What evidence is there that care bundles improve outcomes for patients with COVID-19 in the intensive care setting?

What are care bundles?

Care bundles are a set of care practices that are carried out together (as a bundle) when delivering care to patients with the same condition or in the same healthcare setting. There are usually three to five practices in a bundle. Practices could include any aspect of patient care. For example, a bundle might include guidance on inserting breathing tubes, ventilator settings and care of ventilated patients. All the practices are ‘evidence-based’, that is, they are based on evidence that shows they are useful.

Why might care bundles help?

Some people with COVID-19 can become seriously ill and need intensive care. They will require respiratory (breathing) support and may need to be placed on a ventilator. Recent information suggests that around 26% of people with COVID-19 around the world have been admitted to an intensive care unit (ICU), and of these people, almost one-third have died.

For people with COVID-19 and related conditions (such as viral pneumonia, which also causes serious breathing difficulties), using care bundles will mean that practitioners carry out each care practice in the bundle, each time. Implementing the practices together, rather than individually, should result in better outcomes for patients. Use of care bundles should also reduce variation in how care is delivered and can improve the teamwork needed to provide high-quality health care, which also results in better patient outcomes.

Purpose of the review

The World Health Organization (WHO) commissioned this 'scoping' review to identify how much and what type of evidence is available on the use of care bundles for patients in the ICU setting suffering from COVID-19, acute respiratory distress syndrome (ARDS) or viral pneumonia. We wanted to identify and describe the studies that have been done and what they assessed, but not to appraise their quality or analyse their findings as we would usually do in a standard review. The WHO wanted to use this review to help develop their guidelines, so we prepared it quickly, over a three-week period from 26 October to 18 November 2020.

How did we identify and map the evidence?

We searched for all types of studies that reported on patients who were seriously ill with COVID-19, ARDS or viral pneumonia in the ICU setting, where a care bundle was used. Study participants could be any age. The care bundles could include any practices, but there had to be at least three in a bundle, they had to be evidence-based, and delivered together in the same way each time.

We grouped the studies according to their participants' health condition: confirmed or suspected COVID-19; ARDS; viral pneumonia; severe respiratory failure; and patients with a variety of these conditions.

What did we find?

We included 21 studies and identified three ongoing studies. The studies were conducted in eight countries, most commonly China and the USA, and were published between 1999 and 2020. Over 2000 participants in total were involved in the studies. Seven studies included patients with COVID-19, seven with ARDS, five with viral pneumonia, one with severe respiratory failure and one with a mixture of conditions.

The descriptions of the care bundles were varied, but most involved care practices related to breathing support or ventilator settings, or the positioning of a patient (e.g. face down), for ARDS and COVID-19. COVID-19-specific studies also focused on infection control and use of personal protective equipment (PPE). Some care bundles were specific to parts of the body such as eye or skin care.

Some of the 'evidence gaps' we identified were a lack of care bundles focused on preparing patients to leave the ICU, preventing infections caused by giving medicines intravenously (by drip), and the long-term effects of COVID-19. None of the studies looked at healthcare workers' experience of adapting care bundles.

Authors' conclusions

Information specific to patients with COVID-19 that compares patients receiving care bundles and not receiving care bundles is limited, and more research is needed. We also need information on how care bundles can best be implemented in practice, and the difficulties that might be associated with this. A separate review that assesses the quality of the evidence that we found in this review, and that combines and analyses the data, is required

Authors' conclusions: 

This scoping review has identified 21 studies on care bundle use in critically ill patients in ICU with COVID-19, ARDS, viral influenza or pneumonia and severe respiratory failure. The data for patients with COVID-19 specifically are limited, derived mainly from observational quality improvement or clinical experiential accounts. Research is required, urgently, to further assess care bundle use and optimal components of these bundles in this patient cohort. The care bundles described were also varied, with guidance on ventilator settings described in 10 care bundles, while chest X-ray was part mentioned in one care bundle in one study only. None of the studies identified in this scoping review measured users' experience of adapting care bundles. Optimising care bundle implementation requires that the components of the care bundle are collectively and consistently applied. Data on challenges, barriers and facilitators to implementation are needed. A formal synthesis of the outcome data presented in this review and a critical appraisal of the evidence is required by a subsequent effectiveness review. This subsequent review should further explore effect estimates across the included studies.

Read the full abstract...

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the strain of coronavirus that causes coronavirus disease 2019 (COVID-19) can cause serious illness in some people resulting in admission to intensive care units (ICU) and frequently, ventilatory support for acute respiratory failure. Evaluating ICU care, and what is effective in improving outcomes for these patients is critical. Care bundles, a small set of evidence-based interventions, delivered together consistently, may improve patient outcomes. To identify the extent of the available evidence on the use of care bundles in patients with COVID-19 in the ICU, the World Health Organization (WHO) commissioned a scoping review to inform WHO guideline discussions. This review does not assess the effectiveness of the findings, assess risk of bias, or assess the certainty of the evidence (GRADE). As this review was commissioned to inform guideline discussions, it was done rapidly over a three-week period from 26 October to 18 November 2020.


To identify and describe the available evidence on the use of care bundles in the ICU for patients with COVID-19 or related conditions (acute respiratory distress syndrome (ARDS) viral pneumonia or pneumonitis), or both. In carrying out the review the focus was on characterising the evidence base and not evaluating the effectiveness or safety of the care bundles or their component parts.

Search strategy: 

We searched MEDLINE, Embase, the Cochrane Library (CENTRAL and the Cochrane COVID-19 Study Register) and the WHO International Clinical Trials Registry Platform on 26 October 2020.

Selection criteria: 

Studies of all designs that reported on patients who are critically ill with COVID-19, ARDS, viral pneumonia or pneumonitis, in the ICU setting, where a care bundle was implemented in providing care, were eligible for inclusion. One review author (VS) screened all records on title and abstract. A second review author (DR) checked 20% of excluded and included records; agreement was 99.4% and 100% respectively on exclude/include decisions. Two review authors (VS and DR) independently screened all records at full-text level. VS and DR resolved any disagreements through discussion and consensus, or referral to a third review author (AN) as required.

Data collection and analysis: 

One review author (VS) extracted the data and a second review author (DR) checked 20% of this for accuracy. As the review was not designed to synthesise effectiveness data, assess risk of bias, or characterise the certainty of the evidence (GRADE), we mapped the extracted data and presented them in tabular format based on the patient condition; that is patients with confirmed or suspected COVID-19, patients with ARDS, patients with any influenza or viral pneumonia, patients with severe respiratory failure, and patients with mixed conditions. We have also provided a narrative summary of the findings from the included studies.

Main results: 

We included 21 studies and identified three ongoing studies. The studies were of variable designs and included a systematic review of standardised approaches to caring for critically ill patients in ICU, including but not exclusive to care bundles (1 study), a randomised trial (1 study), prospective and retrospective cohort studies (4 studies), before and after studies (7 studies), observational quality improvement reports (4 studies), case series/case reports (3 studies) and audit (1 study). The studies were conducted in eight countries, most commonly China (5 studies) and the USA (4 studies), were published between 1999 and 2020, and involved over 2000 participants in total. Studies categorised participant conditions patients with confirmed or suspected COVID-19 (7 studies), patients with ARDS (7 studies), patients with another influenza or viral pneumonia (5 studies), patients with severe respiratory failure (1 study), and patients with mixed conditions (1 study).

The care bundles described in the studies involved multiple diverse practices. Guidance on ventilator settings (10 studies), restrictive fluid management (8 studies), sedation (7 studies) and prone positioning (7 studies) were identified most frequently, while only one study mentioned chest X-ray.

None of the included studies reported the prespecified outcomes ICU-acquired weakness (muscle wasting, weight loss) and users' experience adapting care bundles. Of the remaining prespecified outcomes, 14 studies reported death in ICU, nine reported days of ventilation (or ventilator-free days), nine reported length of stay in ICU in days, five reported death in hospital, three reported length of stay in hospital in days, and three reported adherence to the bundle.

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