Welcome to the Quality Improvement boxset by RCVS Knowledge, a series of webinars, podcasts, and video interviews for practices and practitioners. Hi everyone. I'm talking today to Helen Ballantyne. Helen started as an RPN and then moved into human nursing. She's kept up her RVN registration though, and she is a real advocate of one health. Great to speak to you, Helen, all your experience of both human nursing and veterinary nursing. Thank you.
I'd like to talk to you if that's okay about care bundles. I must admit that I really didn't know what care bundles were, at all, until I saw a talk that you actually did, um, before that I had no idea what care bundles were, so I think it'd be really interesting if you can explain to us what they are. That's great. Um, so care bundles are something that, um, I, before I went into human nursing had no idea as well.
But I realized that once I had kind of established had, had seen them formerly, I realized that I'd been doing informal care bundles in my head for many, many years. And I think lots of veterinary nurses have. So, care bundles are a group of evidence-based practices that are related to a disease or a set of symptoms that basically when they are executed altogether result in better outcomes than if
they're implemented individually. And so put in a very basic level, the way that the sort of light bulb moment was, I, like lots of veterinary nurses, would be the duty nurse in a practice and the vet would have gone home. So I'd be there overnight. And sometimes you would get to the stage where you had a patient, an inpatient who needed something and you could start providing care for that patient before the vet arrived.
And I think that was the key thing that made me think these care bundles could be so important in veterinary medicine, because actually what it means is that this isn't just a strategy to improve patient outcomes. Although that is how it started to make sure everybody was doing the best possible thing. It also means that you have got evidence-based practice at your fingertips that you know, that you can implement. So it brings that gap between theory and practice
much, much closer together. And the other thing it does, and actually where's, it all started in human medicine is that it prevents common complications associated with various diagnoses. So historically this was about trying to combat ventilator-required pneumonia. So it was almost taken as given that if you had, if you were put on a ventilator, you probably get some pneumonia at some point.
Also in the ITU context, if you had a central line was put in, you'd probably get an infection in that central line at some point. So we're talking kind of, you know, 10, 10, 15 years ago now. And so what, what happened was that a collection of interactions, a collection of interventions, sorry, were put in place that prevented the ventilator, acquired pneumonia and prevented infections in central lines. And the results were so phenomenal that these things are now considered unusual,
you know, they do happen. Of course they can happen, but actually there so many robust care bundles in place to stop... to do things, to stop these things happening. I think, you know, probably obviously the primary advantage is that they improve patient outcomes. But what's very interesting is that this and the secondary sort of advantages are very, very related, I think, to nursing.
And that's why they, you know, rang a bell. So they, like I said, they closed this gap between theory and practice because when you use a care bundle by default, you are performing evidence-based practice because you've checked that it's, that's, what's included, but then I've seen it in practice that it has this fantastic ability to promote teamwork and also potentially promote job satisfaction.
Because a classic example is, something that's used in the NHS, which is called the sepsis six, which is a care bundle that's put into place, when patients exhibit certain signs and symptoms that indicate they may well be becoming septic. And this is a multidisciplinary team care bundle. So there's elements that the doctor has to do, so there's some prescribing of antibiotics, for example.There's elements that the nurse has to do, so urinary catheterization to monitor urine output, for example.
And then because you've got a care bundle in place that people know what's going to happen, you can have a nursing assistant, I mean, they can be, they're just brilliant at this. You mentioned the sepsis six bundle and suddenly you've got a nursing assistant
who'd gone. A health care assistant has come back with a trolley, stacked full with all the stuff we need, because you need to take blood cultures ,you need to put urinary catheters in, we need to start oxygen, we need to fluid resuscitate this person. And you know, the uniformity of that goal, you know, the fact that we all know what we're doing because of that care bundle means that things are done much quicker, much more efficiently.
And there is certainly a much better cohesive team. And you know, it's not rocket science. We know that when a team has got a unified goal, they work better. And this care bundle can become that goal with, with certain groups of patients. That's really interesting about them having everything prepared. These care bundles are they drawn up sort of centrally somewhere in the NHS, a bit like NICE and the guidelines, or are they local team care bundles?
Well, it's interesting. It varies because of course if you draw anything up in the NHS, it has to go centrally anyway, if it's going to be used. Um, there's a very set pattern when you, you write a care bundle. So, you know, the first thing to do is to identify the theme of whatever the bundle is. And, um, very often care bundles emerge when there has been, um, something very good. That's a good outcome, and it's acknowledged that perhaps the way things worked
were very good. Or alternatively sometimes it can be because there's a deficit. So, so somebody noticed, I, you know, the classic thing in veterinary medicine, you know, is that you've got suddenly you have a run of lines that blow or the lines that get infected. And so maybe it's worth sort of starting to think about what's our practice. Are we doing things the very best way we can, or we sent five dogs home with an IV still in the leg, you know,
I nearly said arm then, but in their leg. So, it's that sort of thing, you know, identifying the care theme and then thinking about all the evidence that's associated with that, sort of challenging that evidence, making sure it's very high quality and then emerging with basically of interventions that are related to that theme.
And it's an interesting point because what you do need to make sure is that, this wouldn't work if it was done very remotely and very centrally, and then just disseminated through. The people who are going to be doing interventions need to be involved.
It needs to be a real multidisciplinary input because everybody needs to be on board with this, even down to, you know, people who you might perceive to not be clinical, because if you're putting a care bundle together, for example, for an emergency procedure, so if you want to put a care bundle together for how you would, you know, assess something that comes through the door, that's choking or that you think is a GDV or something
along those lines. If you engage with your reception staff as well, you know, they're the ones if you're going to have a vet or a nurse, who's going to rush through, take that dog and disappear off the back trying to save its life, it's your receptionist that's going to be left with the hysterical owner. And if they can say, look, these are the sorts of things they're going to do, they have got a process, you know, that that's really helpful.
And it can calm the owner down and it can start a very, kind of a good process so they can understand what's happening to their animal. So you're right. Everything in NHS has to go through, you know, the official channels, but these things must be done locally because otherwise people don't engage. It's got to be useful for whoever's using them.
I think that's such an important point for so many things in Quality Improvement - don't imagine how the work's done, you have to ask the people who do it.
Absolutely. Absolutely. And it leads to other things as well, because if you start, if you want to put a care bundle together and just like with the sepsis six, you know, just very subtle things like when you're stocking a ward or you're rearranging the cupboards, you make sure that the urinary catheters are next to the oxygen, that's next to the blood culture bottles,
because somebody is going to need them all at the same time. And, and actually it's probably not going to be the managers or the vets necessarily that think about that, because maybe they're not the ones that restock the shelves or, you know,
go and get these things. And so that's a very subtle thing, but it can make applying a care bundle very easy or much easier if everything's in the same place, rather than having to go upstairs for something else downstairs for something else and across the courtyard for another thing. Yeah that's, that's a really good idea. And, and it makes me laugh because most of us don't know where anything is! [Laughs]. I mean, you know, [Laughs] you know you can say that you're a vet, but I wouldn't...
Well, we do 'vet looking' when we're trying to find things! So yes, it's very good to have them altogether. But yeah, no, that's that's brilliant. So you think there's potential for there to be veterinary care bundles drawn up? I think so. I mean, I think, I think the reason that I see them as useful is because I remember as a student VN, you know, everyone's got something when they're a student that they really struggle with a
nd mine was always getting everything ready for an IV. And I mean, you know, obviously it got to the stage where I could have done it with one in each hand, you know, priming the line and getting everything ready. But for some reason it was just my absolute thing. You know,
when I was a student, I always forgot something. I brought the wrong stuff, or I couldn't quite work out which... and actually what I done was I'd written myself a checklist in my notebook, and these are the things I needed to get together. And obviously this is a very different sort of thing, preparing an IV, but it was the same concept, I suppose, when I saw these care bundles, because all of a sudden it was like, cause they are checklist format.
I'm the sort of person who responds very well to a checklist. I love a tick box. And actually as actually, probably quite often nurses do, all of a sudden it was in the ITU where I came across them because that's where I started my human practice.
If my patient's central line needed replacing, having that list of things in front of me that I knew needed preparing right down to the position I needed to put the patient in, to the drapes that were needed, and the kit were needed, meant that I could, I was empowered to do that by myself before I'd got, you know, an anaesthetist in the room. So my anaesthetist could walk in and my patient was ready, the kit
was ready and I was good to go. And I think that again, is relevant to veterinary nursing in many, many ways because there's lots of things that there's lots of preparation that goes on that veterinary nurses can do if they are empowered to do that.
And by having a care bundle empower them to do it, you know that they're not just doing what they've always done, they're doing something that has been decided by the team that is appropriate and evidence-based so it's, yes, I think there's a lot of potential. And I think the key thing is it doesn't have to be anything huge either. You know, these, there are care bundles out there that are kind of 15, 20 interventions long.
And actually there's a lot of conversation about those sorts of bundles being just too... they kind of dilute the importance, you know a care bundle can simply be three elements that are critical. And in fact, if you have a care bundle that the practice team has decided they're going to implement every time and it consists of three elements, then probably most nurses and staff members will remember that. And all of a sudden you've got some really excellent practice that is just ingrained.
The critical thing of course is to make sure that the evidence stays current and that you're reviewing them, and you're not just doing it because you've always done it that way. But it sounds like it could be really useful and powerful for saving time, which at the moment, yeah, one thing people haven't really got in practice this time, I think it could be really useful from that point of view. People are doing things, you know, almost as you say automatically, it could save quite a lot of time.
I'm really keen on clinical audit and I presume that it should be a relatively simple procedure to audit, in a process audit, the use of the, of the care bundles. Absolutely. I mean, they are an auditor's dream because, you know, if you do them online or you do them on paper, um, you know, there's a tick list. So it records the care you've given and equally what you can see is, is the care that isn't given. And again, this is about looking at it from, a broader kind of approach.
And th th the example I've used in articles about this is very, very basic, but very important care bundle, so a care bundle that can be put in place, for example, for the recovery of bitch spay post-anaesthetic. And, you know, one of the things that we talk about is obviously feeding animals
post-operatively. Lots of practices for various... both from patient points of view, so patient wellbeing, and from evidence, and also from business models, will use a standard food as part of that recovery protocol. And the classic thing is to, you audit your care bundle, and you find out that actually, um, the patients who were doing very well, they're getting all the clinical outcomes, but they're just not getting, they're being fed something else. And, you know,
veterinary practice is a business. So actually, if the practices decided that this food they want to feed post-operatively, a) is good quality, there's evidence to say it's good for patients postoperatively, but also it benefits the business in some way, because obviously there's partnerships and that kind of thing,
then it's a win-win. So if the practice is starting to lose money, because actually the nurses are using something else, suddenly you've got the evidence to start having a conversation saying, look, these dogs are not being fed what we think they're being fed. First of all, we've decided this is the food we want to feed them. And second of all, this is the agreement we've got, so what's happening.
And it's something usually very, very basic, like the ward nurses are busy and the food they want to feed is on the top shelf and the food they just 'think is all right so we'll just use that', is on the bottom shelf, you know, it's as basic and as simple as that. Or, oh well, they're easier to open, so I just grabbed those.
Or what happens is you have a robust, you know, you have these conversations and all the nurses say, do you know what, this food might be really good on the evidence and we might get a good deal on it, but I'm throwing away more than the animals are eating. And so auditing that care bundle is critical because actually, care bundles that are put in place that are not audited are a waste of time because you're just throwing food away for no good reason.
Your animals are not getting postoperative nutrition before they go home. And you're wasting resources. And if you carried on thinking, oh, we've got this fabulous care bundle in place, but don't audit it, actually, it's a waste of time because you just don't know what's happening until you look at it in detail. Um, and you know, I'm a big advocate for these things, these things are important, you know, what animals eat in practice, how they're exercised, how they toilet, you know,
that is nursing. Those details are absolutely critical. And the care bundle gives a voice for those things, if they're not working, you know, because the nurses can say this bundle is all very well, but you know, it's not quite right. Well, that's such a great example of clinical audit because it could be quite a nice short audit. It doesn't have to take very long.
You can get some nice practical results. I mean, when I used to think oh the important thing is collecting the data, but now I think the most important thing is discussing it with the team, finding out what the barriers are to what's happening, which you've just very eloquently described what the barriers might be. And in this particular case, getting the team to think about how to address those and then repeating it and
seeing if that's made any difference. So I think it's a lovely, simple little clinical audit, which, you know, at the end of the day will produce an improvement in your care, and in your care bundle. That's really interesting. Well, I do understand more now about what care bundles are, so that's absolutely great. And thank you so much for talking to me. You're very welcome. Thank you very much, indeed.
For further courses, examples and templates for quality improvement, please visit our Quality Improvement pages on our website at rcvsknowledge.org.