Fighting Device-related Infections With the Bundled Care Approach

Nearly a decade has passed since the publication of Dr. Atul Gawande’s The Checklist Manifesto: How to Get Things Right, the nonfiction book arguing healthcare providers should dutifully follow written steps. It wasn’t a completely novel idea, but Gawande was a persuasive advocate. The amount of data increased as greater numbers of practitioners incorporated checklists, making a powerful case for the benefits of rigorous consistency.

Of course, the checklist isn’t the sole tool for improving patient safety. There are other ways to facilitate standardization and continuity of care, such as a care bundle, a group of three to five evidence-based practices or interventions that when grouped together lead to a better outcome than if performed individually. A bundle collects all of the components needed for specific processes into a single package.

“While it resembles a list, a bundle is more than that. A bundle has specific elements that make it unique,” says patient safety expert Carol Haraden, Ph.D, vice president of the Institute for Healthcare Improvement. “Because some elements of a checklist are nice to do but not required, there may be no effect on the patient when they are not completed. When a bundle element is missed, the patient is at much greater risk for serious complications,” Haraden explains.

Cheryl Herbert

In particular, bundles are well-suited to one of the most significant concerns in any healthcare facility: the reduction of infections. The bundled care approach began in the early 2000s, when infection prevention specialists determined providers needed to improve patient safety measures, according to Cheryl Herbert, MSN, RN, CIC, service line director for medical, skin and wound care supply chain management at Irving, Texas-based CHRISTUS Health.

Education in infection prevention was already widely offered, but some part of the process was getting lost as staff went on to care for actual patients. Predictability and standardization were lacking, which meant missed steps.

“Ensuring the same level of care for every patient has definitely shown benefits,” Herbert notes. “When you can hardwire processes of care, you will see an improvement in the data.”

The bundled care approach has been especially effective in reducing rates for catheter-associated urinary tract infections (CAUTI) and central line-associated bloodstream infections (CLABSI). A care bundle for preventing CLABSI might involve the following steps: using proper hygiene and sterile contact barriers; properly cleaning the patient’s skin; finding the best location possible for the central line; checking every day for infection; and removing or changing the line only when needed. By putting everything necessary for best practice patient care at the providers’ fingertips, hospitals and other facilities have an easy way to achieve the desired consistency.

“They may know the steps, but the kits will reinforce the steps,” Herbert explains. “It gives you a different opportunity to ensure you can apply the components of that kit in the proper order and as appropriate to the use. From when you wash your hands and put gloves on to when you change gloves and clean the patient’s skin—the kit will guide you in the right direction through each important step.”

Angie Mitchell. RN

Professional organizations and regulatory agencies—such as the Centers for Disease Control and Prevention (CDC)—offer guidelines that help determine the specific products and steps included in the bundle. According to Angie Mitchell, RN, former AVP of physician services at HealthTrust, the CDC cites specific clinical literature in making their recommendations, so users don’t need to worry about the objectivity of the study being impacted by manufacturers who may have footed the bill.

“That’s the type of science HealthTrust looks for when we consider putting any supplier products on contract,” Mitchell says. “And it’s what our members look at before they implement the use of a protocol, bundle or toolkit, or the use of a product that supports a particular toolkit or bundle.”

When a healthcare facility adopts one of these care bundles or toolkits, there’s an education piece that’s needed, too. Training on the use and importance of the bundle should be built into new staff orientation, communicated thoroughly and then reinforced through ongoing efforts. Proper, consistent use of the bundle becomes a core clinical competency.

“These processes have to start from administration down,” Herbert says. “When you’re supported at the executive level and the importance of this kind of work is understood, then there’s a greater chance that a particular facility will have improved patient outcomes.”

Supply chain is another critical touchpoint of institutional support. “We’re starting to see in the medical literature how value analysis and improved patient outcomes are positively impacted by smart supply chain management,” Herbert explains. “When supply chain leaders understand clinical needs and partner with physicians and clinicians to make decisions about products and care bundle kits, it adds a fantastic dimension to the whole world of healthcare.”

The use of bundles also shifts some of the burden of staying clinically up to date from healthcare professionals to the manufacturers providing the kits. Manufacturers have a vested interest in making sure their bundles adhere to the latest recommendations established by regulatory and professional associations.

As appealing as all of these efficiencies and other operational benefits might be, there’s a bottom line argument that’s even more compelling: Bundles provide consistency and consistency is better for patients.

“To make certain that you safeguard the patient, you want that process standardized,” Mitchell says. “So if I’m a nurse on the fifth floor, I want to be using the same protocol as colleagues of mine on the seventh or ninth floor.”


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