INTRODUCTION:

The Government directives is that those who are working in critical care area they ensure whatever they are practicing it should be an evidence based practices.¹ Now a day health care professional were given more emphasizes to use the existing research evidence rather than the generation of new research evidence. There are many ways to introduce evidence into a practice setting, for example, through the development of evidence-based protocols or care pathways.

The National Health Service (NHS 2003a) Agency has prepared toolbox for improvement of health care i.e. ‘Care Bundle’. Ventilator care bundle it is new context which are using in intensive care units (ICUs) ².

Care bundle were first developed over 20 years ago. It is the set of interventions that, when used together, significantly improve patient outcomes. It was used in different medical and surgical specialties special used in cardiology unit is more common.³ The main important of care bundle is that a grouping of several evidence –based practices. When it is used in combination or as cluster it will gave better and positive outcome of the patients.³

The concept of ‘care bundles’ was developed by Institute for health care improvement in North America to describe a collection of interventions needed to effectively and safely care for patients.⁴

In a parallel development, the World Alliance for Patient Safety launched ‘a global patient safety challenge’ by testing the feasibility of using a surgical safety checklist to reduce operative complications.⁴ It aimed to reinforce established safety practices and to foster better communication and teamwork among clinical disciplines.⁵ The care bundle approach is concerned with all these aspects of clinical practice and collaboration, and it is beginning to gain credence as an approach to effective, safe practice; for instance, the Joanna Briggs Institute in Australia has also recently engaged with care bundle development.⁶

The care bundle foundation work was carried out at Johns Hopkins University. Its concept was identified initially in US and introduced into the UK in 2002.

After critically analysed of 35years (1965-2000) of critical care literature of evidence of interventions that could be prevent avoidable morbidity and mortality in intensive care unit (ICU). It was only six evidence based interventions were identified after their rigorous assessment of the quality of research would improve intensive care outcome and six evidence based interventions were effective assessment of pain , appropriate use of blood transfusions , prevention of ventilator –associated pneumonia, appropriate sedation, appropriate peptic ulcer disease prophylaxis and appropriate deep vein thrombosis prophylaxis. Latter four of these interventions have been clustered together to form the ventilator care bundle.⁷ The ventilator care bundle was most advanced and most widely used. There are number of care bundle under development.

This is based on four of the six process components identified originally by Berenholtz et al. (2002):

• Deep vein thrombosis (DVT) prophylaxis

• Gastric ulceration prophylaxis

• Head of bed elevation (>30°)

• Sedation holds (sedation vacation)

These four components are all based on strong evidence. In the UK, some additional components have also been suggested. Because the care bundle is a new concept, there are currently few to choose from. (In fact, a literature search by the authors of CINAHL and Med Line, using the search term ‘care bundle’, did not produce a single journal article.) However, there is no reason that new care bundles cannot be developed. There are examples, a care bundle could be developed around management of acute head injury, clustering together evidence-based practices such as intracranial and cerebral perfusion pressure management, patient positioning and respiratory management. Another example might be a ‘prevention of infection’ care bundle wherein evidence based practices such as hand washing, use of skin disinfectants and catheter/cannula dressings might be stipulated. There are many potential care bundles that could be developed within the critical care setting.⁷

DEVELOPING A NEW CARE BUNDLE

If health professional want to develop new care bundle these are process for it they were as followed

1. Identify a critical care theme

2. Identify a cluster of interventions/practices within the theme

3. Undertake literature searches, related to each of the interventions/practices, to identify all relevant research

4. Extract the research literature

5. Categorise the available research according to its quality

6. Delete any interventions/practices from your list that do not have an adequate evidence-base to refer to

7. On the basis of analysed research evidence, develop evidence-based interventions/practice.

INTRODUCING A CARE BUNDLE INTO CLINICAL PRACTICE

There are so much evidence based research done but the implementation of the care bundle into practices is to very difficulty. The reason for this is limited numbers of staffs; workload is more, resistance to change, they are happy with old practices. This is the small step-change methodology, using (for example) plan-do-study-act (PDSA) cycles, to introduce care bundles into practice.

The importance of a whole team approach to clinical improvement work is worth emphasizing. Once a decision has been taken to introduce a care bundle into a unit, as well as clinical staff involvement, there should be open discussion at both the all members of the group and the unit management team.⁷

Before implementing a care bundle in clinical practice, a planned programme of staff education should take place. If everyone is aware of the development, the projected time plan and the benefits to patients, the transition is likely to proceed smoothly. Adequate time should be provided for this to take place as it can often be difficult to ensure that all staff are involved, taking into account time restrictions, unit activity, professional priorities and unforseen circumstances. It is far better to allow too much time, than to commence ill-prepared and jeopardize the success of the project.⁷

The government has placed great emphasis on delivering a quality service at all levels of the health service. At a clinical level, this is equated with evidence-based practice. However, it has long been recognized that there is a gap between research findings and the introduction of these into clinical practice. Care bundles are a tool that can be used to narrow this gap, contribute to the clinical governance agenda and meet the recommendation in Comprehensive Critical Care (Department of Health, 2000) that the health service should develop a data collecting culture that promotes evidence-base practice.⁸

A care bundle is a tool that is easy to use and relatively easy to audit because the components in care bundles have been developed from a strong evidence base, which indicates potential to improve patient outcomes.

Care bundles in obstetrics:

Now a days in the UK, care bundles have previously been developed in the areas of critical care nursing, infection control and preventative antibiotics for surgery.⁹They have formed a large part of the work of the Health Foundation’s Safer Patients Initiative. Obstetric care bundles within the UK have not yet been widely implemented. This joint NPSA/RCOG/RCM project is therefore pioneering within the field of obstetrics and midwifery.

The aim of introducing care bundles into this area is to achieve an improvement in outcomes, as:

· Since 1995, 61% of all negligence payments related to claims arising out of birth.⁹

· The total cost of Clinical Negligence Scheme for Trusts maternity claims in 2007/08 was £163 million¹³

· Cerebral palsy claims accounted for 66% of these payments (and stillbirths 2%).⁹

Royal College of Obstetricians and Gynecologist and Royal College of Midwives National Patient Safety Agency established three subgroups: the evidence criteria group to define the criteria for acceptable evidence for the development of the two care bundles and two expert groups to develop the electronic fetal monitoring (EFM) and placenta praevia after previous lower section caesarean segment (placenta praevia) care bundles. This approach was particularly helpful for the placenta praevia care bundle. The NPSA therefore developed a partnership with the RCOG and the RCM to address ways in which the patient safety agenda in maternity services could be strengthened. This included the development and testing of two intrapartum care bundles building on the principles developed by the Institute for Healthcare Improvement. These would be for the care of:

· Women for whom electronic fetal monitoring is clinically indicated

· Women with placenta praevia and a previous caesarean section.

In maternity care is very much important to develop care bundles. The group has developed templates to allow others to develop more care bundles in the future. The methodology for piloting and testing is robust, which will make it easier to produce successful care bundles in the future. This is a good beginning in the area of care bundles, which can make a significant difference to the safety of women and their babies in the years to come^.9

Care bundles are one strategy to increase integration of research evidence into clinical practice and facilitate healthcare providers to deliver optimal patient care in busy environments with limited resources. Care bundles are appropriate and feasible for use in emergency care in low resource environments. Care bundles can be used to guide evidence-based emergency nursing care.¹⁰ The construction of a care bundle approach to create a simple checklist that would guide nurses in the right direction to provide quality nursing care. This would standardize and streamline care, removing the margin for potential human error when nurses are working under increasing pressure. This is an area that has enormous potential for further research.¹¹

REFERENCES:

1. Institute for Healthcare Improvement. Bundle up for safety. www.ihi.org/IHI/Topics/CriticalCare/IntensiveCare /Improvement Stories/Bundle Up for Safety.

2. NHS Modernisation Agency (2003a). What New. Available at: http://www.modern.nhs.uk/scripts/default. Accessed 6 October 2003.

3. Paul Fallbrook and Sharon Mooney, Care bundles in critical care: A practical approach of evidence based practices. Care bundles in critical care: a practical approach to evidence-based practice Care bundles in critical care: a practical approach to evidence-based practice Nursing in Critical Care 2003: Volume 8 and No.6

4. World Health Organization. Surgical Safety Checklist. Geneva: WHO; 2009 [www.who.int/patientsafety/ safesurgery/en/.

5. World Health Organization. Background to Safe Surgery Saves Lives [www.who.int/patientsafety/safesurgery/issue/en/index.html

6. Joanna Briggs Institute. JBI COnNECT [www.jbiconnect.org].

7. Berenholtz SM, Dorman T, Ngo K, Provonost PJ. (2002). Qualitative review of intensive care unit quality indicators. Journal of Critical Care; 17: 12–15.

8. Benner PE. (1984). From Novice to Expert: Excellence and Power in Clinical Nursing Practice. London: Addison-Wesley.

9. Higgins J. CNST Maternity Standards launch seminar. NHS Litigation Authority [www.nhsla.com/)

10. Jintana Damkliang abJulie Considine. Bridie Kent Maryann: Nurses' perceptions of using an evidence-based care bundle for initial emergency nursing management of patients with severe traumatic brain injury: A qualitative study: International Emergency Nursing Volume 23, Issue 4, October 2015, Pages 299-305.

11. Martin Kiernan, Fiona Downie; Prevention of pressure ulcers: could a care bundle approach be a success? Wounds uk, 2011, Vol 7, No 1page no 157 to 158.

Received on 22.02.2020 Modified on 25.03.2020

Int. J. of Advances in Nur. Management. 2020; 8(3):257-259.

DOI: 10.5958/2454-2652.2020.00056.6