Identification of factors that support successful implementation of care bundles in the acute medical setting: a qualitative study

Stuart A Green,Derek Bell,Nicholas Mays

doi:10.1186/s12913-017-2070-1

Abstract

BackgroundClinical guidelines offer an accessible synthesis of the best evidence of effectiveness of interventions, providing recommendations and standards for clinical practice. Many guidelines are relevant to the diagnosis and management of the acutely unwell patient during the first 24–48 h of admission. Care bundles are comprised of a small number of evidence-based interventions that when implemented together aim to achieve better outcomes than when implemented individually. Care bundles that are explicitly developed from guidelines to provide a set of related evidence-based actions have been shown to improve the care of many conditions in emergency, acute and critical care settings. This study aimed to review the implementation of two distinct care bundles in the acute medical setting and identify the factors that supported successful implementation.MethodsTwo initiatives that had used a systematic approach to quality improvement to successfully implement care bundles within the acute medical setting were selected as case studies. Contemporaneous data generated during the initiatives included the review reports, review minutes and audio recordings of the review meetings at different time points. Data were subject to deductive analysis using three domains of the Consolidated Framework for Implementation Research to identify factors that were important in the implementation of the care bundles.ResultsSeveral factors were identified that directly influenced the implementation of the care bundles. Firstly, the availability of resources to support initiatives, which included training to develop quality improvement skills within the team and building capacity within the organisation more generally. Secondly, the perceived sustainability of changes by stakeholders influenced the embedding new care processes into existing clinical systems, maximising their chance of being sustained. Thirdly, senior leadership support was seen as critical not just in supporting implementation but also in sustaining longer-term changes brought about by the initiative. Lastly, practitioner incentives were identified as potential levers to engage junior doctors, a crucial part of the acute medical work force and essential to the initiatives, as there is currently little recognition or reward for involvementConclusionsThe factors identified have been shown to be supportive in the successful implementation of care bundles as a mechanism for implementing clinical guidelines. Addressing these factors at a practitioner and organisational level, alongside the use of a systematic quality improvement approach, should increase the likelihood that care bundles will be implemented successfully to deliver evidence based changes in the acute medical setting.

Highlights

Clinical guidelines offer an accessible synthesis of the best evidence of effectiveness of interventions, providing recommendations and standards for clinical practice
The development and implementation of care bundles has been shown to be an effective way of delivering evidence-based care, often based on clinical guidelines, especially within the emergency, acute and critical care settings [3]
Care bundles have been developed for ventilator-acquired pneumonia, myocardial infarction, sepsis and many other conditions [4,5,6]

Summary

Introduction

Clinical guidelines offer an accessible synthesis of the best evidence of effectiveness of interventions, providing recommendations and standards for clinical practice. Clinical guidelines have been defined as “systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances” [1]. They are a well-established mechanism for translating research knowledge into guidance to ensure that patients receive care based on the best available evidence by providing recommendations for care processes to reduce unnecessary variations in clinical outcomes [2]. The development and implementation of care bundles has been shown to be an effective way of delivering evidence-based care, often based on clinical guidelines, especially within the emergency, acute and critical care settings [3]. The ‘care bundle’ approach focuses on specific care processes delivered by individual healthcare professionals and provides a flexible method to adapt and contextualise evidence locally within a healthcare organisation; for example, if services are not available or referral processes differ between organisations bundles can be modified to fit local needs and available resources [8]

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