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Barriers and facilitators to the successful development, implementation and evaluation of care bundles in acute care in hospital: a scoping review

  • Gilhooly, D.1
  • Green, S. A.2, 3
  • McCann, C.1
  • Black, N.3
  • Moonesinghe, S. R.4, 5
  • 1 University College Hospital, UCLH NIHR Surgical Outcomes Research Centre, Department of Anaesthesia and Perioperative Medicine, London, NW1 2BU, UK , London (United Kingdom)
  • 2 Imperial College London Chelsea and Westminster Hospital, NIHR CLAHRC Northwest London, London, SW10 9NH, UK , London (United Kingdom)
  • 3 London School of Hygiene and Tropical Medicine, Department of Health Services Research Policy, 15-17 Tavistock Place, London, WC1H 9SH, UK , London (United Kingdom)
  • 4 University College London, Division of Surgery and Interventional Science Charles Bell House, London, W1W 7TS, UK , London (United Kingdom)
  • 5 Royal College of Anaesthetists, Health Services Research Centre, National Institute for Academic Anaesthesia, Churchill House, 35 Red Lion Square, London, WC1R 4SG, UK , London (United Kingdom)
Published Article
Implementation Science
Springer (Biomed Central Ltd.)
Publication Date
May 06, 2019
DOI: 10.1186/s13012-019-0894-2
Springer Nature


BackgroundCare bundles are small sets of evidence-based recommendations, designed to support the implementation of evidence-based best clinical practice. However, there is variation in the design and implementation of care bundles, which may impact on the fidelity of delivery and subsequently their clinical effectiveness.MethodsA scoping review was carried out using the Arksey and O’Malley framework to identify the literature reporting on the design, implementation and evaluation of care bundles. The Embase, CINAHL, Cochrane and Ovid MEDLINE databases were searched for manuscripts published between 2001 and November 2017; hand-searching of references and citations was also undertaken. Data were initially assessed using a quality assessment tool, the Downs and Black checklist, prior to further analysis and narrative synthesis. Implementation strategies were classified using the Expert Recommendations for Implementing Change (ERIC) criteria.ResultsTwenty-eight thousand six hundred ninety-two publications were screened and 348 articles retrieved in full text. Ninety-nine peer-reviewed quantitative publications were included for data extraction. These consisted of one randomised crossover trial, one randomised cluster trial, one case-control study, 20 prospective cohort studies and 76 non-parallel cohort studies. Twenty-three percent of studies were classified as poor based on Downs and Black checklist, and reporting of implementation strategies lacked structure.Negative associations were found between the number of elements in a bundle and compliance (Spearman’s rho = − 0.47, non-parallel cohort and − 0.65, prospective cohort studies), and between the complexity of elements and compliance (p < 0.001, chi-squared = 23.05). Implementation strategies associated with improved compliance included evaluative and iterative approaches, development of stakeholder relationships and education and training strategies.ConclusionCare bundles with a small number of simple elements have better compliance rates. Standardised reporting of implementation strategies may help to implement care bundles into clinical practice with high fidelity.Trial RegistrationThis review was registered on the PROSPERO database: CRD 42015029963 in December 2015.

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