You must fill in only ONE column on the Literature review table identifying each article's ( Research question/hypothesis). The purpose has been done. Replace one article that is not a retrospective s

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

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

Research question: Will the implementation of the ABCDE bundle decrease LOS, mechanical ventilation

Hypothesis: The study hypothesizes that the implementation of early mobilization on a foundation of targeted sedation practices and routine delirium monitoring would improve clinical outcomes such as mechanical ventilation duration, ICU and hospital length of stay and cost.

Purpose: The authors sought to determine the impact of adding early mobilization, coordination of components to breathing trial and awakening and delirium in the context of staged implementation of the ABCDE bundle in mechanically ventilated (MV) patients,

Prospective cohort study

The study included two medical ICUs within Montefiore Healthcare Center (Bronx, New York). The cohort consisted of all adult mechanical ventilated patients divided into two groups, a complete bundle staffed by medical residents and a partial bundle staffed by physician assistants. Participants were in the ICU for greater than 24hrs, the study period from July 2011 – June 2014, 1,855 were admitted to the full, and 819 underwent partial bundle elements. The complete bundle had younger patients, minor minorities, more comorbidities, higher severity of illness, and fewer lives at home before hospitalization. The study used unadjusted clinical outcomes and periods using descriptive statistics, non-parametric, and a multivariable regression model using the difference-in-difference (DiD) approach.

Data were extracted from electronic medical records using healthcare surveillance software. The collected data were collected for 12 months after protocol implementation. The study was further divided into four phases for data collection. Phase one was collected on all ICU patients for 24 hrs. or more for two months before and two months after implementation. In phase two, data were collected monthly on 20 randomly selected patients in the ICU for three days or more for two months before and 12 months after implementation.

The EHR and descriptive statistics could both be used in the DPI project.

Duration of MV and ICU LOS significantly changed in the full bundle ICU but not in the partial bundle

ICU across three periods ICU LOS was significantly shorter across all three periods in

the full versus partial bundle ICU (p < 0.001)

The primary outcome of interest was the hospital length of stay (LOS). 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. The implementation of ABCDE bundle reduced total ICU and hospital cost by 24.2% and 30.2% respectively.

The study experienced the challenges 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

The study identified the need for further research to include an assessment of patient-centered outcomes such as short and long-term disability and readmission rate and cost analysis identifying the benefit of the ABCDE bundle. Since this study, the (F) family has been included. Future studies must include the F and its impact on LOS and clinical outcomes.

This article assessed the impact of implementing complete versus partial ABCDE bundle elements on mechanical ventilation (MV) duration, intensive care Unit (ICU)and hospital length of stay (LOS), and cost. The study demonstrates that the ABCDE bundle can be successfully early mobilization led to substantial reductions in MV duration, LOS, and hospital cost, liberated patients from restraints, and reduced iatrogenic complications. Most importantly identified that the entire bundle is more impactful than individual elements

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

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Research question:

Hypothesis:

Purpose: The purpose of this quality improvement project is to examine the impact of an interdisciplinary mobility protocol in specialty intensive care

units (ICU’s).

The study is a quality improvement project using the American Association of Critical-Care Nurses

mobility protocol

The quality improvement (QI) project was conducted at a 1200-bed, university-affiliated level I trauma medical center in the Midwest with 132 ICU beds at project initiation. The study used a preintervention-postintervention design using a staggered approach across different units.

The study used evidence-based tools such as the American Association of Critical-Care Nurses (AACN) early progressive mobility protocol, the Richmond Agitation-Sedation Scale (RASS), and the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) and the ICU Mobility Scale (IMS). All data were downloaded from REDCap into IBM SPSS Statistics, version 22, using descriptive statistics; descriptive statistics were calculated mean SD for continuous variables – dichotomous, nominal, and ordinal.

The EHR was the main instrument used in this study that can also be used in this DPI project along with RASS , CAM-ICU

ICU LOS decreased non significantly overall and decreased significantly in the ICUs without dedicated physical therapists (PT) at baseline. The units with dedicated PTs, had a mean (SD) decrease in LOS of more than 1 day, from 6.26 (6.05) to 5.00 (5.15) (p = .01).

The study observed decreased in ICU LOS in both phases and a non-significant decrease in hospital LOS in phase two. Introduction of a standardized early mobility protocol increased the number of patients achieving ambulation and resulted in additional improved outcomes, including decreased delirium days and decreased ICU and hospital LOS.

This study is not without limitations. The study design, a QI initiative, retrospective data can result in incomplete data.

The data was

extracted from the EMR were dependent on documentation it is contingent on accurate data entry and retrieval which may limit the final results due to inaccurate data.

Another limitation is fidelity to the intervention

implementation

More support is needed to demonstrate the effectiveness of full bundle implementation.

This study adds great significance to the DPI project as it identifies decreased length of stay in both phases of the study through the implementation of a nurse-driven early mobility

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

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Research question:

Hypothesis:

Purpose: The purpose of this study was to investigate the association between

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

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 ICU acquired

muscle weakness (ICUAW)) and compliance with bundle

components ABC (analgosedation algorithms), D (delirium prevention

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

A prospective, observational, multicenter cohort study

The study included 605 patients from 80 ICUs in Spain in different Spanish multicenter ICUs receiving invasive mechanical ventilation for at least 48hrs.

Patients’ data were collected from day three of the ICU stay until extubation. Categorical variables were expressed as frequency and percentage, using Fisher or Chi-squared test for between-group comparisons. Quantitative variables were expressed as mean and standard deviation (SD) or median and percentile, as 25 to 75 or 10 to 90 percentile ranges, depending on the distribution, which was analyzed with the Kolmogorov Smirnov test for large sample sizes (n ≥ 30) or the Shapiro-Wilk test for small samples (n < 30). Groups were compared using the student t-test or Mann-Whitney U test. Data were analyzed using IBM SPSS Statistics. The instruments used in this study can also be used in this DPI project, except the Kolmogorov-Smirnov test and the EHR for data collection. 

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,

Tertiary outcomes, ICU length of stay in days was decreased.

The intended Richmond Agitation Sedation Scale (RASS) a valid tool of ABCDE bundle was not implemented due to use of a protocol for analgosedation algorithms. Another limitation, decrease use of the delirium scale due to its subjectively o of the observer. The spontaneous breathing trial and spontaneous awakening trial was replaced with the analgosedation protocol. because the great majority were recorded in patients in

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

In this study the authors identified the need of a nurse-guided algorithm to minimize sedation and incorporating physiotherapist in ICU teams to make to initiate early mobility.

This study adds merit to the DPI project as it identifies that the ABDCE bundle decreases LOS in ICU when all elements are implemented. This study adds to the growing body of evidence supporting the PICOT as it identifies that using bundle components in patients results in a shorter ICU LOS. In addition, the bundle demonstrates fewer invasive mechanical ventilation days, decreased 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., 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

Research Question:

Hypothesis:

Purpose: The research aim to determine

the impact of ABCDE processes on inpatient mortality,

LOS, discharge status, and direct costs of care as a basis to evaluate the cost-effectiveness of the bundle adherence.

This is a prospective study

The study included 2,953 patients. Patients were recruited from a large, urban tertiary referral center and five community hospitals. ICUs included medical/surgical, trauma, neurologic, and cardiac care units from July 2013 to June 2015; of those 18 years old and older with an ICU admission greater than 24hrs, mechanically ventilated greater than 24 hrs, and less than 14 days were included. Outcomes data were collected from the EHR and administrative databases. The study compared differences in continuous variables and outcomes that did not violate normality assumptions with independent t-tests and differences in categorical variables and outcomes with chi-square and Fisher exact tests. Instruments in this study can also be used in the DPI project. 

Hospital LOS and direct costs were significantly higher in patients with bundle adherence greater than or equal to 60%, after risk adjustment

<60% compliance vs > 60% compliance, 9.9(7.0) vs 12.3 (6.8)

p<0.001

The study highlighted patients with high bundle compliance >60% had decrease mortality and decrease in LOS

The limitations in this study were the study design. The severity of illness of each patient was not taken into consideration

Further research is needed to obtain estimates of the bundle effect and its cost over a longer period of time.

This study continues to add to the growing research that the ABCDE bundle compliance decreases mortality, decrease cost and decrease LOS.

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

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Research question:

Hypothesis:

Purpose: The study aim at evaluating the relationship between ABCDEF bundle performance and patient, symptom and healthcare system related outcomes.The study hypothesized that complete and dose-related (i.e., proportional) performance of the ABCDEF bundle would be associated with improved clinical outcomes across these three domains

Prospective cohort study from national quality improvement collaborative

The study included 15226 adult patients on and off mechanical ventilation admitted to a participating medical, surgical, cardiac, or neurology ICU. The study included a total of 20 months of data collected per site. Data included six months of retrospectively collected data from (January 2015−June 2015) and 14 months of prospectively collected data (January 2016–March 2017) from 68 academics, community, and Veterans Administration ICUs from 29 states and Puerto Rico. Data was collected using the Research Electronic Data Capture (REDCap), a secure, web-based application for validated data entry, transmission, and storage. During the retrospective periods, five patients’ data were entered on those admitted to the ICU each month for 30 baseline patients per site. Throughout the prospective period, data was collected in the first 15 months. Data was collected for a maximum of seven ICU days. The study used Cox proportional hazards models with time-varying covariates for these outcomes. The study used R Project for Statistical Computing software version 3.4 for all analyses. The study used a specific data collection instrument. This instrument cannot be used in the DPI project.

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).

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 need to become 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.

This large-scale study adds to the growing evidence supporting the ABCDEF bundle. The art outlined the relationship between ABCDEF bundle performance and patient-centered outcomes in critical care. Therefore, it is clear that ABCDEF bundle performance portrays 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

Research question:

Hypothesis:

Purpose: The aim was to study the relationship between ABCDEF bundle compliance and outcomes including hospital survival and delirium-free and coma-free days

A prospective cohort quality improvement initiative involving ICU patients.

This study occurred in seven community hospitals within California’s Sutter Health System in ICUs ranging from six to 16 beds. The population consisted of medical and surgical ICU patients, ventilated and non-ventilated, between January 1, 2014, and December 31, 2014. The study enrolled 6,6064 patients. The ABCDEF bundle was implemented on each patient every day. The study was designed to utilize an interprofessional team (IPT) model. The team consisted of a dedicated registered nurse (RN), an administrative RN, a pharmacist, a physical therapist, a respiratory care practitioner, and an ICU physician. Data were collected each day by the IPT RN in each ICU during daily rounds and entered into an electronic data collection tool (MIDAS; Kitware, Clifton Park, NY). The data was presented in monthly dashboards that tracked total and partial bundle compliance and patient outcome data. Analyses addressed the relationship between bundle compliance (independent variable) versus hospital survival and delirium-free and coma-free days (DFCFDs) (two dependent/outcome variables). The two outcomes were regressed on each independent variable (total and partial compliance). All analyses were run using Stata 14.1. The EHR was the instrument used in this study, along with a facility dashboard. While the QI project too can abstract data from the EHR, a dashboard cannot.

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).

The evidence-based ABCDEF bundle was successfully implemented in seven community hospital ICUs using an interprofessional team model to operationalize the Pain, Agitation, and Delirium guidelines. Higher bundle compliance was independently associated with improved survival and more days free of delirium and coma after adjusting for age, severity of illness, and presence

of mechanical ventilation.

The authors made note of the QI project limitation, noting the project lacked randomization, or controlled trials. There was a potential risk for data integrity by the IPT nurse as one of the primary investigators. The bundle was applied to patients receiving palliative care, this may have skewed the results. There was a lack of physician buy-in and non-acceptance of patient and family to participation.

The authors noted more advanced study designs should consider stepped-wedge approach that would add value to gain an understanding of the relationship among the bundle elements, compliance, and clinical outcomes.

This large-scale study  demonstrated the value of implementing the PAD guidelines using a bundle of evidence-based steps through interprofessional teamwork. The study highlighted if not all bundle elements are implemented some can make a significant impact on patient outcomes.

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

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Research question:

Hypothesis:

Purpose: The objective of this mixed methods study was to determine how to facilitate ABCDE bundle adoption by examining the impact of two different implementation strategies on bundle adherence rates via basic and enhanced strategies and assessing clinicians' perceptions of the bundle and implementation efforts.

This mixed methods study

This study included patients treated in 12 ICUs of eight Baylor Scott & White Health (BSWH) hospitals, including medical/surgical, trauma, neurological, and cardiac care units. A total of 84 nurses, physicians, and therapists participated in interviews and a survey to assess bundle implementation—two approaches, basic and enhanced. The basic strategy included electronic health record (EHR) modification, whereas the enhanced strategy included EHR modification plus additional bundle training, clinical champions, and staff engagement. A convenience sample was obtained to ensure varied sample schedules were on different days and times encompassing nursing, respiratory therapist, physical therapy managers, physician’s champions, and leaders were contacted via email for scheduled interviews.

Interviews and surveys were the main instruments for each intervention group using the Microsoft Assess database using audio recording. Two researchers analyzed interview responses using a shared codebook. To ensure consistency in coding, both researchers coded three of the same interviews and compared coding schemes to ensure they interpreted and consistently applied the codes. This study uses a mixed method approach, qualitative and quantitative methods. The DPI project is quantitative. THE EHR is an instrument used in this project and can also be used in the DPI project.

The results demonstrated the effect of basic vs enhanced

strategy for bundle

adherence ICU LOS estimate 0.02 95% CI (0.01-0.02)

(p <0.001)

Contrary to the hypothesis, the ICUs in the basic intervention group achieved higher levels of bundle adherence than ICUs in the enhanced intervention group and had the greatest change from pre-period to post-period.

Although the bundle implementation process in both interventions showed improvement in bundle adherence

.

The authors noted data collection was time consuming. The study acquired data through the EHR hence limited to evaluating some elements such as pain and sedation

Physicians’ response on bundle perception may be biased.

Limitations were noted in this study—first leadership. Leadership in the basic intervention group learned about the enhanced intervention through the system-wide critical care council. This unintended exposure resulted in contamination, which made it difficult to determine the impact of the EHR modification alone on bundle implementation for ICUs in the basic intervention group. Second, this study was based on the change model chosen, Rodger’s Diffusion of Innovation theory. This change theory may have only elicited factors about implementing and adopting the bundle that was congruent with the models. Third, the authors note the differences among the ICUs that may have influenced adoption. Fourth, the convenience sample may have resulted in bias by limiting a complete representative sample of ICU staff. Other limitations included sample size, recall bias, and hesitance of respondents to reveal their true feelings about bundle implementation. Data on bundle adherence were based on what was documented in the EHR, which may not reflect actual practice.

The study highlights that applying the ABCDE bundle is feasible in different healthcare settings outside the ICU. The EHR is a valuable tool in identifying bundle documentation and compliance. The ABCDE bundle is effective in reducing the length of stay. It scores that adequately implementing ABCDE bundles improves nursing care and patient outcomes.

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

Research question:

Hypothesis:

Purpose: The purposes of this study were to evaluate the effect of ICU Liberation Collaborative participation on ABCDEF bundle performance and explore whether bundle performance differed among participating ICUs at the end of the quality improvement collaboratives (QIC).

Observational study

In this study, data was collected over 20 months. The data consisted of ABCDEF bundle performance data. The study included six months of baseline (pre-implementation) data from January 2015 through June 2015 and 14 months of data collected prospectively during the QIC from January 2016 through February 2017. The study consisted of 15 226 critically ill adults admitted to the 68 academic, community, and Veterans Affairs ICUs participating in the SCCM ICU Liberation Collaborative at Vanderbilt University Medical Center. Data were manually abstracted data from eligible patients’ medical records (either electronic or paper) at their institutions. The data were then entered into a Research Electronic Data Capture database, a secure web-based application for validated data entry, transmission, and storage.

Data were collected for the first five patients (baseline period) or the first 15 patients (implementation period) consecutively admitted to the ICU each month. Performance data were collected for each qualifying patient for a maximum of seven ICU days or until the patient was transferred out of the ICU, was designated as having non-ICU status, or died. THE EHR was the main instrument used in this study and can also serve as a valuable instrument to the DPI project.

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.

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.

Organizations need to develops strategic plans on how to increase compliance on bundle interventions for sedations, mechanical ventilation weaning and mobility practices.

This study adds to the growing literature supporting the ABCDE bundle and its effects on patient outcomes, mortality rates.

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 without dedicated personnel. Canadian Journal of Critical Care Nursing, 29(3), 26–31.

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Research question:

Hypothesis:

Purpose: 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.

This is a descriptive observational study took place in a general ICU

The study enrolled 482 participants in an eight-bed ICU over one year. Patients were admitted to the ICU, and 94 were mobilized. Data was collected from March 2015 to March 2016 using the electronic health record. Categorical data were presented as absolute numbers and percentages and compared by a two-tailed x2 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. Patients were divided into two groups: non-mobilized patients 388 and mobilized patients 94. All statistical analyses were performed with the STATA software.

The EHR, the main instrument used in the article, can be duplicated in the DPI project.

Mobilized patients had longer ICU and hospital length

p < 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.

The study is noted limitations. The study was not generalized. It is not known if there were any adverse effects during mobilization. The authors noted a lack of control or randomization. The study did not barriers or contraindications to mobilization.

The study notes 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

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

Research question:

Hypothesis:

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

This is an observational study

This study included data from 15 ICUs in seven community hospitals between August 1, 2016, and January 31, 2017, in an extensive western United States health system. The study included 977 adult patients on mechanical ventilation for more than 24 hours admitted to an intensive care unit over six months. There were variations in ICU size, bed type, and study location. The sample included adult patients 18 years old and older. Patients with comfort care and comatose were excluded. Patient-level data were retrieved from a data warehouse for administrative data and the Cerner EHR system for bundle documentation and order entry. Data in this study were stored in a secured data repository at the health system. The study was conducted using all the statistical analyses using the SAS University Edition 9 platform software. The study used dependent and independent variables. Logistic regression analysis was used for individual bundle element adherence scores, categorized into complete (100%) vs. partial. The instruments used in this study could be implemented in the DPI project.

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).

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 had limitations. 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.

The study identified barriers in assessing pain, delirium and mobility. The study notes more education is needed to treat patients requiring sedation to reduce sedatives in order to improve bundle adherence as well as discovering ways to implement delirium assessments in a more diverse population.

This study supports the DPI project since the study identifies the factors associated with ABCDEF bundle adherence in critically ill patients during the first 96 hours of ventilation. The study supports the results that modifiable factors improve the 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

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

Research question:

Hypothesis:

Purpose: The study aims to determine how quality improvement implementing the ABCDEF bundle can improve sepsis outcomes.

Quality Improvement study

This study was conducted in a 609-bed Midwest metropolitan hospital, the medical respiratory intensive care unit, and the surgical intensive care unit. The study used a pre/post-test design. The study used a convenience sample of all patients with sepsis admitted over three months. Data were collected between January 2019 and March 2019, and postimplementation was collected from October 2019 to December 2019. The existing electronic health record (EHR) and the sedation and analgesia order set for patients requiring mechanical ventilation were reviewed and determined to support the needed documentation for pain and delirium. Descriptive statistics, mean (SD) or n (%), and comparative statistical test results for all study outcomes. Ventilator days and ICU and hospital LOS were compared between groups using an independent-sample t-test. The EHR served as the main instrument used in this study that can be used in the DPI project. 

The ABCDEF bundle elements improved 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. There was a 0.5-day reduction in overall ICU LOS (p = .475) Overall hospital LOS increased by 1.1 day, but this was not significant (p = .414)

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

The QI initiative was limited to this single center organization. The authors made note severity of illness was not taken into account. The study lacked randomization, controlled trial, rather used a convenience sample.

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. This study may show greater significance on multicenter vs one while expanding to a larger patient demographic.

The article is relevant to the DPI project since it outlines the guidelines on how the ABCDEF bundle can be applied in nursing to improve clinical outcomes. The study demonstrated that bundle elements decreased ICU LOS.

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

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

Research question:

Hypothesis:

Purpose: 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

This quality improvement study was conducted in two medical ICUs in Montefiore Health Systems, the medical ICU at two academic tertiary care hospitals within the Montefiore Health System in the Bronx, NY. The study compared two time periods, the B-AD from January 1, 2013-June 30, 2013, and the B-AD-CE from July 1, 2013, to December 31, 2013. They included 472 mechanically ventilated patients. The cohort was divided into the intervention ICU group, 259, and the comparison group, 226.

Clinical data were obtained from health care surveillance software (Clinical Looking Glass; Emerging Health Information Technology, Yonkers, NY) and included information on demographics (age, self-reported race, and ethnicity, gender, residence prior to hospitalization)

Baseline characteristics and cost per cost center were compared between ICUs (including data from both periods) using Kruskal-Wallis tests for continuous variables and chi-square tests for categorical variables. The study further used the difference-in-difference analysis to identify significant changes in outcomes associated with the completed ABCDE bundle.

STATA 15 and Microsoft Excel (Microsoft, Redmond, WA) was used for all analyses.

The EHR instrument used in this study can be used in the DPI project.

The results identified LOS (13.9 [8.0-23.6] vs 13.6 [7.9-21.8] days, p = 0.64) were similar in both ICUs, but ICU LOS was shorter in the intervention ICU (6.1 [3.8-10.5] vs 7.2 [4.4-12.8] days, p = 0.013).

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 limitations in this study are it design, retrospective, at a single center organization of two ICUs in one health system. The study did not include A- assessment of pain nor did it include F- family involvement. Lastly, the authors could not evaluate the impact of costs in a larger cohort more than one year.

The study notes the need for additional studies identifying how total hospital cost and ICU cost are impacted by the ABCDE bundle.

The article supports the DPI project as it focuses on how fully implementation of ABCDE bundle significantly reduces hospital laboratory costs decreases LOS.

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

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

Research Question:

Hypothesis:

Purpose: The objective of this study was to determine the association between level of sedation, as quantified by a Richmond Agitation-Sedation Scale (RASS) score, and a positive delirium assessment result in critically ill patients assessed by the ICU nurse with either the Confusion Assessment method for Intensive Care Delirium (CAM-ICU) or the intensive care delirium screening checklist (ICDSC)

prospective study

The study was a secondary analysis of a previous study performed between September 2015 and June 2016. The study included seven countries and 11 ICUs. The study enrolled 1660 patients, of which 1203 (72%) were assessed with the CAM-ICU and 457 (28%) were assessed with the ICDSC. Participants were 18 years old and older. All data were collected electronically in the secured and validated data management system, CastorEDC, Amsterdam, Netherlands. Logistic regression analysis was used to determine the association between the level of sedation expressed in RASS score at the time of delirium assessment and delirium occurrence based on either a CAM-ICU or ICDSC assessment. Data were analyzed using IBM SPSS Statistics for Windows, version 25.0. The instruments used in this study cannot serve in the DPI project.

The study did not show a significant difference between the CAM-ICU and ICDSC p=0.01 when used to decrease LOS.

At a RASS of 0, assessment with the CAM-ICU (vs. the ICDSC) was associated with fewer positive delirium evaluations (odds ratio: 0.58; 95% confidence interval: 0.43–0.78).

At a RASS of −1 or −2, no association was found between the delirium assessment method used (i.e., CAM-ICU or ICDSC) and a positive delirium evaluation.

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

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

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Research question:

Hypothesis:

Purpose: 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 phase 2 Pre/ post bundle.

The study is a retrospective, observational, before-and-after outcome study

The study included adult patients on mechanical ventilation (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). The data were retrospectively collected via medical records. The study periods were divided into two phases: phase 1 (pre-bundle), December 1, 2015, to March 31, 2016. Phase 2 (after bundle) October 1, 2016, to December 31, 2016. Data were analyzed using two independent-sample t-tests with Bonferroni correction. Categorical variables were analyzed using the chi-square or Fisher's exact tests. The instruments used in this study can be used in the DPI project. 

The patients in phase 2 had a significantly lower mean ICU LOS (8.0 vs 12.0) day

p <0.05)

The study demonstrated there were significant differences of MV, ICU and hospital LOS, medical cost and intra- hospital mortality before phase one and after phase two.

The limitations of this study notes, this is a single ICU unit, the study did. Not take in account safety of patient mobilization, the study did not if the patient’s physical function improved pre/post bundle. Lastly the study design type, retrospective lacking randomization.

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 the ABCDE can decrease ICU LOS, hospital LOS, decrease cost, through early mobilization using an interprofessional team approach.

Bardwell, J., Brimmer, S., & Davis, W. (2020). Implementing the ABCDE Bundle, Critical-Care Pain Observation Tool, and Richmond Agitation-Sedation Scale to Reduce Ventilation Time. AACN Advanced Critical Care, 31(1), 16-21.

https://doi.org/10.4037/aacnacc2020451

Research question:

Hypothesis:

Purpose: The study aimed to reduce ventilation time by reducing oversedation, decreasing the incidence of delirium, and improving pain management.

It was hypothesized that reducing oversedation, decreasing the incidence of delirium, and improving pain management would reduce LOS.

The objectives of the study were (1) to determine if using the CPOT along with the RASS could reduce sedation time by treating pain instead of increasing the sedative dose and (2) to use the ABCDE bundle to wean patients from ventilation.

Retrospective study

This study was conducted at a teaching hospital within a 34-bed ICU and included patients in neurosurgical, medical, and surgical (except cardiovascular surgery) ICUs. The study was conducted from February 1, 2017, to April 30, 2017, and after bundle implementation, were for those admitted from February 1, 2018, to April 30, 2018.

Analyses were conducted with spreadsheet software (Microsoft Excel).

The researchers in this study used the rapid shallow breathing index (RSBI) and improved arterial blood gas values as indicators to wean patients from ventilation or to determine the extubation time. The results demonstrate the chances of reintubation.

The RSBI will not be used during the DPI project. The EHR was another instrument for data collection that could also be used in the DPI project.

P values less than .05 were considered statistically significant. A 2-tailed t-test was used to analyze the data. After ABCDE bundle implementation, mean ventilation time significantly decreased by nearly 50% (a difference of 1.98 days). A decrease in ventilation time was observed among all patients.

p=0.02

The nursing staff bundle compliance rate was 76.5%. After ABCDE bundle implementation, mean ventilation time significantly decreased by nearly 50% (a difference of 1.98 days). A decrease in ventilation time was observed among all patients. Using the ABCDE bundle reduced sedation time by almost 50% (a difference of 1.93 days), although this finding was not significant. 33 patients were not readmitted within 30 days of hospital discharge or reintubated within 30 days of extubation.

One of the limitations of the study was the non-controlled design of the study which raises the possibility of confounding variables that may have influenced study outcomes. Second, the study did not include patients with brain injuries which means that the findings may not be generalizable to neurological or trauma ICUs that care for patients with these injuries. Furthermore, the study cannot be generalized to long-term ventilator care units. The purpose of the study was to implement an international guideline and included only adults, which means that the findings should not be considered definitive and should not be generalized for children until randomized controlled studies involving children validate the results.

It is recommended that future studies should include patients with brain injuries for generalizable results in other ICUs. Furthermore, randomized controlled studies should be used in future studies to validate the results. Also, future studies should include both children and adults so that the results can be extrapolated to both adults and children.

The article will be used during the DPI project because it demonstrates that reducing oversedation, decreasing the incidence of delirium, and improving pain management would reduce LOS. It scores the fact that proper implementation of ABCDE bundles improves nursing care and patient outcomes.

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

Research question:

Hypothesis:

Purpose: The aim of this study is to explore the influences of ABCDE bundle on the hemodynamics and prognosis of patients on mechanical ventilation

This is a cross-sectional overall, before-after controlled study

The study included 143 patients in mechanical ventilation admitted to 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 the ABCDE bundle.

Nurses recorded intervention data in the Critical Care Record and entered it into the patient's EHR. 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 to compare the rates of both groups. The instruments used in this study can be used in the DPI project. 

The difference in the prognosis between the bundle and pre-ABCDE bundle groups was statistically significant. Pre bundle 9.76 post bundle 7.47

p 0.000 (p<0.05) statistical significance. 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.

The limitations of this study were lack of randomization

The study highlighted patients with full bundle (ABCDE) are hemodynamically stable, have shorter LOS and shorter duration of mechanical ventilation.

This study adds, the ABCDE 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

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Research question:

Hypothesis:

Purpose: The purpose of this study is 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.

This is a one-day point prevalence study.

The study used questionnaires and surveys for data collection. The questionnaire solicited patient demographics, such as age, gender, Body Mass Index (BMI), and ICU length of stay. The questionnaire identified the use of medical devices, continuous neuromuscular blockade, vasoactive, analgesia, and sedation agents, prone positioning, and duration. In addition, the presence of a target/goal of each ICU care modality given to ICU patients on the survey date and the implementation of each element of the ABCDEF bundle and an ICU diary provided on the survey data were collected. Data was anonymous for both patients and institutions.

All the data were stored online (Google Drive, Google Inc.) and managed or exported by authorized personnel. The ABCDEF bundle and the ICU diary between the groups of patients without 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 instrument used in this study, a questionnaire, can also be used in the DPI project.

ICU LOS: patients without COVID19 infection 5 [2.10], patients with COVID19 infection 9 [2-10]

p<0.001

This study showed the implementation rate of the ABCDEF bundle was low regardless of COVID19

The limitation of the study noted 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

Research question:

Hypothesis:

Purpose: The study sought to improve LOS and ventilator day

measures, reduce hospital expenditures,

and advance pharmacists’

scope of practice within a large community

teaching hospital.

This is a two-phase program a retrospective cohort study

This study included 436. Patients were managed with the ABCDEF bundle, and 499 patients of those with standard care. In a Florida hospital in the United States. 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 treatments groups using Student’s t-test for continuous data and a chi-square test of independence (Fisher’s exact test) for categorical data. The instruments used in this study can also be used in the DPI project

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);

In the 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 the use of continuous sedation, hospital LOS, and ventilator days. Secondary endpoints

were as follows: The total amount of sedation used, ICU LOS, ventilator days, number of Richmond Agitation

Sedation Scale (RASS) scores greater than +1, and reintubation rates.

This study notes 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 for the number of participants in this cohort study that demonstrated the use to bundle with the assistance of a pharmacist managing sedative implementing mobility demonstrated decreased ventilation days and decreased LOS decreased hospital cost by 46%, an estimated saving of 1.2 million 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

Research question:

Hypothesis:

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

This is a retrospective, cohort study

The study initially used a database of 10,529 patients, focusing on 313 of that 179 who met inclusion criteria. The study was conducted at a hospital in New York 764-bed tertiary academic center. A total of 179 patients (mean age, 80.5 years) met the inclusion criteria. Data was extracted from EMR. The study’s primary focus was Geriatric practices and the screening for delirium using the CAM-ICU assessment, a component of the ABCDEF bundle, and pain agitation, using descriptive statistics. The instrument used in this study can also be used in the DPI study.

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) was significantly associated with longer

hospital stays.

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

The limitations were, study design, 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.

The study identified a gap in care relating to geriatric care noting 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. Also, 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 study is relevant to the DPI project as a healthcare worker since it explores geriatric-focused practices and the associated outcomes for older adults in ICU survivors. The authors of this study highlight post-ICU syndrome (PICS) and its association with delirium and clinical outcomes. The authors aimed to use the ABCDEF bundle to assist in the management of geriatric patients. The study highlight that geriatrics were exposed to benzodiazepines, and it was associated with increased 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

Research question:

Hypothesis:

Purpose: 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 in the Neverlands. The size of the units varied between eight and 32 ICU beds. Consecutive ICU patients 18 years old or older were included. 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. Kruskal-Wallis was used to examine between-group differences 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. Data was collected using the Confusion Assessment Method for the ICU (CAM-ICU) checklist and the Intensive Care Delirium Screening Checklist (ICDSC). Study data were prospectively collected by research nurses using a data handling protocol. The instrument used in this study can be used in the DPI project.

The length of mechanical ventilation, length of ICU stays, and hospital

mortality, did not change

ICU length of stay (d),

mean (sd)

PHASE 1= 1,337 4.9 (6.9)

a) –0.3 (–0.8 to 0.1; p = 0.19)

PHASE 2=1,399 4.3 (6.0)

b) –0.1 (–0.6 to 0.3; p = 0.56)

PHASE 3=,194 4.8 (5.9)

c) 0.2 (–0.3 to 0.6; p = 0.49)

Delirium screening increased from 35% to 93%. Continuous intravenous 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 study is in line with the DPI project as it tips how best ICU delirium guidelines can be integrated to improve patients’ clinical adherence. This study demonstrated that implementing the ABCDEF bundle had improved health professionals’ adherence to delirium guidelines, which was linked to reduced brain dysfunction and decreased ICU stay. Data from this study added to existing implementation literature, strongly enhancing the translatability of findings.

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

Research question:

Hypothesis:

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

Meta-Analysis

The study used a standardized data collection where two authors extracted data independently. A total of 26,384 adult participants were included in the meta-analysis. The meta-analysis included five studies; three were randomized clinical trials, and two were cohort studies. The study data sources included the Cochrane Library, PubMed, CINAHL, EMBASE, PsychINFO, and MEDLINE from January 2000 to July 2020. Data were extracted using a standardized data collection form. The quality of studies was assessed using the Modified Jadad Score Scale for randomized clinical trials and the Newcastle -Ottawa Scale for cohort studies. The instruments used in this study cannot be included in the DPI project.

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, 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 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.

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 adverse outcomes. The impacts highlighted in the article are vital for the DPI project in healthcare as it enhances the learner's knowledge of how best ICU conditions can be improved to yield a positive outcome.

Nursing Theory Selected

APA Reference – Seminal Research References

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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.

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Henderson, V. (1966). The nature of nursing: A definition and its implications for practice, research, and education. Macmillan

Virginia Henderson's Nursing Needs Theory will be used to guide the DPI project.

Henderson identified that the unique function of the nurse is to assist the individual, sick or healthy, 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. Moreover, 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 (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 expressing emotions, fears, or needs through communication; the 11th is worshipping, working to express a sense of accomplishment, and participating in various recreational activities (Ahtisham & Jacoline, 2015). Henderson viewed the nursing process as applying the logical approach to solving 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

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

John Kotter’s 8 Steps for Change

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

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Kotter, J. (1995). Leading change: why transformation efforts fail. Harvard Business Review,

73(2), 55-67.

John Kotter’s 8 Steps for Change model applies to implement change (Kotter, 1995). These strategies can be applied in implementing the ABCDEF bundle to decrease LOS. According to Kotter (1995), the first step is creating urgency. Kang et al. (2022) explain the theory. According to Kang et al. (2022), the proposed interventions must develop urgency. Identifying accuracy is needed in identifying the existing threats in 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 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 to the change to drum up support. 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 the change stick. He re-ensures that everyone adapts to new change by illustrating its importance and training them on 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

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APA Reference -
Original Research (All)

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Explanation for How Clinical Practice Guidelines Align to DPI Project