Clinical Care Bundles
Care bundle audit
Clinical Care Bundles
What is a Clinical Care Bundle?
A care bundle is a small number of health care interventions grouped and measured together. This method allows practices to measure several evidence based criteria where the goal is to achieve compliance with ALL components simultaneously. An example would be auditing diabetes care and measuring the percentage of patients whose Blood Pressure, HbA1c and cholesterol are all at or below target levels. The care bundle approach is essentially an aggregated version of criterionbased audit.
Why would you choose this?
This method audits compliance with several components of care (or audit criteria). Individual compliance may be high but overall bundle compliance low. Regular auditing and review can increase compliance, improving overall care.
What is it useful for?
To measure and evaluate quality of care in an area where there are several standards all of which need to be met for good quality care to be achieved.
What is it not useful for?
A small number of specific criteria, an audit may be better. If there are specific criteria whose compliance is more important than others.
Who can do/lead it?
Any relevant member of clinical or administrative staff who understands the method
How do you do it?
• Choose a clinical condition or aspect of patient care as the bundle topic.
• Select, create or adapt a number of bundle components (usually 3-5).
• The practice team or health care worker may already be delivering some or all of the bundle components. Plan how those bundle components (if any) that are not already being delivered can be implemented in practice.
• Measure compliance with each component and with the overall bundle after a suitable period of time. The measure is binary – ‘yes’ or ‘no’. All components have to be delivered before the bundle can be considered as complete. If one component is not relevant/not applicable (e.g. action for an abnormal result) then this counts as meeting the criterion (see example).
• Analyse or reflect on your findings. Are there substantial differences between individual components and overall bundle compliance? If there are, should you consider and implement change/improvement? Is it possible to measure or infer the impact of the bundle on patient outcomes?
• Measure compliance with each component and with the overall bundle again. Compare the findings with the previous results and consider whether further action is required to improve or sustain reliable care delivery.
Top Tips
• All normal Top Tips (listed on page four) for QI apply here.
• Report overall compliance – but remember analysis of individual criteria within the bundle may direct change.
• Formulate action plans that specifically address the gaps identified
Further Info
This example uses the Scottish Patient Safety Programme DMARD care bundle. A local practice decided to use this to measure overall quality of care for their DMARD patients. The following measures are identified for each patient. The rationale for each measure can be found here.
• Measure 1: Appropriate tests are carried out in correct time scale. Has there been a full blood count in the past 12 weeks Azathioprine (AZA) eight weeks Methotrexate (MTX) as per local guidance?
• Measure 2: Appropriate action taken for any abnormal results in previous 12 weeks. If any abnormal results in previous 12 weeks White Blood Count (WBC < 4, neutrophils x2 normal upper limit (>60) has action been recorded in the consultation record?
• Measure 3: Blood tests reviewed prior to prescription. Is there a documented review of blood tests prior to issue of last prescription?
• Measure 4: Appropriate immunisation. Has the patient ever had or declined a pneumococcal vaccine?
• Measure 5: Patient asked about any side effects following last time blood was taken.
Have all measures been met? The records of all patients on DMARDS were accessed and how each one complied with each measure was recorded. The data was then collected and tabulated. The table below shows the results for 10 patients.
| Patient | Appropriate test? | Appropriate action if abnormal results | Blood tests reviewed prior to prescription | Appropriate immunisation | Patient asked about side effects? | All measures met? |
| 1 | Y | N/A | Y | N | Y | N |
| 2 | Y | N/A | N | N | Y | N |
| 3 | Y | Y | N | N | Y | N |
| 4 | Y | N/A | N | N | Y | N |
| 5 | Y | N/A | Y | Y | Y | Y |
| 6 | Y | N/A | Y | N | Y | N |
| 7 | Y | N/A | N | Y | Y | N |
| 8 | N | N/A | Y | N | Y | N |
| 9 | Y | N/A | N | N | Y | N |
| 10 | Y | Y | Y | Y | Y | Y |
| Total no. | 9 | 10 | 5 | 3 | 10 | 2 |
| Prop % | 90 | 100 | 50 | 30 | 100 | 20 |
Implemented changes The practice discussed the findings and designed changes to their systems. The first change implemented was the use of an electronic template to guide actions at review appointments. The impact of this was evaluated by a further care bundle audit of 10 patients seen at review appointments