Abstract
BackgroundCare bundles are small sets of evidence-based recommendations, designed to support the implementation of evidence-based best clinical practice. However, there is variation in the design and implementation of care bundles, which may impact on the fidelity of delivery and subsequently their clinical effectiveness.MethodsA scoping review was carried out using the Arksey and O’Malley framework to identify the literature reporting on the design, implementation and evaluation of care bundles. The Embase, CINAHL, Cochrane and Ovid MEDLINE databases were searched for manuscripts published between 2001 and November 2017; hand-searching of references and citations was also undertaken. Data were initially assessed using a quality assessment tool, the Downs and Black checklist, prior to further analysis and narrative synthesis. Implementation strategies were classified using the Expert Recommendations for Implementing Change (ERIC) criteria.ResultsTwenty-eight thousand six hundred ninety-two publications were screened and 348 articles retrieved in full text. Ninety-nine peer-reviewed quantitative publications were included for data extraction. These consisted of one randomised crossover trial, one randomised cluster trial, one case-control study, 20 prospective cohort studies and 76 non-parallel cohort studies. Twenty-three percent of studies were classified as poor based on Downs and Black checklist, and reporting of implementation strategies lacked structure.Negative associations were found between the number of elements in a bundle and compliance (Spearman’s rho = − 0.47, non-parallel cohort and − 0.65, prospective cohort studies), and between the complexity of elements and compliance (p < 0.001, chi-squared = 23.05). Implementation strategies associated with improved compliance included evaluative and iterative approaches, development of stakeholder relationships and education and training strategies.ConclusionCare bundles with a small number of simple elements have better compliance rates. Standardised reporting of implementation strategies may help to implement care bundles into clinical practice with high fidelity.Trial RegistrationThis review was registered on the PROSPERO database: CRD 42015029963 in December 2015.
Highlights
Care bundles are small sets of evidence-based recommendations, designed to support the implementation of evidence-based best clinical practice
The literature on care bundle implementation and evaluation includes a substantial number of low-quality studies, which means that all findings should be interpreted cautiously
There is a large literature on care bundle implementation in the acute care setting
Summary
Care bundles are small sets of evidence-based recommendations, designed to support the implementation of evidence-based best clinical practice. Evidence-based medicine can be defined as a systematic approach to clinical problem solving which allows the integration of best available research evidence with clinical expertise and patient values [1]. The effective implementation of evidence in clinical practice still presents many challenges to healthcare professionals, illustrated by the vast number of guidelines that are published each year [2]. One mechanism that can support the distillation of this evidence into a more usable and practical form is through the development and implementation of ‘care bundles’. A bundle was defined as ‘A small set of evidence-based interventions for a defined patient segment/population and care setting that, when implemented together, will result in significantly better outcomes than when implemented individually’. The guidelines for the design of each bundle were comprehensive, stating that bundles should only contain three to five interventions with the strong clinical agreement so that implementation would not lead to time lost debating over their validity
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