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Care bundles for acute kidney injury: a balanced accounting of the impact of implementation in an acute medical unit
  1. Rachael Logan1,
  2. Peter Davey1,
  3. Alison Davie2,
  4. Suzanne Grant3,
  5. Vicki Tully1,
  6. Achyut Valluri4,
  7. Samira Bell3,5
  1. 1School of Medicine, University of Dundee, Dundee, United Kingdom
  2. 2NHS Tayside, Dundee, United Kingdom
  3. 3Division of Population Health and Genomics, University of Dundee, Dundee, United Kingdom
  4. 4Acute Medical Unit, NHS Tayside, Dundee, United Kigdom
  5. 5Renal Unit, NHS Tayside, Dundee, United Kingdom
  1. Correspondence to Dr Samira Bell; samira.bell{at}


In 2009, a National Confidential Enquiry into Patient Outcome and Death report detailed significant shortcomings in recognition and management of patients with acute kidney injury (AKI). As part of a national collaborative to reduce harm from AKI, the Scottish Patient Safety Programme developed two care bundles to improve response (‘SHOUT’) and review (‘BUMP’) of AKI.

Baseline data from eight patients with AKI on the acute medical unit (AMU) in Ninewells Hospital showed 62% compliance with SHOUT. However, most patients were transferred from AMU within 24 hours so BUMP could not be assessed. Our aim was to achieve >95% compliance with SHOUT on AMU within 2 months. The content of the SHOUT bundle was condensed onto a sticker for the case notes, which was implemented using Plan-Do-Study-Act cycles. Compliance was assessed weekly and feedback obtained from stakeholders concerning their opinion of the sticker, SHOUT bundle and care bundles in general.

Use of the sticker was 27% in week 1 but fell to 5% by week 4. Compliance with the bundle varied from 45% to 60% and was only slightly improved by use of the sticker (OR 1.58, 95% CI 0.39 to 6.42). Staff found the sticker burdensome and did not agree that all elements of SHOUT were equally important. This opinion was supported by finding that their compliance with sepsis and hypovolaemia recommendations was 91%–100% throughout, whereas urinalysis was documented in only 55%–63% of patients. Several staff mentioned ‘bundle fatigue’ and on one day we identified 22 other care bundles or structured improvement forms in AMU.

We concluded that the AMU staff had legitimate concerns about the SHOUT care bundle and that our intervention was demotivating. Overcoming bundle fatigue will not be a simple task. We plan to work with staff on integrating AKI into patient safety huddles and on using modelling and recognition of good practice to improve motivation.

  • pdsa
  • quality improvement
  • checklists

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  • Patient consent for publication Not required.

  • Contributors RL was involved in the collection of data, developing the care bundle and liaising with the AMU team throughout the improvement project. She was also responsible for writing the first draft of the manuscript. SB was responsible for approving and developing the care bundle, liaising with the Scottish Patient Safety Programme, AMU and renal team and was the clinical supervisor for RL throughout the project. Middle authors are in alphabetical order by surname and all made equally important contributions to interpretation of results and to writing subsequent drafts of the manuscript. PD was the academic supervisor for RL and took a lead role in balanced accounting of the intervention and interpreting results about barriers to change. AD and VT were responsible for assisting with developing a sound quality improvement methodology for implementing the intervention. AD also liaised with SPSP throughout the project. SG is leading research on Video Reflexive Ethnography on the AMU and was responsible for interpreting the results in the context of understanding complex adaptive systems. AV acted as the primary contact for the AMU team and conveyed their feedback throughout the project, as well as providing assistance for implementing the intervention. All authors critically revised the manuscript for important intellectual content, gave their final approval of the version to be published and agree to be accountable for all aspects of the work. RL conducted this work as part of a BMSc in Healthcare Improvement at the University of Dundee.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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