The Care Bundles Project was overseen by the steering group, whose aim was to oversee the development and testing of care bundles, as well as to develop an effective model of working. The steering group established three subgroups: the evidence criteria group to define the criteria for acceptable evidence for the development of the two care bundles and two expert groups to develop the electronic fetal monitoring (EFM) and placenta praevia after previous lower segment caesarean section (placenta praevia) care bundles. These three subgroups were chaired by independent leaders and the membership included a broad cross-section of carers and stakeholders.
The evidence group gave clear guidance on the importance of not only evaluating the scientific strength of the evidence available but also the relevance of the evidence to the question asked. This was particularly helpful in the placenta praevia care bundle, where good scientific evidence was lacking.
Both expert groups struggled to focus the care bundles, as it was obvious there were many areas that could be helped. However, the scope of the project necessitated close focusing. This was partly addressed by producing detailed documentation that supported the care bundles and provided further guidance. This approach was particularly helpful for the placenta praevia care bundle. The National Patient Safety Agency (NPSA) leads provided support and advice on the scopes and structure.
In parallel with the work of the subgroups, the steering group identified pilot sites and their agreement was secured. The project research midwife spent a great deal of time connecting with all the sites but also undertook an engagement exercise with the test sites. It was appreciated that the success of the project would be dependent in part on these preparatory and educational activities. In addition, good communication between the research midwife, the site leads and the sites would be an essential component throughout the project. This consisted of a pre-pilot information day at the RCOG, site visits, weekly telephone calls and a post-pilot feedback day. This continuous two-way dialogue was very informative to both those carrying out the pilots and for the evaluation of the project.
The EFM care bundle was trialled in five units. There was much enthusiasm in one unit, where compliance was the highest and many midwives found it helpful. However, although it was easy to use, the overall compliance was poor. The feedback from the pilot sites suggested that it was seen as an unhelpful exercise, an added burden to the already heavy workload of the midwives. This could of course be due to other reasons, including poor ‘selling’ of the care bundle by the project team. It was clear that there was no problem in collecting the information or understanding the components but that they needed to be incorporated into a system that was more helpful to midwives by easing their workload rather than adding to it. The benefit was not seen as sufficient to justify the perceived increase in work, although it took on average only two minutes to complete each care bundle. This is an important learning point, as the success of the care bundle was linked to the balance between perceived benefit and the amount of effort that went into implementing the activity.
This is demonstrated by the findings of the placenta praevia care bundle, which was well received, had high compliance and was seen to be helpful and beneficial. The users thought that, even in cases where nothing different was done, it was a good guide for ensuring that everything was in place. During the pilot, at least one caesarean section was delayed to make sure that all components were compliant. The success of this care bundle demonstrates the feasibility of care bundle use in maternity care. It also highlights that the care bundle is valued much more if the benefits are linked directly to the area of responsibility of those completing it. This care bundle was seen to be beneficial and the steering group considers that this care bundle, together with the supporting documentation, could be rolled out more widely. This project has also demonstrated the value of multidisciplinary groups working together with a common goal. The choice of diverse topics for care bundle development has been very informative.Where a problem was unusual, the risks high and the planning difficult, as in placenta praevia, the care bundle was welcomed and it did its job well with praise all round. However, the EFM care bundle showed that, where a care covered is common and the poor outcome rare, the increased burden on staff is seen as non-beneficial, even though, when the EFM is abnormal, it could prove extremely helpful. This does not occur often enough to give positive feedback of the care bundle to the user. This approach therefore needs to be reconsidered, with components built into existing documentation to help ease the workload.
Interestingly, the evidence group produced an algorithm which predicted this outcome. This project has achieved its aims. It has been very informative about the methods of developing care bundles in maternity care and the ease of multidisciplinary working. The group has developed templates to allow others to develop more care bundles in the future. The methodology for piloting and testing is robust, which will make it easier to produce successful care bundles in the future. This is a good beginning in the area of care bundles, which can make a significant difference to the safety of women and their babies in the years to come.