Intended for healthcare professionals

Practice Quality Improvement Report

Using care bundles to reduce in-hospital mortality: quantitative survey

BMJ 2010; 340 doi: (Published 01 April 2010) Cite this as: BMJ 2010;340:c1234
  1. Elizabeth Robb, director of nursing1, visiting professor 2,
  2. Brian Jarman, emeritus professor3, part-time senior fellow 4,
  3. Ganesh Suntharalingam, clinical director and consultant in intensive care medicine1,
  4. Clare Higgens, clinical director, director of medical education, and consultant physician 1,
  5. Rachel Tennant, consultant physician1,
  6. Karen Elcock, director of practice and workbased learning 5
  1. 1North West London Hospitals NHS Trust, Harrow HA1 3UJ
  2. 2Nursing, London South Bank University, London SE1 0AA
  3. 3Imperial College, London EC1A 9LA
  4. 4Institute for Healthcare Improvement, Cambridge, MA 02138, USA
  5. 5Thames Valley University, Slough SL1 1YG
  1. Correspondence to: B Jarman b.jarman{at}
  • Accepted 8 February 2010


Problem To reduce hospital inpatient mortality and thus increase public confidence in the quality of patient care in an urban acute hospital trust after adverse media coverage.

Design Eight care bundles of treatments known to be effective in reducing in-hospital mortality were used in the intervention year; adjusted mortality (from hospital episode statistics) was compared to the preceding year for the 13 diagnoses targeted by the intervention care bundles, 43 non-targeted diagnoses, and overall mortality for the 56 hospital standardised mortality ratio (HSMR) diagnoses covering 80% of hospital deaths.

Setting Acute hospital trust in north west London.

Strategies for change Use of clinical guidelines in care bundles in eight targeted clinical areas.

Interventions Use of care bundles in treatment areas for the diagnoses leading to most deaths in the trust in 2006-7.

Key measures for improvement Change in adjusted mortality in targeted and non-targeted diagnostic groups; hospital standardised mortality ratio (HSMR) during the intervention year compared with the preceding year.

Effect of the change The standardised mortality ratio (SMR) of the targeted diagnoses and the HSMR both showed significant reductions, and the non-targeted diagnoses showed a slight reduction. Cumulative sum charts showed significant reductions of SMRs in 11 of the 13 diagnoses targeted in the year of the quality improvements, compared with the preceding year The HSMR of the trust fell from 89.6 in 2006-7 to 71.1 in 2007-8 to become the lowest among acute trusts in England. 255 fewer deaths occurred in the trust (174 of these in the targeted diagnoses) in 2007-8 for the HSMR diagnoses than if the 2006-7 HSMR had been applicable. From 2006-7 to 2007-8 there was a 5.7% increase in admissions, 7.9% increase in expected deaths, and 14.5% decrease in actual deaths.

Lessons learnt Implementing care bundles can lead to reductions in death rates in the clinical diagnostic areas targeted and in the overall hospital mortality rate.


  • We thank the many excellent clinicians at North West London Hospitals NHS Trust for their collaboration. Derek Bell was external adviser in the early stages of developing the acute assessment unit and supported the care bundle concept and Theresa Murphy was the project leader. Dr Foster Intelligence provided access to adjusted death rates data and the Institute for Healthcare Improvement gave advice on the use of care bundlesFrank Davidoff, Paul Batalden, Paul Aylin, Alex Bottle, Gareth Parry, Joanne Zaborowski, and Steve Middleton read and commented on the paper. We found the SQUIRE guidelines ( particularly helpful.

  • Contributors: ER provided much of the background information about the project. ER, GS, CH, RT, and KE planned, conducted, and reported the work. BJ wrote the paper and did the analyses. All authors read and commented on the manuscript. BJ is guarantor.

  • Funding: No separate funding.

  • Competing interests: ER, GS, CH, and RT work at the North West London Hospitals NHS Trust. BJ is director of the Imperial College Dr Foster unit, advises Dr Foster Intelligence, and is part time senior fellow at the Institute for Healthcare Improvement.

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

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