this assignment uses a template, the template must be followed precisely. Read the template, then fill in the paper. Attached are documents used to assist with filling in the paper. must use APA 7 f

APA Reference

(Include the GCU permalink or working link used to access the article.)

Research Questions/ Hypothesis, and Purpose/Aim of Study

Type of Primary Research Design

Research Methodology

• Setting/Sample (Type, country, number of participants in study)

• Methods (instruments used; state if instruments can be used in the DPI project)

• How was the data collected?

Interpretation of Data

(State p-value: acceptable range is p= 0.000 – p= 0.05

Outcomes/
Key Findings

(Succinctly states all study results applicable to the DPI Project.)

Limitations of Study and Biases

Recommendations for Future Research

Explanation of How the Article Supports Your Proposed Intervention

Hsieh, S. J., Otusanya, O., Gershengorn, H. B., Hope, A. A., Dayton, C., Levi, D., Garcia, M., Prince, D., Mills, M., Fein, D., Colman, S., & Gong, M. N. (2019). Staged implementation of awakening and breathing, coordination, delirium monitoring and management, and early mobilization bundle improves patient outcomes and reduces hospital costs. Critical Care Medicine, 47(7), 885–893. https://doi-org.lopes.idm.oclc.org/10.1097/CCM.0000000000003765

https://lopes.idm.oclc.org/login?url=https://search.ebscohost.com/login.aspx?direct=true&db=cmedm&AN=30985390&site=eds-live&scope=site&custid=s8333196&groupid=main&profile=eds1

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6579661/

The research question aimed at measuring the impact of staged implementation of complete versus virtual ABCDE bundle on mechanical ventilation (MV) duration, intensive care unit (ICU) and hospital length of stay(LOS), and cost

Prospective cohort study

The study included two medical ICUs within Montefiore Healthcare Center (Bronx, New York). The study also included 1855 mechanically ventilated patients admitted to ICUs between July 2011 - July 2014.

After early coordination (EC)

was implemented (period 2), 65% of patients stood, 54% walked

at least once during their ICU stay, and ICU-acquired pressure

ulcers and physical restraint use decreased (period 1 vs 2: 39%

vs 23% of patients; 30% vs 26% patient days, respectively; p <

0.001 for both). After adjustment for patient-level covariates, implementation

of the full (B-AD-EC) versus partial (B-AD) bundle

was associated with reduced mechanical ventilation duration

(–22.3%; 95% CI, –22.5% to –22.0%; p < 0.001), ICU length of

p<0.05

Early mobilization and coordination (EC) portrayed improvement of patients in ICU by 30%

Implementation of full (B-AD-EC) vs (B-AD) resulted to a decrease in MV duration.

Implementation of ABCDE bundle reduced total ICU and hospital cost by 24.2% and 30.2% respectively.

The study experienced the challenge of unmeasured changes which could have affected the results

The study also was conducted in a single medical center hence limiting generalizability.

The study also may have experienced cross-contamination of practices between two ICUs

The study was unable to compare costs between two seasonal periods due to cost-to-charge ratios changes hence study used smaller cohort for cost analyses.

The study did not collect all the data in the partial bundle ICU for comparison

There is need for physicians to acquire training on implementing ABCDE bundle to improve patient’s conditions on ICU and reduce length of hospital stay.

There is need for teamwork between physicians in ICU to enhance patient’s health and medication adherence.

There is need for improvement of working conditions in health facilities to safeguard patient’s health.

This article accessed the impact of implementing complete versus virtual ABCDE bundle on mechanical ventilation (MV) duration, intensive care Unit (ICU)and hospital length of stay (LOS), and cost.

However, the article has also determined that early mobilization and structured condition of ABCDE bundle results to a spontaneous awakening, breathing, and delirium management leading to reduced mechanical duration (MV), length of hospital stay and the cost.

Schallom, M., Tymkew, H., Vyers, K., Prentice, D., Sona, C., Norris, T., & Arroyo, C. (2020). Implementation of an interdisciplinary AACN early mobility protocol. Critical Care Nurse, 40(4), e7–e17. https://doi-org.lopes.idm.oclc.org/10.4037/ccn2020632

https://lopes.idm.oclc.org/login?url=https://search.ebscohost.com/login.aspx?direct=true&db=ccm&AN=146029040&site=eds-live&scope=site&custid=s8333196&groupid=main&profile=eds1

To examine the impact of an interdisciplinary mobility protocol in 7 specialty intensive care

units that previously implemented other bundle components.

quality improvement project using the American Association of Critical-Care Nurses

mobility protocol

The project was conducted at a 1200-bed, university affiliated level I trauma medical center in the Midwest

with 132 ICU beds at project initiation. QI

preintervention-postintervention design was used The American Association of Critical-Care Nurses (AACN) early progressive mobility protocol was used, The Richmond Agitation-Sedation Scale (RASS) The Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) was also used. All data were downloaded from REDCap into IBM SPSS Statistics, version 22 using descriptive statistics

Level of significance for pre-implementation post implementation

differences was set at a = 0.05.

(p <0.05)

In phase 1, the mean

(SD) mobility level increased in all intensive care units, from 1.45 (1.03) before to 1.64 (1.03) after implementation

(P < .001). Mean (SD) ICU Mobility Scale scores increased on initial evaluation from 4.4 (2.8)

to 5.0 (2.8) (P = .01) and at intensive care unit discharge from 6.4 (2.5) to 6.8 (2.3) (P = .04). Complications

occurred in 0.2% of patients mobilized. In phase 2, 84% of patients had out-of-bed activity after implementation.

The time to achieve mobility levels 2 to 4 decreased (P = .05). Intensive care unit length of stay

decreased significantly in both phases.

QI initiatives

using retrospective reviews of medical records The data we

extracted from the EMR were dependent on documentation

quality. Another limitation is fidelity to the intervention

implementation.

Implementing the ABCDEF bundle can produce significant impact on pt outcomes. Implementing the E and produce greater results

This study adds great significance to my DPI project as it clearly identifies implementation of the ABCDEF bundle can reduce length of stay in the ICU setting.

Frade-Mera, M. J., Arias-Rivera, S., Zaragoza-García, I., Martí, J. D., Gallart, E., San José-Arribas, A., Velasco-Sanz, T. R., Blazquez-Martínez, E., & Raurell-Torredà, M. (2022). The impact of ABCDE bundle implementation on patient outcomes: A nationwide cohort study. Nursing in Critical Care. https://doi-org.lopes.idm.oclc.org/10.1111/nicc.12740

https://lopes.idm.oclc.org/login?url=https://search.ebscohost.com/login.aspx?direct=true&db=cmedm&AN=34994034&site=eds-live&scope=site&custid=s8333196&groupid=main&profile=eds1

The aim of this study was to investigate the association between

patient outcomes (pain level, level of cooperation, patient days with

2 FRADE-MERA ET AL.

delirium, patient days with physical restraint, level of mobility, drug

levels of analgesia, sedatives, muscle relaxants, and antipsychotics,

need for re-intubation or tracheostomy, ICU length of stay in days,

IMV days, bed rest days, ICU mortality, and development of ICUacquired

muscle weakness (ICUAW)) and compliance with bundle

components ABC (analgosedation algorithms), D (delirium prevention

and management protocol), and E (early mobilization protocol).

A 4-month, prospective, observational, multicentre cohort study was

conducted in adult patients receiving IMV for at least 48 h in ICUs

across Spain.

531 patients Data were collected from day 3 of the ICU stay until extubation A Spanish multicentre cohort study of adult patients receiving invasive

mechanical ventilation (IMV) for ≥48 h until extubation.

Primary outcome Pain level, level of cooperation, incidence of delirium and physical restraints, and level of mobility related to the implementation of bundle components ABC, D, and E.

secondary outcome-Drug levels of analgesia, sedatives, muscle relaxants, and antipsychotics (cumulative drug dosing by IMV days   100) associated with

implementation of bundle components ABC, D, and E. Opioids were

calculated with morphine equivalents, and benzodiazepines with

midazolam equivalents

Tertiary outcome- Need for re-intubation or tracheostomy, ICU length of stay in days, IMV days, bed rest days, ICU mortality, and development of ICUAW

associated with implementation of bundle components ABC, D, and E.

The following indices and scores were applied: Charlson, Barthel,

Acute Physiology And Chronic Health Evaluation II (APACHE II),

and Sequential Organ Failure Assessment (SOFA).

Categorical variables were expressed as frequency and percentage,

using Fisher or Chi-squared test for between-group comparisons.

Groups were compared using the Student t test or

Mann-Whitney U test, depending on whether data followed a normal or

non-normal distribution; Data were analysed using IBM SPSS

Statistics 21.0 forWindows (SPSS Inc., Chicago IL, USA).

Patients had shorter stays in ICUs with bundle protocols and fewer days of IMV

in ICUs with delirium and mobilization bundle components (P = 0.006 and P = 0.03,

The implementation rate of ABCDE bundle components was very low

in our Spanish setting, but when implemented, patients had a shorter ICU stay, more

analgesia dosing, and lighter sedation.

unable to analyse the Richmond agitation-sedation scale

(RASS) results because the great majority were recorded in patients in

ICUs implementing protocols with analgosedation algorithms. very low implementation of delirium scales; did not analyse the use of SAT or SBT as a strategy in bundle components

ABC.

Applying some but not all the bundle components improves the quality

of care and the clinical outcome of critically ill patients.; agitation-sedation and delirium monitoring

should be reinforced,, physiotherapists need to be incorporated into ICU teams to

make early mobilization more efficient and effective.

patients in ICUs that apply protocols

have shorter ICU stays, this study adds to the growing body of evidence that supports my PICOT as it identifies that the use of bundle components in patients resulted in a shorter ICU stay, fewer IMV days, greater use of analgesia, and a change in sedation strategies, with decreased use of benzodiazepines, and increased use of dexmedetomidine and propofol- components of the ABCDEF bundle

* Collinsworth, A. W., Brown, R., Cole, L., Jungeblut, C., Kouznetsova, M., Qiu, T., Richter, K. M., Smith, S., & Masica, A. L. (2021). Implementation and routinization of the ABCDE bundle: A mixed methods evaluation. dimensions of critical care nursing : DCCN, 40(6), 333–344. https://doi-org.lopes.idm.oclc.org/10.1097/DCC.0000000000000495

https://lopes.idm.oclc.org/login?url=https://search.ebscohost.com/login.aspx?direct=true&db=cmedm&AN=34606224&site=eds-live&scope=site&custid=s8333196&groupid=main&profile=eds1

The study determines how to facilitate ABCDE bundle adoption by analyzing different implementation strategies on bundle adherence rates.

The study also aims at assessing clinician’s perception of the bundle and the implementation effort.

Mixed method eval

The study examined effect of 2 bundle implementation on 8 patient adults in ICU.

Electronic Health Record(EHR) modification was used as the primary strategy while enhanced strategy uses HER plus additional bundle training

84 nurses, therapists and physicians participated in the survey.

Effect of Basic vs Enhanced

Intervention on Bundle

Adherence ICU LOS 0.02 (0.01-0.02) <.0001a

(p <0.05

The response from the participants show that bundle use resulted in best care and patient outcomes.

After bundle implementation process, ICUs in both interventions showed improvement in bundle adherence

ICUs in the basic intervention outperformed others after initiating own implementation strategies.

Data collection was time consuming

The study acquired data through HER hence limited to evaluating some elements such as pain and sedation

Physicians response on bundle perception may be biased.

There is need for adequate training for physicians on how best to implement ABCDE bundle to improve care for patients

Promote teamwork to enhance coordination between healthcare professionals for easier implementation of ABCDE bundle.

The article highlights the effects of applying ABCDE bundle in healthcare for the patients in ICU

It scores the fact that proper implementation of ABCDE bundles results to improvement in nursing care and patient outcomes.

Pun, B. T., Balas, M. C., Barnes-Daly, M. A., Thompson, J. L., Aldrich, J. M., Barr, J., Byrum, D., Carson, S. S., Devlin, J. W., Engel, H. J., Esbrook, C. L., Hargett, K. D., Harmon, L., Hielsberg, C., Jackson, J. C., Kelly, T. L., Kumar, V., Millner, L., Morse, A., … Ely, E. W. (2019). Caring for critically ill patients with the ABCDEF bundle: Results of the ICU liberation collaborative in Over 15,000 adults. Critical Care Medicine, 47(1), 3–14. https://doi-org.lopes.idm.oclc.org/10.1097/CCM.0000000000003482

https://lopes.idm.oclc.org/login?url=https://search.ebscohost.com/login.aspx?direct=true&db=cmedm&AN=30339549&site=eds-live&scope=site&custid=s8333196&groupid=main&profile=eds1https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6298815

The study aim at evaluating the relationship between ABCDEF bundle performance and patient-centered outcomes in critical care.

Prospective cohort study from national quality improvement collaborative

The research collected a 20-month period data on 68 academics, community, and federal ICUs

The study also included 15226 patient adults and at least one ICU every day.

There was a consistent dose-response relationship between higher proportional bundle performance and improvements in each of the above-mentioned clinical outcomes (all p < 0.002). Significant pain was more frequently reported as bundle performance proportionally increased (p = 0.0001).

p < 0.002

Complete ABCDE bundle performance demonstrated a reduction in mortality rate within 7 days, mechanical ventilation, delirium and physical restraint use.

Patients also demonstrated an increased dose response relationship between higher proportion bundle performance.

Frequent pain was reported with increased bundle performance.

 The study did not use a randomized study design, nor did it have access to concurrent control.

ICU liberation collaborative included numerous ICU types as part of a larger effort to understand the impact of the ABCDE bundle on various types of critically ill patients while understanding the implementation strategies unique to each setting.

The patient-level outcomes are not wholly independent of one another and are assessed within a short time frame during which patients did not experience those outcomes.

The ICU liberation collaborative study lacked sufficient funds to support data accuracy

auditing.

Cohort analysis is from patient data collected within a larger QI project that collected a minimum and de-identified dataset, limiting the study’s ability to answer some questions.

Physicians ought to familiarize with ABCDE bundle performance to enhance patients’ dose adherence to the critically ill adults in ICU.

Physicians need to collaborate with other professionals in health sector and attend to ICU cases with open minded ready to learn from others.

The article analyzes measures to take in caring for the critically ill patients in ICU with ABCDEF bundle with reference to the results of the ICU liberation collaborative of over 15000 adults.

The article however outlined the relationship between ABCDEF bundle performance and patient centered outcomes in critical care.

Therefore, it is clear that ABCDEF bundle performance portray significant clinical improvements in patient survival, mechanical ventilation use, coma and delirium, restraint free care, ICU re-admissions and post ICU discharge disposition.

APA Reference

(Include the GCU permalink or working link used to access the article.)

Research Questions/ Hypothesis, and Purpose/Aim of Study

Type of Primary or Secondary Research Design

Research Methodology

• Setting/Sample (Type, country, number of participants in study)

• Methods (instruments used; state if instruments can be used in the DPI project)

• How was the data collected?

Interpretation of Data

(State p-value: acceptable range is p= 0.000 – p= 0.05)

Outcomes/
Key Findings

(Succinctly states all study results applicable to the DPI Project.)

Limitations of Study and Biases

Recommendations for Future Research

Explanation of How the Article Supports Your Proposed DPI Project

Barnes-Daly, M. A., Phillips, G., & Ely, E. W. (2017). Improving hospital survival and reducing brain dysfunction at seven California community hospitals: Implementing PAD guidelines via the ABCDEF bundle in 6,064 patients. Critical Care Medicine, 45(2), 171–178. https://doi-org.lopes.idm.oclc.org/10.1097/CCM.0000000000002149

https://ubccriticalcaremedicine.ca/academic/jc_article/Improving%20Hospital%20Survival%20and%20Reducing%20Brain%20Dysfunction%20(Jan-19-17).pdf

The research question was tailored on tracking compliance by an interprofessional team with the (ABCDEF) bundle in enforcing the Agitation, Pain, and Delirium procedures. The aim was to examine the connection between ABCDEF bundle compliance and consequences, including clinic survival and delirium-free and coma-free days in community infirmaries

A prospective cohort quality improvement initiative involving ICU patients.

1. Random selection of 1 patient from the daily census at each hospital

2. Study included patients who were 66 years or older with a diagnosis of AMI. Exclusion criteria included age <66 years, primary diagnosis of a noncardiac etiology (e.g., sepsis), and a transfer from another acute care hospital.

Data collection Data on patient characteristics, processes of care, and outcomes were collected during the baseline period (January 1, 2008, to July 31, 2009) and during the follow-up period (August 1, 2009, to September 30, 2011) for a total of 2 years of data.

For every 10% increase in total bundle compliance, patients

had a 7% higher odds of hospital survival (odds ratio, 1.07; 95%

CI, 1.04–1.11; p < 0.001). Likewise, for every 10% increase in partial

bundle compliance, patients had a 15% higher hospital survival

(odds ratio, 1.15; 95% CI, 1.09–1.22; p < 0.001). These results

were even more striking (12% and 23% higher odds of survival

per 10% increase in bundle compliance, respectively, p < 0.001)

in a sensitivity analysis removing ICU patients identified as receiving

palliative care. Patients experienced more days alive and free of

delirium and coma with both total bundle compliance (incident rate

ratio, 1.02; 95% CI, 1.01–1.04; p = 0.004) and partial bundle compliance

(incident rate ratio, 1.15; 95% CI, 1.09–1.22; p < 0.001).

P < 0.05 

The mortality rate for patients with sepsis was decreased by 42 percent (from 20.7 percent to 12.1 percent) in the 23 months after implementation of the ABCDEF bundle, compared with the 21 months before the institution of the bundle.

Mortality rates for patients with pneumonia were also lower after bundle implementation (35.4 percent before the intervention vs. 28 percent afterward)

The number of days’ patients spent in the intensive care unit within 30 days after arriving at the hospital was reduced by an average of 1.7 days for patients who had sepsis, and by an average of 1.5 days for those with pneumonia

The number of brain dysfunction events (such as coma, seizures, and infection) within 30 days after an ICU admission dropped by 36 percent improving Hospital Survival and Reducing Brain Dysfunction at Seven California Community Hospitals: Implementing PAD Guidelines Via the ABCDEF Bundle in 6,064 Patients.

First, this QI project lacked the strict protocols found in randomized, controlled trials.

The design and sample size benefits of the investigation did not trump other statistical concerns.

- Physicians need further education on guidelines and protocols, as well as how to collaborate with other physicians and experts.

- Physical environment needs to be improved along with an organized system for transferring patients.

- Physicians should be more open to changing their thought process.

- Better communication between nurse and physician needs to be encouraged, as well as between physicians and experts such as cardiologists.

The article describes the implementation of acute care for older adults’ guidelines at seven California community hospitals and has been used to determine whether a regional quality improvement initiative is associated with improved hospital survival, functional status, and intensive care unit (ICU) length of stay after acute myocardial infarction (AMI).

The article also determined whether a regional quality improvement initiative is associated with improved hospital survival, functional status, and ICU length of stay after AMI.

Balas, M. C., Tan, A., Pun, B. T., Ely, E. W., Carson, S. S., Mion, L., Barnes-Daly, M. A., & Vasilevskis, E. E. (2022) Effects of a national quality improvement collaborative on ABCDEF bundle implementation. American Journal of Critical Care, 31(1), 54–64. https://doi-org.lopes.idm.oclc.org/10.4037/ajcc2022768

https://aacnjournals.org/ajcconline/article-abstract/31/1/54/31644/Effects-of-a-National-Quality-Improvement?redirectedFrom=fulltext

What are the effect of quality improvement collaborative participation on ABCDEF bundle performance?

This study examined the NQIC's impact on the implementation of the six components of the ABCDEF Bundle in four types of hospitals:

The authors hypothesized that with an increase in safety culture, there would be an increased implementation of the ABCDEF Bundle.

• The purpose of this study was to determine whether the ABCDEF Bundle could be implemented in a variety of hospitals across the United States with a focus on safety culture.

Quasi-experimental design

This study used a non-experimental design to determine the impact of the ABCDEF Bundle on safety culture, defined as the degree to which a system is characterized by attention to safety in tasks, relationships, and attitudes. The study included 114 acute care hospitals that were participating in the NQIC.

In the ARISE and ProCESS trials, ABCDEF Bundle reduced ICU mortality by 12.6% (P=0.04) and hospital mortality by 15.1% (P=0.007)

Complete bundle performance increased by 2 percentage

points (SE, 0.9; P = .06) immediately after collaborative

initiation. Each subsequent month was associated with

an increase of 0.6 percentage points (SE, 0.2; P = .04).

Performance rates increased significantly immediately

after initiation for pain assessment (7.6% [SE, 2.0%],

P = .002), sedation assessment (9.1% [SE, 3.7%], P = .02),

and family engagement (7.8% [SE, 3%], P = .02) and then

increased monthly at the same speed as the trend in the

baseline period.

P <0.05 

Conclusion: These studies showed that the ABCDEF Bundle is associated with lower ICU and hospital mortality

The first limitation is that the study involved observational studies, and residual confounding cannot be omitted as an explanation for the observed changes in bundle performance.

Secondly, conclusions cannot be made on long-term sustainability despite ICUs demonstrating improvements during a 20-month period.

Authors should use an experimental research design

The language used should be simplified for easier understanding by all audience

The article provides information on reducing the use of common potentially preventable complications (PPCs) in acute care hospitals, connected to my DPI project. The Central Line Bundle demonstrated a 19% reduction in complications, and the ABCDEF Bundle demonstrated a 21% reduction. The ABCDEF Bundle can be implemented in various hospitals across the United States with a focus on safety culture, defined as the degree to which a system is characterized by attention to safety in tasks, relationships, and attitudes.

Negro,A., Cabrini, L., Lembo, R., Monti, G., Dossi, M., Perduca, A., Colombo,S., Marazzi, M., Villa,G., Manara, D., Landoni, G., & Zangrillo, A. (2018). Early progressive mobilization in the intensive care unit with out dedicated personnel. Canadian Journal of Critical Care Nursing, 29(3), 26–31.

https://lopes.idm.oclc.org/login?url=https://search.ebscohost.com/login.aspx?direct=true&db=ccm&AN=132043106&site=eds-live&scope=site

The purpose of this study was to assess the feasibility (meaning

the capability of performing advanced mobilization) and safety

(meaning the capability of avoiding adverse events during

mobilization) of an early progressive mobilization protocol,

focusing on the three most advanced steps (dangling, out-of bed

and walking) implemented without additional dedicated

personnel, as part of the ABCDE bundle.

observational study took place in the general ICU

482 of a 8 bed ICU over a one year period patients were admitted in

the ICU and 94(19.5%) were mobilized. Non-mobilized patients

were more frequently surgical patients. We conducted 356 mobilization sessions a teaching hospital in Italy.

Nurse led- mobility protocol, The protocol was entirely nurse-led and mobilization

was performed only with patients passing the safety checklist

derived from the original ABCDE protocol The mobilizations were considered

“early” only when the patient was mobilized for the first time

within 48 hours of admission using a mobilization diary; data was collected from March

2015 to March 2016: Categorical data are presented as absolute numbers and percentages

and compared by two tailed yl test or Fisher’s exact

test when appropriate. using the Mann-Whitney U test or T test if data were normally

distributed. Two-sided significance tests were used throughout.

A P-value less than 0.05 was considered statistically significant.

All statistical analyses were performed with the STATA software

(ver. 13; Texas USA).

A P-value less than 0.05 was considered statistically significant.

All statistical analyses were performed with the STATA software

(ver. 13; Texas USA).

Hospital length of stay, days mobilized 11(6-19)

Non-mobilized 25 (11-47) <0.001

The study found that there was a significant increase

over time of patients being mobilized while receiving mechanical

ventilation.

Mobilized patients had longer ICU and hospital length

of stay and a better ICU survival rate.

To note no adverse event

took place after the first three months, despite a growing number

of patients who were mobilized even while ventilated.

the implementation of an early and progressive

mobilization program in a mixed ICU proved feasible and safe even in its more advanced steps despite the lack of

additional personnel dedicated to mobilization, but the number

of mobilized patients was low

This study is a descriptive study that shows the experience

in a single ICU. Therefore, these results cannot be

generalized. lack of a historical control group weakens the studys

finding.

Further research is required to

evaluate the efficacy and generalizability of our strategy and the additional nurse-workload.

This study adds to the current growing body of research that supports the implementation of the ABCDEF bundle as all components were utilized with a special attention to early mobility – it supports its use as feasible , safe with the absence of PT while results demonstrated a decrease length of stay

DeMellow, J. M., Kim, T. Y., Romano, P. S., Drake, C., & Balas, M. C. (2020). Factors associated with ABCDE bundle adherence in critically ill adults requiring mechanical ventilation: An observational design. Intensive & Critical Care Nursing, 60. https://doi-org.lopes.idm.oclc.org/10.1016/j.iccn.2020.102873

https://lopes.idm.oclc.org/login?url=https://search.ebscohost.com/login.aspx?direct=true&db=edselp&AN=S0964339720300768&site=eds-live&scope=site&custid=s8333196&groupid=main&profile=eds1

https://pubmed.ncbi.nlm.nih.gov/32414557/

The study aim at identifying factors associated with ABCDEF bundle adherence in critically ill patients during the first 96hours of ventilation.

Observational using electronic health record data

The study used 15 ICUs located in seven community hospitals in western United States

The study also included 977 adult patients who were on mechanical ventilation for more than 24hours and admitted to an intensive care unit over the six months.

Multiple regression analysis was used to examine factors contributing to bundle

Adherence while adjusting for severity of illness, days on mechanical ventilation, hospital site and time elapsed.

ABCDEF bundle adherence was higher in patients on mechanical ventilation for less than 48 hours (p=0.01), who

received continuous sedation for less than 24 hours (p < 0.001), admitted from skilled nursing facilities (p<0.05),

and over the course of the six-month study period (p < 0.01). Bundle adherence was significantly lower for Hispanic patients (p < 0.01).

(p <0.05)

The observational results from the data identified that modifiable factors improved team’s performance of the ABCDEF bundle in critically ill patients in need of mechanical ventilation.

The study was restricted to EHR clinical data available hence managed to only evaluate assessment for pain, sedation, delirium, and mobility elements.

The study did not use analgesic infusions as sedation to determine duration of sedation and adherence of awakening trials.

The study was limited to the examination of the early 96hours on MV adherence to bundle by the care unit.

There is need for openness in data sharing among the physicians to develop a complete system that can identify all the factors associated with ABCDEF bundle adherence in severely ill patients

The article supports my DPI project since the article identifies the factors associated with ABCDEF bundle adherence in critically ill patients during the first 96 hours of ventilation.

The article supports the results that modifiable factors improve team’s performance of the ABCDE bundle in critically ill patients in mechanical ventilation.

Loberg, R. A., Smallheer, B. A., & Thompson, J. A. (2022). A quality improvement initiative to evaluate the effectiveness of the ABCDEF bundle on Sepsis outcomes. Critical Care Nursing Quarterly, 45(1), 42–53. https://doi-org.lopes.idm.oclc.org/10.1097/CNQ.0000000000000387

https://lopes.idm.oclc.org/login?url=https://search.ebscohost.com/login.aspx?direct=true&db=cmedm&AN=34818297&site=eds-live&scope=site&custid=s8333196&groupid=main&profile=eds1

https://pubmed.ncbi.nlm.nih.gov/34818297/

The study aims to determine how quality improvement initiative can evaluate the effectiveness of the ABCDEF bundle elements to improve clinical outcomes

Quality Improvement

Secondary research through sampling

Interventions was done in (609-bed) Midwest metropolitan hospital.

Pre-implementation data were collected between January 2019 and March 2019.

A pre/posttest design was used, and a convenience sample of all patients with sepsis admitted

ABCDEF bundle elements and improve clinical outcomes.

A significant improvement was seen in the completion of spontaneous awakening and

breathing trials (P = .002), delirium assessment (P = .041), and early mobility (P = .000), which

was associated with a reduction in mortality and 30-day readmission rates.

(p <0.05

The study results indicated overall implementation of ABCDEF bundle in the setting resulted to enhanced care delivery and improved clinical outcomes.

The QI initiative has problem with its generalizability

Lower than desired rate with bundle elements was experienced

The intervention was not designed as randomized controlled study but rather utilized as convenient sampling.

There is need to provide nursing care education to healthcare workers to implement the ABCDEF bundle since its implementation has a direct impact on enhancing care giving and clinical outcomes.

The government should support the implementation of the QI initiative to enhance quality care for patients.

The article is relevant to my DPI project since it outlines the guidelines on how best ABCDEF bundle can be applied in nursing to improve clinical outcomes.

Otusanya, O. T., Hsieh, S. J., Gong, M. N., & Gershengorn, H. B. (2021). Impact of ABCDE bundle implementation in the intensive care unit on specific patient costs. Journal of Intensive Care Medicine, 8850666211031813. https://doi-org.lopes.idm.oclc.org/10.1177/08850666211031813

https://lopes.idm.oclc.org/login?url=https://search.ebscohost.com/login.aspx?direct=true&db=cmedm&AN=34286609&site=eds-live&scope=site&custid=s8333196&groupid=main&profile=eds1

https://pubmed.ncbi.nlm.nih.gov/34286609/#:~:text=Conclusions%3A%20Full%20ABCDE%20bundle%20implementation,increase%20in%20physical%20therapy%20costs.

The study objective is to measure the impact of full versus partial ABCDE bundle implementation on specific cost centers and related resource utilization.

Retrospective cohort study

The study was conducted in two medical ICUs in Montefiore Health Systems

The study also involved 472 mechanically ventilated patients admitted in the ICU between 1st January 2013 and 31st December 2013.

Relative to the comparison ICU, implementation of the entire bundle in the intervention ICU was associated

with a 27.3% (95% CI: 9.9%, 41.3%; P   0.004) decrease in total hospital laboratory costs and a 2,888.6% (95% CI: 77.9%,

50,113.2%; P   0.018) increase in total hospital physical therapy costs. Cost of total hospital medications, diagnostic radiology and

respiratory therapy were unchanged. Relative to the comparison ICU, total hospital resource use decreased in the intervention

ICU (incidence rate ratio [95% CI], laboratory: 0.68 [0.54, 0.87], P   0.002; diagnostic radiology: 0.75 [0.59, 0.96], P   0.020).

(p <0.05)

There was a relationship between ABCDE bundle implementation and the cost

Relative to the comparison ICU, implementation of the entire bundle in the intervention resulted to a decrease of 27.3%in total hospital laboratory cost

Total hospital resource use resource use decreased in the intervention ICU.

The research data collection and analysis was only limited to two ICU centers.

There is need for teamwork between professionals in nursing to fully implement ABCDE bundle intervention to increase ICU discharges and reduce total hospitalization cost

Physicians also need conducive environment and support to fully implement ABCDE bundle in health centers

The article supports my DPI project as it focuses on how fully implementation of ABCDE bundle significantly reduces hospital laboratory costs and the hospital resource use also decreased.

van den Boogaard, M., Wassenaar, A., van Haren, F. M. P., Slooter, A. J. C., Jorens, P. G., van der Jagt, M., Simons, K. S., Egerod, I., Burry, L. D., Beishuizen, A., Pickkers, P., & Devlin, J. W. (2020). Influence of sedation on delirium recognition in critically ill patients: A multinational cohort study. Australian Critical Care, 33(5), 420–425. https://doi-org.lopes.idm.oclc.org/10.1016/j.aucc.2019.12.002

https://lopes.idm.oclc.org/login?url=https://search.ebscohost.com/login.aspx?direct=true&db=ccm&AN=145414398&site=eds-live&scope=site&custid=s8333196&groupid=main&profile=eds1

https://www.australiancriticalcare.com/article/S1036-7314(19)30131-6/pdf

The study aim to determine the association between level of sedation and delirium occurrence in critically ill patients

Observation of cohort study.

Patients aged above 18years from multinational ICUs participated since ICU patients are at risk of developing outcome of interest and delirium.

The study was a secondary analysis of a multinational prospective cohort study performed in 9 ICUs in different countries

Patients were assessed either through CAM-ICU or ICDSC

1660 patients were involved in the study.

Length of stay (ICU)

(p <0.05)

At a RASS of 0, assessment with the CAM-ICU (vs. the ICDSC) was associated with fewer positive delirium evaluations

The influence of level of sedation on delirium assessment depends on whether the CAM-ICU or ICDSC is used

The study based on comparison between sedation and delirium hence need to compare both CAM-ICU to ICDSC simultaneously and determine its impact on critically ill patients.

There is need to compare the CAM-ICU and ICDSC simultaneously in sedated and non-sedated ICU patients

There is need to offer training to nurses in intensive care units on how best sedation and delirium influence affects critically ill patients in ICU.

The article is relevant since it focuses on determining the influence of sedation on delirium which aligns with DPI project as heath care personnel.

Part 2 (3-09-2022)

Chen, C., Cheng, A., Chou, W., Selvam, P., & Cheng, C. M. (2021). Outcome of improved care bundle in acute respiratory failure patients. Nursing in Critical Care, 26(5), 380–385. https://doi-org.lopes.idm.oclc.org/10.1111/nicc.12530

https://lopes.idm.oclc.org/login?url=https://search.ebscohost.com/login.aspx?direct=true&db=a9h&AN=152166449&site=eds-live&scope=site&custid=s8333196&groupid=main&profile=eds1

This study aim is to determine if such an

improved ABCDE bundle would shorten ICU and hospital length of

stay (LOS) and lower medical costs and intra-hospital mortality

between phases 1 and 2 Pre/ post bundle.

retrospective, observational, before-and-after outcome study

The study included adult patients on MV (N = 173) admitted to a medical center ICU with 19 beds in southern Taiwan comprised of a multidisciplinary team (critical care nurse, nursing assistant, respiratory therapist, physical therapist, patient's family) performed ABCDE with early mobilization. The data were retrospectively collected. The study periods were divided into phase 1 (before ABCDE bundle,

from December 1, 2015 to March 31, 2016 phase 2 (after application of the ABCDE bundle, from October 1st to December 31st, 2016). Continuous data were compared

using two independent-sample t-tests with Bonferroni correction. Categorical variables were analysed using the chi-square or Fisher's

exact tests.

Significance was set at (p<0.05)

The ABCDE care bundle improved the outcome of acute renal failure

patients with MV, especially shortening ICU stays and lowering medical costs and

hospital mortality.

The patients in phase 2 had a significantly lower mean ICU length of stay (8.0 vs

12.0 days) but a similar MV duration (170.2 vs 188.1 hours), hospital stays (21.1 vs

23.3 days) with reduced costs (22.1 vs 31.7   104 NT$), and intra-hospital mortality

(8.3 vs. 36.6%).

First, findings are based on

the experience in a single ICU. Second, safety or

feasibility of early mobilization was considered. Third, physical function

before and after implementation of the care bundle was not measured and fourth, this

study was based on a retrospective design

This study adds the clinical outcomes (as a shortened duration of MV and ICU stays) of patients receiving an ABCDE care bundle with early mobilization and family member participation were improved.

This study adds the growing body of evidence that implementing An ABCDE care bundle with an inter-professional, evidence-based, multicomponent ICU management strategy can reduce unnecessary ICU and general hospital stays, hospital expenditure, and mortality among ARF patients on MV.

Collinsworth, A., Priest, E., & Masica, A. (2020). Evaluating the Cost-Effectiveness of the ABCDE Bundle: Impact of Bundle Adherence on Inpatient and 1-Year Mortality and Costs of Care*. Critical Care Medicine, 48(12), 1752-1759. https://doi.org/10.1097/ccm.0000000000004609

The research aim to determine

the impact of ABCDE processes on inpatient mortality,

LOS, discharge status, and direct costs of care

Retrospective Cohort study

The study included 2,953 patients, 18 years and above, with an ICU stay greater than 24 hours, who were on a ventilator for more than 24 hours and less than 14 days.

It also included 12 adult ICUs in six hospitals belonging to a large, integrated healthcare delivery system.

The Unadjusted and Adjusted

Effect of Bundle Adherence on Inpatient

Outcomes Length of stay (d) 0.64

(0.51–0.76)a

0.57

(0.45–0.69)a (p <0.05)

Differences in patient characteristics may have influenced bundle adherence rates, potentially overestimating the impact of improved bundle adherence on outcomes.

Physicians need support to fully implement ABCDE bundle since it is cost effective in reducing mortality rate in ICUs.

Programs on ABCDE bundle application should be integrated with curriculum to equip physicians with the skills.

My proposed DPI project focuses on the impact of ABCDE bundle on inpatient mortality LOS, discharge and its cost effectiveness which the article clearly outlines.

Ren, X. L., Li, J. H., Peng, C., Chen, H., Wang, H. X., Wei, X. L., & Cheng, Q. H. (2017). Effects of ABCDE bundle on hemodynamics in patients on mechanical ventilation. Medical science monitor : international medical journal of experimental and clinical research, 23, 4650–4656. https://doi.org/10.12659/msm.902872

to explore the influences of ABCDE bundle on the hemodynamics and prognosis of patients on mechanical ventilation

cross-sectional overall, before-after controlled study

143 patients on mechanical ventilation admitted at the ICU

Those admitted from May to December 2015 were classified into the pre-ABCDE bundle group (n=70) and received conventional sedation and analgesia; while those admitted from January to October 2016 were classified into the post-ABCDE bundle group (n=73) and received ABCDE bundle.

SPSS17.0 statistical software was used for statistical analysis. Repeated measures analysis of variance was used for comparison of repeated measurements, the t test was used for comparison of the means of 2 groups, and the χ2 test was used for comparison of the rates of both groups. P<0.05 was considered statistically significant.

(p <0.05)

The difference in the prognosis between the bundle and pre-ABCDE bundle groups was statistically significant (P<0.05), as the post-ABCDE bundle group had shorter duration of mechanical ventilation and length of ICU stay, as well as reduced 28-d mortality.

ABCDE bundle can significantly improve the hemodynamics indicators of patients on mechanical ventilation, reduce the dose of the sedatives and analgesics used, and keep the hemodynamics indicators, including MAP, CVP, and HR, at levels beneficial to patients

the ABCDE bundle is not only beneficial to the venous return, cardiac work, but also could protect the other organs, all of which could increase the oxygenation index and improve the circulatory function.

Non randomized

few studies have assessed the effects of hemodynamics more studies of this caliber need to be conducted to determine the hemodynamic affect the ABCDE bundle can have

ABCDE was implemented identifying significant substantial differences in pre/post bundle implementation that demonstrated to significantly improve the hemodynamics indicators of patients on mechanical ventilation, reduce the dose of the sedatives and analgesics used, and keep the hemodynamics indicators, and has shown to reduce LOS in the vulnerable patient population

Liu, K., Nakamura, K., Katsukawa, H., Nydahl, P., Ely, E. W., Kudchadkar, S. R., Takahashi, K., Elhadi, M., Gurjar, M., Leong, B. K., Chung, C. R., Balachandran, J., Inoue, S., Lefor, A. K., & Nishida, O. (2021). Implementation of the ABCDEF Bundle for Critically Ill ICU Patients During the COVID-19 Pandemic: A Multi-National 1-Day Point Prevalence Study. Frontiers in Medicine, 8, 735860. https://doi-org.lopes.idm.oclc.org/10.3389/fmed.2021.735860

https://lopes.idm.oclc.org/login?url=https://search.ebscohost.com/login.aspx?direct=true&db=cmedm&AN=34778298&site=eds-live&scope=site&custid=s8333196&groupid=main&profile=eds1

to investigate the implementation rate of evidence-based ICU

care for both patients without and with COVID-19 infections

and the impact of COVID-19 infections on implementation

on a world-wide scale to capture the current clinical practice

situation. We sought to identify ICU-related factors associated

with implementation in the ICU.

1-day point prevalence study,

The primary outcome was the implementation rate of the entire ABCDEF bundle. Secondary outcomes were the implementation rates for each element of the ABCDEF bundle, including element

A (regular pain assessment), element B [both spontaneous awakening trials (SAT) and spontaneous breathing trials (SBT)],

element C (regular sedation assessment), element D (regular

delirium assessment), element E (early mobility and exercise), and element F (family engagement and empowerment), and an ICU diary. the ABCDEF bundle, and the ICU diary between the groups of patients with out and with COVID-19 infections were made with the Mann-Whitney U-test for non-normally distributed continuous data and the chi-squared test and Fisher’s exact test for categorical data. The calculated sample size with 95% power and a two-sided alpha of 0.05 was 508 patients under the assumption of the implementation rate of the entire ABCDEF bundle for patients without and with COVID-19 infections

The p-value was reported as two-sided and p < 0.05 was

considered statistically significant.

Multidisciplinary rounds were

conducted significantly less frequently for patients with COVID-

19 infections (p = 0.004). Compared to before the pandemic,

family visiting hours to patients both without and with COVID-

19 infection were reduced (<0.001 and p = 0.004, respectively),

and more stringent restrictions imposed on families of patients

with COVID-19 infections (p < 0.001).

There were significant differences in the demographics of

the two groups for ICU length of stay, age, BMI, gender, use

of mechanical ventilation (49 vs. 66%)

Comparison of delirium incidence, 28-d survival, mechanical ventilation duration, and length of ICU stay between 2 groups showed that the delirium incidence in the pre-ABCDE bundle group was higher than in the post-ABCDE bundle group, while the prognostic indicators in the post-ABCDE bundle group were better than in the pre-ABCDE bundle group, and the difference was statistically significant (P<0.05,

ABCDE bundle can significantly improve the hemodynamics indicators of patients on mechanical ventilation, reduce the dose of the sedatives and analgesics used, and keep the hemodynamics indicators, including MAP, CVP, and HR, at levels beneficial to patients

First, the

limited number of patients and participating countries (Japan

accounts for 40%) could lead to selection bias and limit

generalizability to other ICUs and countries. Second, the nature of a point prevalence study does not define

a causal relationship and reflects the overwhelming situation

at participating sites. This point prevalence study took place

entirely on 1 day. Third, potential confounding factors associated

with implementation, such as disease-related factors, were not

investigated. Finally, an odds ratio with a relatively broad

confidence interval may indicate an unstable model created

by multivariate analysis.

As the guideline suggests, it is important to note that evidence based

ICU care, such as the ABCDEF bundle and ICU diary,

should be incorporated into clinical practice for all ICU patients

regardless of their underlying diseases or the ICU length of stay

These results particularly

show that a promising strategy to introduce or implement a

specific element of the bundle in an ICU could vary and should

be designed depending on the context and local situation in

which it will be implemented.

COVID- 19 infection was not a barrier to the implementation of each

element of the ABCDEF bundle. This study had a different approach other than mobility, but included the use of a diary (the F) of the bundle .It added to growing evidence the use of the bundle can reduce length of stay and make noted low or incomplete implementation can result in longer hospitalization , it identified the bundle as a cohesiveness to reduce LOS

Louzon, P., Jennings, H., Ali, M., & Kraisinger, M. (2017). Impact of pharmacist management of pain, agitation, and delirium in the intensive care unit through participation in multidisciplinary bundle rounds. American Journal of Health-System Pharmacy, 74(4), 253–262. https://doi-org.lopes.idm.oclc.org/10.2146/ajhp150942 https://lopes.idm.oclc.org/login?url=https://search.ebscohost.com/login.aspx?direct=true&db=a9h&AN=121191406&site=eds-live&scope=site&custid=s8333196&groupid=main&profile=eds1

sought to improve LOS and ventilator day

measures, reduce hospital expenditures,

and advance pharmacists’

scope of practice within a large community

teaching hospital.

A two-phase program a retrospective cohort study

This study included 436. Patients manged with the ABCDEF bundle and 499 patients of those with standard care. In. Florida hospital in the US. Steps to implement this program

occurred in two phases. Phase 1 involved

an initial pilot program designed

to allow ICU pharmacists to

directly manage sedative therapy for

mechanically ventilated patients in

collaboration with an intensivist. In

phase 2, that initiative was expanded

to include comprehensive pharmacist

PAD management as well as the development

of a multispecialty interprofessional

team to encourage early

mobilization of mechanically ventilated

patients. This study used the APACHE outcomes tool for managing critical care outcomes methodology

Variables were compared between the two treatment

groups using Student’s t test for continuous

data and a chi-square test of

independence (Fisher’s exact test) for

categorical data.

P < 0.05

Patients who

received care via the pharmacist directed

sedation management strategy

were exposed to a mean of 102 fewer

hours of continuous sedation, a 40.4%

reduction relative to mean hours in

the standard-care cohort (p = 0.0025);

intervention-group

patients had a reduction of 1.2 ventilator

days, which did not reach statistical

significance (mean, 8.6 days versus

7.4 days; p = 0.07); however, this was

considered a clinically important difference

due to the potential impact on

ICU resource consumption and ICU

LOS.

Mean

ICU LOS did not significantly change

with the use of the ABCDE bundle

versus standard care (4.6 days versus

4.3 days, p = 0.26), but the APACHE

ratio for ICU LOS was significantly decreased,

from 0.96 to 0.81 (p = 0.02).

The objective was to

determine the effects of pharmacist directed

sedation management on use

of continuous sedation, hospital LOS,

and ventilator days. Secondary endpoints

were as follows: total amount

of sedation used, ICU LOS, ventilator

days, number of Richmond Agitation

Sedation Scale (RASS) scores greater

than +1, and reintubation rates.

The previous culture of deeper

sedation and continuous infusions of

analgesic and sedative regimens was

engrained in the daily processes of the

ICU team. Introducing a new culture

took intensive continuing education

and daily reinforcement of concepts.

Some physicians were initially hesitant

to support increased pharmacist

involvement in management of their

patients; challenge was the need

to dedicate limited ICU pharmacist

resources to a new daily patient care

service.

Delirium

screening was not fully implemented

until phase 2 of the project, so comparative

data on the impact of screening

were not available for analysis in

the cohort study; this is an area for

future study.

This study was significant or its number of participants in this cohort study that demonstrated the use to bundle with the assist of pharmacist managing sedative implementing mobility demonstrated decrease ventilation days and decrease LOS decrease hospital cost by 46% an estimatd saving of 1.2million dollars.

Sinvani, L., Kozikowski, A., Patel, V., Mulvany, C., Talukder, D., & Akerman, M. et al. (2018). Nonadherence to Geriatric-Focused Practices in Older Intensive Care Unit Survivors. American Journal Of Critical Care, 27(5), 354-361. https://doi.org/10.4037/ajcc2018363

The study aim at exploring geriatric-focused practices and associated outcomes in older intensive care survivors.

retrospective, cohort study

The study included 179 older adults with a mean age of 80.2 years

Bladder catheters were associated with hospital-acquired pressure injuries.

In A total of 179 patients (mean age, 80.5 years)

met inclusion criteria. Nonadherence to geriatric-focused

practices, including nothing by mouth (P = .004), exposure

to benzodiazepines (P = .007), and use of restraints

(P < .001), were associated with longer stay in the intensive

care unit. Nothing by mouth (P = .002) and restraint

use (P = .003) were significantly associated with longer

hospital stays. (P<.05)

The study indicated high levels of non-adherence to geriatric-focused practices depending on hospital length of stay.

The data was collected retrospectively from one site.

Multiple studies in outpatients and inpatients, but not in ICU patients, have indicated better compliance with general medical best practices than with geriatric focused practices.

Since half of the ICUs are occupied by older adults, there is need to train healthcare providers geriatric focused practices to cater for the elderly.

Healthcare workers need to go for a thorough training on ICU safety measures to cater for the elderly to improve clinical outcomes.

There is need to increase number of geriatric health care providers dedicated to the care of hospitalized older adults to meet the growing demands of the aging population.

The article is relevant to my DPI project as a healthcare worker since it explores geriatric-focused practices and the associated outcomes for older adults in ICU survivors. The practices can be used to care for the elderly adults visiting ICUs to improve their medical adherence. The aim

of the ABCDEF bundle is to improve adherence to

best practices, they are geared to the general adult

population, in this study it was used to manage

specific needs of geriatric patients. This study foion the geriatric population of ICU survivors to assess the association between nonadherence to geriatric focused practices such as delirium, early mobility and clinic outcomes one being LOS

Trogrlić, Z., van der Jagt, M., Lingsma, H., Gommers, D., Ponssen, H., & Schoonderbeek, J. et al. (2019). Improved Guideline Adherence and Reduced Brain Dysfunction After a Multicenter Multifaceted Implementation of ICU Delirium Guidelines in 3,930 Patients. Critical Care Medicine, 47(3), 419-427. https://doi.org/10.1097/ccm.0000000000003596

The study aim to evaluate the impact of a tailored multifaceted implementation program of ICU delirium guidelines on processes of care and clinical outcomes and draw lessons regarding guideline implementation.

Prospective cohort study

The study involved ICUs in one university hospital and five community hospitals.

Consecutive medical and surgical critically ill patients were enrolled between April 1, 2012, and February 1, 2015.

A total of 3,930 patients were included in the study.

To examine between-group differences,

The stude used Kruskal-Wallis test for nonparametric analyses.

Differences in clinical outcomes between the three phases were assessed with adjusted regression models. Poisson regression was used for count data (e.g., number of delirium assessments per day), logistic regression for binary outcomes, and linear regression

for continuous outcomes.

(P<.05)

The primary outcome was

adherence changes to delirium guidelines recommendations,

based on the Pain, Agitation and Delirium guidelines. Secondary

outcomes were brain dysfunction (delirium or coma), length of

ICU stay, and hospital mortality. A total of 3,930 patients were

included. Improvements after the implementation pertained

to delirium screening (from 35% to 96%; p < 0.001), use of

benzodiazepines for continuous sedation (from 36% to 17%;

p < 0.001), light sedation of ventilated patients (from 55% to

61%; p < 0.001), physiotherapy (from 21% to 48%; p < 0.001),

and early mobilization (from 10% to 19%; p < 0.001). Brain dysfunction

improved: the mean delirium duration decreased from 5.6 to 3.3 days (–2.2 d; 95% CI, –3.2 to –1.3; p < 0.001), and coma days decreased from 14% to 9% (risk ratio, 0.5; 95% CI,

0.4–0.6; p < 0.001). Other clinical outcome measures, such as

length of mechanical ventilation, length of ICU stay, and hospital

mortality, did not change

ICU length of stay (d),

mean (sd)

PHASE 1= 1,337 4.9 (6.9) PHASE 2=1,399 4.3 (6.0) PHASE 3=,194 4.8 (5.9)

ADJUSTED OR.RATE RATIO BETAa

a) –0.3 (–0.8 to 0.1; p = 0.19)

b) –0.1 (–0.6 to 0.3; p = 0.56)

c) 0.2 (–0.3 to 0.6; p = 0.49)

Delirium screening increased from 35% to 93%

Continuous IV benzodiazepine sedation decreased from 36% to 31% to 17%.

Physical therapy (PT), early mobilization of patients, sedation assessments, and light sedation improved significantly.

The duration of delirium decreased over three periods after guideline implementation.

Other clinical outcome measures, such as

length of mechanical ventilation, length of ICU stay, and hospital

mortality, did not change.

the participating ICUs already

applied light sedation practices in general, it was decided not to

focus strongly on safety screens for Spontaneous Awakening

Trials (SATs) and Spontaneous Breathing Trials (SBTs), which

may have precluded improvements of the secondary outcomes,

such as length of ventilation, ICU stay, or mortality. In the study, the Hawthorne effect was not avoided, seeing that delirium screening implementation alone resulted in improved adherence to several guideline recommendations.

duration of delirium might be a doubtful outcome parameter due to the difference between a clinical diagnosis as assessed by chart review at baseline compared with the second and third phases.

Certain changes over time may have been overestimated in the presence of secular trends

Since implementation of delirium guidelines in ICUs resulted to a decrease in brain dysfunction outcome, there is need for clearer guidelines to improve clinical care adherence and overall outcome.

Collaboration between healthcare professionals is also paramount to the success of the guidelines implementation process.

There is need for additional health professionals to care for the ICU patients by screening delirium to boost the clinical outcomes.

This article is in line with my DPI project as healthcare professional as it gives tips on how best ICU delirium guidelines can be integrated to improve patient’s clinical adherence.

This study showed that the implementation of the ABCDEF bundle

had improved health professionals’ adherence to delirium guidelines, which was linked to reduced brain dysfunction which link to decrease ICU stay

data from this study added to existing implementation literature strongly enhancing translatability of findings. the feasibility of staggered versus

simultaneous implementation of bundle elements, that seem strongly dependent on local resources (e.g., “local champions” vs interprofessional implementation teams or level of previous

experience with the guidelines), and 2) the fact that our “error of omission” of daily safety screens for SATs and SBTs may have precluded concurrently improved clinical outcomes, adding strong empirical support from a “real-life setting” for effectiveness

of individual ABCDE bundle elements.

Zhang, S., Han, Y., Xiao, Q., Li, H., & Wu, Y. (2021). Effectiveness of Bundle Interventions on ICU Delirium: A Meta-Analysis*. Critical Care Medicine, 49(2), 335-346. https://doi.org/10.1097/ccm.0000000000004773

This study aim at evaluating the impact of bundle interventions on ICU delirium prevalence, duration, and other patients’ adverse outcomes.

Meta-Analysis

The study involved using a standardized data collection where two authors extracted data independently

A total of 26,384 adult participants were included in the meta-analysis.

The study data sources included, the Cochrane Library, PubMed, CINAHL, EMBASE, PsychINFO, and MEDLINE from January 2000 to July 2020.

(P<0.05)

Add interpretation

There were

nine studies (seven RCTs and two cohort studies) reporting

results on the ICU LOS. With a total of 5,184

ICU patients included in the meta-analysis using a

random-effects model, the pooled result showed that

the MD was 1.08 days shorter (95% CI, –2.16 to 0.00;

p = 0.05)

In addition, five studies (four RCTs and one cohort

study) measured hospital LOS (Table 2), and the

meta-analysis using a fixed-effects model (I2 = 42%;

p = 0.14) found that the MD of hospital LOS was

1.47 (95% CI, –2.80 to –0.15; p = 0.03) days shorter

among 726 ICU patients in the intervention group

compared with patients in the control group

The two cohort studies that applied bundle interventions lowered the ICU delirium prevalence by 8% but no significant differences were detected.

The study indicated that bundle interventions are effective in reducing the proportion of patient-days experiencing coma, hospital length of stay, 28-day mortality and mechanical ventilation.

In ICU Delirium Duration, there was no difference identified between participants in the bundle intervention group

The study included both RCT and cohort studies in the current analysis, and heterogeneity was identified among studies in terms of results on the ICU delirium prevalence and duration, MV days, ICU, or hospital LOS.

The number of studies included in the current analysis reporting outcomes on ICU mortality is small, which may have insufficient power to assess the differences and limited the interpretation of our pooled data.

Although some studies reported coma-related outcomes, we failed to combine these data for analysis due to different presented data formats.

Majority of the studies in this analysis did not include all elements of the bundle approach, the modifiable risk factors identified by the PADIS Guidelines are not fully addressed in the interventions.

Further studies should be conducted to evaluate a more modifiable risk factors for ICU Delirium intervention to enhance bundle effectiveness.

A more rigorous RCTs and full implementation of ABCDEF bundle should be considered to test effect of ICU intervention.

Clinicians should regularly attend training on implementation of bundle intervention to improve ICU clinical outcomes.

This study highlights the impacts of bundle interventions on ICU delirium prevalence, duration and other patient’s adverse outcomes. The impacts highlighted in the article are vital for my DPI project in healthcare as it enhances my knowledge on how best ICU conditions can be improved to yield a positive outcome.

Nursing Theory Selected

APA Reference – Seminal Research References

(Include the GCU permalink or working link used to access each article.)

Explanation for the Nursing Theory Guides the Practice Aspect of the DPI Project

Virginia Henderson’s Nursing Needs Theory

Ahtisham, Y., & Jacoline, S. (2015). Integrating Nursing Theory and Process into Practice; Virginia’s Henderson Need Theory. International Journal of Caring Sciences, 8(2), 443–450.

https://lopes.idm.oclc.org/login?url=https://search.ebscohost.com/login.aspx?direct=true&db=ccm&AN=102972280&site=eds-live&scope=site&custid=s8333196&groupid=main&profile=eds1

Virginia Henderson Nursing Needs Theory will be used to guide the DPI project. Henderson identified the unique function of the nurse is to assist the individual, sick or well, in the performance of those activities contributing to health or its recovery (or to peaceful death) that he would

perform unaided if he had the necessary strength, will or knowledge. And to do this in such a way as to help him gain independence as rapidly as possible (Henderson, 1966). Henderson named her theory The Nursing Needs Theory as it categorizes nursing into fourteen components based on human needs such as (Ahtisham & Jacoline, 2015). The first nine are physiological, such as breathing normally, eating and drinking adequately, excretion, mobility and maintaining body postures, enough sleep and rest, suitable clothing, maintaining body temperatures by wearing different clothes in different environments, maintaining body hygiene and avoiding dangers both personal and from endangering others. The 10th and 14th are psychological aspects of learning and communication, such as in expression of emotions, fears or needs through communication, the11th is worshipping, working in a way to express a sense of accomplishment, participating in various recreational activities (Ahtisham & Jacoline, 2015). Henderson viewed the nursing process as an application of the logical approach to the solution of the problem (Ahtisham & Jacoline, 2015). Implementing this theory in the DPI project will aid nursing in the implementation of the ABCDEF bundle successfully.

Change Theory Selected

APA Reference - Seminal Research References

(Include the GCU permalink or working link used to access each article.)

Explanation for How the Change Theory Outlines the Strategies for Implementing the Proposed Intervention

John Kotter’s Change Model

Kang, S. P., Chen, Y., Svihla, V., Gallup, A., Ferris, K., & Datye, A. K. (2022). Guiding change in higher education: an emergent, iterative application of Kotter’s change model. Studies in Higher Education, 47(2), 270–289. https://doi-org.lopes.idm.oclc.org/10.1080/03075079.2020.1741540

https://lopes.idm.oclc.org/login?url=https://search.ebscohost.com/login.aspx?direct=true&db=ehh&AN=155185571&site=eds-live&scope=site&custid=s8333196&groupid=main&profile=eds1

John Kotter’s 8 step change processes applies to implement change (Kotter, 2012). These strategies can be applied in implementing the ABCDEF bundle to decrease LOS. According to Kotter (2012) the first step is creating urgency. Kang et al., (2022) provides an explanation of the theory. According to Kang et al., (2022) first, there is a need to develop urgency for the proposed interventions. This is possible by identifying the existing threats caring for patients. Therefore, discuss the weaknesses with the stakeholders and colleagues and ask for their support to implement the change. Secondly, put together a guiding coalition. Come up with a group of competent leaders and professionals to steer the agenda to influence the stakeholders. Thirdly develop vision and strategies. In this step, come up with a clear vision of how the organization will look if the change is implemented. A clear vision of how the health sector would look after implementing intervention will enhance action and decision-making. The next step is communicating the change vision. In this step, communicate to capture the hearts of other health workers to support the change. The next step is avoiding barriers. The guiding team avoids barriers from the change to drum up support for the change. The next step is accomplishing short-term wins. These short-term wins serve as encouragement and should be related to the change. E.g., win by demonstrating the effectiveness of the proposed intervention. The next step is building on the change. This step ensures the team is overworking to achieve the change and measure progress. The last step is to make change stick. He re-ensure that everyone adapts to new change by illustrating its importance, training them the skills necessary to maintain the new change. These steps will be used to implement unit change, implementing the ABCDEF bundle for the DPI project.

APA Reference -
Clinical Guideline

(Include the GCU permalink or working link used to access the article.)

APA Reference -
Original Research (All)

(Include the GCU permalink or working link used to access the article.)

Explanation for How Clinical Practice Guidelines Align to DPI Project