What Are the Pros and Cons of Using Bundles to Prevent Infection in the ICU?

Ruth M. Kleinpell, PhD, RN, FAAN, FCCM

Disclosures

March 11, 2009

Question

I have seen many references to "bundles" lately. What are bundles, and how can they be used to prevent infection in the ICU setting?

Response From the Expert

Ruth M. Kleinpell, PhD, RN, FAAN, FCCM
Professor, Rush University College of Nursing, Chicago, Illinois; Nurse Practitioner, Our Lady of the Resurrection Medical Center, Chicago, Illinois

"Bundles" have emerged as frameworks for addressing clinical healthcare conditions with evidence-based practices. A bundle is a set of interventions (usually 3 to 5), when grouped and implemented together, promote best outcomes with a greater impact than if performed individually.[1,2] Care bundles aim to ensure that patients receive recommended treatments on a consistent basis.[3] The Institute for Healthcare Improvement (IHI) is one of the main drivers of the bundle concept. It is recommended that when planning bundle-based care, each aspect be well defined and based on evidence from at least 1 systematic review of multiple well-designed randomized controlled trials (RCT) or on data from at least 1 well-designed RCT.[4]

The IHI has developed a series of bundles, including a ventilator bundle for prevention of ventilator-associated pneumonia, bundles for the prevention of surgical site and catheter-associated central line infections, and a bundle for sepsis care. Other bundles offered by national or international groups and institutions relate to different care processes, including the prevention of urinary tract infection, promotion of palliative care,[5] and prevention of pressure ulcers[6] to improve quality of care in the intensive care unit (ICU).

In the ICU, bundles can be implemented to target infection prevention including surgical site infections, central line catheter-associated infections, and urinary tract infections. Table 1 , Table 2 , and Table 3 outline the components of these 3 bundles.

To prevent central line catheter-associated infections, the bundle care recommendations include maximal barrier precautions upon insertion of the catheter, the use of chlorhexidine skin antisepsis, optimal catheter site selection with subclavian vein as the preferred site for non-tunneled catheters, hand hygiene measures before insertion, proper asepsis with catheter care, and daily review of line necessity with prompt removal of unnecessary central lines.

To prevent urinary tract infection, the bundle care recommendations include the use of sterile technique for catheter insertion, daily review of the need for continuing the indwelling catheter, daily catheter care hygiene measures, maintaining a sterile closed drainage system, securing the catheter to prevent migration, and maintaining the drainage bag below the level of the patient's bladder.

ICUs can create customized protocols to standardize the implementation of bundle care components. A primary benefit of bundle care is the structuring of care processes to promote consistency in the management of clinical conditions using evidence-based practices. Studies reporting the impact of implementing bundles to prevent central line infections and urinary tract infections have highlighted the importance of both a focused approach to implementation and periodic evaluation of adherence to the bundle components.[7,8] In addition, large collaborative groups, such as the Michigan Hospital Association Keystone ICU, the Voluntary Hospitals Association, and IHI's 5 Million Lives Campaign have demonstrated improved care and better patient outcomes following the implementation of bundles.[9]

Bundle Controversies

The bundle care concept is not without controversy. A number of different bundles exist, some targeting the same clinical condition. Differences in these bundles can lead to variability in bundle compliance rates and confusion when institutions attempt to benchmark performance.[9] In addition, while it is maintained that a bundle encompasses a series of "proven" practices, healthcare clinicians need to evaluate the evidence behind the bundle components. A scattering of clinical trial evidence exists for some of the components and the strength of evidence for each component varies.

Strategies for Promoting Bundle Care

Several strategies can be used to evaluate and implement bundle care in the ICU. These include forming a committee to review bundle care recommendations and compare them to current unit practices, generating a timeline for implementation, providing education and communication to unit staff regarding bundle care components, conducting audits to assess compliance with bundle care components, and regularly reporting the results back to unit staff. Aragon and Sole[10] also recommend that a multidisciplinary team approach be used to develop and implement bundle interventions.

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