As IV access specialists we have a multitude of national and international guidelines and standards to advise us on best IV practice. It is easy for us to see why they are important and the difference good IV access can make for a patient.
However, IV access is not just practised by specialists; it is an essential skill carried out by a wide variety of health professionals. Engaging, educating and standardising practice in such a large workforce can have many problems. Individual clinicians may not have the time to stay up-to-date with the latest IV access literature and studies. So how can we, as specialists, make things easy for them?
One way of getting health professionals to adhere to best practice has been through the use of care bundles. The Institute for Health Improvement (2017) describes care bundles as a small, straightforward set of evidence-based interventions, for a defined patient population and care setting, which when implemented together will result in an improvement to patient outcomes.
Care bundles for IV access have been around since the early 2000s when they were originally implemented into intensive care units as a way of reducing infection. Since then, their use has spread across other areas of health care. Care bundles should comprise 3–6 key elements supported by ‘level one’ evidence with no controversy of the elements’ effectiveness. They work on the basis that all elements must be completed with no option for ‘partial credit’ and aim to standardise and reduce variations in practice. It is important that staff understand each element of the care bundle and its rational to aid compliance.
There is currently no consensus in the literature as to what the defined elements should be. They are often flexible in their design and adapted to suit local need and priorities. In IV access, two different care bundles are often required for each IV access device, one for the insertion phase and one for maintenance—both need to be adhered to for success.
Many studies have shown the effectiveness of using a care bundle approach to drive down infection rates. However, although the literature and national guidelines can quite strongly recommend the use of care bundles (eg epic 3 (Loveday et al, 2014)), it is not without flaws. Bringing in a care bundle can require both technical and cultural change that needs to be supported by enhanced teamwork, education, communication and commitment, which for an IV device may need to cover a vast amount of staff. Enhanced funding may be required and dedicated time and resources invested for success. This can be extremely difficult to achieve in today's health care.
Designing a care bundle can also be problematic. Choosing the core elements required for safe IV access can be difficult particularly when aiming for just 3-6 elements. This can lead to care bundles having more than 6 core elements, and the greater the number of elements, the higher the risk of non-compliance. Each element could also have additional steps leading to a bundle within a bundle. Care bundles can keep being added to or changed ultimately to the point where they are no longer practical in a busy health care setting.
Care bundles focus on a precise problem at a single point in time and can fail to acknowledge that IV access care happens along a continuum rather than an isolated point (Jackson, 2018). Achieving full compliance can be challenging with some studies showing compliance being as low as 16% (Whelchel et al, 2013). However, there is an inverse relationship between care bundle compliance and infection rates (Fortunatti, 2017), so perhaps it is not quite time to give up on them yet.
Is the key to a successful care bundle integrating it into practice in a complementary way, one that does not create additional workload or paperwork? We should aim for the elements to become instinctive rather than onerous. Going back to keeping the care bundle elements simple, logical and easy may help, as may the advent of electronic monitoring systems and availability of equipment and IV technology to aid patient care. We can but keep persevering.