Marjon Borgert

65 A flowchart for building evidence-based care bundles INTRODUCTION Guidelines are developed in order to standardize care processes to improve the quality of care. However, it is known that guidelines are often not followed completely and therefore patients do not receive the care they need. 1 In 2001, the Institute for Healthcare Improvement (IHI) developed the concept of care bundles. 2 Care bundles aim to enhance the reliability of care and to improve clinical outcomes by bundling a small set of interventions together. 2 The IHI de ned criteria for evidence-based care bundles. For example, care bundles consist of three to a maximum of ve evidence-based interventions, or so called ‘elements’, for a clinical process or patient population. The elements should be applied together in every eligible patient. The completion of an element could only be answered with ‘yes’ or ‘no’. Compliance should be measured by using the all-or-none approach. This means that the bundle should be counted as completed only in case all included bundle elements are performed. The strength of bundling a small set of elements is to ensure that evidence-based care will be uniformly applied together in every eligible patient so that patients receive reliable care. 2-4 Care bundles are widely applied tools in intensive care units (ICUs). They are frequently introduced as components of quality improvement initiatives. 5,6 The earliest developed care bundles, i.e. the central line bundle and ventilator bundle, are nowadays generally accepted in ICUs. 5 The e ectiveness of these bundles has led to the development of more care bundles for other care processes or patient populations, such as the sepsis care bundle 7 or the urinary tract infection bundle (UTI). 8 The IHI described the process on how they developed the central line bundle and ventilator bundle. 3,4 Their reports were descriptive in nature. They described the main steps of the bundle design process as well as the particular methods they have used within each process step. For instance, the rst step they described was to identify certain processes at risk for ICU patients or that contributed to great harm. 2-4 This was done by systematically reviewing the literature. 9 Throughout the bundle development process other methods were used by the IHI. However, the methods used by the IHI may not always be applicable to all ICUs and in every situation. For example, use of systemic reviews is not for all ICUs a useful method to identify risks when the results are not valid due to the heterogeneity of data or due to the low quality of the included studies. In the literature, other useful methods to design care bundles have been published as well, such as a Root Cause Analysis (RCA) to identify risks or the use of a weighing and scoring technique for selecting bundle elements. 10,11 We wanted to identify what methods were