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Care Bundles for Perioperative Improvement


Key Points

  • Care bundles provide a means of grouping a small number of evidence-based components together for a defined patient group or setting of care to facilitate a desired and improved outcome.

  • The processes, when grouped into a bundle, should have a synergistic impact compared with individual use.

  • The processes in the care bundle should be delivered regularly and highly reliably.

  • An effective bundle should have all or no responses (e.g., in the central line insertion bundle, the answer to the question “Was the patient appropriately draped?” can only be yes or no).

  • For effective implementation of a care bundle to occur, teamwork and communication are central, and culture change may be necessary.

  • Care bundles are not the same as “bundled care”; the latter term is applied in the United States to care management and associated funding across the continuum of care for a defined procedure, such as a total joint replacement.

Background

The concept of a care bundle was developed in 2001 by the Institute of Healthcare Improvement (IHI) to improve management and decrease harm in intensive care unit (ICU) patients who were on ventilators. This bundle is now well recognized as the “care of the ventilated patient” bundle. The central line bundle was also developed as part of the same project, “Idealized Design of the Intensive Care Unit,” in which the two topic areas (ventilators and central lines) were chosen because they were recognized to have high rates of patient harm and to have clear evidence-based practices, which if applied reliably, could lead to improved outcomes. The need to group key processes together to lead to better outcomes than would occur if the processes were delivered singly was recognized during the IHI ICU project. Teams were required to work together to create solutions that would facilitate reliable delivery of all components of the bundle.

In addition to the central line bundle and the care of the ventilated patient bundle, another application of care bundles familiar to perioperative clinicians is found in the “Surviving Sepsis” campaign. Increasing bundle compliance in the Surviving Sepsis campaign has been associated with decreasing mortality. Short, clear, and concise bundles are easier to implement, and the Surviving Sepsis bundle approach has evolved from two bundles to a simpler 1-hour bundle. Evolution and adaption of a bundle over time as new evidence emerges should occur because bundles form only one part of an improvement approach, which must include measurement and behavioral change.

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