ICU Care Bundle Compliance Checklist
Record and verify adherence to ICU care bundle elements for quality and patient safety.
Date of Assessment
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Patient Identifier (e.g., MRN or initials)
*
ICU Unit/Location
*
Please Select
Medical ICU
Surgical ICU
Cardiac ICU
Neuro ICU
Other
Name of Person Completing Checklist
*
First Name
Last Name
Role of Person Completing Checklist
*
Please Select
Nurse
Physician
Respiratory Therapist
Other
ICU Care Bundle Elements Compliance
*
Rows
Yes
No
Not Applicable
Head-of-bed elevated 30-45° (if applicable)
1
2
3
Daily sedation interruption and assessment of readiness to extubate
4
5
6
Oral care with chlorhexidine
7
8
9
DVT prophylaxis provided (unless contraindicated)
10
11
12
Stress ulcer prophylaxis (if indicated)
13
14
15
Blood glucose maintained within target range
16
17
18
Review of need for central lines and urinary catheters
19
20
21
Peptic ulcer prophylaxis (if indicated)
22
23
24
Daily spontaneous breathing trial (if applicable)
25
26
27
If any bundle element was not compliant, please specify reasons or barriers
Additional Comments or Observations
Recommendations or Actions Taken
Reviewer Signature
*
Submit Checklist
Submit Checklist
Should be Empty: