BUNDLES AS THE CORE OF IMPROVEMENT


The severe sepsis bundles form the core of the implementation phase of the Surviving Sepsis Campaign. Bundle science is the result of an integration of medical science and improvement work. Several years ago, as a part of an Institute for Healthcare Improvement (IHI) intiative on care in the ICU, participants considered a small set of evidence-based interventions for patients on mechanical ventilation. These interventions were: DVT prophylaxis, peptic ulcer disease prophylaxis, elevation of the head of the bed, and sedation vacation. This set of four interventions is known as the "ventilator bundle." Each of the teams measured the degree of compliance with the bundle, giving credit for medical contratindications. For each patient, a 1 or 0 was recorded, indicating whether or not all four elements of the bundle were implemented. A marked reduction in ventilator-associated pneumonia was noted when teams consistently implemented the bundle.

Reorganizing to Increase the Reliability of Care

The use of the bundle prompted various disciplines in the ICU to reorganize their work. The results for ventilator-associated pneumonia were interesting and unexpected because for only two of the four elements in the bundle was there any scientific evidence that the element itself would reduce ventilator-associated pneumonia.This new method of clinical improvement - a bundle process that combines the best of medical science and improvement science - is developed in the following way   

   1. Identify a set of four to six evidence-based interventions that apply to a cohert of
       patients with a common disease or a common location.

   2. Develop the will in the providers to deliver the interventions every time they are
       indicated.

   3. Measure compliance as "all" or "nothing."

   4. Redesign the delivery system to ensure the interventions in the bundle are delivered.

   5. Measure related outcomes to ascertain the effects of the changes in the
       delivery system.

The sepsis bundles were developed in just such a manner, based on the experience of the ventilator bundle. The goal now is to motivate the providers in your hospital to deliver the sepsis interventions every time they are indicated based on your policies. If the bundle elements are reliably performed the desired outcome of reducing sepsis-related deaths by 25% can be achieved.