Implement a COVID care bundle in the ICU? Please No!

If I could do care bundle implementation all over again – what would I do differently?

Well, firstly I would not make the focus the implementation of the care bundle. That sounds counter-intuitive, but I promise it is not!

I want you to step back from care bundles and think about how you respond to being told you have a problem? And before you have even had a chance to acknowledge that you might have a problem, you are instructed that you must do X, Y and Z to address it? How is that going to sit with you? From experience I know that the response is on a continuum from arm crossing to complete resistance and defiance. And instead of the focus being resolving the problem (through whatever changes are required for that unique context), the focus can easily and incorrectly shift to (bundle) compliance, (bundle) implementation and the associated (and somewhat incorrectly used and dreaded) bundle checklists.

And just like that you have turned sustainably addressing a problem into something tedious and onerous.

I am going to turn back the clock to 2010 when I first got involved in implementing care bundles. In the context in which I worked the care bundles were a major step change because of knowledge, behavioural and equipment deficits. There is a lot of published evidence telling us what we should be doing in healthcare – usually in the form of long guidelines with 30+ interventions. The care bundles were excitingly different because they clustered together 3-5 of these interventions (called elements) into a care bundle. And groups that reliably implemented these care bundles saw reductions in the problem they were trying to address (such as reducing surgical site infections).

In the South African context, a decade ago, it was common place to shave surgical sites with razors (and not even wet shaving), causing micro cuts in the skin thereby introducing bacteria into the skin even prior to surgery; to administer extended prophylactic antibiotics (but not necessarily prior to the surgical incision for there to be a reasonable concentration at tissue level prior to cutting); and for patients to be hypothermic peri-operatively (impacting coagulation, tissue metabolism, wound healing etc). That is unheard of 10 years on - and now if it happens it would be seen as extremely poor practice. Challenging this way of doing things with the evidence on why not to do it was quite challenging a decade ago. So much energy went into scrutinising the evidence, arguing about the rigor of the intervention, and pushing back against the change in practice.

I wonder what would have happened if multifunctional teams were first guided to understand if they have a problem with surgical site infections (SSIs), and if they did have a problem, guided to analyse the problem comprehensively and then mentored in testing change ideas to see which ones resulted in improvement and to identify barriers to implementing these changes sustainably.

I wonder if we would still be unnecessarily utilising manpower to complete bundle checklists and measure bundle compliance had this approach been followed and supported with the necessary mentorship.

Fast forward to 2021 amid the Covid-19 pandemic. Let us examine one element of the care bundle for preventing ventilator-associated pneumonia (VAP) – mouth care. In this context a decade ago there was a scarcity of equipment for performing mouth care (limited to the patient’s old manky toothbrush and pH altering lemon & glycerine swabs – later evidenced as a no-no!). Mouth care trays were not routinely available and there was a lack of knowledge about the importance of performing mouth care (technique and frequency) to prevent a patient from developing a secondary pneumonia while ventilated. Mouth care trays (containing a suctionable soft toothbrush and foam swabs to regularly moisturise the patient’s mouth) were then developed and manufactured locally to make them affordable and to address this constraint.

Back to 2021 – in this same context, a lack of knowledge and equipment is no longer the constraint preventing ventilated patients from reliably receiving the mouth care they need to prevent acquiring a healthcare-associated pneumonia. Now it is the actual manpower, workload and the teamwork required in order to reposition a patient's head in the prone position in order to do 2hrly mouth care. Nurses are now managing a much higher caseload – and something must give.

The barriers to reliably implementing all these evidence-based practices constantly evolves and must be continually addressed. Taking a compliance dipstick will show that there are issues – your effort should be applied in addressing those barriers, not in compiling the compliance data. And as with all ideas or potential solutions – the best will come from those on the frontline who understand the contextual barriers. It will not come from those removed from the frontline.

I asked a good friend who has been a frontline critical care nurse for yonks to read this blogpost and give me critical feedback and she reminded me that

“the people on the ground know what the problems are and will most likely have good suggestions on how to solve the problem, but without the relevant people listening who have the power to make these things possible it’s also not going to work”.

She reminded me that it required someone with power to replace razors with clippers and to provide affordable mouth care trays a decade ago. “There needs to be a willingness to listen to the people on the ground, and then the people with the power need to implement suggestions”.

Lastly, no matter how desperate we are to see an improvement or how convinced we are that we have the solution, ideas must be tested before being implemented.

I am working shifts in a Covid ICU at present and although I have all sorts of ideas on how to improve teamwork and reduce the workload that I think is not value-adding, there may be unintended consequences that I did not envisage, and other things may ‘break’ in an attempt to address one problem.

Improvement requires acknowledgement of a problem. Understanding that system’s contributing factors and constraints. And then testing ideas to address those contributing factors and to lessen the constraints. It requires autonomy and buy-in. And a team approach. But most importantly the ideas must be generated from the bottom up and be contextually relevant. And as my dear friend emphasised – for some changes it is also critical that the people with the power are willing to acknowledge the need for change and do the necessary.