The Intensive Care Unit Bundle Board: A Novel Real-Time Data Visualization Tool to Improve Maintenance Care for Invasive Catheters

Abstract

Background: Critically ill patients are at greater risk of healthcare-associated infections (HAIs). The use of maintenance bundles helps to reduce this risk but also generates a rapid accumulation of complex data that is difficult to aggregate and subsequently act upon.

Objectives: We hypothesized that a digital display summarizing nursing documentation of invasive catheters (including central venous access devices, arterial catheters, and urinary catheters) would improve invasive device maintenance care and documentation. Our secondary objectives were to see if this summary would reduce the duration of problematic conditions, that is, characteristics associated with increased risk of infection.

Methods: We developed and implemented a data visualization tool called the "Bundle Board" to display nursing observations on invasive devices. The intervention was studied in a 28-bed medical intensive care unit (MICU). The Bundle Board was piloted for 6 weeks in June 2022 and followed by a comparison phase, where one MICU had Bundle Board access and another MICU at the same center did not. We retrospectively applied tile color coding logic to prior nursing documentation from 2021 until the pilot phase to facilitate comparison pre- and post-Bundle Board release.

Results: After adjusting for time, other quality improvement efforts, and nursing shift, multiple linear regression demonstrated a statistically significant improvement in the completion of catheter care and documentation during the pilot phase (p < 0.0001) and comparison phase (p = 0.002). The median duration of documented problematic conditions was significantly reduced during the pilot phase (p < 0.0001) and in the MICU with the Bundle Board (comparison phase, p = 0.027).

Conclusion: We successfully developed a data visualization tool that changed ICU provider behavior, resulting in increased completion and documentation of maintenance care and reduced duration of problematic conditions for invasive catheters in MICU patients.

Fig. 1

ICU Bundle Board displays. ( A ) The ICU Bundle Board is a display screen with three columns: each patient's room and initials in one column, central lines in the second column, and “other lines, drains, and tubes” (e.g., urinary and arterial catheters) in a third column. Each invasive catheter is represented as a tile on the Bundle Board. The tiles are coded as one of four colors (red, yellow, green, or blue) based on flowsheet documentation for each catheter. ( B ) When tiles are clicked, more information about the invasive catheter will display in a pop-up window.

Fig. 2

Tile color changes relative to nursing documentation. ( A ) In this example, a nontunneled hemodialysis and infusion power injectable catheter is appearing as a red tile. The default information display is that the catheter needs attention because there is drainage noted at the catheter dressing and that the patient's chlorhexidine gluconate (CHG) bath is overdue. Additionally, the patient is lacking documentation for the dressing status and site assessment. ( B ) In this example, the patient receives their CHG bath and has a dressing change. However, the nurse has forgotten to document a required observation: that on the site assessment, the site is “clean.” Therefore, the tile now appears yellow. ( C ) The nurse then observes that the tile is yellow. They then document that the site is clean. The tile updates to a green color. Clicking on the green tile will display all completed and documented care. (Data present in the figure are imaginary).

Fig. 3

Distribution of tiles across study periods. The x -axis shows the tile distributions of a particular week; we specify phase of the study at the top of ( A and B ) (pre-BB, pilot, without BB, with BB.) Pre-BB = Year prior to Bundle Board Pilot. BB Pilot = 6-week period of Bundle Board pilot. Without BB = MICU that did not have access to Bundle Board data. With BB = MICU that did have access to Bundle Board data. The y -axis shows the distribution of tile colors for invasive catheters as a percentage. Tile colors can only be red, yellow, or green and thus add to 100%. The percentage of invasive catheters with complete care and documentation with no problematic conditions is shown in green. Yellow corresponds to the percentage of catheters with incomplete documentation. Red is the percentage of catheters with a concerning feature documented. ( A ) The tile distribution trends over time in the year before the Bundle Board Pilot, as well as the 6-week Pilot, starting in June 2022. Postlaunch completion of care and documentation increased significantly compared to pre-launch (8.9% increase; CI: 6.6–11.1; p  < 0.0001). ( B ) The comparison in tile distribution for invasive catheters between MICUs with and without access to the Bundle Board. Comparison phase lasted 6 weeks. The MICU with access to the Bundle Board had a significant increase in catheter care completion and documentation compared to the MICU without access (8.0% increase; CI: 4.0–12.0; p  = 0.0001).

Fig. 4

Grouped summary of median duration of problematic conditions across study periods. The y -axis shows the median duration in hours of problematic conditions (as shown on the Bundle Board by red tiles.) Before the launch of the Bundle Board (Pre-BB), the median duration of problematic conditions for invasive catheters (on a grouped level) was 12 hours (IQR: 7,22.5). During the pilot (BB Pilot), the median duration was significantly lower (median 7.7 hours, IQR: 4.5, 13, Wilcoxon's rank sum test p  < 0.0001). During the comparison phase, the median duration of red conditions remained lower for the MICU with Bundle Board access (median 7.5 hours, IQR: 4.7, 10.9). The MICU without the Bundle Board returned to prelaunch durations, with a similar duration of problematic conditions to that of pre-BB periods, with a median duration of 11 hours (IQR: 6, 12.9). The difference in durations during the comparison phase was statistically significant (Wilcoxon's rank sum test p  = 0.027).