Understanding
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care
bundles
A care bundle is a set of interventions that,
when used together, significantly improve
patient outcomes. Multidisciplinary teams work
to deliver the best possible care supported by
evidence-based research and practices, with
the ultimate outcome of improving patient care.
We help you understand how bundles apply to
your practice.
By Kim McCarron, MS, CRNP
Clinical Associate Professor • Towson University • Towson, Md.
Editorial Advisory Board Member • Nursing made Incredibly Easy!
30 Nursing made Incredibly Easy! March/April 2011
Copyright © 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
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 sig-
nificant 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 ele-
ments 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.
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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 meth-
od to provide the best possible outcome for
your patient.
Now that you have the operational defini-
tion 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 in-
terventions to be developed as an outcome of
the Institute for Healthcare Improvement’s
100,000 Lives Campaign. The bundle was cre-
ated to prevent complications associated with
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Copyright © 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
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 inter-
ventions. 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 hold-
ing a sedative for the purpose of assessing
whether the patient can breathe indepen-
dently 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
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decreasing catheter-related bloodstream infec-
With bundles, tions. Annually, 80,000 bloodstream infections
occur from central catheter use, resulting in
the whole is
28,000 deaths among ICU patients.
greater than Using evidence-based procedures recom-
the sum of its mended by the CDC, the central line bundle
parts. comprises the following components:
• 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 fem-
oral vein
• removing unnecessary I.V. catheters.
Adopting these straightforward measures
resulted in a significant reduction in illness,
with a median infection rate that plummet-
ed to 0 after 3 months of implementing
bundle practices. The success of this initia-
tive spurred the development of bundles
worldwide.
The severe sepsis bundles were developed
by the Surviving Sepsis Campaign, an interna-
tional 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
Selected care cheat
bundles
sheet
• Ventilator bundle
• Central line bundle
• Severe sepsis bundles (sepsis resusci-
tation bundle and sepsis management
bundle)
• Methicillin-resistant Staphylococcus aureus
bundle
• Stroke and transient ischemic attack bundles
32 Nursing made Incredibly Easy! March/April 2011
Copyright © 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
• 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 mechani-
cally ventilated patients.
Using bundles to improve
practice
Providing nursing care to critically ill pa-
tients is a challenge that requires you to
be astute, competent, and compassionate.
Nursing skills that were introduced in a
fundamentals course provide the founda-
tion for practice, but elements of some
skills change as research discloses new in-
formation. 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 proce-
dure for intubated patients.
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You’re now using research-supported ele-
ments 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, car-
diovascular risk reduction, stroke manage-
ment, palliative care, antibiotic usage, and
geriatric care coordination. In your organiza-
tion, care bundles may be part of the stan-
dard 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 investi-
gated. 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 evi-
dence-based clinical practice guidelines.
After you’ve examined a variety of resourc-
es, the next step is to identify a cohort, or
group of patients. For example, if you’re estab-
lishing a care bundle focused on diabetes man-
agement, 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
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Copyright © 2011 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
each occasion of care
is challenging but Elements of a cheat
bundle
sheet
essential. Each and
every one of the • Interdisciplinary
interventions must be • Small set of practices
performed in the • Scientific
sequence recom- • Level 1 evidence
• All-or-nothing measurement
mended; elimination
• Improves patient outcomes
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 Each
modify the delivery system to make it easy to patient, each
deliver the bundle. Set realistic goals—initially component,
an 80% success rate while striving for a consis- each time is
tency of 95%. Expect the care bundle to evolve the name of the
over time. Establishing a care bundle isn’t a game.
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 inter-
ventions, each component is vital; the bundle
should be delivered on each occasion to every
patient meeting the bundle criteria. Multidis-
ciplinary teams work in unison to deliver the
best possible care supported by solid underly-
ing evidence, with the ultimate outcome of
improving patient care. ■
Learn more about it
Haraden C. What is a bundle? http://www.ihi.org/IHI/
Topics/CriticalCare/IntensiveCare/ImprovementStories/
WhatIsaBundle.htm.
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 interven-
tion 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. http://www.medscape.com/viewarticle/567786_4.
Surviving Sepsis Campaign. Severe sepsis bundles. http://
www.survivingsepsis.org/Bundles/Pages/default.aspx.
DOI-10.1097/01.NME.0000394024.85792.42
March/April 2011 Nursing made Incredibly Easy! 33