Implementation Of Bundle Research Articles

PUMPING IRON: A QUALITY IMPROVEMENT STUDY FOR THE TREATMENT OF IRON DEFICIENCY ANEMIA IN AMBULATORY HEART FAILURE PATIENTS

PUMPING IRON: A QUALITY IMPROVEMENT STUDY FOR THE TREATMENT OF IRON DEFICIENCY ANEMIA IN AMBULATORY HEART FAILURE PATIENTS

Antifungal stewardship in solid-organ transplantation: What is needed?

Antifungal stewardship (AFS) lags behind antimicrobial stewardship (AMS) in terms of implementation, evidence base, and workforce experience. Solid-organ transplantation (SOT) carries a significant risk of invasive fungal infection, with high associated mortality, and is therefore associated with significant opportunities to optimize antifungal use. A literature search for the terms "antifungal stewardship" and "solid-organ transplant" revealed a small evidence base to support AFS programs in this patient group. There is significant overlap in the methodology used in AMS and AFS programs, with notable differences in diagnostics, which are discussed in detail. The primary AFS interventions tested in SOT recipients are implementation of clinical guidelines and care bundles, digital enablers of AFS, and post-prescription review/audit and feedback. There is an urgent need for further research to support effective AFS strategies in this highly susceptible population.

Implementing a Resilience Bundle for Emergency Nurses: An Evidence-Based Practice Project

IntroductionResilience bundles are designed to work within and enhance existing routines. In the wake of COVID-19, nurses are reporting high levels of burnout and are leaving the field at an alarming rate. Hospital system leaders across the country are working to develop wellness programs to improve nurse morale, decrease burnout, and enhance resilience. Resilience can help mitigate nurse burnout, and using a bundle of tools to help nurses develop resilience is more effective than a single strategy. MethodsUsing the Connor-Davidson Resilience Scale-10 and the Perceived Stress Scale 4, emergency nurses were surveyed to measure resilience and stress before and after implementation of a 3-strategy resilience bundle. We surveyed at baseline, phase 1 (6 weeks after implementation), and phase 2 (15 weeks after implementation). ResultsA statistically significant increase in the Connor-Davidson Resilience Scale-10 scores was identified between the baseline and phase 1 surveys. A measurable decrease in the Perceived Stress Scale 4 was found between the baseline survey and the phase 1 and phase 2 postintervention surveys. DiscussionAlthough evidence suggests a multifocal approach to improving resilience, use of resilience bundles is new. To enhance nurse resilience and mitigate burnout, nurse leaders may consider resilience bundles to prioritize the mental health and wellness of their staff.

Implementing Bundle Care in Major Abdominal Emergency Surgery: Long-Term Mortality and Comprehensive Complication Index

BackgroundMajor abdominal emergency surgery (MAES) has a high risk of postoperative mortality and a high complication rate. The aim of this study was to evaluate whether the implementation of a perioperative care bundle reduced long-term mortality and the Comprehensive Complication Index (CCI) after MAES.MethodsThis study was a single-centre retrospective cohort study. Data in the intervention group were collected prospectively and compared with a historical cohort from the same centre. It includes adult patients undergoing MAES. We implemented a care bundle under the name Abdominal Surgery Acute Protocol (ASAP). We initiated fast-track initiatives and standardised optimised care in before, during and after surgery. Data were analysed using survival analysis and multiple regression.ResultsWe included 120 patients in the intervention cohort and 258 in the historical cohort. The one-year mortality rate was 21.7% in the intervention cohort compared to 28.3% in the standard care cohort. Adjusted odds ratio of one-year mortality 0.81 (CI95% 0.41–1.56). The 30-day mortality was lowered from 19.0 to 6.7% (p = 0.003). The CCI in the intervention cohort was 8.7 (IQR 0–34) compared to 21 (IQR 0–36) in the control cohort (p = 0.932) The length of stay increased by two days (p = 0.021). Most cases had 71–80% protocol compliance.ConclusionImplementing bundle care in major abdominal emergency surgery lowered the 30-day postoperative mortality. The difference in mortality was preserved over time although not significant after one year. The changes in the Comprehensive Complication Index were not statistically significant.

Journal Club: “Implementation of an evidence-based bundle to reduce surgical site infection after cesarean section–Review of the interventions”

In their article “Implementation of an Evidence-based bundle to reduce surgical site infection after cesarean section- review of the interventions1,” Mahomed et al. describe interventions to reduce surgical site infections post cesarean section at a regional hospital in Australia. These interventions included discussing and receiving buy-in from critical stakeholders: obstetric, midwifery, anesthesia, operating room staff, and infection prevention. Using a retrospective audit of patient records pre- and post-intervention, the authors aimed to determine whether the interventions reduced the number of post-cesarean surgical site infections based on readmission rates and staff compliance in following a surgical bundle.

Implementation of an evidence-based bundle to reduce surgical site infection after caesarean section – Review of the interventions

BackgroundSurgical site infection (SSI) is the most common complication post caesarean section (CS) with a significant impact on women and health services. A bundle approach incorporating previously studied individual interventions has shown increased reductions in SSI. AimTo assess compliance with a SSI intervention bundle and to examine readmission rates for SSI. MethodsA retrospective audit of women who underwent CS at a regional hospital in Queensland, Australia pre-intervention (February 2015-January 2017) and post-intervention (February 2018-December 2020). ResultsThere was good compliance with vaginal cleansing (27.7% vs 84.8%), chlorhexidine skin preparation (90.4% vs 98.4%), BMI-based antibiotic dose adjustment (48.8% vs 74.3%), and Alexis retractor use (9.9% vs 66%), pre and post-implementation periods respectively. There was a reduction in documented hair shaving (2.1% vs 0.5%). There was a trend towards less admission for SSI, a trend that could have been even better had there not been an increasing number of women with high BMI over the years. Fewer cases needed return to theatre post-implementation. Endometritis rates were unchanged. ConclusionsGood compliance can be achieved with good collaboration. There was a reduction in admission rates for SSI. Larger prospective studies are needed to further examine these findings.

Reducing external ventricular drain associated ventriculitis: An improvement project in a level 1 trauma center

External ventricular drain (EVD)-associated infections have a negative impact on healthcare cost and patient outcomes. Practice variation in EVD management may place patients at increased risk for EVD-associated infection. This project aimed to evaluate the impact of implementing an interprofessional evidence-based EVD bundle of care on reduction of EVD-related ventriculitis rates. An interprofessional team developed an evidence based EVD care bundle and order set to eliminate practice inconsistencies. Standardization of EVD equipment and optimization of the electronic health record occurred. Education and competency validation were completed with neurosurgical providers and nurses. Interprofessional rounds occur weekly for observation, recognition, and in-the-moment education. A pre/post intervention design was used to show that the rate of EVD-associated ventriculitis decreased from 8.8 per reported EVD days in 2019 to 0 per reported EVD days in 2021 after implementation of the EVD care bundle. Through an interprofessional team approach, reduction in EVD-associated infection rates is feasible with implementation of an evidence based EVD care bundle.

PreciSSIon: a collaborative initiative to reduce surgical site infections after elective colorectal surgery

Surgical site infections (SSIs) are common after colorectal surgery, but most hospitals do not know their SSI rates. Approximately half of SSIs occur after discharge, and postdischarge surveillance is needed for accurate measurement. Perioperative care bundles are known to reduce SSI rates. PreciSSion is a collaboration between seven hospitals in the West of England. To establish reliable SSI measurement after elective colorectal surgery using 30-day patient-reported outcome measures, and to implement an evidence-based four-point care bundle that had already demonstrated a reduction in the SSI rate in a local hospital. The bundle included: 2% chlorhexidine skin preparation, a second dose of antibiotic after 4h, use of a dual-ring wound protector, and use of antibacterial sutures for abdominal wall closure. The 30-day patient-reported SSI rate was determined using the Public Health England questionnaire, and response rates were recorded. The baseline SSI rate was measured from November 2019 to May 2020, and continued after implementation of the care bundle until March 2021. Bundle compliance was also measured. The average questionnaire response rate was 81%, and average compliance was 92%, 96%, 79% and 85% for each element of the bundle. The baseline SSI rate was 8-30%. Six of seven hospitals reduced their SSI rate, and the regional average SSI rate almost halved from 18% (1447 patients) to 9.5% (1247 patients). A care bundle developed in a single hospital can be adopted in other hospitals, and a 50% reduction in SSI rate after elective colorectal surgery can be replicated in other hospitals within 18 months.

Nurses' knowledge and confidence in recognizing and managing patients with sepsis: A multi-site cross-sectional study.

(1) To examine registered nurses' knowledge and confidence in recognizing and managing to patients with sepsis and (2) identify nurse and workplace factors that influence their knowledge on sepsis. A multi-site, cross-sectional survey. An online survey was developed and content validated. Data was collected from registered nurses working in the inpatient wards and emergency departments of three hospitals of a single healthcare cluster in Singapore during August 2021. Statistical analyses of closed-ended responses and content analysis of open-ended responses were undertaken. A total of 709 nurses completed the survey. Nurses possessed moderate levels of knowledge about sepsis (mean score=10.56/15; SD=2.01) and confidence in recognizing and responding to patients with sepsis (mean score=18.46/25; SD=2.79). However, only 369 (52.0%) could correctly define sepsis. Nurses' job grade, nursing education level and clinical work area were significant predictors of nurses' sepsis knowledge. Specifically, nurses with higher job grade, higher nursing education level or those working in acute care areas (i.e. emergency department, high dependency units or intensive care units) were more likely to obtain higher total sepsis knowledge scores. A weak positive correlation was observed between sepsis knowledge test scores and self-confidence (r=.184). Open comments revealed that participants desired for more sepsis education and training opportunities and the implementation of sepsis screening tool and sepsis care protocol. A stronger foundation in sepsis education and training programs and the implementation of sepsis screening tools and care bundles are needed to enhance nurses' knowledge and confidence in recognizing and managing patients with sepsis. The findings of this study are beneficial to administrators, educators and researchers in designing interventions to support nurses in their role in recognizing and responding to sepsis.

Reducing intraventricular hemorrhage following the implementation of a prevention bundle for neonatal hypothermia.

In very low birth weight (VLBW) infants, hypothermia immediately following birth is common even in countries rich in medical resources. The purpose of this study is to design a standard prevention bundle that decreases the rate of hypothermia among infants after birth and to investigate efficacy of the bundle and short-term outcomes for VLBW infants. This quality improvement project was conducted from February 2017 to July 2018 on all VLBW preterm infants admitted at a single referral level III neonatal intensive care unit. The infants were classified into the pre-intervention (February to September 2017) and post-intervention (October 2017 to July 2018) groups according to the time periods when they were recruited. During the pre-intervention period, we analyzed the primary causes of hypothermia, developed solutions corresponding to each cause, integrated all solutions into a prevention bundle, and applied the bundle during the post-intervention period. Afterwards, the incidence of neonatal hypothermia and short-term outcomes, such as intraventricular hemorrhage (IVH), acidosis, and shock requiring inotropic agents, in each group were compared. A total of 95 VLBW infants were enrolled in the study, including 37 pre-intervention, and 58 post-intervention cases. The incidence of hypothermia in preterm infants decreased significantly upon the implementation of our prevention bundle, both in the delivery room (from 45.9% to 8.6%) and on admission (59.5% to 15.5%). In addition, the short-term outcomes of VLBW infants improved significantly, especially with the decreased incidence of IVH (from 21.6% to 5.2%, P = 0.015). Our standardized prevention bundle for preventing hypothermia in VLBW infants is effective and decreased the IVH rate in VLBW infants. We strongly believe that this prevention bundle is a simple, low-cost, replicable, and effective tool that hospitals can adopt to improve VLBW infant outcomes.

Assess Nursing Performance during Implementation of Care Bundle for Critically Ill Patients

Assess Nursing Performance during Implementation of Care Bundle for Critically Ill Patients

The Central HAC Team: Advancing the Culture of Safety Through Practice Observations.

Background: At SickKids, central line-associated blood stream infections (CLABSIs) remain one of the most prevalent hospital acquired conditions. Despite implementation of evidence-based prevention bundles, adherence remains a challenge and obtaining reliable bundle adherence data is complex. An innovative approach to address gaps in practice was developed. Objectives: A centralized hospital acquired conditions team consisting of nurse leaders was created to improve bundle adherence and data reliability. The team partners with local leadership to reinforce the CLABSI maintenance bundle organization wide. The team completes observations, provides just-in-time feedback to nurses, and obtains reliable bundle adherence data. Methods: The team developed a defined model to complete observations: identify, coordinate, observe, feedback, document, and collaborate. Feedback is provided using error prevention strategies. Observations are electronically documented and visualized in real-time to trend results. The team identifies data-driven opportunities to inform priorities. Results: Since September 2018, the team has completed nearly 1500 practice observations with an observed 45% CLABSI reduction and a statistically significant centerline shift (Fig. 1). To evaluate team effectiveness, 118 nurses completed a survey. Seventy-eight percent of respondents agreed feedback was clear and 59% felt it helped improve their practice. Bundle adherence data comparing the team to local unit observers remains variable; however, education of local champions is improving reliability. Conclusions/Implications: The centralized approach for providing just-in-time feedback is an effective method to promote evidence-based practice and drive CLABSI maintenance bundle adherence. This method improves understanding of common failure modes to target improvements. Preliminary evaluation highlights how the team impacts safety culture and improves patient outcomes through practice observations.Fig. 1.: The Hospital for Sick Children Statistical Process Control Chart displaying hospital CLABSI rate comparative to the Solutions for Patient Safety network from August 2018 to February 2022. CLABSIs = central line-associated blood stream infections.

Optimization of Opioid Discharge Prescriptions Following Thyroid and Parathyroid Surgery.

To evaluate the impact of a quality improvement bundle on opioid discharge prescribing following thyroidectomy and parathyroidectomy. This before-and-after study included patients undergoing thyroidectomy or parathyroidectomy at an academic medical center. The quality improvement bundle included a patient education flyer, electronic health record order sets with multimodal analgesia regimens, and provider education. The preimplementation cohort included patients treated from January 2018 to December 2019. The postimplementation cohort included patients treated from June 2021 to August 2021. The primary outcome was the proportion of patients who received new opioid discharge prescriptions. A total of 160 patients were included in the preimplementation cohort, and the first 80 patients treated after bundle implementation were included in the postimplementation cohort. Patients receiving new opioid discharge prescriptions decreased from 80% (128/160) in the preimplementation cohort to 35% (28/80) in the postimplementation cohort with an unadjusted absolute reduction of 45% (95% CI, 33%-57%; P < .001; number needed to treat = 3) and an adjusted odds ratio (OR) of 0.08 (95% CI, 0.04-0.19; P < .001). The bundle was associated with reductions in opioid discharge prescriptions that exceeded 112.5 oral morphine milligram equivalents (33% pre- vs 10% postimplementation; adjusted OR, 0.20; P = .001) or 5 days of therapy (17% pre- vs 6% postimplementation; adjusted OR, 0.34; P = .049). Implementation of a pain management quality improvement bundle reduced opioid discharge prescribing following thyroidectomy and parathyroidectomy. Unnecessary opioid prescriptions generate unused opioids in patients' homes that can lead to opioid misuse. We believe that this bundle reduced the risk for opioid misuse in our community. The study was registered at ClinicalTrials.gov (NCT04955444) before implementation.

Ventilator-associated pneumonia in PICU - how are we doing?

Background Ventilator-associated pneumonia (VAP) is a common hospital-acquired infection in children, leading to an increase in morbidity and mortality. A previous study in 2013 showed that VAP rates decreased dramatically after implementation of a VAP bundle and appointing a VAP coordinator. As part of a ‘Plan, Do, Study, Act’ cycle, it was necessary to evaluate the efficacy of these interventions. Objectives To evaluate the VAP rate in the paediatric intensive care unit (PICU) over 2 years (2017 - 2018), and to describe the causative organisms and antibiotic sensitivity/resistance patterns during this period. Methods This was a retrospective, descriptive study using the existing PICU VAP database as well as clinical folders. Results Over the 2 years, 31 VAP cases were identified. The VAP rate for 2017 was 4.0/1 000 ventilator days and 5.4/1 000 ventilator days for 2018. Compliance with the VAP bundle was 68% in 2017 and 70% in 2018. The median (interquartile range (IQR)) duration of ventilation in 2017 was 9 (6 -12) days and 15 (11 - 28) days in 2018. The median (IQR) length of PICU stay in 2017 was 11 (8 - 22) days and 25 (17 - 37) days in 2018. The most common cultured organism was an extended-spectrum beta-lactamase (ESBL) Klebsiella pneumoniae sensitive to amikacin and carbapenems. Conclusion Our VAP rate has not decreased since 2013. It is imperative that we improve compliance with the VAP bundle, in order to reduce VAP rates. K. pneumoniae and Pseudomonas aeruginosa were the most common organisms causing VAPs and empiric use of piptazobactam and amikacin is still appropriate. Contributions of the study This study highlights the need for ongoing evaluation of quality improvement initiatives in PICU, considering that VAP rates remained largely unchanged from 2013 to 2018.

Surgical Site Infections in Post-Living Donor Liver Transplantation: Surveillance and Evaluation of Care Bundle Approach

Background and Aim: Although implantation of a care bundle approach is well established in intensive care units (ICUs), yet its impact on reducing surgical site infections (SSI) among post living-donor-liver transplantation (LDLT) patients has not been established. Our aim is to evaluate the impact of a care bundle in reducing SSI and to detect the pattern of antibiotic resistance in LDLT. Materials and Methods: This before and after comparative study was conducted at Elmanial specialized tertiary hospital, Cairo University over a period of 3 years (January 2016 - December 2018) including 57 LDLT patients. We introduced a care bundle comprised of a group of evidence-based practices implemented together. The study was divided into three phases. All bacterial identification and antibiotic sensitivity testing were done by a Vitek 2 compact system. Results: SSIs rates were reduced significantly by 30.4% from the pre-implementation to the post implementation phase (from 13/24, 54.2% to 5/21, 23.8%, OR 0.21, CI 95%: 1.137- 0.039). This reduction went hand in hand with increase in the hand hygiene compliance from 57.3 % to 78 %, then remained sustained with a median rate of 78% in the last 6 months. Klebsiella pneumoniae 11\25 (44% of SSIs), Acinetobacter baumannii 8\25 (32% of SSIs), Escherichia coli 5\25 (20%), Pseudomonas aeruginosa 5\25 (20%) and MRSA 4\25 (16%). With predominance of XDR phenotype 14/25 (56%), followed by ESBL of gram-negative bacteria 6/25 (24%), then MRSA 4/25 (16%). Conclusion: SSIs in LDLT mandates strict implementation of comprehensive evidence-based care bundles for better patent outcome.

Serratia marcescens outbreak in a neonatal intensive care unit associated with contaminated donor milk.

Investigation of the origin of a Serratia marcescens outbreak in a neonatal intensive care unit. Retrospective case-control study. Regional level 3 perinatal center in Germany. This study included 4 S. marcescens-positive and 19 S. marcescens-negative neonates treated between February 1 and February 26, 2019, in the neonatal intensive care unit. A case-control study was performed to identify the source of the outbreak. The molecular investigation of S. marcescens isolates collected during the outbreak was performed using pulsed-field gel electrophoresis and next-generation sequencing. The retrospective case-control study showed a significant correlation (P < .0001) between S. marcensens infection or colonization and consumption of donor milk that had tested negative for pathogenic bacteria from a single breast milk donor. Pulsed-field gel electrophoresis and next-generation sequencing retrospectively confirmed an S. marcescens strain isolated from the breast milk of this donor as the possible origin of the initial outbreak. The outbreak was controlled by the implementation of an infection control bundle including a multidisciplinary infection control team, temporary nutrition of infants with formula only and/or their mother's own milk, repeated screening of all inpatients, strict coat and glove care, process observation, retraining of hand hygiene and continuous monitoring of environmental cleaning procedures. Low-level contaminated raw donor milk can be a source of infection and colonization of preterm infants with S. marcescens even if it tests negative for bacteria.

What's New in Practice Improvements in Neonatal Care?

What's New in Practice Improvements in Neonatal Care?

Antibiotic exposure around first line chemotherapy and survival in ovarian cancer (347)

<b>Objectives:</b> To assess whether exposure to antibiotics (ABX) in the 90 days preceding initiation through the completion of first-line chemotherapy for epithelial ovarian carcinoma (EOC) is associated with decreased overall survival (OS) and truncated treatment-free interval (TFI), which we hypothesized. <b>Methods:</b> A retrospective cohort study of women with newly diagnosed stage III/IV EOC between 2009 to 2019 treated at a single institution was conducted. ABX exposure of >48 hours, timing with respect to chemotherapy initiation, and ABX class were captured. The association of ABX with TFI and OS was assessed with univariate and multivariable Cox proportional hazard models. <b>Results:</b> Of the 360 eligible women, 47% (<i>n</i>=170) were exposed to antibiotics, with 12% (<i>n</i>=46) receiving them only prior to first-line chemotherapy initiation, 23% (<i>n</i>=81) receiving them during chemotherapy, and 12% (<i>n</i>=43) receiving them before and during chemotherapy. Exposure to any ABX was associated with a decreased median OS (42.1 vs 60.0 months, HR: 1.33, 95% CI: 1.02-1.73, p=0.03) compared to no ABX. On subset analyses, ABX, specifically during chemotherapy, was associated with a decreased median OS (42.2 vs 60.0 months, HR: 1.46, 95% CI: 1.01-2.10). While exposure to ABX as a whole was not associated with TFI, receipt of ABX before chemotherapy was associated with a decreased TFI, with an HR of 1.76 (95% CI: 1.00-3.11, p=0.05), when compared to no ABX. Treatment with antibiotics against gram-positive organisms (GPO) with vancomycin, lin- cosamides, and macrolides was associated with worse OS (HR: 1.49, 95% CI: 1.01-2.20, p=0.049). In a multivariable analysis accounting for bowel surgery, exposure to granulocyte colony-stimulating factor, and IP chemo administration, exposure to ABX remained associated with an increased risk of death (HR: 1.38, 95% CI: 1.02-1.68, p=0.039). <b>Conclusions:</b> Patients with stage III/IV EOC exposed to ABX 90 days prior to chemotherapy had statistically significantly worse TFI compared to unexposed patients. In contrast, patients exposed to ABX during chemotherapy had worse OS compared to unexposed patients. Treatment with ABX targeting GPO decreased OS. Efforts to decrease the need for ABX, such as judicious prescription of ABX and implementation of perioperative infection prevention bundles, may offer an opportunity to increase survival in EOC.

Perioperative mental health intervention bundle for older surgical patients: protocol for an intervention development and feasibility study

IntroductionThe perioperative period is high risk for older adults. Depression and anxiety are common perioperative problems, frequently coexisting with cognitive impairment. Older patients with these conditions are more likely than...

Is every microorganism detected in the intensive care unit a nosocomial infection? Isn't prevention more important than detection?

The present letter to the editor is related to the study entitled “Multidrug-resistant organisms in intensive care units and logistic analysis of risk factors.” Not every microorganism grown in samples taken from critically ill patients can be considered as an infectious agent. Accurate and adequate information about nosocomial infections is essential in introducing effective prevention programs in hospitals. Therefore, the development and implementation of care bundles for frequently used medical devices and invasive treatment devices (e.g., intravenous catheters and invasive ventilation), adequate staffing not only for physicians, nurses, and other medical staff but also for housekeeping staff, and infection surveillance and motivational feedback are key points of infection prevention in the intensive care unit.