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Understanding care bundles

McCarron, Kim MS, CRNP

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Nursing Made Incredibly Easy!: March 2011 - Volume 9 - Issue 2 - p 30-33
doi: 10.1097/01.NME.0000394024.85792.42
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The crux of the term bundle is that the whole is more than the sum of its parts. You may have heard this buzzword and wondered: What exactly is a care bundle?

Conceived by a group of intensive care practitioners in a quest to improve outcomes in care for ventilated patients, the concept of care bundles was developed. Simply put, a care bundle is a set of three to five evidence-based practices—interventions supported by research—that when used together cause significant improvement in patient outcomes. The interventions or components that make up the bundle must be grounded in solid research and, most importantly, all of the elements of the bundle must be performed in a series of steps by one healthcare team within the same time frame to ensure that clinical improvement occurs. A step in the process must not be eliminated or else the intended effect will be altered.

The care bundle is an ongoing process that's repeated daily until the patient no longer requires an invasive device or his or her status has improved. The steps of the care bundle are carefully selected, well-established practices that are packaged together and scientifically supported. The focus of the bundle is on how to deliver the best care using a clear-cut method to provide the best possible outcome for your patient.

Now that you have the operational definition of a care bundle, let's discuss it in practical terms and explore how the care bundle applies to your clinical practice.

Types of bundles

The ventilator bundle was the first set of interventions to be developed as an outcome of the Institute for Healthcare Improvement's 100,000 Lives Campaign. The bundle was created to prevent complications associated with mechanical ventilation, specifically ventilator-associated pneumonia (VAP). This hospital-acquired pulmonary infection develops more than 48 hours following intubation and may be prevented or delayed using specific interventions. The ventilator bundle comprises four core components:

  • administering deep vein prophylaxis
  • administering medications to prevent gastric ulceration
  • elevating the head of the bed between 30 and 45 degrees
  • providing a daily sedation vacation or holding a sedative for the purpose of assessing whether the patient can breathe independently of the ventilator.

These combined steps have been effective in reducing the incidence of VAP and decreasing the length of stay in a critical care unit. After improvements were seen using the ventilator bundle, researchers directed their attention to decreasing catheter-related bloodstream infections. Annually, 80,000 bloodstream infections occur from central catheter use, resulting in 28,000 deaths among ICU patients.

Using evidence-based procedures recommended by the CDC, the central line bundle comprises the following components:

With bundles, the whole is greater than the sum of its parts.
  • practicing meticulous hand hygiene
  • using full barrier precautions during central line insertion
  • applying chlorhexidine to the patient's skin as a cleansing agent
  • avoiding central line insertion into the femoral vein
  • removing unnecessary I.V. catheters.

Adopting these straightforward measures resulted in a significant reduction in illness, with a median infection rate that plummeted to 0 after 3 months of implementing bundle practices. The success of this initiative spurred the development of bundles worldwide.

The severe sepsis bundles were developed by the Surviving Sepsis Campaign, an international forum convened to examine the effect of sepsis, severe sepsis, and septic shock. The two bundles are the sepsis resuscitation bundle and the sepsis management bundle.

The resuscitation bundle is a set of evidence-based interventions delivered within 6 hours of recognition of severe sepsis, a window of opportunity in which aggressive treatment is warranted. These interventions include:

  • obtaining blood cultures
  • administering a broad-spectrum antibiotic
  • measuring serum lactate levels or arterial blood gases with correction of metabolic acidosis
  • inserting a urinary catheter to monitor fluid balance
  • treating hypotension with fluid challenges and vasopressors if needed.

The sepsis management bundle consists of interventions that must be performed within 24 hours of the diagnosis of severe sepsis or septic shock. These interventions include:

  • administering low-dose steroids for septic shock, in accordance with a standardized ICU policy
  • administering recombinant human activated protein C, in accordance with a standardized ICU policy
  • maintaining a glucose control lower limit of normal, but below 180 mg/dL (10 mmol/L)
  • maintaining a median inspiratory plateau pressure of less than 30 cm H2O for mechanically ventilated patients.

Using bundles to improve practice

Providing nursing care to critically ill patients is a challenge that requires you to be astute, competent, and compassionate. Nursing skills that were introduced in a fundamentals course provide the foundation for practice, but elements of some skills change as research discloses new information. So you may notice that your practice is evolving in an evidence-based manner as you adopt new ways to care for your patients.

For instance, you're now paying careful attention to serum glucose level trends and using targeted treatment to achieve specific goals. Or you've changed the skin prep agent used for central line placement because research points to its favorable effect on microbe removal. A decade ago it wasn't common practice to lighten up on sedation to determine if patients could breathe on their own, but now it's a recommended daily procedure for intubated patients.

You're now using research-supported elements of care to guide patient management with the goal of improving quality of care.

Developing a bundle

Since the inception of the care bundle, the concept has expanded beyond the ICU to involve many facets of healthcare delivery. Bundling has been applied to skin care, cardiovascular risk reduction, stroke management, palliative care, antibiotic usage, and geriatric care coordination. In your organization, care bundles may be part of the standard of practice or you may be considering developing a bundle.

After you've chosen an issue of concern, peruse the scientific literature, glean research from random control trials, review clinical practice guidelines, and consult experts on the topic to establish the core elements needed to construct a set of three to five evidence-based interventions.

The literature search is a time-consuming yet rewarding process. It's important to use peer-reviewed journals and databases that will yield information on the topic being investigated. The Cumulative Index to Nursing and Allied Health Literature and the U.S. National Library of Medicine (PubMed) will direct you to peer-reviewed journals. The Cochrane Library provides systematic reviews using a statistical method called meta-analysis, which combines research evidence that can be applied to larger populations. And the National Guideline Clearinghouse is a U.S. government resource to obtain current evidence-based clinical practice guidelines.

After you've examined a variety of resources, the next step is to identify a cohort, or group of patients. For example, if you're establishing a care bundle focused on diabetes management, patients with diabetes who have peripheral neuropathy and will benefit from the interventions would be a cohort. After choosing a patient cohort, the next step is to build consensus for use of a bundle among care providers. Motivating care providers to unfailingly deliver the set of interventions on each occasion of care is challenging but essential. Each and every one of the interventions must be performed in the sequence recommended; elimination of a step negates the positive outcome intended by using the bundle.

Work with quality improvement experts to develop a system to measure compliance, then modify the delivery system to make it easy to deliver the bundle. Set realistic goals—initially an 80% success rate while striving for a consistency of 95%. Expect the care bundle to evolve over time. Establishing a care bundle isn't a static process, but one that changes as new evidence is revealed or organizational needs change.

Each step, every time

In summary, a care bundle is an explicit tool with clear parameters. As a package of interventions, each component is vital; the bundle should be delivered on each occasion to every patient meeting the bundle criteria. Multidisciplinary teams work in unison to deliver the best possible care supported by solid underlying evidence, with the ultimate outcome of improving patient care.

Each patient, each component, each time is the name of the game.

cheat sheet

Selected care bundles

  • Ventilator bundle
  • Central line bundle
  • Severe sepsis bundles (sepsis resuscitation bundle and sepsis management bundle)
  • Methicillin-resistant Staphylococcus aureus bundle
  • Stroke and transient ischemic attack bundles

cheat sheet

Elements of a bundle

  • Interdisciplinary
  • Small set of practices
  • Scientific
  • Level 1 evidence
  • All-or-nothing measurement
  • Improves patient outcomes

Learn more about it

Haraden C. What is a bundle?
    Krein SL, Kowalski CP, Damschroder L, Forman J, Kaufman SR, Saint S. Preventing ventilator-associated pneumonia in the United States: a multicenter mixed-methods study. Infect Control Hosp Epidemiol. 2008;29(10):933–940.
      Pronovost P, Needham D, Berenholtz S, et al. An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med. 2006;355(26):2725–2732.
        Dontje, Katherine J. Evidence-based practice: understanding the process: implementing evidence-based practice: The Iowa Model.
          Surviving Sepsis Campaign. Severe sepsis bundles.
            © 2011 Lippincott Williams & Wilkins, Inc.