الفهرس 
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Abstract
Summary
Care bundles have been around for almost 30 years. The bundles were employed in a wide variety of medical and surgical fields, in which cardiology was the most common. Care bundles are the most common form of standardizing patient care that can lead to a high quality of care for frequent admission diagnoses. Gastrointestinal (GI) bleeding is still a prevalent and potentially fatal emergency problem that encounters the critically ill patients. Despite the advances in medical knowledge and nursing care, acute GI bleeding accounts for a considerable proportion of intensive care unit (ICU) patients.
Multiple guidelines have been established to define standards of care in acute upper gastrointestinal bleeding and improve patient outcomes. Critical care nurses play anessential role in the implementation of the standards of care through recognizing the importance of early and timely management as rapid resuscitation and early endoscopy are associated with better outcomes. The British society of gastroenterology emphasized ongoing differences in practice and inadequate management of patients with acute upper GIT haemorrhage. That is why, major initiatives such as the acute upper GI bleeding bundle are still required to address these differences and improve patients’ clinical outcomes. Therefore, the aim of this study is to determine the outcomes of implementing a care bundle for the early management of patients with acute upper gastrointestinal bleeding.
Materials &Method
A quasi-experimental research design was used to determine the outcomes of implementing a care bundle for the early management of patients with acute upper gastrointestinal bleeding. This study was performed in the hematemesis intensive care unit of Alexandria University Main Hospital. The bed capacity in the hematemesis intensive care unit is 5 beds.
A convenience sample of 60 newly admitted adult patients with acute upper gastrointestinal bleeding were included in this study.Patients were assigned into two equal groups (30 patients each); group “A” (control group) was subjected to the unit routine care, whilegroup “B” (study group) was subjected to the acute upper GIT bleeding bundle of care.“Assessment of Upper Gastrointestinal Bleeding Bundle Implementation Outcomes” is the tool used to collect the data of this study. This tool consists of four parts;Patient’s demographic and clinical data, National early warning score (NEWS), modified Glasgow Blatchford Score (GBS) and patient’s clinical outcomes respectively.
Data were collected from 60 patients by the researcher over approximately a period of five consecutive months (starting from August 2021 till December 2021). Data was collected from group “A” (control group) first then from group “B” (study group)to avoid the double Hawthorne effect.
The interventions for the study group were conducted in three phases:
Phase I: Patients’ Assessment
Patients in both control and study groups were assessed from ICU admission till transfer to the ward using (tool I). each patient was reassessed three times daily at the beginning of each of the morning, the evening, and the night shift till transfer to the ward. Patient’s demographic data was recorded such as age, gender, level of education, and clinical data namely; date of admission, diagnosis, medications, past medical/ surgical history, APACHE II score, vital signs, level of consciousness using Glasgow coma scale and fluid balance. Furthermore, lab investigation samples were taken to assess hemoglobin, Platelets count, Serum blood urea, Serum Creatinine (S. Cr) and International normalized ratio (INR)
Phase II: Upper GIT bleeding bundle implementation
The upper gastrointestinal bleeding bundle was applied to the study group according to six domains which are recognizing bleeding through reporting/recording the presence of hematemesis, melena, or coffee ground vomiting from newly admitted patients, providing fluid resuscitation, using Modified Glasgow Blatchford Score (GBS) for risk stratification of patients with acute upper GIT bleeding, Administering treatment in collaboration with physician, Nothing per mouth and starting gastric lavage for performance of endoscopy after patient stabilization.
Phase III: Bundle Evaluation
Both groups were assessed for clinical outcomes as Perfusion (through measuring the mean arterial pressure, urinary output per hour, and level of consciousness), mortality rate, length of ICU stay, blood transfusion requirements, incidence of rebleeding and the use of balloon tamponade
Results
The current study shows that more than half of the patients in the study groups were males (60%, and 53.3%) respectively. Their mean age were47.7± 9.7 and 47.8± 9.4 respectively.
Concerning health-related data.It was noticed that less than half of the studied patients chief complain on admission was hematemesis (46.7%, 43.3%) respectively. It was also observed that more than half of the patients in the control group (60%) had non variceal bleeding origin compared to two thirds in the study group (66.6%).
The median number of packed RBCs needed for the control group was 2 compared to 1 for the study group and a statistical significance difference was found between the two groups (P= 0.015).
there was a statistical significant difference between the study and control groups in the first, second, and third day readings of MAP (p= 0.001, <0.001 and 0.013) respectively. Moreover, within the same group, it can be noted that there was a statistical significance differences in MAPwhen comparing from admission to fourth day for the control and the study groups (p= 0.002 and p= <0.01) respectively.
a statistical significant difference between the study and control groups was observed in the first, second, and third day of GCS readings (p= <0.001, 0.008 and 0.03) respectively. Also, it was noted that level of consciousness reached normal level for the study group from the first day to the fourth.
Time waiting until doing endoscopy was less for the study group (57.6±16.2 hours) compared to the control group (42.8±10.3 hours) with significant difference between both groups.Mortality rate, incidence of rebleeding and length of stay was higher in the control group compared to the study group with no statistical significant difference.
Conclusion
from the present study it could be concluded that the implementation of a care bundle for upper GIT bleeding patients can lead to improvement of their management and outcomes.
Recommendations
the following recommendations are suggested:
• Encourage nurses to attend workshops about upper GIT bleeding bundle to clarify their further role in collaboration with other health team members.
• Implement quality improvement strategies to enhance appropriate use of risk assessment scales of upper GIT bleeding patients.
• Develop policies to simplify the charting and documentation system for surveillance and management of upper GIT bleeding.
• Assess barriers for implementation of upper GIT bleeding bundle in intensive care units.
• Apply this study on larger sample size from different health care organization ICUs.