Bundle Up for Safety

​If you are new to the science of health care quality improvement or perhaps implementing your first formal program in this area, it’s helpful to become familiar with some basic terms. One of these is “bundle.” At least two of the six interventions at the heart of the 100,000 Lives Campaign depend on implementing bundles in critical care or surgical settings.
So, what is a “bundle”? It’s a term or concept developed by faculty at the Institute for Healthcare Improvement (IHI) as a way to describe a collection of processes needed to effectively care for patients undergoing particular treatments with inherent risks. The idea is to bundle together several scientifically grounded elements essential to improving clinical outcomes. A bundle should be relatively small and straightforward − a set of three to five practices or precautionary steps is ideal.
Most important, a bundle is a cohesive unit. The steps must all be completed to succeed; the “all or none” feature is the source of the bundle’s power. In his December 2004 IHI National Forum plenary launching the 100,000 Lives Campaign, Donald Berwick, IHI’s former President and CEO, described the bundle as central to what he called a new scoring system for clinicians that would “up the stakes on reliability.” Rather than scoring ourselves, he said, for successfully completing individual steps in a list of proven interventions for a group of patients, what if we rate ourselves “on a pass-fail basis for the whole bundle of things?” So, he continued, “a patient gets a ‘yes’ if we actually did everything we planned to do, and a ‘no’ if anything, even one thing, was left out.” This bundled scoring system pushes us to raise the bar on health care performance. 
For example, one intervention in the 100,000 Lives Campaign, Prevent Ventilator-Associated Pneumonia, recommends reliable use of the Ventilator Bundle. This bundle is designed to help clinicians in the intensive care unit (ICU) better care for patients on ventilators or breathing machines. Patients on these machines are at risk of developing ventilator-associated pneumonia, which can be deadly. There are guidelines for preventing ventilator-associated pneumonia, but even the most rigorous institutions fall short in efforts to adhere to them. The Ventilator Bundle addresses this challenge. It includes these steps:
  • Elevating the head of the patient’s bed to 30 to 45 degrees
  • Daily "sedation vacations," or gradually lightening the use of sedatives each day
  • Daily assessment of the patient’s readiness to extubate or wean from the ventilator
  • Peptic ulcer prophylaxis
  • Deep venous thrombosis prophylaxis
Teams that have adopted the Ventilator Bundle report that having the steps joined provides a “forcing function.” And the rewards are significant; use of the Ventilator Bundle has resulted in dramatic reduction of ventilator-associated pneumonia in scores of hospitals. For example, a team in the ICU at St. Vincent’s Hospital in Birmingham, Alabama, reported no cases of ventilator-associated pneumonia over 255 days in 2004 after implementing the Ventilator Bundle. This enhancement in care means better outcomes, reduced hospital stays, lower costs, and improved staff morale.
It’s also important to understand what a bundle is not. It is not a list of absolutes or precise protocols. It is a set of steps that experts believe are critical, but in many cases the clinical values attached to each step are locally defined or may change over time based on evolving research and the experiences of users. 
Think of a bundle as a starting point, a tool that your organization can shape and develop to your needs. Ideally, performing the steps in a bundle means simply answering ‘yes’ or ‘no,’ in Don Berwick’s exacting new scoring system. “Yes, we did this step, that step, and these two others.” The “how,” “when,” “what,” and “how much” that will trigger a task at your patients’ bedside with each step may involve decisions for your internal experts. 
We encourage you to read more about the two bundles central to the 100,000 Lives Campaign. The bundle approach is quickly becoming a standard in quality improvement strategies embraced by large and small institutions, medical associations, and policy makers. And it’s likely to be important to your organization’s success in helping to drive the movement focused on saving 100,000 lives.
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