Bundling Hospital Processes May Help Prevent Infections

By Allison Baker, USA TODAY

Hospitals are attacking potentially fatal bacterial infections by marrying a series of proven medical treatments in an approach called a "bundle."

The Institute for Healthcare Improvement, a non-profit organization based in Cambridge, Mass., reports that thousands of hospitals, both national and international, have joined its campaign against preventable complications that requires the adoption of bundles.

The IHI defines bundling as a group of processes needed by patients undergoing certain risky treatments. The idea is to join scientifically grounded elements that reduce the risk of serious complications, such as pneumonia or central-line infections.

Ventilator-associated pneumonia is one of the most common hospital-acquired infections. The related bundle requires that the head of the bed be elevated, the patient be woken daily for assessment, and preventative steps be taken to prevent blood clots and ulcers.

The medical/surgical intensive care unit at BryanLGH Medical Center in Lincoln, Neb., put this bundle into effect and went 27 months without a case of the targeted infection. "Bundles aren't rocket science, but they're effective and they work," says Mona Reynolds, a clinical nurse manager at BryanLGH.

Central-line catheters also get their own bundle because of the risk that their insertion into major veins could open the door to infection. In this case, the bundle is completed before every insertion.

The checklist includes hand hygiene, using scrubbing agents to destroy normal skin bacteria that could wreak havoc in the bloodstream, choosing the optimal placement for insertion, and daily review of the line's necessity.

Septic shock, in which infection leads to low blood pressure and low blood flow, has a very high death rate.

There are two sepsis bundles: resuscitation and management, which include specific blood tests and the administration of broad antibiotics that kill maximal germs early. Resuscitation is the emergency protocol when sepsis is identified; management is done to prevent further permanent damage to organs.

The bundle's magic is in the "all-or-nothing" approach, says IHI director Fran Griffin. "We don't want to say (to patients), 'We'll give you half of the items on the list — which ones do you want?' "

According to IHI, bundling the steps together makes patient care a collaborative effort. Rather than acting independently, the doctors, nurses, therapists and pharmacists all have to work together. "Quality improvement isn't about blaming people," says Donald Goldmann, IHI senior vice president. "It's about getting it right."

Hand hygiene is a basic element of most bundles. Hospital staff compliance has hovered around 50% in recent years, Goldmann says. But time-saving alcohol-based hand rubs have made compliance easier.

There's not any one way to make the bundle work, but the successful hospitals say that by taking this approach, their staffs work better as a team, Griffin says.

The Institute for Healthcare Improvement gives this example of a bundle that has reduced hospital acquired infections. These steps are designed to prevent surgical site infections:

1. Monitor appropriate use of antibiotics before and after surgery.

2. Stop the use of razors to remove a patient's hair. Razors can nick the skin and lead to infections.

3. Keep the patient warm during surgery.

4. Monitor the patient's blood sugar after surgery.