Pediatric Informatics: Computer Applications in Child Health (Health ...

9 Pediatric Care, Safety, and Standardization 125
Care bundles consist of selected CPGs or evidence-based protocols that have
been grouped together as a unit to encourage their consistent and systematical
application as part of specific treatment regimens. In theory, by grouping several
evidence-based interventions together in a single protocol, it is more likely that
caregivers will provide a complete set of interventions, and patient outcomes will
improve. A bundle should contain no more than three to five practices or precautionary
steps that are effected at the same time and in the same space. 27
The success of the care bundle is based in part on its focus on goal achievement,
which encourages development of the teamwork necessary for effective implementation.
29 Furthermore, the simplicity of the bundle should make it easy to
implement and easy to audit compliance. 30 Three bundles in particular have been
widely touted: the ventilator care bundle, the central line bundle, the sepsis bundle
( comprised of the resuscitation bundle and the sepsis management bundle). 31 In
both the UK and the USA, introduction of the ventilator bundle (prophylaxis
against peptic ulceration, prophylaxis against deep vein thrombosis, daily cessation
of sedation and elevation of the patient’s head and chest to at least 30° to the
horizontal) was effective in reducing the length of ventilation and ICU length of
stay, 32 as well as reducing the incidence of ventilator associated pneumonia, respectively.
30 IHI’s central line bundle which targets central line-related bloodstream
infection consists of five components: hand hygiene, maximal barrier precautions,
chlorhexidine skin antisepsis, optimal catheter site selection, and daily review of
line necessity with prompt removal of unnecessary lines. 33 The IHI website is rife
with success stories from organizations that have successfully implemented the
central line bundle. For example, Regions Hospital in St. Paul, Minnesota, reported
a progressive fall in catheter related blood stream infection rate from over 8 in the
medical ICU and burn centre to 0 infections per 1,000 line days within 3 years after
the bundle was implemented. 34
It is to be noted that the six bundles in the 100,000 Lives Campaign were
developed from evidence well founded in the adult population. A Pediatric Node,
consisting of the Child Health Corporation of America (CHCA), the National
Association of Children’s Hospitals and Related Institutions (NACHRI), and the
National Initiative for Children’s Healthcare Quality (NICHQ) adapted the bundles
for use in children. 35 For example, the pediatric central line bundle is divided
into insertion and maintenance bundle elements, and is outlined in Table 9.2. 36
The pediatric ventilator care bundle excludes the daily “sedation vacation.”
Anecdotal evidence suggests that outcomes in pediatric care have been improved
by use of the bundles.
The beauty of using the bundle lies not only with the framework for implementing
multiple evidence based practices as part of a unit, but in the proposed
strategy for measuring compliance. Rather than focusing on compliance with
each individual component of the bundle, compliance is measured using the
“all or nothing” approach, i.e. the rate at which all elements in the bundle are
followed. 37 Although the journey to 100% compliance may be long, the end
result is that more “best practices” are followed, with the likelihood of better
patient outcomes.