Marjon Borgert

111 Implementation of care bundles in ICUs INTRODUCTION Because of the aging population the number of patients with chronic illnesses and comorbidities increases. 1 More complex medical care is needed for these patients when admitted to hospitals 1 of which the critically ill are admitted to the intensive care units (ICUs). To provide comprehensive care according to the best available evidence and to decrease the variation in daily care, clinical guidelines and protocols are developed. 2 Despite the e orts made in implementation, the adherence to guidelines and protocols is often poor 3 , which negatively in uences the quality of care. 3,4 In order to encourage the adherence to clinical guidelines and to improve care processes, the Institute for Healthcare Improvement (IHI) has developed the concept of ‘care bundles’. 4-6 Initially, care bundles were introduced to reorganize the structure and organization of care processes within the ICU departments. For example, the central line bundle was developed to reduce bloodstream infections. 5,7 Care bundles are designed around speci c elements of patient care and consist of three to ve key interventions, the so called ‘elements’. 4 These elements are either evidence based or are already generally accepted in ICUs and in national guidelines. The strength of a care bundle is that all elements must be performed in every eligible patient, unless medically contraindicated, using the all-or-none (AON) approach. 4-6,8 The bundled approach has already proven to be e ective in improving clinical outcomes. 7,9,10 In accordance with the model of Donabedian, high levels of bundle compliance should be achieved to improve clinical outcomes. 11 For instance, Resar et al. have shown that ICUs with the highest levels of bundle compliance had the highest rate of infection reduction. 12 Pronovost et al. demonstrated that the implementation of the central line bundle resulted in a large reduction in infection rates (up to 66%) during the study period of 18 months. 9 Positive results can be obtained when improving the reliability of care processes to ensure patients receive all evidence-based interventions needed. This also includes the improvement of the organizational culture, i.e. the context in which care is delivered. 13 The IHI recommends achieving more than 95% reliability. 4 Care bundles formed part of multiple patient safety initiatives in hospitals and ICUs worldwide and are nowadays widely accepted on ICUs. Various strategies were described in the literature to encourage the implementation of care bundles on ICUs. 14,15 Single strategies as well as multifaceted approaches, e.g. the combination of at least two strategies, were commonly used. 9,16 It is not known which strategies were used to implement care bundles nor which ones are the most e ective. Therefore, we conducted a systematic review to determine the strategies