Send to

Choose Destination
Implement Sci. 2019 May 6;14(1):47. doi: 10.1186/s13012-019-0894-2.

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

Author information

UCLH NIHR Surgical Outcomes Research Centre, Department of Anaesthesia and Perioperative Medicine, University College Hospital, London, NW1 2BU, UK.
NIHR CLAHRC Northwest London, Imperial College London Chelsea and Westminster Hospital, London, SW10 9NH, UK.
Department of Health Services Research Policy, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, UK.
UCLH NIHR Surgical Outcomes Research Centre, Department of Anaesthesia and Perioperative Medicine, University College Hospital, London, NW1 2BU, UK.
Division of Surgery and Interventional Science Charles Bell House, University College London, London, W1W 7TS, UK.
Health Services Research Centre, National Institute for Academic Anaesthesia, Royal College of Anaesthetists, Churchill House, 35 Red Lion Square, London, WC1R 4SG, UK.



Care 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.


A 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.


Twenty-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.


Care 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.


This review was registered on the PROSPERO database: CRD 42015029963 in December 2015.


Care bundles; Evaluation; Evidence-based care; Healthcare improvement; Implementation; Improvement science; Intervention design; Quality improvement

[Indexed for MEDLINE]
Free PMC Article

Supplemental Content

Full text links

Icon for BioMed Central Icon for PubMed Central
Loading ...
Support Center