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 Table of Contents  
Year : 2021  |  Volume : 23  |  Issue : 2  |  Page : 69-74

Care bundles: A boon to prevent health care-associated infections

1 A. J. Institute of Medical Sciences and Research Centre, Mangalore, Karnataka, India
2 A. J. Institute of Hospital Administration, Mangalore, Karnataka, India

Date of Submission20-Jun-2021
Date of Decision16-Jan-2021
Date of Acceptance13-Sep-2021
Date of Web Publication27-Jan-2022

Correspondence Address:
Dr. Roopa Bhandary
A. J. Institute of Medical Sciences and Research Centre, Mangalore, Karnataka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jacm.jacm_55_21

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INTRODUCTION: Health care-associated infection (HCAI) is one of the most common threats to patient safety and is associated with a significant mortality and morbidity. Evidence-based practices can be adopted to prevent HCAI. Care bundle is one of the prevention strategies designed to ensure uniform application of best practices to all patients.

  1. To study the impact of care bundles on device-associated infection
  2. To study the compliance in execution of the care bundles.

MATERIALS AND METHODS: A time series study was conducted in a 17-bedded medical intensive care unit (ICU). Care bundles were uniformly implemented in the ICU from January 2015. Surveillance and identification of HCAI were done on the basis of CDC guidelines. Statistical analysis was performed using the SPSS software version 2.0.
RESULTS: During the pre-implementation phase, the ventilator-associated pneumonia, catheter-associated urinary tract infection and central line-associated bloodstream infections rates were 9.57, 27.28 and 4.62/1000 device days which reduced to 1.51, 1.25 and 1.20/1000 device days, respectively, in the post-implementation phase. The compliance percentage for the execution of care bundles for central line, urinary catheter and ventilator improved, respectively, from 80%, 90% and 85% in 2016 to 85%, 97% and 92%, in 2017.
CONCLUSION: Care bundles can have a significant impact on health care-associated infections. However, to have a sustained impact on HCAI continuous training and monitoring is required.

Keywords: Care bundles, device-associated infections, health care-associated infections

How to cite this article:
Bhandary R, Marla A, Anita K B. Care bundles: A boon to prevent health care-associated infections. J Acad Clin Microbiol 2021;23:69-74

How to cite this URL:
Bhandary R, Marla A, Anita K B. Care bundles: A boon to prevent health care-associated infections. J Acad Clin Microbiol [serial online] 2021 [cited 2022 May 23];23:69-74. Available from: https://www.jacmjournal.org/text.asp?2021/23/2/69/336585

  Introduction Top

Health care-associated infection (HCAI) is one of the most common threats to patient safety and is associated with a significant mortality and morbidity.[1] Recent analysis by the WHO found that HCAIs are more frequent in resource-limited settings than in developed countries, with a prevalence rate between 5.7% and 19.1%.[2] Annually 12 million deaths are reported in low- and middle-income countries due to poor infection prevention and control protocols. One-thirds of these deaths can be prevented in health-care facilities by surveillance and implementation of evidence-based guidelines for the prevention of infections.[3],[4] HCAI can be prevented by adhering to easy, cost-effective evidence-based practices that can be incorporated in routine patient care.

The adverse events and the financial resources taken up by the device-associated infection (DAI) underscore the importance of prevention.[5],[6]

Institute for Health-care Improvement, USA, has developed the concept of bundle to help deliver bedside care more reliably and effectively. Care bundle is one of the prevention strategies designed to ensure the uniform application of best practices to all patients. A care bundle is a powerful tool for improving patient care and outcome.[7] The implementation of all the criteria in a care bundle can have a synergistic effect in the prevention of DAI.[8]

Various studies have evaluated the efficacy of bundles in the prevention of a single type of DAI. However, very few studies have evaluated the impact of these care bundles on all the DAI.

This study was undertaken to evaluate the rates of DAI overtime and to understand the impact of care bundles on DAI.

  Materials and Methods Top

Study design

A time series study.


This study was conducted in a 17-bedded Medical Intensive Care Unit (ICU) of tertiary care hospital.

The study period was divided into three phases

  • Pre-implementation phase
  • Implementation phase
  • Post-implementation phase.


During the pre-implementation phase (from… to…), the baseline DAI rates (CLABSI, CAUTI, and ventilator-associated pneumonia [VAP]) of the hospital were calculated as per the standard health care-associated infections surveillance guidelines laid down by Centre Disease Control (CDC) National Hospital Surveillance Network followed as the routine surveillance protocol of the hospital.

During the implementation phase, the care bundles for the prevention of DAIs were prepared as per the guideline (CDC, infusion nursing society, etc.,) and also after discussions with the stakeholders namely, intensivist and the nursing department.

A central line insertion policy was developed in January 2014. The ventilator bundle, central line insertion and maintenance bundle and daily catheter care bundle were introduced in July 2014. The use of these bundles was initiated in January 2015.

The concerned doctors and nurses of the ICU were trained about the different components of the care bundles and the importance of adhering to the care bundles.

During the post-implementation phase (from…. to…), regular audits on the maintenance and execution of the care bundles were carried out and regular trainings with regard to the non-compliances observed were given to the staff.

Components of the care bundles

Central line care bundle

  • Removal of non-essential catheters
  • Hand hygiene
  • Maximum barrier precautions during insertion
  • Skin antisepsis
  • Scrub the hub
  • Flushing of the line
  • Dressing change and labelling
  • Maintenance of closed system
  • Change of tubing and devices.

Urinary catheter maintenance bundle

  • Daily assessment for the need of urinary catheter
  • Maintenance of closed drainage system
  • Emptying the urosac bag when 3/4th full into a separate clean container
  • Metal hygiene
  • Hand hygiene
  • Observation/inspection of urine flow, urine clarity and patient discomfort.

Ventilator care bundle

  • Hand hygiene
  • Chlorhexidine mouth wash
  • Subglottic secretion drainage
  • Maintenance of closed suction system
  • Head end elevation 30°–45°
  • HME filter change
  • Cuff pressure monitoring 25–30 mm Hg
  • Sedation vacation and assessment of readiness to extubate
  • Peptic ulcer prophylaxis.

Study procedure

All patients admitted in the ICU were included in the study. Surveillance of DAI was done by the Infection Control Professional on the basis of CDC/National Nosocomial Health surveillance guidelines.

Definitions of device-associated infection

The diagnosis of DAI was based on the NHSN definition.

VAP was identified using a combination of radiology, clinical and laboratory criteria. VAP was considered present in patients on mechanical ventilation with chest X-ray showing a new or progressive infiltrate, consolidation, cavitation or pleural effusion. Clinical criteria included at least one of the following: New onset of purulent sputum, a change in character of sputum and isolation of a bacterial agent from tracheal aspirate/brushing or bronchoalveolar lavage.

CLABSI was defined as a laboratory confirmed infection in a patient with a central line in place for >48 h who had a recognized pathogen isolated from one or more percutaneous blood cultures and when the infection was not related to an infection at another site. Isolation of the same organism from a semiquantitative or quantitative culture of a catheter segment and from the blood of a patient with accompanying clinical symptoms of BSI (fever >38°C, chills or hypotension and no other apparent source of infection were required. For common skin contaminants including Diphtheroids, Bacillus spp, Propionibacterium spp, coagulase-negative Staphylococci, viridans group Streptococci, Aerococcus spp and Micrococcus spp, two or more blood cultures drawn on separate occasions were required to be positive.

CAUTI was defined in a patient with a urinary catheter in place exhibiting either one of the following two criteria: One or more of the following signs and symptoms with no other recognized cause: Fever (temperature >38°C), urgency, suprapubic tenderness and urine culture >105 CFU/ml, with no more than two species of microorganism isolated; or (2) positive dipstick analysis for leukocyte esterase or nitrate and pyuria (urine specimen with 10 white blood cells/mm3 or >3 white blood cells/high power field of unspun urine), microorganisms seen on Gram stain of unspun urine and a positive urine culture of >103 and <105 CFU/ml with no more than two species of microorganism isolated.

The incidence of CAUTI, VAP and CLABSI between the pre-implementation, implementation and post-implementation period was compared.

Calculation of device-associated infection rates

The calculation of device days was done based on daily prevalence measure as required by the NHSN. The DAI rates were calculated per 1000 device days.

Monitoring the compliance to implementation of care bundle

Compliance was defined as the number of ICU patients on a particular device for whom all the elements of the bundle were executed and documented.

Collection of data

The patients on a device were assessed for compliance with the bundle. If even one element was not adhered to it was considered as a non-compliance with the care bundle for that particular device.

Calculation of compliance rate

The compliance rate was calculated as follows.

The number of ICU patients on a particular device who receive all the elements of a bundle/total number of ICU patients on that device on the day of week of sample collection ×100.

Feedback to the stakeholders

Monthly feedback of the DAI rates and compliance to care bundles were sent to the respective ICU staff. Further necessary steps taken to improve the compliance to care bundles were discussed and appropriately executed.


Multiple training sessions on the care bundle practices for all the cadres of health-care workers (HCW). Care bundle display boards to improve the knowledge and practices of the staff. All non-compliant HCW were personally informed about their non-compliant status.

Statistical analysis

Data were analysed using the SPSS software version 17 (SPSS Inc. Released 2008. SPSS Statistics for Windows, Version 17.0. Chicago: SPSS Inc..). The comparison of pre- and post-intervention period was performed using the Chi-square test. t-test and P value was calculated for comparative analysis. P < 0.05 was considered statistically significant.

  Results Top

The VAP, CLABSI and CAUTI rates during the three phases were analysed for significance.

[Table 1] shows that there was a significant and highly significant reduction in the rates of CAUTI in the year 2016 and 2017, respectively, post-implementation of catheter maintenance bundle.
Table 1: Catheter-associated urinary tract infections

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[Table 2] depicts no significant changes in the catheter days of the year 2015, 2016 and 2017.
Table 2: Urinary catheter days

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[Table 3] shows that although there was a steady reduction in the rates of CLABSI in the year 2016 and 2017, a significant reduction was not observed.
Table 3: Central line-associated blood stream infections

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[Table 4] depicts that there were no significant changes in the central line catheter days of the year 2015, 2016 and 2017.
Table 4: Central line days

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[Table 5] shows that there was a significant reduction in the VAP rates in the year 2017, whereas in the year 2016, no significant reduction was noted.
Table 5: Ventilator-associated pneumonia

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[Table 6] demonstrates no significant reduction in the ventilator days of the three consecutive years.
Table 6: Ventilator days

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[Table 7] depicts a steady increase in the compliance rates for the maintenance and execution of care bundles.
Table 7: Compliance rates for the maintenance of bundles

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The non-compliances in the execution of the care bundles were analysed.

[Figure 1], [Figure 2], [Figure 3] depicts the analysis of non-compliances in the care bundles. The feedback of the non-compliances with the corrective and preventive actions to be taken was communicated to the stakeholders in a timely manner.
Figure 1: Non-compliance in central line bundle

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Figure 2: Non-compliance in catheter care bundle

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Figure 3: Non-compliance in ventilator care bundle

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  Discussion Top

With the advent of newer technologies, the number of devices used in critically ill patients has increased. Along with the long-term presence of device in situ, other pre-existing risk factors make these categories of patients more prone for DAI. DAI is a major problem in health-care settings, causing increased morbidity and mortality. The serious medical consequences and the increase in cost associated with the DAI underscores the importance of prevention. In this category of patients, 95% of cases of urinary tract infections are catheter associated, 87% of cases of bloodstream infections originate from an indwelling vascular catheter and 86% of cases of pneumonia are associated with mechanical ventilator.

There are three major DAIs-central line-associated blood stream infections, catheter-associated urinary tract infections and VAP.[9]

Bundled interventions are a cost-effective way to bring about a change and develop a patient safety culture. To successfully implement and sustain such changes team work, measuring the compliance, providing feedback and accountability to team workers and effective hospital leadership is needed.[8]

Care bundles help in implementing evidence based practices on a daily basis, which in turn can substantially improve patient outcome.[10] The aim of the care bundle is to improve the compliance to good practices during routine patient care thus reducing the rates of DAI and improving the patient safety. Compliance to care bundles is calculated as compliance to all the criteria of the care bundle If any one of the criteria is missed the compliance for the care bundle is considered zero.[3]

We could demonstrate a significant reduction in the rates of DAI after the introduction of care bundles.

In the present study, there was a decrease in the CLABSI rates after the introduction of CLABSI Bundle. This is in concordance with the statewide study conducted in Michigan by Pronovast et al. where CLABSI rates reduced from 2.7/1000 central line days to 0 within 3 months after implementation of CLABSI bundle.[11] Furuya et al. reported that only when an ICU had a policy, monitored compliance and had 95% compliance, CLABSI rates decreased.[12] Studies have demonstrated a significant reduction in the rates of CLABSI post-implementation of CLABSI care bundle. In our study, although there was a reduction in the rates of CLABSI, a statistical significance could not be demonstrated.

There was a significant reduction in CAUTI rates post-implementation of CAUTI bundle. Studies by Blanck et al. and Davis et al. also reported a significant reduction in the CAUTI rates post-implementation of CAUTI bundle.[13],[14]

A study done by INICC demonstrated a reduction in VAP rate from 52.63 to 15.32 per 1000 mechanical ventilator days showing a 70% reduction in VAP rates.[15] A similar decline in the VAP rates has been documented in other centres also. A study done by Bukhari et al. demonstrated that there was a significant correlation between VAP incidence rate with its bundle compliance.[16]

The success of a care bundle mainly depends on the compliance rates of the implementation of each component of the care bundle. Hence, regular reinforcement of the bundle criteria is needed to have a positive impact on patient care. In addition to this the study also states that outcome and process surveillance that is integrated into an intervention bundle containing performance feedback of ICP has been shown to reduce and control DAIs. Care bundles can further promote the culture of patient safety by promoting team work, measuring compliance and providing feedback and accountability to frontline teams and hospital leadership to improve care.[11] In our study, it was observed that awareness, training, feedback to the stakeholders aided the optimal sustenance and execution of care bundles thus promoting the culture of patient safety.

  Conclusion Top

Care bundles can have a significant impact on health-care-associated infections. However, to have a sustained impact on HCAI continuous training and monitoring is required. Identification of priority areas, focused interventions and prompt information dissemination can help in the reduction of DAI.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

World Alliance for Patient Safety. Global Patient Safety Challenge 2005 – 2006. Clean Care is Safer Care. Available from: : https:// www.who.int/patientsafety/events/05/GPSC_Launch_ ENGLISH_FINAL.pdf. [Last accessed on 2021 Nov 02].  Back to cited text no. 1
World Health Organisation. The Burden of Health Care Associated Infection Worldwide; 2008. Available from: https://www.who.int/gpsc/country_work/burden_hcai/en/. [Last accessed on 2018 Dec 26].  Back to cited text no. 2
Pittet D, Allegranzi B, Storr J, Bagheri Nejad S, Dziekan G, Leotsakos A, et al. Infection control as a major World Health Organization priority for developing countries. J Hosp Infect 2008;68:285-92.  Back to cited text no. 3
McFee RB. Nosocomial or hospital acquired infections. An overview. Dis Mon 2009;55:422-38.  Back to cited text no. 4
Haley RW, Quade D, Freeman HE, Bennett JV. The SENIC project. Study on the efficacy of nosocomial infection control (SENIC project). Summary of study design. Am J Epidemiol 1980;111(5):472-85.  Back to cited text no. 5
Harbarth S, Sax H, Gastmeier P. The preventable proportion of nosocomial infections: An overview of published reports. J Hosp Infect 2003;54:258-66.  Back to cited text no. 6
Cooke FJ, Holmes AH. The missing care bundle: Antibiotic prescribing in hospitals. Int J Antimicrob Agents 2007;30:25-9.  Back to cited text no. 7
Resar R, Griffin FA, Haraden C, Nolan TW. Care Bundles to Improve Health Care Quality. IHI Innovation Series White Paper. Cambridge, (MA): Institute for Healthcare Improvement; 2012. Available from: http://www.ihi.org/resources/Pages/IHIWhitePapers/UsingCareBundles.aspx. [Last accessed on 2018 Dec 26].  Back to cited text no. 8
Richards MJ, Edwards JR, Culver DH, Gaynes RP. Nosocomial infections in medical intensive care units in the United States. National nosocomial infections surveillance system. Crit Care Med 1999;27:887-92.  Back to cited text no. 9
Speck K, Rawat N, Weiner NC, Tujuba HG, Farley D, Berenholtz S. A systematic approach for developing a ventilator-associated pneumonia prevention bundle. Am J Infect Control 2016;44:652-6.  Back to cited text no. 10
Pronovost P, Needham D, Berenholtz S, Sinopoli D, Chu H, Cosgrove S, et al. An intervention to decrease catheter-related bloodstream infections in the ICU. N Engl J Med 2006;355:2725-32.  Back to cited text no. 11
Furuya EY, Dick A, Perencevich EN, Pogorzelska M, Goldmann D, Stone PW. Central line bundle implementation in US intensive care units and impact on bloodstream infections. PLoS One 2011;6:e15452.  Back to cited text no. 12
Blanck AM, Donahue M, Brentlinger L, Dixon Stinger K, Polito C. A quasi-experimental study to test a prevention bundle for catheter-associated urinary tract infections. J Hosp Adm 2014;3:101-8.  Back to cited text no. 13
Davis KF, Ann MC, Eithan BL, Klieger SB, Meredith DJ, Plachter N, et al. Reducing catheter associated urinary tract infections: A quality improvement initiative. Pediatrics 2014;134:e857-64.  Back to cited text no. 14
Guanche-Garcell H, Morales-Pérez C, Rosenthal VD. Effectiveness of a multidimensional approach for the prevention of ventilator-associated pneumonia in an adult intensive care unit in Cuba: Findings of the international nosocomial infection control consortium (INICC). J Infect Public Health 2013;6:98-107.  Back to cited text no. 15
Bukhari S, Banjar A, Futani M, Ashshi AM, Husain WA, et al. Application of ventilator care bundle and its impact on ventilator associated pneumonia incidence rate in the adult intensive care unit. Saudi medical journal 2012;33:278-83.  Back to cited text no. 16


  [Figure 1], [Figure 2], [Figure 3]

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]


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