  So that's answering the question, who has to do what? To make this happen in clinical practice, who is doing what? And these performance objectives, really important,  they have to be action-oriented, right? So we're not gonna be talking about cognitive processes, and we'll see why, that's another step, but really action-oriented steps  that they take to get it into practice. So here's an example, if we think about spontaneous breathing trials.  We're gonna talk about three different people, so the, and who's the target, right? So in the case of spontaneous breathing trials,  in this example, one, a doctor would be the ICU director. So the ICU director is the adopter, and their outcome that we're expecting to occur is that they decide to adopt  a daily spontaneous breathing protocol in their units, and that's evidenced by, they told their department chair they're gonna do it.  The performance objectives for the ICU director, again, they're behavioral-focused, not cognitive, right? So they have to agree to participate in the protocol development,  they're going to identify who's gonna be the SBT champion, they're gonna gain support from stakeholders, and agree to participate in evaluation efforts.  Another example would be the respiratory therapist. So they're your implementers, right? They're gonna conduct a SBT once a day on all eligible patients.  You see how very specific that implementation outcome is?  And then to the right, you'll see those performance objectives. What are they gonna do? Well, one is they're gonna screen patients. Next one, they're gonna determine  if they meet the criteria. Next one, they'll do the spontaneous breathing trial. And then finally, they will evaluate whether or not  the patient passed the spontaneous breathing trial.  So very important in terms of setting up those objectives. They're equally important is the necessity to identify personal determinants for adoption. And what do I mean by that?  What I mean by that is determinants are those modifiable internal factors  that adopters and implement deal with, through cognitive reasons. Why do they want to do this? Have to address those whys.  And we have to come up with a way of addressing those whys. And one way to do it is through matrices and chain objectives, change objectives. So here's another example.  With the respiratory therapist in the spontaneous breathing trials, one of their performance objectives was they were going to determine  if a patient meets the criteria for an SBT eligibility.  So what are some personal determinants of whether or not a respiratory therapist may actually do that on a daily basis? Well, one that might affect it would be their awareness  or perception of the protocol, right? So they might think every doctor on the unit wants their SBTs done differently, so why do it? Or they may think that SBTs don't work.  The way we're doing it now is fine. So what you have to do is also come up with objectives on how you're going to reframe people's thoughts, right?  The cognitive reasons why they do things. So for example, one of those outcomes for the awareness and perception is,  we want all of our respiratory therapists to describe what our new SBT eligibility criteria are. We want them to know what time of day it occurs, to be able to describe  where SBT eligibility criteria are documented. So some examples of addressing outcomes for those personal determinants.  In the same vein, we also want to think about what are some of the ways we can correct behavioral behaviors that might be not conducive to implementation?  And there's a lot of great literature on the subjects, and we can see one of the examples here. I strongly encourage anyone who's interested  in behavioral change theory to look up this article, particularly the appendix. But common challenges we see with bundle implementation include increasing knowledge, right?  So how can we increase knowledge if it's a problem? We could use chunking. We can use discussions. We could elaborate on the things that we're doing.  Or if the problem with implementation surrounds changing attitudes and beliefs, how can we do that? We could give direct experience.  We could elaborate on the things that we're doing. Some really great evidence-based ways of changing clinician behavior.  Question number six, did you select the most appropriate implementation strategy?  Again, there's many different ways, there's many different strategies of getting evidence into care, and I highly recommend the 68 from the ERIC project  if you're interested in learning more. But there's strategies that surpass just providing knowledge. Providing handouts and education alone  rarely does anything to increase bundle adoption. So there's a variety of other ways that we can look into as a community to raise awareness and increase adoption  of evidence into practice.  Did you produce implementation protocols, create design documents, draft content, pre-test, refine that content, produce your final materials? You don't have to reinvent the wheel.  Particularly with things like the ICU liberation or A through F bundle or ABCDEF bundle, whatever you wanna call it, there's a ton of great resources out there for you  that you could then tweak and deliver to your institution to make it more conducive to care.  Did you choose the correct implementation outcome? You know, there are things that are very objective in terms of measuring program success, bundle success.  Did the patient receive the bundle? Yes, no. Did they receive the SAT? Did they receive the SBT? But also, and equally important,  are other implementation outcomes that we need to consider. Did the staff find it acceptable? Did they think it is appropriate for what they're doing in clinical practice?  Was it expensive? What was the cost?  Are they able to do the bundle or the evidence-based practice the way it's intended, right? Fidelity, the way it was implemented as it should be. How many people adopted it?  Was it sustained? So really important to think about those implementation outcomes. This is the paper where a lot of this presentation came from that expands and moves you past  that sole PDSA cycle alone  and really dives deeper into some of these individual questions that I asked for those that are interested in learning more. But I'm going to propose one final important question.  And that final important question is, did you ask for a raised promotion and or award for your efforts?  Through the three presentations that we've heard today about implementing bundles, we know it's hard. And anyone who is committed  to these implementation efforts really deserves recognition for just how difficult it is  and just how much the knowledge of implementation is growing.  The importance of advanced practice nurses, clinical nurse specialists in particular, in terms of taking up these implementation efforts  or perfectly designed for DMP prepared practitioners who have the training to know how to do the implementation importantly, but also importantly, how to do that evaluation.  So that's my rather brief discussion about things you consider when you're evaluating your implementation efforts. Each one of these could have probably been a three-hour talk.  I'm more than happy to take questions via email. You should have my contact information. Otherwise, again, thank you for this opportunity  and I'm hoping you're all staying safe and healthy. Thank you.  Hi and good afternoon everybody. After these excellent presentations, we've got loads of questions from the audience, so I will start with a very topical one. There is a pandemic  and suddenly we've got a lot of ICU staff who didn't work on the ICUs. What bundles should they first review? How would they make things stick in the short amount of time?  I'll ask Dr. Deflin. Yeah, I think obviously these patients have sepsis, so it's important to review the surviving sepsis, you know, the SEP1 bundles. Most of  these patients are going to be in the ICU for a long time, so it's important that they review the A to F bundle. I published with a few others a paper in Crow Care Explorations  last spring, really looking at the A to F bundles and strategies to, you know, still consider them, even where there might be barriers and how to overcome these barriers to using  the A to F bundle in these patients. And obviously things like BBT prophylaxis, etc. should be a focus of efforts. Anything else to add, Michael? I would say that one thing that's  really important right now is that we simplify as much as possible some of the things that  we're doing where we have a lot of these non-ICU staff coming in. I know at Vanderbilt, one of our challenges is we've moved our regular MICU staff to staff our COVID units, so our  MICU is full of travelers right now. And so it's hard to make sure that our regular non-COVID  practices are being maintained, because it's full of people that are outsiders to our unit that we're trying to really get established. And so some of the things that we're finding  is that our attendings are the regulars that are in both places, and so really helping to make sure they set a tone and they set some in, you know, when they do rounds, that  they're really modeling the regular way to do things, and that's been helpful. And I think  it's looking for visual ways to say, this is what we do, posting things up, having checklists  there that are, this is how we do it, these are our scripts, you know, maybe some things we might  have had a couple years ago that everybody got used to doing, and so we don't have all of our  prompts and our little things around, bringing those back so that it really equips. And I find  that people are really welcoming of those things right now, because everybody wants to do the right  and best thing, but they're a bit like deer in the headlights, and you know, point me in the right  direction, I'm here to help, I want to do what I can, and I think that those prompts are really  helpful. Thank you very much. It leads us nicely to the next question, that there is a pro-con  about the guidelines and bundles, and there is a lot of con arguments, which says that this  makes our practice like a cookbook, and that the professionals in training don't learn to think for  themselves. How can we counter that con, when we are talking about bundles? And probably I look for Dr. Ballas. I love that question, by the way, I selected that question. You know,  working with so many different hospitals over the years, one of the most common implementation  challenges that you're going to experience is that resistance from many colleagues, not just  physicians, but nurses and others, that using bundles or clinical practice guidelines, like  you said, is cookbook medicine. One of the things I think that we need to appreciate is the amount  of evidence showing that bundles and providing evidence-based care is important. I think another  thing that we need to consider in terms of, you know, countering that con is, there was one recent  quote that came out that said, a new physician would have to read, because of the amount of information overload we experience, and the amount of science that's coming out daily,  and the Facebook and the Twitter and reading studies in 30 seconds, a new physician would  have to read over 5,000 journals every week just to keep up on the science and literature that came  up in the field. It's just physically not possible for any of us to stay up to date with all the  advances that are happening in healthcare. So the bundles is a great way of tying that evidence  together, delivering what we know is best. You know, these bundles should change when new evidence  comes out, but it's a way of summarizing the most current evidence. But it is a huge implementation  challenge, and nobody's telling you to make it cookie-cutter, patient-centered, family-centered  first. But to improve those outcomes, it really is important to stick with what we know works.  And I think just to add to that, Michelle, is, you know, these bundle elements should probably  be sort of the default, and it's fine to have a discussion about patient appropriateness for bundle  elements, whatever bundle we're talking about, and that's healthy, I think. And again, that should  be done with the interprofessional team, not just sort of a unilateral decision, maybe by the  intensivist or somebody else. Thank you very much, and I think that really nicely led to the end of  our session. I would like to thank the three speakers for their excellent talks, and I will see you later. Thanks so much for leading the discussion.

Video Summary

In this presentation, three speakers discuss the implementation of critical care bundles. The first speaker, John Devlin, focuses on bundle creation and defines a bundle as a structured way of improving the processes of care and patient outcomes. He emphasizes that the power of a bundle lies in the execution and adherence to evidence-based practices. Devlin explains that a bundle should consist of three to five evidence-based interventions, be widely accepted as good practice, and be applicable to every patient in the ICU. He also stresses the importance of measuring bundle compliance rather than the efficacy of individual interventions. The second speaker, Brenda Punn, discusses the implementation of a bundle and emphasizes the need for an interprofessional team to engage in the process. She suggests conducting a comprehensive needs assessment and evaluating the readiness of the organization to implement the bundle. Punn highlights the importance of educating the team on the bundle and creating clear protocols and materials for implementation. She also emphasizes the need for ongoing evaluation and celebration of successes. The third speaker, Michelle Ballas, focuses on evaluating bundle implementation efforts. She suggests evaluating the evidence behind the bundle and assessing the applicability to the population being served. Ballas also encourages the use of implementation frameworks and strategies to address resistance to change. Overall, the speakers provide guidance on creating, implementing, and evaluating critical care bundles to improve patient outcomes.

Asset Subtitle

Quality and Patient Safety, 2021

Asset Caption

The Society of Critical Care Medicine's Critical Care Congress features internationally renowned faculty and content sessions highlighting the most up-to-date, evidence-based developments in critical care medicine. This is a presentation from the 2021 Critical Care Congress held virtually from January 31-February 12, 2021.

Learning Objectives

Describe the scientific rationale behind designing a new bundle in the ICU and evaluate the best strategies for designing a successful bundle
Examine the role of the multiprofessional team in bundle development
Discuss the implementation pitfalls of a new bundle and analyze successful bundle implementation examples
Identify the most appropriate quality improvement and research methods for bundle evaluation

Build a Bundle: More Than Just Common Sense
John W. Devlin

Implement a Bundle
Brenda T. Pun

Evaluate a Bundle
Michele C. Balas

Meta Tag

Content Type Presentation

Knowledge Area Quality and Patient Safety

Knowledge Level Intermediate

Knowledge Level Advanced

Membership Level Select

Tag Evidence Based Medicine

Tag Guidelines

Year 2021

Keywords

critical care bundles

bundle creation

improving processes of care

patient outcomes

bundle compliance

implementation of a bundle

interprofessional team

educating the team

evaluating bundle implementation efforts

implementation frameworks

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