運用組合式照護改善健康照護品質

Using Care Bundles to Improve Health Care Quality

10.6530/YYN/2017.5.3

黃鈴婷(Ling-Ting Huang)；李佳晏(Chia-yen Li)；張乃文(Nai-Wen Chang)

組合式照護 ； 遵從性 ； 健康照護品質 ； care bundles ； compliance ； health care quality

源遠護理

11卷1期（2017 / 03 / 01）

18 - 24

繁體中文

「組合式照護（care bundles）」是為提升健康照護品質而發展出來，於2001年美國醫療照護改善研究機構（Institute for Healthcare Improvement, IHI）與志願醫院公會（Voluntary Hospital Association, VHA）聯合倡議，希望透過跨領域團隊的合作及溝通協調，透過3-5種有實證基礎的結構化重症照護措施，共同且確實的執行，以建立安全並可靠的照護條件改善照護過程和病人的健康結果。組合式發展剛開始著重於有潛在性傷害及高花費的問題，如呼吸機及中心導管病人之照護，透過實證基礎研究，強烈證據顯示實施「組合式照護」的效益極佳。本文藉由說明組合式照護之發展、設計、推行及成效等，以使醫療照護相關人員能更瞭解相關概念以改善照護品質。

Care bundles were developed for improving health care quality by the Institute for Healthcare Improvement (IHI) as part their joint initiative with the Voluntary Hospital Association, named Idealized Design of the Intensive Care Unit (IDICU) in 2001. They combined 3-5 evidence-based interventions to develop the process of improving critical care to the highest levels of reliability, which would result in considerably ameliorated outcomes. It was believed that improving teamwork and communication in multidisciplinary teams would facilitate the conditions necessary for safe and reliable care in the intensive care unit. They focused on regions with potential for great harm and high cost, and where the evidence base was robust. While there were many changes the teams where this initiative was implemented, the care of patients on ventilators and those who had central lines became a powerful focus, as it fulfilled all the criteria and produced reliable change and superior patient outcomes. By using a ＂bundle (a small set of evidence-based interventions)＂ with a defined patient population and care setting, the improvements in patient outcomes exceeded expectations. Thus began an innovative approach of the use of bundles to improve critical care. In this paper, we illustrate the history, theory of change, design concepts, and outcomes associated with the use of bundles for further implementation of the bundle approach to improving the quality of care.

1. Balas, M. C.,Devlin, J. W.,Verceles, A. C.,Morris, P.,Ely, E. W.(2016).Adapting the ABCDEF bundle to meet the needs of patients requiring prolonged mechanical ventilation in the long-term acute care hospital setting: Historical perspectives and practical implications.Seminars in Respiratory and Critical Care Medicine,37(1),119-135.
2. Bird, D.,Zambuto, A.,O’Donnell, C.,Silva, J.,Korn, C.,Burke, R.,Agarwal, S.(2010).Adherence to ventilator-associated pneumonia bundle and incidence of ventilator-associated pneumonia in the surgical intensive care unit.Archives of Surgery,145(5),465-470.
3. Blamoun, J.,Alfakir, M.,Rella, M. E.,Wojcik, J. M.,Solis, R. A.,Anees Khan, M.,DeBari, V. A.(2009).Efficacy of an expanded ventilator bundle for the reduction of ventilator-associated pneumonia in the medical intensive care unit.American Journal of Infection Control,37(2),172-175.
4. Borgert, M.,Binnekade, J.,Paulus, F.,Vroom, M.,Vlaar, A.,Goossens, A.,Dongelmans, D.(2016).Implementation of a transfusion bundle reduces inappropriate red blood cell transfusions in intensive care - a before and after study.Transfusion Medicine,26(6),432-439.
5. Burger, C. D.,Resar, R. K.(2006)."Ventilator bundle" approach to prevention of ventilator-associated pneumonia.Mayo Clinic Proceedings,81(6),849-850.
6. Coryn, C. L. S.,Noakes, L. A.,Westine, C. D.,Schrőter, D. C.(2011).A systematic review of theory-driven evaluation practice from 1990 to 2009.American Journal of Evaluation,32(2),199-226.
7. D’Angelo, R. G,Rincavage, M.,Tata, A. L.,Millstein, L. S.,Gulati, M. S.,Flurie, R. W.,Gonzales, J. P.(2017).Impact of an antipsychotic discontinuation bundle during transitions of care in critically ill patients.Journal of Intensive Care Medicine
8. Eveleigh, M. O.,Howes, T. E.,Peden, C. J.,Cook, T. M.(2016).Estimated costs before, during and after the introduction of the emergency laparotomy pathway quality improvement care (ELPQuIC) bundle.Anaesthesia,71(11),1291-1295.
9. Fleming, I. O.,Garratt, C.,Guha, R.,Desai, J.,Chaubey, S.,Wang, Y.,Kunst, G.(2016).Aggregation of marginal gains in cardiac surgery: Feasibility of a perioperative care bundle for enhanced recovery in cardiac surgical patients.Journal of Cardiothoracic and Vascular Anesthesia,30(3),665-670.
10. Furuya, E. Y.,Dick, A. W.,Herzig, C. T.,Pogorzelska-Maziarz, M.,Larson, E. L.,Stone, P. W.(2016).Central line-associated bloodstream infection reduction and bundle compliance in intensive care units: A national study.Infection Control and Hospital Epidemiology,37(7),805-810.
11. Furuya, E. Y.,Dick, A.,Perencevich, E. N.,Pogorzelska, M.,Goldmann, D.,Stone, P. W.(2011).Central line bundle implementation in US intensive care units and impact on bloodstream infections.PloS One,6(1),e15452.
12. Haraden, C. (2017). Evidence-Based Care Bundles. Retrieved from http://www.ihi.org/resources/Pages/ImprovementStories/WhatIsaBundle.aspx
13. Health protection surveilance centre. (2014). Care Bundles. Retrieved from http://www.hpsc.ie/A-Z/MicrobiologyAntimicrobial Resistance/CareBundles/
14. Hoo, W. E.,Muehlberg, K.,Ferraro, R. G.,Jumaoas, M. C.(2009).Successes and lessons learned implementing the sepsis bundle.Journal of Healthcare Quality,31(4),9-14.
15. Hutton, J.,Graham, S.(2015).Chest drain care bundle: Improving documentation and safety.BMJ Quality Improvement Peports,4(1)
16. Institute for Healthcare Improvement. (2012a). How to Guide: Prevent Ventilator-Associated Pneumonia. Retrieved from http://www.ihi.org/resources/Pages/Tools/HowtoGuidePreventVAP.aspx
17. Institute for Healthcare Improvement. (2008, October 23). IHI Shares Achievements of the 5 Million Lives Campaign. Retrieved from http://www.ihi.org/about/news/Documents/IHIPressRelease_IHISharesAchievementsof5MillionLivesCampaign_Oct08.pdf
18. Institute for Healthcare Improvement. (2012b). How to Guide: Prevent Central Line Infection-Associated Bloodstream Infection. Retrieved from http://www.ihi.org/knowledge/Pages/Tools/HowtoGuidePreventCentralLineAssociated-BloodstreamInfection.aspx
19. Institute for Healthcare Improvement. (2002). IHI Intensive Care Unit (ICU) Adverse Event Trigger Tool. Retrieved from http://www.ihi.org/resources/Pages/Tools/ICUAdverseEventTriggerTool.aspx
20. Langley, G. L.,Moen, R.,Nolan, K. M.,Nolan, T. W.,Norman, C. L.,Provost, L. P.(2009).The Improvement Guide: A Practical Approach to Enhancing Organizational Performance.San Francisco:Jossey-Bass Publishers.
21. McCall, K.,Hussin, H. M.,Gregory, M. E.,Dutton, G.,Richardson, J.(2016).A bundle improves eye care in PICU.Archives of Disease in Childhood,101(9),832-835.
22. McPherson, S.,Dyson, J.,Austin, A.,Hudson, M.(2016).Response to the NCEPOD report: development of a care bundle for patients admitted with decompensated cirrhosis-the first 24 h.Frontline Gastroenterol,7(1),16-23.
23. Morris, A. C.,Hay, A. W.,Swann, D. G.,Everingham, K.,McCulloch, C.,McNulty, J.,Walsh, T. S.(2011).Reducing ventilator-associated pneumonia in intensive care: Impact of implementing a care bundle.Critical Care Medicine,39(10),2218-2224.
24. Nakibuuka, J.,Sajatovic, M.,Nankabirwa, J.,Ssendikadiwa, C.,Kalema, N.,Kwizera, A.,Katabira, E.(2016).Effect of a 72 hour stroke care bundle on early outcomes after acute stroke: A non randomised controlled study.PloS One,11(5),e0154333.
25. Nguyen, H. B.,Corbett, S. W.,Steele, R.,Banta, J.,Clark, R. T.,Hayes, S. R.,Wittlake, W. A.(2007).Implementation of a bundle of quality indicators for the early management of severe sepsis and septic shock is associated with decreased mortality.Critical Care Medicine,35(4),1105-1112.
26. Parikh, R.,Shah, T. G.,Tandon, R.(2016).COPD exacerbation care bundle improves standard of care, length of stay, and readmission rates.International Journal of Chronic Obstructive Pulmonary Disease,11,577-583.
27. Pinto, F.,Biancofiore, G.(2016).The ABCDE bundle: A survey of nurses knowledge and attitudes in the intensive care units of a national teaching hospital in Italy.Dimensions of Critical Care Nursing,35(6),309-314.
28. Pogorzelska, M.,Stone, P. W.,Furuya, E. Y.,Perencevich, E. N.,Larson, E. L.,Goldmann, D.,Dick, A.(2011).Impact of the ventilator bundle on ventilator-associated pneumonia in intensive care unit.International Journal for Quality in Health Care,23(5),538-544.
29. Render, M. L.,Hasselbeck, R.,Freyberg, R. W.,Hofer, T. P.,Sales, A. E.,Almenoff, P. L.,Group, Va Icu Clinical Advisory(2011).Reduction of central line infections in Veterans Administration intensive care units: An observational cohort using a central infrastructure to support learning and improvement.BMJ Quality & Safety,20(8),725-732.
30. Resar, R.,Pronovost, P.,Haraden, C.,Simmonds, T.,Rainey, T.,Nolan, T.(2005).Using a bundle approach to improve ventilator care processes and reduce ventilator-associated pneumonia.The Joint Commission Journal on Quality and Patient Safety,31(5),243-248.
31. Speck, K.,Rawat, N.,Weiner, N. C.,Tujuba, H. G.,Farley, D.,Berenholtz, S.(2016).A systematic approach for developing a ventilator-associated pneumonia prevention bundle.American Journal of Infection Control,44(6),652-656.
32. Tanner, J.,Kiernan, M.,Hilliam, R.,Davey, S.,Collins, E.,Wood, T.,Leaper, D.(2016).Effectiveness of a care bundle to reduce surgical site infections in patients having open colorectal surgery.Annals of the Royal College of Surgeons of England,98(4),270-274.
33. Tarrant, C.,O’Donnell, B.,Martin, G.,Bion, J.,Hunter, A.,Rooney, K. D.(2016).A complex endeavour: an ethnographic study of the implementation of the Sepsis Six clinical care bundle.Implementation Science,11(1),149.
34. Tayyib, N.,Coyer, F.(2017).Translating pressure ulcer prevention into intensive care nursing practice: Overlaying a care bundle approach with a model for research implementation.Journal of Nursing Care Quality,32(1),6-14.
35. Youngquist, P.,Carroll, M.,Farber, M.,Macy, D.,Madrid, P.,Ronning, J.,Susag, A.(2007).Implementing a ventilator bundle in a community hospital.The Joint Commission Journal on Quality and Patient Safety,33(4),219-225.
36. Zambon, M.,Ceola, M.,Almeida-de-Castro, R.,Gullo, A.,Vincent, J. L.(2008).Implementation of the surviving sepsis campaign guidelines for severe sepsis and septic shock: We could go faster.Journal of Critical Care,23(4),455-460.