Ventilator Bundles

David Gourley, BS, RRT

Director of Cardiopulmonary Services
Chilton Memorial Hospital
Pompton Plains, New Jersey
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
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
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.
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
Ventilator Bundle
Elements
 HOB elevation
 Appropriate DVT prophylaxis
 Appropriate PUD prophylaxis
 Appropriate sedation
 Assessment of readiness to extubate
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
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%
Appropriate PUD
Prophylaxis
 Reduces risk of upper GI bleeding
 Risk increased in:
 Mechanical ventilation greater than 48 hours
 Coagulopathy
 No specific therapy
 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
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
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
 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
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.
 Fact Sheet
QUALITY MEASURE ADVERSE COSTS
EVENTS
Elevate HOB xx deaths $xx
xx hospital days
DVT prophylaxis xx deaths $xx
xx hospital days
PUD prophylaxis xx deaths $xx
xx ICU
Appropriate sedation Xx ICU days $xx
 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
Ventilator Bundles

 Ventilator bundles and performance improvement

 Elements of a ventilator bundle
 Systems of independent redundancy
 Fact Sheet
 Additional elements for future implementation