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Care or practice "bundles," defined as a set of evidence-based practices that when
implemented together result in better
outcomes, have become a mainstay for improving
health care quality and safety since
the concept was first introduced by the Institute
for Healthcare Improvement (IHI)
in 2001. 1 Bundles for improving the care
of patients being mechanically ventilated
and with central lines soon led to a focus
on sepsis, prevention of catheter-associated
urinary tract infection (CAUTI), falls, and
pressure ulcers, as well as a host of other
outcomes. Indeed, some of these bundles
have been a key component in successful
care improvement initiatives both inside
and outside the Department of Veterans
Affairs (VA) healthcare system.
A recent example involving the implementation
of care bundles in VA hospitals
includes a virtual breakthrough series collaborative,
led by the VA National Center
for Patient Safety, which focused on reducing
CAUTI and hospital-acquired pressure
ulcers.2 The CAUTI breakthrough initiative
used a bundle that was based on prior
work by a VA research team 3 and had been
implemented at one VA medical center
as well as regionally. This single site and
regional work also informed a large-scale
program that led to a significant decrease
in CAUTI rates in a cohort of more than
600 hospitals across the United States.
Results for sites participating in the VA
CAUTI prevention breakthrough collaborative
were also positive, with a decrease in
the mean CAUTI rate from 2.37 in the prework
phase to 1.06 per 1,000 catheter days
during the implementation phase. In contrast,
there was no change in the CAUTI
rate for non-participating sites during the
same timeframe.
The pressure ulcer program focused on
implementing a previously established
VA skin bundle. As with the CAUTI
prevention program, researchers found a
notable decrease (1.80 to .99) in hospitalacquired
pressure ulcers among those sites
participating in the VA pressure ulcer
collaborative.
Bundle Implementation: The Critical Role
of Nurses
With these efforts, however, the bundle
was only part of the program and what
may not be immediately obvious is the
critical role played by nurses in bundle
implementation and the improvement
process. In addition to nurses often leading
the improvement teams, many of the
bundle practices focused on nursing activities
(e.g., patient repositioning for pressure
ulcer prevention) or required nursing
engagement (e.g., routine review and assessment
of ongoing urinary catheter need
to promote timely removal and prevent
CAUTI). That is not to say that collaboration
amongst clinical care providers is
not necessary. Rather, bundles, by design,
highlight the unique and important roles of
all members of the care team and, particularly
in the inpatient setting, bundles can
emphasize the contribution of nursing and
the importance of teamwork for optimizing
patient care and outcomes.
While some clinical care providers
may now suffer from what might be
characterized as "bundle fatigue," the
principles behind the bundle, as originally
conceptualized, remain a useful strategy
for enhancing nursing practice, reinforcing
the importance of nurses as part of the
healthcare team, and promoting safer
and more effective patient care. These
principles include: 1) developing and using
a bundle to ensure that a core set of care
practices, as determined by evidence and
clinician agreement, are being reliably
delivered; and 2) fostering communication
and improving teamwork by involving
care team members and individuals
from multiple disciplines in bundle
development.1 Bundles can, therefore,
prove beneficial in making sure everyone is
working together and providing care from
the same evidence base.
In sum, nurses not only can and should
consider care bundles as an important
strategy for enhancing and ensuring effective
care delivery, but also nurses can and
should play a role in identifying, testing,
and developing the components of these
practice bundles. While not all care activities
or outcomes may fit with a bundled
approach, for those that do, nurses can
be instrumental in using this strategy for
improving care and patient outcomes
throughout VA.
- Resar R, Griffin FA, Haraden C, Nolan TW. "Using
Care Bundles to Improve Health Care Quality." IHI
Innovation Series white paper. Cambridge, Massachusetts:
Institute for Healthcare Improvement, 2012.
- Zubkoff L, et al. "Preventing Two Hospital-Acquired
Conditions in the VHA Using a Virtual Breakthrough
Series," The Joint Commission Journal on Quality and
Patient Safety 2016; 42(11):485-96.
- Saint S, et al. "Translating Hospital-Associated Urinary
Tract Infection Prevention Research into Practice
via the Bladder Bundle," The Joint Commission
Journal on Quality and Patient Safety 2009; 25:449-55.
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