Why Care Bundles Work
What do central line-associated bloodstream infections, ventilator-associated events, catheter-associated UTIs, surgical site infections, and hospital-acquired C. diff all have in common? They are all healthcare-associated infections or HAIs.
Healthcare-associated infections are a primary source of illness and death among hospitalized patients. Roughly 15% of patients obtain an infection while hospitalized, accounting for 1.7 million infections and 99,000 deaths each year (Septimus & Moody, 2016). HAIs are now the fifth leading cause of death in U.S. acute care hospitals (Magill, Edwards, Bamberg, Beldavs, Dumyati, Kainer, et al., 2014). The use of care bundles to prevent HAIs has become increasingly popular over the past decade.
Gathering the Evidence
As new research becomes available, the evidence must be transferred to the bedside for it to become effective. Most often, groups of professionals or professional organizations rigorously evaluate the evidence, and, if deemed substantial, they translate the recommendations to a best practice. A care bundle is a compilation of these evidence-based practices that have been shown to independently improve patient care and clinical outcomes.
Creating a Bundle
There are many reasons why a patient may contract a healthcare-associated infection. As an example, let’s examine a catheter-associated urinary tract infection or CAUTI. Nearly 70% of CAUTIs are preventable and each episode costs at least $896 (Septimus & Moody, 2016). If you are caring for a patient who has been diagnosed with a CAUTI, it is critical that your team identifies potential root causes.
Ask yourselves, “Do staff have poor hand hygiene compliance? Are there dependent loops in the tubing? How is catheter care being performed? Do staff empty the collection bag prior to transport? Is there still an indication that the catheter should remain in place?”
As you can see, there are MANY reasons why a UTI may have developed. In order to tackle this multifaceted issue, we must create a multifaceted approach. This particular HAI has abundant evidence to support practice changes in reducing, if not eliminating, CAUTIs.
After reviewing the evidence, it can then be categorized. For CAUTIs, we have three categories of best practices: insertion, maintenance, and removal.
Using the Bundle
Bundle elements have been identified, now it’s time to examine the structures and processes currently in place and identify any gaps that would prevent successful application. Do we have the right equipment? Are the physicians on board with this plan? Can we enhance our insertion trays to include evidence-based supplies?
Once everything is in place, the three-pronged bundle (covering insertion, maintenance, and removal) is now ready for use. The application of each bundle component is crucial to avoid an infection. Washing your hands and performing good catheter care is futile if the tubing has dependent loops allowing urine to freely flow back into the bladder. To be successful, all components must be diligently applied by each team member, every time.
Answering Two Common Questions
Q. These care bundles often come with extra supplies that I end up throwing away. Why so wasteful?
A. Question why those supplies are available to you. Likely, it’s not a matter of too many supplies, it’s often a lack of education on how and when to use the supplies. Seek clarification about the presumed waste with your unit leaders to see if you can come to a better understanding. Disseminate your findings among your team to enhance the adoption of best practices.
Q. How effective can these bundles be? I’ve been practicing this way all my career and haven’t caused an HAI so far; why change now?
A. Change can be difficult, especially when you don’t understand why the change is occurring. Multiple studies have demonstrated tremendous success in reducing patient harm by utilizing a bundled care approach:
- Central line-associated bloodstream infections decreased significantly from a median 6.4 per 1000 catheter days to 2.5 per 1000 catheter days after implementation of bundles (Ista, van der Hoven, Kornelisse, van der Starre, Vos, Boersma, et al., 2016)
- The use of an evidence-based, surgical care bundle in patients undergoing colorectal surgery significantly reduced the risk of surgical site infections, or SSIs (Tanner, Padley, Assadian, Leaper, Kiernan, & Edmiston, 2015)
- Increased adherence to resuscitation and management of sepsis bundles showed reduced mortality in patients with sepsis, severe sepsis, or septic shock (Damiani, Donati, Serafini, Rinaldi, Adrario, Pelaia, et al., 2015)
Care bundles enhance clinical outcomes through consistent use of reliable interventions that define a standard of care. As professional nurses, we are charged to “do no harm” to those in our care. Applying evidence-based care in the form of bundles allows clinicians to adequately and efficiently deliver safe patient care. As the body of evidence regarding infection control and other patient care issues continues to grow, you can expect to see an increase in the application of care bundles in clinical practice (Plume & van Weijen, 2014).
Damiani, E., Donati, A., Serafini, G., Rinaldi, L., Adrario, E., Pelaia, P., Busani S., & Girardis, M. (2015). Effect of performance improvement programs on compliance with sepsis bundles and mortality: a systematic review and meta-analysis of observational studies. PloS one, 10(5), e0125827.
Ista, E., van der Hoven, B., Kornelisse, R. F., van der Starre, C., Vos, M. C., Boersma, E., & Helder, O. K. (2016). Effectiveness of insertion and maintenance bundles to prevent central-line-associated bloodstream infections in critically ill patients of all ages: a systematic review and meta-analysis. The Lancet Infectious Diseases.
Magill, S. S., Edwards, J. R., Bamberg, W., Beldavs, Z. G., Dumyati, G., Kainer, M. A., ... & Ray, S. M. (2014). Multistate point-prevalence survey of health care–associated infections. New England Journal of Medicine,370(13), 1198-1208.
Plume, A., & van Weijen, D. Publish or perish? The rise of the fractional author…–Originally published on the Elsevier newsletter “Research Trends Issue 38”.
Septimus, E. J., & Moody, J. (2016). Prevention of Device-Related Healthcare-Associated Infections. F1000Research, 5.
Tanner, J., Padley, W., Assadian, O., Leaper, D., Kiernan, M., & Edmiston, C. (2015). Do surgical care bundles reduce the risk of surgical site infections in patients undergoing colorectal surgery? A systematic review and cohort meta-analysis of 8,515 patients. Surgery, 158(1), 66-77.