The Impact of Low-Cost Protocols and Bundles on Mortality, Length of Stay, and Resource Utilization in Intensive Care Units: An Umbrella Review

Abstract

INTRODUCTION: The popularization of care bundles for organizing and systematizing care in the Intensive Care Unit (ICU) is a reality, characterized by low costs and demonstrated impact on clinical outcomes. There are no studies in the literature that seek to establish a priority order for their implementation. OBJECTIVE: To map, synthesize, and prioritize evidence from systematic reviews and meta-analyses regarding the impact of implementing low-cost protocols on clinical outcomes and management indicators (mortality, ICU length of stay, duration of mechanical ventilation [MV], incidence of delirium, ventilator-associated pneumonia [VAP], and costs) in adult patients in general ICUs. METHODOLOGY: Umbrella review. A search and selection of systematic reviews (SR), meta-analyses, and scoping reviews was conducted on PubMed. The search yielded 186 studies; after a careful reading of titles and abstracts, nine studies were included and analyzed. Data were grouped and synthesized narratively by type of intervention. RESULTS: Review evidence consistently demonstrates that the application of bundles has a significant impact on the incidence of Healthcare-Associated Infections (HAIs), as well as on ICU length of stay and duration of MV. The implementation of 

VAP bundles, including oral hygiene with chlorhexidine, significantly reduces the incidence of VAP and associated treatment costs. Implementation of the complete ABCDEF bundle is associated with a robust reduction in the incidence and duration of delirium, in addition to reductions in MV duration and ICU length of stay. The impact on mortality is less clear, although some studies suggest a reduction. Interventions focused on family engagement (such as flexible visitation and voice messages) show a favorable effect on reducing the incidence and duration of delirium. The use of daily checklists during multidisciplinary rounds is an effective Quality Management tool that improves bundle adherence and is associated with reduced ICU length of stay and MV duration. CONCLUSION: The review literature is robust in favor of implementing ICU protocols aimed at quality improvement, such as focused bundles (VAP and ABCDEF) and process tools (checklists) to improve ICU outcomes. Due to the heterogeneity of the studies, it is not possible to prioritize the order of implementation for each bundle.