What is a care bundle and why are care bundles important? Most surgeons and indeed most healthcare workers don't know the answer to that question. They may well have a reasonable understanding of IPC principles but the fact that they have never heard of care bundles is a very important performance indicator. What it signifies is that there is a complete failure of communication in the NHS. Since Saving Lives was published in 2005, care bundles have been a central componenet of the Department of Health's approach to tackling HAIs. The commitment to care bundles was reaffirmed in the HPA Point Prevalence Survey reported last year.
The value of care bundles is open to debate, but if it is a central plank of the Department of Health's strategy to target HAIs and nobody on the ground is interested or aware... then there is a serious problem. The ventilator associated respiratory infection care bundle has been widely adopted by ITUs. The MRSA screening care bundle has also been widely adopted. The SSI care bundle has not been. The fact that SSIS is generally non-existent is probably no coincidence.
Care bundles seem to have been invented by the Institute of Healthcare Improvement in the USA. Each care bundle consists of no more than 4 or 5 High impact interventions (HIIs). Each HII is backed by level one evidence (randomised controlled studies). It is important that the whole cluster of HIIs are implemented together.
It is likely that any patient who suffers an SSI who can prove that the hospital staff had not adhered to the NICE approved SSI care bundle would successfully litigate against that hospital.
SSI care bundles evolve as new evidence becomes available, practice improves, and new innovations become accepted. Furthermore every practice is unique and a basic care bundle should be tailored to individual circumstances.
For instance in surgery involving lymph node dissection where seroma formation is an expensive and inconvenient problem, and which can lead to SSI, a specific intervention such as ambulatory suction drainage can be added to the care bundle.
Original NICE Guidelines 2008 were updated November 2011
In the USA their version APIC has been reviewed by Edmiston who proposes extending the bundle for instance to include the use of triclosan sutures. The APIC guidelines are under review with certain interventions such as 'hair removal' having 'topped out'. In a similar fashion Under the Knife advocates an extended care bundle.
Extended Care Bundles include:
- Ambulatory redivac drainage for up to 6 weeks
- Total/ Body Washing in CHG soap for 3 days prior to admission
- TC Sutures
- Dermabond as a dressing
The Under the Knife care bundle and the NICE care bundle both include 2% CHG in 70% Isopropyl alcohol as a skin prep. The only licensed version of this is the CareFusion product Chloraprep. TCSs and Dermabond are both Ethicon products. There is no alternative antimicrobial suture but alternatives to Dermabond do exist.