CARE

BUNDLES

By
Dr. YASSER I. FATHI, MBBS, MSC, MD

CHIEF OF ICU, CONSULTANT

ANESTHESIA
KING SAUD HOSPITAL, UNAIZAH
Principles of Care

What are the “Care Bundles”

Importance of Care Bundles

Background of Care Bundles

Types of Care Bundles

 Healthcare workers are committed to deliver
high standards of care to all patients
 Standards of care are generally defined by

evidence based guidelines, e.g. infection control

guidelines e.g

 SARI guidelines (Ireland)

 CDC guidelines (USA)
 EPIC/NICE guidelines (UK)
At least 35-50% of all healthcare-associated
infections are associated with only 5 patient care
practices:

 Use and care of urinary catheters.

 Use and care of vascular access lines.
 Therapy and support of pulmonary functions.
 Surveillance of surgical procedures.
 Hand hygiene and standard précautions.
Sax H, et al, J Hosp Infect, 2007;67:9-21
A care bundle is a collection of interventions
(usually 3-5) that are evidence based, approved
to improve the patient outcome.
 All clinical staff know that these interventions are

best practice but frequently their application in

routine care is inconsistent.
 A care bundle is a means to ensure that the

application of all interventions is consistent for all

patients at all times thereby improving outcomes.
 Bundle compliance can easily be measured as

done or not done: “All – or – None”.

 Methodology to spread the use of generally
accepted science
 Provide a “pressure” for teamwork
 Simple, memorable checklist
 Audit tool
 All aspects should be done to get the maximum

benefit
 To ensure ALL patients receive the best care or
treatment, based on evidence, ALL the Time.

 To improve delivery of clinical care to achieve

better outcomes. E.g. Prevent avoidable
morbidity, reduce length of stay.

 To reduce unwarranted clinical variation.

 To make it easier for clinicians to bring guidelines

into practice and thus improve the outcome.
Background to Care Bundles
 Dr.Peter Pronovost is accredited
with developing the first Care
Bundle-insertion and management
of CVC’S.
 Intensivist in a hospital in Michigan.
 Developed a checklist for insertion
and management of CVC’s to
ensure that key interventions
recommended by the CDC, 2002
guidelines were implemented every
time a CVC was inserted.
Pronovost. New Engl J Med 2006;355:27-25
Interventions:
1. Hand hygiene. K-ICU CLBSI Prevention
2. Max. barrier precautions Project
during insertion. 3.5
3. CHG antiseptic on All
3
insertion site. 2.5 Teach
4. Avoid femoral C. Lines. 2
5. Remove C. Lines when 1.5 Non
Teach
not needed. 1
<200
0.5
Results : B
0 >200
66% reduction in Central Before After B
Line Blood stream
Infections (CLBSI)
Pronovost P, et al. NEJM 2006;355:2725-32.
 Michigan Hospital Association.
 127 intensive care units (ICUs) in Michigan and five

other states.
 68 ICUs totally eliminated CVC-BSIs.
 For 6 months, they eliminated VAP.
 Estimates that they saved >1,578 lives, reduced

81,000 hospital days, and saved $165 million.

 Hospitals in Rhode Island, New Jersey and

Maryland replicated the Keystone Project.

Pronovost P. et al NEJM 2006;355:2725-32
 WHO Surgery Safety Checklist.
 Urinary Catheter Care Bundle.
 Clostridium Difficile Care Bundle.
 Ventilator Assisted Pneumonia Care Bundle.
 Palliative Care Bundle.
 Pressure Area Care Bundle.
 Sepsis Care Bundle.
 PVC Care Bundle.
Surgery
Safety
Bundle
NEJM 2009;360:491-9
Central
Venous
Catheter
Bundle
Insertion Maintenance Removal
 Central venous catheters (CVCs) disrupt
the integrity of the skin, making infection
with bacteria and/or fungi possible.
 Infection may spread to the bloodstream
and hemodynamic changes and organ
dysfunction (severe sepsis) may ensue.
 Approximately 90% of the catheter-related
bloodstream infections (BSIs) occur with
CVCs.
Maki DG. Infections due to infusion therapy. In: Hospital
Infections, Third Edition, Bennett JV, Brachman PS (eds),
Little, Brown, Boston 1992.
 Hand hygiene
 Decontaminate hands before and after each patient contact
 Use correct hand hygiene procedure
 Maximal Barrier Precautions
 Single use gloves
 Eye/face protection
 Aseptic technique
 Sterile gown, gloves, mask and full body drape.
 Chlorhexidine Skin Antisepsis (2% Chlorhexidine
Gluconate in 70% Isopropyl Alcohol)
 Catheter
 Optimal catheter site selection, with subclavian vein as
the preferred site for non-tunnelled catheters
 Single lumen unless indicated otherwise
 Central Line Insertion Checklist -Adults
Operator:________________________________________Date:_______________________
RN Assisting:____________________________________ Room/Location:______________
Safety Pause:
 Correct Patient  Correct Procedure
 Correct Site  Verbal agreement from all members of the team.
In order to eliminate central line associated blood stream infections, we will be following the
Central Line Insertion Procedure Checklist based on CDC Guidelines.
Prior to the Procedure:
1. Hand Hygiene done with Chlorhexidine Gluconate (CHG) 2% surgical hand scrub and water or waterless
alcohol based gel before patient contact and before donning sterile gloves.
YES
2. Cleanse Site with 2% CHG with sponge 1.5mL.
YES
3. Disinfect Site with a back and forth friction scrub, utilizing 2% CHG wand 10.5mL for 30 seconds and
allow to dry completely before catheter insertion.
YES
4. Maximum Barriers Did the operator wear:
YES Cap/Bouffant
YES Mask
YES Sterile Gown
YES Sterile Gloves
YES Patient draped with full body sterile sheet.
During the procedure:
5. YES Operator(s) maintained the sterile field.
6. YES Personnel assisting wore a cap, mask and donned gloves appropriately.
After the procedure:
6. Sterile dressing applied immediately by the operator.
YES

QUALITY IMPROVEMENT
THIS FORM IS NOT PART OF THE PATIENT'S PERMANENT RECORD.
Please return the form to your Nurse Manager. If a step has was not followed, please note and
the Nurse Manager will follow up with the physician.
 Hand hygiene
 Decontaminate hands before and after each patient contact.
 Use correct hand hygiene procedure.
 Catheter site inspection
 Regular observation for signs of infection ie. leakage,
inflammation, ... etc – AT LEAST DAILY.
 Dressing
 A sterile, transparent, semi-permeable dressing should be in
place.
 Ensure dressing is intact and dry.
 Catheter access
 Aseptic technique swabbing ports/hubs with 2%
Chlorhexedine prior to access.
 Daily review of line necessity with prompt removal of
unnecessary lines.
Ventilator
Bundle
 HOB elevation.
 Appropriate DVT prophylaxis.
 Appropriate PUD prophylaxis.
 Appropriate sedation.
 Assessment of readiness to extubate.
 HOB elevated greater than 30 degrees.
 Reduces frequency and risk of nosocomial
pneumonia.
 Simple, no-cost intervention.
 Incidence of aspirations reduced 30%.
 Ventilator and ICU LOS are reduced.
 Thromboprophylaxis effective in preventing DVT.
 Multiple methods of thromboprophylaxis

 Unfractionated heparin
 Low Molecular Wt. Heparin.
 Intermittent Pneumatic Compression.
 Graduated elastic Stockings.
 Baseline incidence of DVT at 30%.
 Reduces risk of upper GI bleeding.
 Risk increased in:
Mechanical ventilation greater than 48 hours.
Coagulopathy.
 No specific therapy.
 Daily interruption decreases ventilator and ICU
LOS:
 Vent LOS reduced by 33%
 ICU LOS reduced by 35 %
 Hold sedation daily (Sedation vacation) until
patient can be weaned.
 Reduce vent LOS, complications, and ICU costs:
 Daily screening of respiratory function
 Spontaneous breathing trials
 Vent LOS reduced by 1.5 days.
 Reduced self extubation, reintubation, prolonged
mechanical ventilation.
Urinary
Catheter
Bundle
 Catheter Associated Urinary Tract Infection (CAUTI) is
the second leading cause of device-related
bacteraemia. They increase the risk of UTI by:

 Enabling organisms to gain entry to the bladder - via

external surface or opened connection.
 Reducing the body defence of flushing out organisms

during micturition.
 The organisms causing CAUTI, can be endogenous

from the patient's own gut flora, or cross-transmitted

through poor infection control practices.
 Perform a daily review of the need for the urinary catheter.
 Check the catheter has been continuously connected to the
drainage system.
 Ensure patients are aware of their role in preventing urinary
tract infection. (Alternative bundle criterion if the patient is
unable to be made aware: Perform routine daily meatal
hygiene).
 Regularly empty urinary drainage bag as a separate
procedure, each into a clean container.
 Perform hand hygiene, gloves and apron prior to each
catheter care procedure; on procedure completion, remove
gloves and apron and perform hand hygiene again.
 Insert only for specific reasons:
 Urinary output in critical ill.
 Bladder outlet obstruction or neurogenic
bladder dysfunction.
 Prevent contamination of sacral wounds.
 Terminal care.
 Competent HCW to insert.
 Aseptic technique.
 Closed system with bag below bladder.
 Review need for catheter daily.
 Empty when ¾ full and use clean container for
each patient.
 Secure catheter to leg/abdomen.
 Urine samples from sampling port only.
 Hand hygiene before and after any catheter care.
 r e
th ca
e a l
g h
k i n f e r
M a s a

ry
 Centres for Disease Control and Prevention
(2002). Guidelines for the prevention of
intravascular catheter-related infections. MMWR
Mortality and Morbidity Weekly Report 2002, vol
51, (No RR10), pp 1-26.
 Health Information Quality Authority (2009).
National Standards for the Prevention and Control
of Healthcare Associated Infections.
 Health Protection Surveillance Centre. (2009).
SARI Prevention of Intra- Vascular related
Catheter Infections in Ireland.
 Pittet, D. (2005). Infection control and quality
health care in the new millennium. American
Journal of Infection Control, vol 33, pp 258-67.
 An Intervention to Decrease Catheter-Related
Bloodstream Infections in the ICU
 Peter Pronovost et al. N Engl J Med 2006;
355:2725-2732 December 28, 2006.
 Institute for Healthcare Improvement website for
infection prevention bundles:
www.IHI.orghttp://www.ihi.org/IHI/Topics/CriticalCare/
IntensiveCare/Changes/
ImplementtheVentilatorBundle.htm and
http://www.ihi.org/IHI/Topics/CriticalCare/IntensiveCar
e/Changes/ImplementtheCentralLineBundle.htm and
http://www.ihi.org/IHI/Programs/AudioAndWebProgra
ms/ExpeditionReducingCatheterAssociatedUrinaryTr
actInfections.htm
 Health Protection Scotland Bundle site 2009
http://www.hps.scot.nhs.uk/haiic/ic/guidelines.aspx#b
undles
 HOME MESSAGE

Care Bundles are collections of

best practices or processes
based on level 1 or 2 evidence
(Standard of Care).

Individual Bundle improves

care, but when applied together
result in substantially greater
improvement.
 HOME MESSAGE

Use of Care Bundles can

save lives, time and money.