Care Bundles and Safe Distancing: Keeping the Patient Not So Distant

Believed to have originated in North America, care bundles are described as groups of evidence-based practice interventions aimed at improving patient outcome (Fullbrook & Mooney, 2003). The bundles, composed of three to five evidence-based practices, provide structure in implementing consistent care processes aimed at the highest quality of care (Clarkson, 2013; Resar et al., 2005). Care bundles aim to improve standard of care and patient outcome through the consistent implementation of a group of evidence-based interventions (Camporota & Brett, 2011, p. 159).

Care Bundles in Clinical Practice
Bundles have been widely used to improve clinical care in various settings and specialties (Chuan et al., 2020; Kourouche et al., 2019; Okonofua, 2020; Smith et al., 2019; Sopina et al., 2017). In the landmark study by Resar and colleagues (2005), a bundle of ventilator care processes was implemented to reduce ventilator associated pneumonias (VAPs). The use of bundle by 35 units that consistently reported data on adherence to the ventilator bundle showed an average of 44.5% reduction of VAPs (Resar et al., 2005). In 2011, Rello et al. (2011) conducted a similar study on the use of care bundle for management of VAP in Europe. The authors concluded that the adoption of the care bundles should promote consistency and improve compliance with the care guidelines to prevent VAPs (Rello et al., 2011). The 100,000 lives campaign brought the use of bundles into the limelight through the nation-wide adoption of a bundle to prevent Central-Line Associated Blood Stream Infections (CLABSI) (Berwick et al., 2006; Karapanou et al., 2019). Gould and colleagues, along with the Healthcare Infection Control Practices Advisory Committee (HICPAC) have produced a bundle referred to as the Guideline for Prevention of Catheter-Associated Urinary Tract Infections (CAUTI) (2009).

Use of Bundles in Administrative and Improvement Initiatives
Bundles have been used in administrative and non-clinical practice areas including mortality reduction (Safeek & May, 2010), reimbursement (Gillespie & Privitera, 2019), and patient experience (Nelson & Staffileno, 2017; Skaggs et al., 2018). The philosophy of care bundles is compatible with the Plan, Do, Check, Act model of performance improvement (Clarkson, 2013). Bowling and his colleagues (2019) have published the results of their quality improvement initiative to demonstrate the effectiveness and efficacy of creating and implementing a leadership rounding bundle. This bundle was developed to achieve and sustain outcomes in preventing hospital-acquired infections, specifically CAUTI and CLABSI. This improvement initiative aims to create a sense of urgency and accountability amongst the staff, nursing leaders, and providers through a disciplined approach to multidisciplinary rounding.

Leadership Rounding Bundle
Care bundles are evidence-based and aim to support the implementation of best clinical practice; however, variation exists in their design and execution (Gilhooly et al., 2019). Several strategies have been suggested to assist in the effective use of care bundles. The most frequently cited effective strategies include education, reminders, and audit and feedback (Borgert et al., 2015). Popularized by the Studer (2003) leadership rounding has been found to be an effective strategy to achieve outcomes. The components of a leadership rounding bundle that can be used to lead inter-disciplinary and inter-professional teams that address clinical improvement initiatives, whether for routine rounding such as nurse leader rounding, or targeted rounding such as the CAUTI or CLABSI rounding, should include the following:

Multidisciplinary Triad Rounding. A multidisciplinary team is key to the success of any rounding initiative. For example, the key stakeholders for multidisciplinary rounding should include nursing, physician, and infection preventionist when addressing hospital associated infections. Physicians and infection prevention leaders play a key role in the prevention and control of infection, particularly those in senior leadership roles who have the authority to enforce compliance (Gould et al., 2016; Mertz et al., 2010).

Nursing Executive Leadership. Effective rounding that address direct patient care staff requires a disciplined-approach led by a nursing executive. To sustain accountability, nursing leaders should promote a culture of collaboration, collegiality, and co-ownership amongst all stakeholders. Acting as role models, nurse executive leaders set the culture for meaningful and purposeful rounding on both patients and staff.

Electronic Protocols and Reports. The use of electronic protocols such as CAUTI and CLABSI prevention protocols promote the consistent use of care bundles. These automated protocols in the electronic medical records are accessible and optimize the use of computerized information in integrating best practices into the care planning process. The use of personal devices such as iPads provides versatility and flexibility in performing audits because they can be modified without fear of using outdated versions that is typically found in paper audits.

Frontline Peer-Validation and Feedback Process. Peer-checks and peer-validations are important part of ensuring consistency and compliance with care bundles. This can be done during bedside shift report and during random multidisciplinary weekly audits. Engaging the frontline staff during the daily communication and organizational huddles keeps them informed. During this time of social distancing, huddles may be done with limited number of staff at any one location, telephonically, webex or video conferencing, and in corridors, instead of the crowded huddle rooms. Appropriate precautions should be maintained to ensure the privacy of the patients and the confidentiality of the information.

Rounding During the COVID19 Pandemic
The recent events surrounding the COVID19 pandemic have caused anxiety, uncertainty, and confusion among healthcare leaders and the frontline staff with regard to rounding. As a result of the call for social distancing, patient rounding and patient contact have been done with great caution. With abundant precautions, routine patient rounding may have been limited or suspended. More than ever, patients need more reassurance while they are hospitalized, whether or not they are afflicted with the COVID19. Making the patients feel safe and not feel alone with increased focused on empathy and hope should remain as one of the top priorities for nurses and their nursing leaders (Romano, 2020).

Safe Distancing While Providing Safe Care
To limit exposure for both the patient and the healthcare worker, many nursing activities have been consolidated or combined during patient contact including assessment, medication administration, turning and positioning, and hygiene. During times of great uncertainty and anxiety such as pandemics, the non-negotiables of patient experience should be delivered with the appropriate precautions and safe distancing.

Bedside Shift Reporting. With the appropriate precautions, the nursing staff should continue with bedside shift reporting. The Infection Prevention Department and Materials Management Department will be important partners in ensuring that the appropriate personnel protective equipment is utilized, monitored, and conserved. Bundling of care during bedside shift reports would also minimize the number of possible exposures to both the patients and the healthcare workers.

The 5 P’s of Care. The physical distancing and limitations placed on visitations have made the 5 Ps’ more critical than ever. Each encounter with the patient should include pain assessment, positioning, provision for hygiene and bathroom needs, prevention of infection, and personal presence. All healthcare workers who come in contact with patient should be mindful of these important aspects of care.

Communication Board. The threats of social isolation, anxiety, and loneliness are real during this time of the COVID19 pandemic. Updating the communication board could eliminate the anxieties of the patients by keeping them informed. The timely information on the board would also minimize the times that each healthcare worker may have to go out of the room to ask other co-workers about the key activities for the day.

Phone Calls and Video-Communication. As appropriate, calling the patients in their rooms allows the nurse leaders to keep the communication open, provide reassurance that their care needs will be met, and identify gaps in their care (Romano, 2020). Attending to the other personal needs of the patients such as ensuring that a phone charger is available or offering a communication device such as an iPad that can be used for family conferencing would be helpful.

Why Leaders’ Presence Matters During a Pandemic
In spite of the COVID19 crisis, the outlook of healthcare consumers have continued to be positive. According to the Beryl Institute (2020), nearly 95% of healthcare consumers reported that patient experience is either “very important” or “extremely important.” The patients’ perception of their own health, how their physical needs are met, and their belief that healthcare outcomes are a result of good patient experience influence the overall care experience. The media has been flooded with positive messages about the heroic work of healthcare workers. Even in the midst of the COVID19 pandemic, 85% or consumers rated their experience as “very” or “somewhat” satisfied during their hospital stay (The Beryl Institute, 2020).

Should bundles be used by clinicians, especially during a pandemic? The answer would be much simple and direct when there is clear and sound evidence that supports the practice. Lavallee et al. (2017) warn that only findings from controlled, pre and post- studies with very low quality show a reduction of risk of negative outcomes in comparison with usual care. Gilhooly et al. (2019) have reported that care bundles, particularly those with small number of simple elements, show better compliance rates. The ease by which care bundles can be developed, implemented, and audited could provide the practicing clinicians a practical approach to implementing evidence-based practice (Fullbrook & Mooney, 2003). The goal-oriented nature of implementing bundle requires teamwork in order to promote and improve reliability (Resar et al., 2005). Oliver (2019) sums up the relevance of care bundle by advocating that the elements of the care bundles should remain instinctive, simple, and logical.

As COVID-19 pandemic continues, nursing leaders persevere to keep the patients and the staff safe. They continue to maintain staff and patient engagement efforts with due diligence and with the utmost consideration to appropriate precautions. During this crisis, nurse leaders are adapting to the changing needs of patients and their loved ones. By exhibiting leadership through rounding, they bring empathy and hope while addressing care gap needs. It’s more important now than ever that patients and staff feel safe, supported, and protected.

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