Health Services Research & Development

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Research Highlight

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.

  1. 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.
  2. 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.
  3. 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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