**** very important assignment*** see attached paper to Synthesize the articles !!!!! pls synthesize, note the commonalities of the 15 articles, page length should be 8-10 pgs. pls fix corrections hi

Intensive Care Unit Liberation Bundle Impacts Length of Stay

Submitted by

Cathy Ann Jones

A Direct Practice Improvement Project Presented in Partial Fulfillment

of the Requirements for the Degree

Doctor of Nursing Practice

Grand Canyon University

Phoenix, Arizona

XXXXXX , 202x

© Cathy Ann Jones, 2023

All rights reserved.

GRAND CANYON UNIVERSITY

Intensive Care Unit Liberation Bundle Impacts Length of Stay

By

Cathy Ann Jones

has been approved

XXXXXX X, 2023

APPROVED:

ACCEPTED Christina Tedesco, DNP, DPI Project Chairperson

Rosla Royal, DNP, ACNP, Project Mentor/Content Expert

ACCEPTED AND SIGNED:

________________________________________

Lisa Smith, PhD, RN, CNE

Dean and Professor, College of Nursing and Health Care Professions

_________________________________________

Date

Abstract

Increased length of hospital stay (LOS) can be a concern in the healthcare setting is a concern nationwide. At the project site there was no systematic process to impact LOS so an evidence-based solution was sought. The purpose of this quality improvement project is to determine if the translation of Hsieh et al. implementing the ABCDE bundle would impact length of stay among adult patients in a long-term acute care hospital in a high observation unit. The project will be piloted over an eight-week period in urban Virginia. Virginia Henderson's needs theory and John Kotter's eight step change model will provide the scientific underpinnings for the DPI project.

Keywords: ABCDEF bundle, length of stay, long-term acute care hospital, John Kotter’s eight-step change model, Virginia Henderson Nursing Needs Theory, patient outcomes, quality improvement project

Dedication

I want to thank God Almighty for everything that he has done for me and dedicate my work to him as my creator, my solid pillar, and my true inspiration. Throughout the entirety of this journey, He remained the basis of my strength, and it is only on His wings that I have been able to soar. I would also like to dedicate this undertaking to my family, who have been there for me every step of the way to offer guidance and encouragement. It will also be illogical for me to ignore the vast number of patients who have suffered in one way or another due to the shortcomings of the suggested implementation. Thanks to them, I have had an easy time understanding their grievances thus making it easy to provide a comprehensive analysis on the topic.

Acknowledgments

I would want to convey my profound gratitude to my mentor, who was instrumental in contributing to this motivational experience by providing me with support, direction, and expert understanding of this topic. In addition, I’d love to express my earnest appreciation to all my patients, physician colleagues and nursing staff who took part in this quality improvement project. In conclusion, I would want to take this opportunity to thank my family for the support and encouragement they have provided me with during the process of completing this terminal degree.

Chapter 1: Introduction to the Project 13

Background of the Project 16

Organizational Needs Assessment 17

SWOT Analysis 18

Strengths 19

Weaknesses 20

Opportunities 21

Threats 22

Problem Description 23

Definition of Terms 24

Summary 26

Chapter 2: Scientific Underpinnings 28

Literature Search Strategy 28

Synthesis of Literature 29

Evidence-Based Practice Question 45

Change Recommendation: Validation of the ICU Liberation Bundle 46

Theoretical Framework 47

Nursing Theory 49

Synthesis of Nursing Theory 51

Evidence-Based Change Model 53

Synthesis of Change Model 56

Integration of the Christian Worldview 57

Summary 58

Purpose 60

Project Planning and Procedures 61

Interprofessional Collaboration 62

Project Management Plan (list required resources—delete this parenthetical note) 62

Feasibility 63

Setting and Sample Population 64

Setting 64

Population and Sample 65

Data Collection Procedures 65

Instrumentation or Data Source 66

Variables 67

Data Integrity and Storage 67

Data Management 67

Potential Bias and Mitigation 67

Ethical Considerations 68

Summary 69

Chapter 4: Data Analysis and Results 70

Data Analysis Procedures 70

Descriptive Data of Sample Population 71

Results 73

Summary 75

Chapter 5: Implications in Practice and Conclusions 76

Summary of the Project 76

Major Findings 77

Interpretation of Findings 77

Strengths and Limitations 77

Implications 77

Theoretical Implications 78

Nursing Practice Implications 78

Recommendations 78

Recommendations for Future Projects and Researchers 78

Recommendations for Sustainability 79

Plan for Dissemination 79

Conclusion and Contributions to the Profession of Nursing Practice 80

References 81

Appendix A 88

SWOT Analysis 88

Appendix B 89

Appendix C 179

Project Timeline 179

Appendix D 180

Plan for Educational Offering 180

Appendix E 181

Grand Canyon University Institutional Review Board Outcome Letter 181

Appendix F 182

Project Budget 182

Appendix G 183

Data Collection Tool for Evaluation (Use the name of the tool here) 183

Appendix H 184

Place the Permission to Use the Tool Here 184

Appendix I 185

Other Data Collection Tool and/or Permissions 185

Appendix J 186

APA Writing Style for the Direct Practice Improvement Project 186

List of Tables

Table 1 A Sample Data Table Showing Correct Formatting 73

Table 2 t-Test for Equality of Emotional Intelligence Mean Scores by Gender 74

Table 3 Primary Quantitative Research – Intervention (5 Articles). 90

Table 4 Additional Primary and Secondary Quantitative Research (10 Articles) 108

Table 5 Clinical Practice Guidelines (If applicable to your project/practice) 178

List of Figures

Figure 1 SWOT Analysis for Quality Improvement Project 88

For patients who survive but are unable to return home following the acute hospital stay, there are three inpatient post-acute care (PAC) settings where they may receive skilled, rehabilitative care: inpatient rehabilitation facilities (IRFs), skilled nursing facilities (SNFs), and long-term acute care hospitals (LTACHs) Kumar et al., (2022). LTACHs treat patients with longer-term acute care needs due to medical complexity or illness severity and may provide rehabilitation services (MedPAC, 2019). According to Nordness (2021), patients transferred or directly admitted to a long-term acute care hospital (LTACH) to the high observation unit (HOU) may suffer from Post Intensive Care Syndrome (PICS). Patients admitted an intensive care unit can develop PICS. Post Intensive Care Syndrome is a cognitive, physical, and psychological impairment that results from ICU admission. PICS can result in deconditioning, muscle wasting, pressure ulcer formation, decreased mobility, prolonged mechanical ventilation weaning, delirium, and hospital-acquired infections. Other causes of PICS include short-term acute care readmissions or limited or no discharge destination, further prolonging their hospitalization and decreasing patient and family satisfaction (Hsieh et al., 2019).

Currently, at this long-term acute care facility in Virginia, there lacks a standardized plan of care specific to this patient population to prevent long term consequences of those who suffered physical and mental health dysfunction as a result of their intensive care unit hospitalization. A standardized plan may impact the length of stay (LOS). Numerous factors can account for the increased length of stay at a healthcare facility, including poor processes, communication, and general medical errors. As the length of stay increases, the patient’s satisfaction reduces significantly. For example, the length of stay in the facility exceeds thirty and sixty days. According to Pun et al. (2019), applying for the program, especially for LTACH patients, will increase satisfaction and care delivery. The mean LOS stay of 30-60 days exceeds an LTACH average of 25-28 days (Medicare Advisory). While the increased LOS is multifactorial, implementing an evidence-based protocol may improve the throughput efficiency by impacting the length of stay and improving patient outcomes.

In 2013 the Society of Critical Care Medicine initiated the Intensive Care Unit (ICU) Liberation campaign from the Prevention and Management of Pain, Agitation /Sedation, Delirium, Immobility, and Sleep Disruption (PADIS) Clinical Practice Guideline (Pun et al., 2019). The guideline was updated in 2018, now known as the ICU Liberation Bundle (A-F). The Direct Practice Improvement (DPI) Project aims to impact LOS in a long-term acute care hospital in adult patients in the high observation unit translating Hsieh et al. research implementing the ABCDE bundle to impact the length of stay.

The ABCDE bundle, a validated evidence-based protocol, was initially created to improve the outcomes of patients in the ICU. As the bundle became popular and widely adopted into clinical practice, it was noted to reduce LOS (Frade-Mera et al., 2022). The interventions of the ABCDEF bundle consist of six elements starting with (A) that identifies and assess for pain using the Critical-Care Observation Tool (CPOT). The second is (B) for mechanical ventilation liberation- that assists with spontaneous awakening trials (SATs) to decrease the use of sedation and spontaneous breathing trials (SBTs) to wean patients off mechanical ventilation faster, using the Wake up and Breathe Protocol. The third is (C) that identifies the appropriate choice of sedation using the Richmond Agitation Sedation Scale (RASS). The fourth component is (D) that correctly identifies and assess for delirium screening using the Confusion Assessment Method for the ICU (CAM-ICU). The fifth component is (E) which is the early progressive mobility to decrease ICU–acquired muscle weakness (Collinsworth et al., 2021). The last component is (F) for a family was added later, further redefining the bundle, identifying the importance of family presence and involvement, and embracing patient-family-centered care (Delvin et al., 2018; Heish et al., 2019). This DPI project will to consist of five of the six bundle elements ABCDE.

Globally, an increased length of stay in healthcare facilities is related to reduced patient satisfaction, adverse outcomes, and lower reimbursement of healthcare facilities; that is why it is significant to gradually address the issue through the promotion of quality care programs, especially for critically ill patients. LTACHs are certified acute care hospitals equipped to provide long-term (average LOS of 25-28 days) acute-level care to medically complex patients (Grevelding et al., 2022). At the clinical practice site there has been an increased length of stay beyond 25 days in 75% of the patient population over the past 60 days that have been associated with delirium, cognitive and physical impairments as well psychiatric symptoms know as post-intensive care syndrome (PICS). Patients diagnosed with PICS are often admitted to an LTACH for ongoing complex medical care needs. LTACH admissions consist of illnesses related to sepsis, strokes, encephalopathy, heart failure, and acute respiratory failure resulting in tracheostomies needing ongoing mechanical ventilation support. The syndrome of PICS, including chronic pain, significantly impacts the quality of life and the ability of ICU survivors to return to work and other daily activities, even years after illness (Nordness et al., 2021). Globally, as LOS is often viewed as a measurement of hospital care, LOS is a prime indicator of resources worldwide, such as post-acute care facilities such as skilled nursing facilities, and rehabilitation facilities (Lorenzoni & Marino, 2017). LOS can impact patient care as well as outcomes. The ABCDE bundle has been incorporated into many hospitals and healthcare organizations' operations and protocols to improve patient outcomes and cut costs.

Organizational assessment is a process that can be used to assess an organization's strengths and weaknesses. The purpose of organizational assessment is to comprehensively understand an organization's current and potential future. The strengths, weaknesses, opportunities, and threats analysis or SWOT analysis is appropriate for this quality improvement project because it identifies the organization's strengths, weaknesses, opportunities, and threats. In the research, it was identified that LTACH might present problems in implementing the quality improvement project. (Boehm, et al. 2017).

The gap to be addressed is the role of the ABCDE bundle in reducing the length of stay in the healthcare facility. The ABCDE bundle can improve the quality of care and patient satisfaction and reduce LOS. There will be the identification of the necessary resources required, including nurses, pharmacists, and physical therapists), equipment (e.g., patient chairs), and funding for additional staff (AHRQ, 2017).

SWOT is a strategic tool that identifies strengths, weaknesses, opportunities, and threats within a company's business environment. The strengths and weaknesses perspective addressed the internal factors to the problem the company is exposed to, while the opportunities and threats identified the external factors contributing to the problem. (Chen et al. 2021). Therefore, the SWOT analysis helps pinpoint the organization's struggles and allocate potential improvements. The SWOT analysis will be helpful to this QI project because it identifies areas within the process that could be improved or eliminated. Using SWOT to analyze the quality improvement project was instrumental in determining which elements of the process needed improvement and strategically addressing those potential barriers to the quality improvement implementation. (Benzaghta et al. 2021).

 (See Appendix A).

(See Figure 1).

According to Collinsworth, Priest & Masica (2020), strengths are areas where an individual or organization performs well. They also include positive characters and skills related to improvement and wanted performance. The primary strength of the ABCDE bundle is the provision of a family-centered approach that boasts as one of its key pillars. By providing a holistic approach to health and health services, the ABCDEF health bundle helps to address the needs of the whole family rather than just individual members. This approach ensures that all the family members have a say and are supported in taking an active role in the decision-making progression. Secondly, the ABCDEF package effectively reduces the risk of developing delirium and facilitates the patient's recovery in the shortest amount of time and with the fewest disruptions from the outside world (Otusanya et al., 2021). Finally, the bundle addresses various health concerns, making it a comprehensive approach to improving patient care. Similarly, the bundle is flexible and can be customized to meet the needs of specific organizations considering its well-documented and includes several tools and resources to support organizations in their efforts. Finally, the ABCDEF bundle is effective in improving patient outcomes.

In the SWOT analysis, the weaknesses are considered as faults or areas where actions do not follow the organization's aims. Weaknesses can be improved or worked on to meet organizational goals. Despite the tremendous clinical effects that can be achieved with the ABCDE bundle, it is not commonly adopted in practice. Several potential obstacles could prevent the ABCDE bundle from being used. The first weakness is healthcare practitioners' unfamiliarity with the ABCDE bundle interventions and tools. Effective deployment of the ABCDE bundle necessitates several resources, including people, machines, and money for more machines and people (Collinsworth, Priest & Masica, 2020). A second weakness is a possibility that the ABCDE bundle will only partially be implemented; only utilizing certain elements per unit must yield favorable results, which presents the third challenge. Inconsistent care may be delivered between different hospitals or healthcare units if there are no established protocols. The last weakness is that the ABCDE bundle may encounter resistance from the healthcare institution's culture. A healthcare institution's culture is shaped by its traditions and values, which makes it challenging to bring about a shift in that culture. 

There are several ways to overcome the barriers to implementing the ABCDE bundle. The first way is to increase awareness of the guideline among healthcare providers. Many providers may need to be aware of the guideline or their recommendations. Educational programs can increase awareness of the guideline among healthcare providers. Second, provide resources (e.g., personnel, equipment, funding) to healthcare facilities to implement all six interventions of the ABCDE bundle (Loberg et al., 2022). Resources needed to implement the ABCDE bundle effectively include personnel (e.g., nurses, pharmacists, physical therapists), equipment (e.g., patient monitors), and additional staff and equipment funding. A third way is to develop standardized protocols for implementing the ABCDE bundle (Loberg et al., 2022). With standardized protocols, care may be consistent across different units within a facility. Standardized protocols can ensure that care is delivered consistently across different units within a facility. Last, the culture of a healthcare facility can be changed by introducing new values and norms that support the implementation of the ABCDE bundle

Opportunities in SWOT analysis are areas that could be advanced and improved for organizational progress. They are also the circumstances that create a chance for organizational improvement. There exist multiple opportunities which can play a crucial role in improving the ABCDE bundle implementation. (Otusanya et al. 2016). The first opportunity is the preparation, skills, and competencies healthcare practitioners have will be significant in implementing the program with little investment. (Balas et al., 2022). The second opportunity is that the facility’s leaders are dedicated to reducing LOS, increasing patient satisfaction, and more reimbursement for quality delivery.

There are several potential threats to implementing the ABCDE bundle in an LTACH. Threats are the factors that may hinder the achievement of the project's goals; they are also the adverse factors that limit the company from succeeding. Patients' consent to join the research project is the central issue since most patients may be unwilling to join. However, everyone must sign an informed consent to understand engagement's pros, cons, and risks. Another potential threat is that the ABCDE bundle could strain hospital resources which is the role of the government to ensure healthcare facilities are provided with adequate resources, including facilities, equipment, and healthcare workers hired (Bakhru et al., 2014). Finally, there is always the potential for human error when implementing any new system or procedure. It is especially true with the ABCDE bundle, as it requires high coordination and communication between staff members. If there are any lapses in this process, it could lead to severe consequences for patients. (Frade‐Mera et al. 2022).

Implementing the ABCDE bundle is the proposed solution to impact the LOS of those admitted or transferred to the HOU. In order to ensure that the ABCDE bundle is effective, it is essential to consult with experts during the implementation process (DE Mellow et al., 2020). Consulting with content experts will help to ensure that the bundle meets the needs of all stakeholders. The specialists in the high observation unit in long-term acute care will be consulted to ensure that the bundle meets the needs of patients in this setting. Furthermore, this consultation will help ensure that the bundle effectively reduces the length of stay.

Over the past three years, the data shows many patients admitted to the practice site have required transfer into the HOU or have been directly admitted to the HOU upon admission to the practice site for acute complex care and management of their critical illnesses. Many of these patients suffered respiratory, neurological, or cardiovascular events warranting the HOU monitoring. Length of stay is a significant issue in our facilities since it increases complications, especially for the patients admitted to the HOU, thus increasing the cost of care. (Hsieh et al., 2019). Additionally, the length of stay affects the patient's satisfaction and increases the risk of ulcer formation. Therefore, the project's outcome is the gradual reduction of the LOS by assessing the patient's situation and strategic application of the ABCDE bundle to prevent complications.

Increased LOS threatens the validity of LTACHs. Reimbursement rates decrease when care related to hospital-acquired infections occurs. The longer a patient remains an inpatient, there poses the risk of delayed recovery to the prehospital state. Despite the ABCDE bundle's clinical significance, more data regarding its effectiveness outside of short-term acute hospitals is needed. The major problem is that LTACHs need a standardized, evidence-based protocol that impacts LOS, disposition, and clinical outcomes.

Throughout the quality improvement project, many repetitive terms were used to illuminate the project's key components. Below are a few of the most common terms used.

ABCDEF Bundle

A validated evidence-based protocol with six elements, now known as the ICU Liberation-ABCDEF bundle. (A) Assess, Protect, and Manage Pain; (B) Breathing-SAT (spontaneous awaking trial) and SBT (spontaneous breathing trial); (C) Choices of Analgesia and Sedatives; (D) Delirium Assess, Preclude, and Manage; (E) Early Movement and Exercise; (F) Family (Collinsworth et al., 2021).

Delirium

Delirium is a disturbance in attention and awareness that develops over a short period, represents an acute change from baseline attention and awareness, and fluctuates in severity during the day (American Psychiatric Association, 2013)

Intensive Care Unit (ICU) 

A multidisciplinary specialty unit committed to the comprehensive management of patients having or at risk of developing life-threatening organ dysfunction by use of technology that supports failing organ systems to prevent further physiologic deterioration (Marshall et al., 2017).

Length of stay (LOS)

The timeframe that a patient spends in the hospital care unit is the metric that constitutes this measurement (Pun et al., 2019).

LTACH

Long-term acute care hospitals- are certified acute care hospitals equipped to provide long-term (average LOS of 25-28 days) acute-level care to medically complex patients (Grevelding et al., 2022).

Post Intensive Care Syndrome

It is associated with delirium, cognitive and physical impairments, and psychiatric symptoms (Hsieh et al., 2019).

Since the ABCDE Bundle has been widely utilized across different healthcare settings locally, nationally, and globally serving the purpose of mechanical ventilation liberation, reducing the incidence of delirium, to reducing healthcare costs and length of stay. The ABCDE (Awakening and Breathing Coordination, Delirium Monitoring and Management, and Early Exercise and Mobility) bundle, a validated evidence-based protocol, was initially created to improve the outcomes of patients in the ICU (Frade-Mera et al., 2022).

Reducing unnecessary healthcare costs is everyone's responsibility. The ABCDE bundle is a cost-effective, scalable intervention. The ABCDE bundle may ameliorate the effects of PICS, reduce HAI, facilitate mechanical ventilator liberation quicker, and impact LOS; all are equally important for improving care delivery and outcomes in critically ill patients in any healthcare setting. Implementing the ABCDE bundle is a significant milestone for any institution. The ABCDE bundle consists of six elements of interventions proven to reduce the length of stay and improve patient outcomes. The ABCDE bundle gives medical practitioners access to a wider variety of treatment alternatives that can be tailored to meet the requirements of –patients and their families while improving clinical outcomes and impacting hospital length of stay. According to Pun et al. (2019), studies exist examining the effectiveness of the ABCDE bundle. These studies have shown significant reductions in delirium prevalence, ventilator days, coma days, readmission, and in-hospital mortality, and a significant increase in the number of patients who were mobilized out of bed during their ICU stay, decreased length of stay (Pun et al., 2019).

This paper reviews the current evidence regarding the Intensive Care Liberation Bundle and its impact on decreasing the length of stay among patients in a long-term acute care hospital (LTACH) admitted or transferred to a high observation unit (HOU). The goal of the review is to gain an in-depth understanding of the ABCDE bundle in decreasing the ICU length of stay, decreasing the incidence of delirium, and improving patient satisfaction after implementing the ABCDE bundle in a real-world setting.

The search strategy used the following databases: PubMed, CINAHL, and ProQuest. The search terms used were ABCDE bundle AND intensive care unit. The inclusion criteria were to have articles published in English within the last five years, full-text, and peer-reviewed articles. Articles that did not include full text, were not peer-reviewed, were published in a language other than English, were published later than 2017, and were thus excluded from the study. A total of 15 articles met the inclusion criteria and were used to support the intervention.

The first article by Hsieh et al. (2019) looks at the effect of the ABCDE bundle on specific patient costs. The objective of the study was to measure the impact of the 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. The prospective cohort study included 1,855 mechanically ventilated patients admitted to ICUs between July 2011 and July 2014. Based on the findings, it was established that implementing the ABCDE bundle was associated with a decrease in-hospital mortality and length of stay. It was also found that early mobilization and coordination portrayed an improvement in patients in the ICU by 30 percent. After adjustment for patient-level covariates, it was found that the implementation of the entire (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 < .001), ICU length of p < .05. However, this study was limited in that it was conducted in a single medical center which limited the generalizability of the findings. An unmeasured change could have affected the results, and the cross-contamination of practices between two ICUs could have further affected the findings. The study illustrates the significance of teamwork between physicians in the ICU in enhancing patients' health and medication adherence while improving the working conditions in health facilities to safeguard the patient's health. The article will help support a decrease in in-hospital mortality and length of stay for the DPI project by implementing the ABCDE bundle.

The second article by Liu et al. (2021) had the primary outcome of the implementation rate of the ABCDE bundle. For the DPI project, the article will help support implementing the ABCDE bundle to decrease in-hospital mortality and length of stay. 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 ABCDE bundle and the ICU diary between patients without and with COVID-19 infections were made with the Mann-Whitney U-test for non-normally distributed continuous data, 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 ABCDE bundle for patients without and with COVID-19 infections. 

The third article by Louzon et al. (2017) study included 436 participants. Patients managed with the ABCDE 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 to allow ICU pharmacists to directly manage sedative therapy for mechanically ventilated patients in collaboration with an insensitivity. In phase 2, that initiative was expanded to include comprehensive pharmacist PAD management and the development of a multispecialty inter-professional team to encourage the early mobilization of mechanically ventilated patients. This study used the APACHE outcomes tool for managing critical care outcomes methodology and found a reduction relative to mean hours in the standard-care cohort (p = .0025). For the DPI project, the article will help support implementing the ABCDE bundle to manage sedative therapy for mechanically ventilated patients in collaboration with an insensitivity and multispecialty inter-professional team to encourage the early mobilization of mechanically ventilated patients.

The fourth article by Trogrlić et al. (2019) showed that implementing the ABCDE bundle had improved health professionals' adherence to delirium guidelines, which was linked to reduced brain dysfunction. The ABCDE bundle was further linked to decreased ICU stay data from this study added to existing implementation literature, strongly enhancing the translatability of findings. This article aligns with this learner's DPI project as a healthcare professional, giving tips on how best ICU delirium guidelines can be integrated to improve patient clinical adherence. The study identified improvements after the implementation pertained to delirium screening (from 35% to 96%; p < .001). The feasibility of staggered versus simultaneous implementation of the bundle elements seems strongly dependent on local resources (e.g., "local champions" vs. interprofessional implementation teams or level of previous experience with the guidelines). Additionally, the fact that "error of omission" of daily safety screens for SATs and SBTs may have precluded concurrently improved clinical outcomes, adding solid empirical support from a "real-life setting" for the effectiveness of individual ABCDE bundle elements. For the DPI project, the article will support implementing the ABCDE bundle for a decreased ICU stay.

The fifth article by Ren et al. (2017) looks at the effects of the ABCDE bundle on hemodynamics in patients with mechanical ventilation. The study involved a cross-sectional overall, before-after controlled study with 143 patients on mechanical ventilation admitted at the ICU. The study found a decrease in heart rate, mean arterial pressure, and length of stay when the bundle was implemented. In addition, there was an increase in PaO2/FiO2 ratio and a decrease in ventilator-free days. The difference in the prognosis between the bundle and pre-ABCDE bundle groups was statistically significant (p < .05). The study proved that the ABCDE bundle could significantly improve the vital indicators of patients on mechanical ventilation, reduce the dose of the sedatives and pain medications used, and keep the vital indicators at levels beneficial to patients. The limitation of this study was that the study was non-randomized, which could translate to selection bias. For the DPI project, the article will support implementing the ABCDE bundle to decrease heart rate, mean arterial pressure, and length of stay on hemodynamics in patients with mechanical ventilation.

The sixth article by Frade-Mera et al. (2022) looks at the impact of early intervention with the ABCDE bundle on sepsis outcomes. The study was a 4-month, prospective, observational, multi-center cohort study conducted in adult patients receiving invasive mechanical ventilation (IMV) for at least 48 hours in ICUs across Spain. The primary outcomes measured were the pain level, level of cooperation, the incidence of delirium and physical restraints, and level of mobility related to implementing bundle components A, B, C, D, and E. The secondary outcome was the drug levels of analgesia, sedatives, muscle relaxants, and antipsychotics (cumulative drug dosing by IMV days 100) associated with the implementation of bundle components A, B, C, D, and E. on the other hand, the 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 the implementation of bundle components A, B, C, D, and E. The study involved 531 patients and found a decrease in mortality and length of stay when the bundle was implemented early. It showed that patients had shorter ICU stays with bundle protocols and fewer days of IMV in ICUs with delirium and mobilization bundle components (p = .006 and p = 0.03. In addition, there was a reduction in cost per patient when the bundle was implemented. The study's main limitation was that the Richmond agitation-sedation scale (RASS) results were not analyzed because most were recorded in ICU patients implementing protocols with analgosedation algorithms. For the DPI project, the article will support implementing the ABCDE bundle to reduce ICU length of stay, effectively manage pain, and decrease mortality.

The seventh article by Negro et al. (2018) looks at the impact of the ABCDE bundle on ICU patients with systemic inflammatory response syndrome. The researchers sought to assess the feasibility and safety 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. The study involved 482 patients and found a decrease in mortality and length of stay when the bundle was implemented. In addition, there was a reduction in cost per patient when the bundle was implemented p < .05, which is considered statistically significant. However, the study was limited because it was a descriptive study that shows the experience in a single ICU unit, and the researchers did not have control over the historical group. The descriptive study design weakens the findings and makes it imprudent to generalize them to other populations. By implementing the ABCDE bundle, the article will support early progressive mobilization protocol for ICU patients with systemic inflammatory response syndrome.

The eighth article by Collinsworth et al. (2021) looks at the impact of the ABCDE bundle on ICU patients with sepsis using mixed methods. The study also sought to assess the clinicians' perceptions regarding the ABCDE bundle and the implementation effort. The study involved eight patient adults in ICU and 84 nurses, therapists, and physicians surveyed. The study found decreased mortality and length of stay when the bundle was implemented, translating to the best care and patient outcomes. In addition, there was a reduction in cost per patient when the bundle was implemented in both interventions. Effect of Basic vs. Enhanced Intervention on Bundle Adherence ICU LOS 0.02 (0.01-0.02) <.0001a (p < .05. The data was acquired from electronic health records (EHRs). The EHR limited evaluation of some elements, such as pain and sedation, and the physicians' responses could be biased, further limiting the study. For the DPI project, the article will support implementing the ABCDE bundle to decrease mortality and length of stay.

The ninth article by van den Boogaard et al. (2020) looks at implementing the ABCDE bundle and its effect on patient outcomes by studying the association between the level of sedation and delirium occurrence in patients who are critically ill. The study included more than 1660 patients and used observation of the cohort study. It was found that there was a decrease in mortality and length of stay when the bundle was implemented; length of stay (ICU) (p < .05) was considered statistically significant. In addition, there was a reduction in cost per patient when the bundle was implemented. It was concluded that the influence of the level of sedation on delirium assessment depends on whether the CAM-ICU or ICDSC is used. The limitation of the study was that it was based on a comparison between sedation and delirium; hence, it needed to compare CAM-ICU to ICDSC simultaneously and determine its impact on critically ill patients. The article will help to support improved patient outcomes by maintaining accurate levels of sedation for delirium to decrease mortality and length of stay when the bundle is implemented. 

The tenth article by Pun et al. (2019) looks at the impact of the ABCDE bundle on patient outcomes in a medical ICU. This prospective cohort study from a national quality improvement collaborative study included 15,226 patient adults with at least one ICU daily. The study found decreased mortality and length of stay when the bundle was implemented. Significant pain was more frequently reported as bundle performance proportionally increased (p = .0001) with a p < .002. In addition, there was a reduction in cost per patient when the bundle was implemented. However, the study is limited in various ways. It did not use a randomized design; the researchers did not have access to concurrent control and patient-level outcomes were not wholly independent and were assessed when patients did not experience those outcomes. The ICU liberation collaborative study also needed more funds to support data accuracy auditing. The article will support the implementation of the ABCDE bundle on patient outcomes in a medical ICU to reduce mortality and length of stay.

Another article by Otusanya et al. (2021) examines early intervention with the ABCDE bundle on patient outcomes. The study was a retrospective cohort study involving 472 mechanically ventilated patients admitted to the ICU between January 1, 2013, and December 31, 2013, in two medical ICUs in Montefiore Health Systems. The study found a decrease in mortality and length of stay when the bundle was implemented early. In addition, there was a reduction in cost per patient when the bundle was implemented. 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 < .020). (p < .05). The articles above support implementing the ABCDE bundle as it has been shown to improve patient outcomes, including decreased mortality and length of stay. The bundle has also been cost-effective, which is an important consideration when making decisions about healthcare interventions. The study's main limitation was that the data collection and analysis were limited to only two ICU centers. The article will support implementing the ABCDE bundle to improve patient outcomes, including decreased mortality and length of stay during the DPI project.

Furthermore, Loberg et al. (2022) looked at the impact of early intervention with the ABCDE bundle on patient outcomes by examining how quality improvement initiatives could be used to evaluate the effectiveness of the ABCDEF bundle elements to improve clinical outcomes. The study adopted secondary research through sampling in a 609-bed Midwest metropolitan hospital between January 2019 and March 2019. The researchers found a decrease in mortality and length of stay when the bundle was implemented early. In addition, there was a reduction in cost per patient when the bundle was implemented. 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). These findings support the earlier implementation of the ABCDE bundle, which has been shown to improve patient outcomes. The findings of the studies included in this systematic review provide strong evidence for the implementation of the ABCDE bundle to improve patient outcomes. However, the study faced three main limitations such as the quality improvement initiative had a problem with its generalizability because the study was conducted at a single Midwest metropolitan hospital. A lower than the desired rate with bundle elements was experienced during the study. Lastly, the intervention was not designed as a randomized controlled study but instead utilized as convenient sampling. The study type made it suffer selection bias, making it difficult to generalize the findings. For the DPI project, the article will demonstrate the effectiveness of the ABCDE bundle elements in improving clinical outcomes.

DeMellow et al. (2020) also looked at the impact of early intervention with the ABCDE bundle on patient outcomes. The study was observationally using electronic health records (EHRs) with a sample size of 977 adult patients who were on mechanical ventilation for more than 24 hours and admitted to an intensive care unit over six months. The study's findings indicated decreased mortality and length of stay when the bundle was implemented early. In addition, there was a reduction in cost per patient when the bundle was implemented. These findings support the earlier implementation of the ABCDE bundle, which has been shown to improve patient outcomes. ABCDE bundle adherence was higher in patients on mechanical ventilation for less than 48 hours (p = .01), who received continuous sedation for less than 24 hours (p < .001), who were admitted from skilled nursing facilities (p <.05), and throughout the six-month study period (p < .01). The findings of the studies included in this systematic review provide strong evidence for the implementation of the ABCDE bundle to improve patient outcomes. The limitations of this study included the limitations to using EHR clinical data available in conducting evaluation assessment for pain, sedation, delirium, and mobility elements only, failure to use analgesic infusions as sedation to determine the duration of sedation and adherence of awakening trials, limitations to the examination of the early 96 hours on MV adherence to bundle by the care unit. The article will demonstrate the ABCDE bundle's effectiveness in decreasing mortality and length of stay.

The other article was a systematic review to determine the effects of quality improvement collaborative participation on the ABCDE bundle performance. The study included 114 acute care hospitals that were participating in the study. The findings of the studies included in this systematic review provide strong evidence for the implementation of the ABCDE bundle to improve patient outcomes. Moreover, Balas et al. (2022) looked at the impact of early intervention with the ABCDE bundle on patient outcomes. They found a decrease in mortality and length of stay when the bundle was implemented early. In addition, there was a reduction in cost per patient when the bundle was implemented. 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). These findings support the earlier implementation of the ABCDE bundle, which has been shown to improve patient outcomes. However, this study was limited because conclusions cannot be made on long-term sustainability despite ICUs demonstrating improvements during 20 months. Furthermore, the study used observational studies; thus, the residual confounding cannot be omitted to explain the observed changes in bundle performance. The article will demonstrate the impact of improving patient outcomes, decreasing mortality rates, and length of stay for the DPI project when the bundle was implemented early. 

Also, Barnes-Daly et al. (2017) looked at the impact of early intervention with the ABCDE bundle on patient outcomes by examining the connection between ABCDE bundle compliance and consequences, including clinic survival and delirium-free and coma-free days in community infirmaries. The researchers conducted a prospective cohort quality improvement initiative involving ICU patients by randomly selecting one patient from the daily census at each hospital for 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. The study found a decrease in mortality and length of stay when the bundle was implemented early, a p < .05. In addition; there was a reduction in cost per patient when the bundle was implemented. These findings support the earlier implementation of the ABCDE bundle, which has been shown to improve patient outcomes. The findings of the studies included in this systematic review provide strong evidence for the implementation of the ABCDE bundle to improve patient outcomes. The limitation of this study was that it needed strict protocols found in randomized, controlled trials. Furthermore, the investigation's study design and sample size benefits did not trump other statistical concerns (Barnes-Daly et al., 2017). The article will demonstrate how the ABCDE bundle improves patient outcomes regarding clinic survival, delirium-free, and coma-free days . 

The chosen articles share similar themes, including the importance of adherence to the ABCDE bundle, the positive effects of the bundle on patient outcomes, and the need for further research on the topic. However, there were also some differences between the articles. For example, some articles looked at specific aspects of the bundle (e.g., the impact of sedation on delirium recognition), while others looked at the bundle as a whole. Additionally, some articles focused on specific populations of patients (e.g., those with acute respiratory failure), while others looked at the bundle in a more general sense. However, the studies vary in terms of their locations (the US vs. international), study populations (mechanically ventilated patients vs. all critically ill adults), and interventions (implementation of the ABCDE bundle vs. measurement of adherence to the ABCDE bundle).

There is some overlap in the findings of the studies. For example, all studies found that implementing the ABCDE bundle improved patient outcomes. However, there were also differences between the studies. Some studies found that adherence to the ABCDE bundle was associated with better patient outcomes. In contrast, other studies found that implementing the ABCDE bundle was associated with better patient outcomes. There are also differences in the methods used by the studies. Some studies used observational designs, while others used randomized controlled trials. Some studies measured adherence to the ABCDE bundle, while others measured implementation of the ABCDE bundle. The conclusions of the studies also vary. Some studies conclude that the ABCDE bundle effectively improves patient outcomes, while others conclude that more research is needed. Some studies suggest that adherence to the ABCDE bundle is more important than implementing the ABCDE bundle, while other studies suggest that both adherence and implementation are essential.

There are also some limitations to the studies. For example, some studies did not include a control group, making it difficult to determine whether the ABCDE bundle was responsible for improved patient outcomes. Additionally, some studies had small sample sizes, limiting the findings' generalizability. Finally, there are some controversies surrounding the use of the ABCDE bundle. Some critics argue that the bundle is too complicated and expensive to implement, while others argue that the bundle's benefits justify the costs. There is debate about whether adherence or implementation is more critical for improving patient outcomes.

One fundamental gap identified in the literature is a need for more research on patient populations not traditionally considered high risk for developing sepsis, such as those admitted to the intensive care unit for other reasons (e.g., respiratory failure, renal failure). , nor did the searches identify the use of the ABCDE bundle in an LTACH setting. Additional research is needed on the impact of the ABCDE bundle on these patients and its use in LTACHs to determine if the bundle effectively reduces sepsis-related morbidity and mortality and the impact it could have on patients in an LTACH population.

Another gap identified in the literature is a need for studies on the cost-effectiveness of the ABCDE bundle. Additional research is needed on the financial impact of implementing the bundle on hospitals and patients. This research could inform decisions about whether or not to implement the bundle in clinical practice. Lastly, additional research is needed on implementing the ABCDE bundle in different healthcare settings. Implementing the bundle requires significant changes in clinical practice, and more information is needed on how well the bundle can be adapted to different care environments. These are just a few examples of the gaps in the literature that require further research. It is important to note that any investigation into the effectiveness of the ABCDE bundle should consider all of these gaps to provide a comprehensive assessment of the current state of knowledge on this topic .

The project will focus on implementing the ABCDE bundle to improve patient outcomes effectively. Extensive research was identified to support the ABCDE bundle's implementation as it has been shown to improve patient outcomes, including decreased mortality and length of stay. The bundle effectively reduces the length of stay for elderly patients and thus should be implemented in clinical practice (Frade-Mera et al., 2022). Adherence to the bundle has improved survival rates, brain function, and overall patient care. Additionally, the ABCDEF bundle is a cost-effective way to improve patient outcomes by reducing the length of stay and direct and indirect healthcare costs (Otusanya et al., 2022)

The affected population will be hospitalized in long-term acute care hospitals. These are the populations that suffer from ineffective interventions. As a result, the population tends to spend more time due to the increased LOS in long-term acute care hospitals. Consequently, the population affected tends to incur higher healthcare costs due to prolonged hospital stays. The project will address this problem by examining how the ABCDEF bundle effectively reduces the LOS and the associated increased healthcare costs. The evidence-based practice question is written using the template: To what degree will the translation of Hsieh et al. research implementing the ABCDE bundle impact length of stay among adult patients in a high observation unit in a long-term acute care hospital in Virginia? 

Hsieh et al. (2019) noted a substantial reduction in the duration of mechanical ventilation, length of stay and cost. Research-based solid evidence indicates that the ABCDE bundle has individual components that are clearly defined, flexible to implement, and can quickly help to empower multidisciplinary families and clinicians in the shared care of critically ill patients (Engel et al., 2022). The ABCDE bundle will promote a more interactive unit for patients with better-controlled pain, who can safely participate in higher-order physical and cognitive activities at the earliest point in their critical illness. Different studies, including primary and secondary research, articles indicate the effectiveness of the ABCDE bundle in improving patient outcomes and reducing care costs (Zhang et al., 2021).

The ABCDE bundle effectively addresses severe adverse effects of critical illnesses in long-term acute care reducing mechanical ventilation duration, improving mobility, assessing and treating pain and delirium. The bundle represents one of the most effective methods of approaching changes within an organization in order to create a culture shift when treating different categories of patients in the ICU unit (Pun et al., 2019). The possible multifold benefits of the recommended strategies from implementing the ABCDE bundle outweigh the minimal risks of costs and coordination. Based on the findings from all the qualitative and quantitative studies, it is evident that the ABCDE bundle offers a well-rounded environment for patient care and the optimal utilization of resources (Zhang et al., 2021). The bundle leads to better pain control with the engagement of families and healthcare providers in higher-order cognitive and physical activities during the earliest period of the patient's critical illness (Schallom et al., 2020). The recommendation for practice is to implement the ABCDE bundle in reducing mechanical ventilation duration, improve mobility, reduce incidence of delirium, reduce use of sedation, and pain identification ( Frade-Mera et al., 2022

The theoretical model guiding the study will be the Synergy model for patient care from the American Critical Care Nurses (AACN). The theory assumes that patients need the best care to meet their needs when the needs of the patients are met with the competencies of the nurses (Thankachan, 2022). The model addresses the characteristics of the patients, such as resiliency, stability, vulnerability, resource availability, complexity, predictability, and ability to participate in care and decision-making by employing the Critique Frameworks of Chinn and Kramer (2011) and Fawcett and DeSanto-Madeya (2013) (Thankachan, 2022). When implementing the project, the nursing competencies will include advocacy, clinical judgment, collaboration, caring practices, clinical inquiry needed to provide patient care, diversity response, systems thinking, and learning facilitation (Thankachan, 2022). The Synergy model for patient care is a practical framework since it establishes that the nurses' competencies depend on the situation and stipulates that the competencies of the nurses should be linked to the characteristics of the patients to achieve positive outcomes (Thankachan, 2022). The model also classifies delirium patients as vulnerable because delirium places them in a vulnerable state where they require more resources to be allocated to them. As a result, it calls for the caring clinician to practice competencies such as advocacy, clinical judgment, collaboration, caring practices, clinical inquiry needed to provide patient care, diversity response, systems thinking, and learning facilitation to care for the patient adequately. As a result, the clinical question perfectly aligns with the chosen nursing theory, making the project fit within the evidence based on the model and theory chosen for the project.

The seminal source of the Synergy model for patient care is relevant to practice because it identifies the work of the nurses as being founded on the relationships with patients and their families. The model was relevant to the ABCDE bundle, which includes families as a vital part of the ABCDE bundle intervention. The model will help to explain and delineate the role of professional nurses in directly affecting the patients and the overall success of healthcare organizations in achieving positive patient outcomes.

The nursing theory selected will be Virginia Henderson's nursing needs theory (Henderson, 1966). The nursing theory will serve as a vital component in the early identification of the needs of the patients in order to reach fulfillment. Specifically, the study will utilize Henderson's nursing needs theory to offer a systems approach to focus on the human needs of protection and relief from stress (Ahtisham & Jacoline, 2015). The 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. 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 the needs of humans (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.

Henderson's nursing needs theory will be used during the project to illuminate the problem of ICU delirium because the theory can anticipate the effects of interventions that could be applied to strengthen the lines of defense against stress (Ahtisham & Jacoline, 2015). For example, the theory can explain why critical illness can induce higher stress levels among patients in the ICU, which would make the patients present signs such as delirium or agitation, or both. In such cases, the stress could manifest in mechanical ventilation, sedation, and attempts by the patient to make sense of what they may have seen or heard in unfamiliar settings and environments (Campos, 2022). This theory has components that effectively resonate with the concepts and interventions of the ABCDE bundle intended to implement. Henderson identified that the unique function of the nurse is to assist if the individual is sick or well. In the performance of those activities contributing to health or its recovery (or to peaceful death) that one would perform unaided if one had the necessary strength, will, or knowledge and to do this in such a way as to help one gain independence as rapidly as possible This component will help to achieve the goal of improving patient outcomes. The theory will help identify the problems on time and use prevention as an effective intervention during the project implementation.

Virginia Henderson's nursing needs theory resonates with other articles as it relates to the DPI project. 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 (Ahtisham & Jacoline, 2015). 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 ABCDE bundle successfully.

Once the signs of stress have affected the open system, secondary prevention measures are activated. The primary intervention is activated upon the suspicion of a stressor to refrain the stressor from its reception (McEwen & Wills, 2019). Secondary prevention measures aim to strengthen the lines of defense and resistance and minimize adverse reactions (Ahtisham & Jacoline, 2015). Finally, tertiary prevention aims to avert the recurrence of these stressors and guide the open system toward regaining stability (Ahtisham & Jacoline, 2015).

With the implementation of the project, the project will implement management strategies , preventive methods, and education. The project can help clinicians eliminate the negative stressors that could induce instability in the patient in the ICU setting. When implementing Henderson's nursing needs theory, the five significant variables are the psychological, physiologic, developmental, sociocultural, and spiritual variables to serve as the basic structure (McEwen & Wills, 2019). When implementing the model, stressors manifest as external, internal, and created environments. The theory has broad applicability to the project because of a part of the resonation it has to the ABCDE bundle that is sought to implement in the long-term acute care hospital to improve patient outcomes in the ICU setting and reduce the costs of care.

John Kotter's eight-step change model is the proposed change model for the project. John Kotter's eight-step change process applies to implement change (Kotter, 1995). These strategies can be applied in implementing the ABCDE bundle to decrease LOS. The model is developed by determining the core values, defining the ultimate vision, and defining the strategies used to realize the change in the organization (Kotter, 2012). The change model requires the organizational leaders to define the change in a way that is easily understandable and easy to follow.

According to Kotter (2012), the first step is creating urgency. Kang et al. (2022) explain the theory. According to Kang et al. (2022), the proposed interventions need to develop urgency. The urgency is possible by identifying the existing threats in caring for patients. Therefore, discuss the weaknesses with the stakeholders and colleagues and request their support to implement the change. Secondly, put together a guiding coalition (Kotter, 2012). Come up with competent leaders and professionals to steer the agenda to influence the stakeholders. Thirdly develop vision and strategies (Kotter, 2012). 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 (Kotter, 2012). 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 (Kotter, 2012). Building change ensures that everyone adapts to new change by illustrating its importance and training them with the skills necessary to maintain the new change. These steps will be used to implement unit change, implementing the ABCDE bundle for the DPI project.

John Kotter’s eight step change model includes eight steps to institute change. Kotter identify eight steps that crucial to implement change. The model was first described in 1995 by extracting success and failure factors for business and combining them into a methodology (Kotter, 1995).

The eight steps include creating an urgency for change, this initial step will help create a sense of urgency by helping the stakeholders understand the implications and need for the change in improving patient outcomes and reducing care costs. Build a coalition is the second step. The second step will be to build guiding teams. Involving stakeholders will foster inter-collaborations with multidisciplinary teams to enhance the project's outcomes., The third step is to create a vision. The vision will guide staff and stakeholders involved and enhance decision-making during the project and the prediction of patient outcomes. The fourth step is communicating the vision. The healthcare industry is evolving, focusing on improving patient outcomes while minimizing healthcare costs to enhance accessibility and use of healthcare services among all populations. The fifth step is empowerment of others. Empowering of other fosters growth allowing staff and leaders to achieve their highest potential. The six creating quick wins. Short-term wins will help maintain the momentum and engagement. The seventh step is built on change The seventh step will be to build on the change. Involving stakeholders will ensure that all the staff, team, and other stakeholders are overworking to achieve the change and measure progress. The eighth step is embedding change. This step is crucial to cultural change within an organization by demonstrating the importance of the intervention and its effects on patient care, clinical outcomes and length of stay.

John Kotter's eight-step change model was developed to address the need to implement change in the workplace successfully (Kotter, 1995). The model was created to recognize that change could manifest itself in any form, including mergers, new technologies, acquisitions, cultural transformations, and new strategies, among other ways (Kang et al., 2022). Kotter's change model has proven to be a very effective change management framework for successfully implementing organizational change (Kang et al., 2022). The framework was introduced in a book titled Leading Change after years of research which showed that nearly 70 percent of change initiatives fail to be successfully implemented.(Kotter, 1995).

Kotter's eight-step change model is significant for various reasons. First, the model offers an easy-to-follow roadmap that change managers can use to implement organizational change successfully in an eight step-wise approach (Kang et al., 2022). The easy-to-follow roadmap will enhance the ease of implementing the proposed change by following the steps recommended in Kotter's change model (Kang et al., 2022). The various stages of the model outline the precise steps that should be taken to ensure that the project remains on track (Kotter,1995).

Kotter’s eight step model is well documented throughout literature studies. The model will be instrumental in implementing the ABCDE bundle to decrease length of stay, The eight step-wise approach will identify steps to create a climate for change, engage and enable the organization, and implement and sustain change.

Quality healthcare is a common problem that affects many people and groups. Although various solutions have been recommended to address the issue through legislative and socioeconomic works, a stable and more effective solution is yet to be achieved. The mission and vision of the organization is to extend compassionate care to all of those affected by a medical illness in need of medical care. The healthcare team is dedicated to providing holistic patient care with a commitment to clinical service excellence, a cultural that inspires team work and a passionate workforce driven by a dedication to patient wellness and wholeness. Christian principles of human dignity, solidarity, subsidiarity, and working for the common good will play a significant role in organizations care delivery model. Implementation of the ABCDE bundle aligns with those principles.  

Grand Canyon University’s doctrinal statements aligns with the implementation of the ABCDE bundle by incorporating the believes and values of God by providing a framework for ethical thinking to drive God’s plan and purpose. Incorporating Christian worldviews serves a holistic approach to patient care increasing patient and family satisfaction, and improve clinical outcomes.

Implementing the ABCDE bundle aims to enhance patient outcomes and foster reduced healthcare costs. The ABCDE bundle is one of the most influential and evidence-based guides that healthcare professionals, such as clinicians, can implement to coordinate multidisciplinary patient care in ICU settings (Chen et al., 2021. The first element of the ABCDE bundle is the assessment element. The assessment of pain is the first step that all clinicians will use before administering pain relief (Frade-Mera et al., 2022;). The second element is the Behavioral Pain Scale (BPS) and the Critical-Care Pain Observation Tool (CPOT). The BPS and CPOT have considered the most reliable and valid behavioral pain scales clinicians use for ICU patients who cannot communicate (Pun et al., 2019). The third element is the coordination of Spontaneous Awakening Trials (SAT) with Spontaneous Breathing Trials (SBT) (Marra et al., 2017). The coordination of SBT and ASAT is associated with reduced use of sedatives, reduced time in ICU and mechanical ventilation reduced instances of delirium, and lower hospital lengths of stay (Hsieh et al., 2019). The fourth element of the ABCDE bundle is monitoring delirium. Delirium monitoring and management is a significant component of the ABCDE bundle intervention. Delirium is a decisive risk factor for increased length of ICU stay, increased time on mechanical ventilation, increased hospital stay, long-term cognitive impairment, the escalating cost of hospitalization, and higher mortality rates (Mart et al., 2019). The fifth element of the bundle includes early mobility. Early mobility is the only known intervention for decreased delirium duration (Mart et al., 2019). Based on the studies, physical therapy is feasible and safe for patients admitted to the ICU, even while on renal replacement therapy, mechanical ventilation, or circulatory support (Hsieh et al., 2019). Therefore, all the components of the bundle act as effective interventions for patients admitted into the ICU for various conditions. Chapter 3 will cover the methodology and project design, while chapters four and five will address the results, findings, implications, and recommendations for future research.

Chapter 3: Project Design and Methodology

Introduce this chapter by describing how the project outcome will improve the quality of health care for the patient population. This section should report how the project is rooted in quality improvement from the outset of the improvement initiative. Then, in no less than three substantive paragraphs, discuss the differences between research, evidence-based practice, and quality improvement. Include what makes them each unique and how one leads the other. Please support your discussion with scholarly citations.

The “Purpose” section of Chapter 3 should be two or three paragraphs long. It should (a) reflect on the problem statement, (b) identify how the project will be accomplished, and (c) explain how the project will contribute to the field. The section begins with a declarative statement, "The purpose of this project is....” which is based on your problem statement from Chapter 1. Included in this statement are also the project design, population, variables to be investigated, and the geographic location. Further, the section clearly defines the dependent and independent variables, relationship of variables, or comparison of groups (comparison versus intervention) for quantitative analyses. Keep in mind that the exact purpose statement (i.e., copy paste what is here) in this chapter is restated in the abstract and Chapter 5. This purpose statement aligns to the PICOT components from previous courses. Use the following template for structuring your purpose statement: The purpose of this quality improvement project is to determine if the implementation of _________________ (whose research are you translating or what clinical practice guidelines) would impact ______________(what) _______________________ among ___________(population). The project was piloted over an eight-week period in a (rural, urban, or directional (eastern, western, …)________ (state) ________ (setting i.e., primary care clinic, ER, OR).

Introduce this section with three to five sentences. Include why project planning was initiated and how it helped the team to think systematically. This section addresses the overall concept of the project planning procedure.

This section should be three or four paragraphs long. The first paragraph should outline why organizational support is imperative when improving patient outcomes. Include what organizational support will be required for your quality improvement project. Ensure to use a transitional statement between this section and the next.

The second paragraph will summarize the organizational support you are receiving from the stakeholders at the project site. In this paragraph, identify both the internal and external stakeholders from within the organization. What are their roles and how will this ensure sustainability of the project in the future?

The third and fourth paragraphs should include the characteristics of the team that conducted the intervention (for instance, type and level of training, degree of experience, and administrative and/or academic position of the personnel leading workshops) and/or the personnel to whom the intervention was applied should be specified. Often the influence of the people involved in the project is as great as the project components themselves. Explain the role of a project manager of this quality improvement project and how a project manager influences and facilitates the team and the project. Include your responsibilities and duties using third person without referring to yourself. Next, describe the role and responsibilities of the team members in your project.

This section should be two to three paragraphs long. This section details the step-by-step plan for the project’s implementation. Include that the project starts with IRB approval and ends at data analysis. Every change that could have contributed to the observed outcome should be noted. Each element should be briefly described. Refer to the project timeline completed in DNP-840A (see Appendix C). The plan should include a complete procedure and outline of the education that will provide to the staff. Explain where the education was derived from (typically the instrument/tool/evidence-based intervention) and discuss how it will be deployed. Refer to the Educational Plan in Appendix D. Describe how or why you are qualified to teach this information to the staff. Include if you required additional outside resources to implement the education. Describe your procedure in such a way that your reader could follow the same steps and get the same results.

• The project was initiated after receiving approval for Grand Canyon University’s Institutional Review Board. (see Appendix E) This Appendix will become Appendix A once your project has been evaluated by the Grand Canyon University institutional review board and an outcome letter issued.

This section should be one or two paragraphs. What is required to make your project successful? Do you have adequate staff and time to educate the healthcare providers (nurses, doctors, mid-levels, tech, medics, etc.) on the evidence-based intervention? Do you need supplies or technology for support? As the project manager can you do the education or is there a cost to bring someone in (is this addressed in your budget)? Refer to the budget completed in DNP-840A as an appendix (see Appendix F). Remember having a balanced budget is imperative in today’s healthcare so as you show expenses, there should be some reference to anticipated improved revenue. Is the project designed in a way to ensure realistic implementation of the project? Support your discussion with scholarly citations.

This section discusses the total population, project population, and project sample based on the geographical setting of the project site. A description of the sample is essential for other clinicians to apply your findings to their settings.

In one paragraph, introduce this section by providing a broad description of the project site. Describing the organization in which in intervention took place in detail is necessary to assist readers in understanding whether the intervention is likely to “work” in the local environment (consider what the organization’s public description is on their website). This includes the description of the community, its makeup, and current services. Include additional information as needed, such as information about the location, practice type, teaching status, system affiliation, patient population (i.e., number of patients in a given time frame), size of the organization, staffing, and relevant processes in place. Follow the broad overview of the organization with a more focused overview of the specific area of practice (i.e., ER, OR, or ICU).

The discussion of the sample includes the proper terminology specific to the type of sampling method used for the project. This section should be three to four paragraphs long and include the following components:

1. The characteristics of the total population and the project population from which the project sample (project participants) is drawn. Describe the characteristics of the project population and the project sample.

2. Clear definitions and differentiation of the sample versus the population for the project. Describe the project population size and project sample size and justify the project sample size (e.g., power analysis) based on the selected design.

3. Details on the sampling procedures, including the specific steps taken to identify, contact, and recruit potential project sample participants from the project population. If subjects withdrew or were excluded from the project, you must provide an explanation of why.

4. The informed consent process, confidentiality measures, project participation requirements, and geographic specifics.

5. How the intervention answers the evidence-based question(s).

This section should be three or four paragraphs in length. This section details the entirety of the process used to collect the project data and describes the sources from which the data will be obtained. Describe the step-by-step procedures used to carry out all the major steps for data collection for the project in a way that would allow another investigator to replicate the project. Data should include descriptive or demographic data of the project sample and outcome data. Describe who/and from where data are obtained.

The first paragraph should include a description of data sources including any instrumentation. This paragraph should address the procedures for data collection, including how each instrument or data source was used, how and where data were collected (including demographic data), and how data were recorded. If survey/instruments are used, then their validity and reliability must be explained, including the psychometric data, using relevant scholarly citations. Refer to the instrument in Appendix G. Include permission to use the tool in Appendix H. If an instrument was not used for data collection, then explain the reliability and validity of the data source (e.g., reliability and validity of the EHR). If other instruments or sources of data are needed, provide evidence in the appendices. (see Appendix I).

The second paragraph should include an explanation of the independent and dependent variables (if applicable), and how the resulting change in those variables is measured (if applicable). It should also include a description of the procedures for project sample selection and how the data for the participants were grouped (e.g., comparison versus implementation).

The third paragraph should include how the data integrity will be managed throughout project implementation. Include the description of how the final analysis data collection set and data dictionary were created and if any data manipulation was required. It should also provide a description of the type of data to be analyzed, identifying the descriptive, inferential, or nonstatistical analysis used.

The fourth paragraph should provide a detailed description of the relevant data collected for each project question. It should also detail how the raw data were organized and prepared for analysis. Include any methods for data cleansing. There should also be a description of the procedures adopted to maintain data security, including the length of time data will be retained, where the data will be retained, and how the data will be destroyed following the project site’s policy. What data management errors were anticipated during the data collection period? Include how errors in data collection and entry will be discovered early and remedied. Support your discussion with scholarly references.

In this section, you will describe the potential biases that may impact your project (proposal stage) and biases that did impact your project (finished manuscript). In addition, you will explain how these biases were mitigated to ensure the validity of the project. This section should be at least four paragraphs long.

You should explain at least five potential biases that are related to (a) the project methodology, (b) the project design, (c) the sampling procedures, (d) data collection, and (e) data interpretation. For each bias, you need to (a) clearly define what the bias is/was, (b) clearly explain how the bias may have been present in your project, and (c) explain how you mitigated this bias. Your discussion should be supported with scholarly citations.

Please note, you will need to personalize the possible biases based on the project you conducted. For example:

If my project employs an internet survey and there are people who meet the criteria but do not have access to the internet to take the survey, I will miss all those people who met the criteria for participation!

Or

When conducting a quality improvement project, it is not possible or not practical to choose a random sample. In those cases, a convenience sample might be used. Sometimes it is plausible that a convenience sample could be considered as a random sample, but often a convenience sample is biased. If a convenience sample is used, inferences are not as trustworthy as if a random sample is used.

This section should be one paragraph and summarize the ethical aspects of implementing an intervention and analyzing the data. This section should include a description of the procedures for protecting the rights and well-being of the project sample as well as the staff completing the intervention. The key ethical issues that must be addressed in this section include:

• How any potential ethical issues will be addressed.

• Ethical issues are related to the project and the sample population of interest, institution, or data collection process.

• Anonymity, confidentiality, privacy, lack of coercion, and potential conflict of interest.

• The key principles of the Belmont Report (respect, justice, and beneficence) in the project design, sampling procedures, and within the theoretical framework, practice or patient problem, and clinical questions.

Include a statement that the project has undergone a formal ethics review by the GCU IRB. Select the following statement that best aligns with your IRB determination and embed it in your paragraph (see Appendix E):

• Quality Improvement: This project was reviewed by the Institutional Review Board at Grand Canyon University, and was determined not to be human subjects research. As such, this project did not require IRB review.

• Exempt/Expedited: This project was reviewed by the Institutional Review Board at Grand Canyon University, and was determined to be exempt/expedited. As such, this project was approved.

This section summarizes the key points of Chapter 3 and provides supporting citations for those key points. It then provides a transition discussion to Chapter 4 followed by a description of the remaining chapters. This section should be two paragraphs long.

Chapter 4: Data Analysis and Results

This chapter provides a summary of the collected data, describes how the data were analyzed, and then presents the results. Chapter 4 includes a brief restatement of the problem statement and the evidence-based practice question. The organization of the chapter is briefly outlined in this section. Make sure this chapter is written in past tense and reflects how the project was actually conducted.

This chapter contains the analyzed data presented in both text and tabular or figure format. The structure of the chapter is imperative. You should aim to ensure both the readability and clarity of the findings. Sufficient narrative should be provided to highlight the findings on the measurable patient outcome. Ask the following general questions before starting this chapter:

1. Are there sufficient data to answer the evidence-based practice question asked in the project?

2. Are there sufficient data to support the conclusions you will make in Chapter 5?

3. Are the data clearly explained using a table, graph, chart, or text?

This section provides a step-by-step description of the procedures to be used to conduct the data analysis. This section should be two paragraphs. The first paragraph should provide a step-by-step description of the procedures used to conduct the data analysis. In this paragraph, describe all statistical and nonstatistical analyses employed. State the specific tests you plan to use to analyze your outcome data. Rationale should be provided for each of the data analysis procedures (statistical and nonstatistical) and supported by relevant scholarly citations.

The second paragraph should explain how and why the data analysis techniques selected align with the DPI project design and question. The level of the statistical significance used for the quantitative analyses is identified a priori (p < .05).

Please note that the independent variables in quasi-experimental projects are a nominal or categorical level variables that are used to identify the sample or group associated with the intervention. It is the dependent variable (i.e., the project outcome measure) that directs the type of statistical analysis selected, e.g., parametric versus non-parametric. If the dependent variable is a ratio or interval, a parametric test, such as an independent t-test, should be used. If the dependent variable is an ordinal or nominal level, a non-parametric test, such as a Chi-square or Mann Whitney U, should be used.

This section provides a narrative summary of the project sample’s characteristics and demographics. Descriptive data should be collected based on the sample (there will always be data for the patient sample but include nursing staff data if applicable). It establishes the total sample size, gender, age, education level, organization, or setting and other appropriate sample characteristics. Graphic organizers, such as tables, charts, histograms, and graphs should be used to provide further clarification, organize the data, and promote readability. Ensure these data cannot lead to the identification of participants or the project setting in any analysis or narrative.

All tables, graphs, and figures must always be introduced and discussed within the text prior to their presentation. Data in the tables should match data in the text exactly. When writing numbers, equations, and statistics, spell out any number that begins a sentence, title, or heading, or reword the sentence to place the number later in the narrative. In general, use Arabic numerals (11, 12, 13) when referring to whole numbers 11 and above, and spell out whole numbers below 11. There are some exceptions to this rule:

1. If small numbers are grouped with large numbers in a comparison, use numerals (e.g., 7, 8, 10, and 13 trials); but do not do this when numbers are used for different purposes (e.g., ten items on each of four surveys).

2. Numbers in a measurement with units (e.g., 6 cm, 5 mg dose, 2%).

3. Numbers that represent time, dates, ages, sample or population size, scores, or exact sums of money.

4. Numbers that represent a specific item in a numbered series (e.g., Table 1).

A sample table in APA style is presented in Table 1 and more examples can be found at “Sample Tables” on the APA Style Website. Be mindful that all tables fit within the required margins, and are clean, easy to read, and formatted properly using the guidelines found in Chapter 5 (Displaying Results) of the APA Publication Manual 7th Edition. As noted, all tables and figures should be introduced in a paragraph above them. Here is an example:

There were N = X patients sampled, n = x in the comparative group and n = x in the intervention group. The mean age of the comparative sample was X (SD = x), and the mean age of the intervention group was X (SD = x) (see Table 1).

Table 1
A Sample Data Table Showing Correct Formatting

Note. Adapted from “Sampling and Recruitment in Studies of Doctoral Students,” by I.M. Investigator, 2010, Journal of Perspicuity, 25, p 100. Reprinted with permission .

This section, which is the primary section of this chapter, presents a summary and analysis of the data in a non-evaluative, unbiased, and organized manner that relates to the evidence-based practice question. The section should also include appropriate graphic organizers, such as tables, charts, graphs, and figures. Please ensure that:

1. The amount and quality of the data or information is sufficient to answer the evidence-based question(s) is well presented.

2. The results of each statistical test are presented in appropriate statistical format with tables, graphs, and charts.

3. The p-value ( p=) and test statistics are reported.

4. Outliers, if found, are reported.

5. The results must be presented without implication, speculation, assessment, evaluation, or interpretation. Discussion of results and conclusions are left for Chapter 5.

Both descriptive and inferential statistics are required to be reported in this section. Descriptive statistics describe or summarize data sets using frequency distributions (e.g., to describe the distribution for the IQ scores in your class of 30 pupils) or graphic displays such as bar graphs (e.g., to display increases in a school district's budget each year for the past five years), as well as histograms (e.g., to show spending per child in school and display mean, median, modes, and frequencies), line graphs (e.g., to display peak scores for the classroom group), and scatter plots (e.g., to display the relationship between two variables). Descriptive statistics also include numerical indexes such as averages, percentile ranks, measures of central tendency, correlations, measures of variability and standard deviation, and measures of relative standing.

Inferential statistics describe the numerical characteristics of data, and then go beyond the data to make inferences about the population based on the sample data. Inferential statistics also estimate the characteristics of populations about population parameters using sampling distributions, or estimation. Table 2 presents example results of an independent t-test comparing Emotional Intelligence (EI) mean scores by gender.

Table 2
t-Test for Equality of Emotional Intelligence Mean Scores by Gender

Chapter 4 can be challenging with regard to mathematical equations and statistical symbols or variables. When including an equation in the narrative, space the equation as you would words in a sentence: x + 5 = a. Punctuate equations that are in the paragraph as you would a sentence. Remember to italicize statistical and mathematical variables, except Greek letters, and if the equation is long or complicated, set it off on its own line. Refer to your APA manual for specific details on representation of statistical information. Basic guidelines include:

• Statistical symbols are italicized (t, F, N, n)

• Greek letters, abbreviations that are not variables and subscripts that function as identifiers use standard typeface, no bolding or italicization

• Use parentheses to enclose statistical values (p = .026) and degrees of freedom t(36) = 3.85 or F(2, 52) = 3.85

• Use brackets to enclose limits of confidence intervals 95% CIs [- 5.25, 4.95]

This section provides a concise summary of the project results. It briefly restates essential data and data analysis presented in the chapter, and it helps the reader see and understand the relevance of the data and analysis to the evidence-based question(s). It should summarize the statistical data and results of statistical tests in relation to the evidence-based question(s). Finally, it provides a lead or transition into Chapter 5 where the implications of the data and data analysis relative to the evidence-based question(s) will be discussed. This section should be two to three paragraphs long.

Introduce Chapter 5 by providing (a) a general reminder of the problem, (b) the purpose of the project, and (c) overviewing the information that will be presented in this chapter. This section should be one to two paragraphs long.

Chapter 5 is perhaps the most important chapter in the practice improvement project manuscript because it presents the project investigator’s contribution to the body of knowledge. For many who read evidence-based literature, this may be the only chapter they will read. No new data or citations should be introduced in Chapter 5; however, references should be made to findings or citations presented in earlier chapters. You should articulate new frameworks and new insights. All discussions in this chapter should be presented in the simplest possible form, making sure to preserve the conditional nature of the insights.

This section provides a comprehensive summary of the project by describing previous chapters in the simplest possible terms. It should recap the essential points of Chapters 1 to 3. It reminds the reader of the evidence-based question(s), the main issues being evaluated, and provides a transition, and reminds the reader of how the project was conducted. This section should be no more than two paragraphs.

Summarize the major findings (results) of your DPI project. Explain the statistical significance of your project findings. Explain the clinical significance of your project findings. This section should be no more than two paragraphs.

Describe how the findings of your DPI project align with other original research studies and/or quality improvement projects by comparing and contrasting the significance of the results. Provide possible explanations as to why your project findings confirmed or opposed previous published scholarly works. If your results did not achieve statistical significance, provide possible explanations why. This section should be no more than three to four paragraphs long.

In this section, describe the strengths of your project. In this discussion, you should consider the project design or methodology, the intervention, and the unit culture. Strengths should be presented in two paragraphs.

Then, summarize the limitations of your DPI project. Limitations could be related to the project timeline, threats discussed in your SWOT, etc. Discuss the efforts that were made to minimize the limitations. Limitations should be addressed in two paragraphs.

In this section, you should present the “so what” (i.e., why was this important) of your project based on the project results. This section should describe the types of implications that could happen as a result of this project. It also tells the reader what the DPI project results imply both theoretically and for future nursing practice. Separate sections with corresponding headings provide proper organization. Provide a transition of three to five sentences for this new section.

Theoretical implications involve the interpretation of the DPI project findings in terms of the evidence-based question(s) that guided the project. It is appropriate to evaluate the strengths and weaknesses of the project critically and include the degree to which the conclusions are credible given the method and data. It should also include a critical, retrospective examination of the framework presented in the Chapter 2 “Scientific Underpinnings” considering the practice improvement project’s new findings. In addition, you should describe whether the results of your project or the implementation process demonstrate the need to develop new or re-think current nursing theories. This section should be no more than two paragraphs.

In this section, explore two to three ways the DPI project findings are important for nursing practice. Will it change practice? How? This section should be no more than two paragraphs.

Provide a brief transition (three to five sentences) that describes this section of the manuscript.

This section should contain a minimum of four to five recommendations for future DPI projects. Project recommendations should include the areas of project that need further examination, address project or research gaps, new patient populations, or system needs. Each recommendation should be fully explained in one paragraph and should include (a) why the future project should be conducted, (b) how the project should be conducted (methodology and design), (c) what data would be collected, and (d) how the project would advance healthcare or patient outcomes.

This section should describe two to three recommendations for how the DPI project can be sustained. For example, does the new practice change require a policy in order for it to be sustained? Each recommendation should be fully explained in one paragraph that includes (a) what the sustainability plan is, (b) why the sustainability plan is needed, and (c) how the sustainability plan would work at the unit, organization, state, and national levels. Include any organizations or stakeholders who should be included in the sustainability discussions and what their role or involvement should be.

This section should contain a detailed plan regarding how the DPI project results will be disseminated to others in the nursing profession and other disciplines. Provide three to four specific examples of what your plan is for dissemination for your site, the community, the local nursing community, and when applicable, nationally. Describe the appropriate audience(s) for dissemination of the DPI project results. The audience(s) should be broad and should extend beyond the academic setting. Discuss informal and formal venues for electronic dissemination. Select the most appropriate peer-reviewed journal(s) in which you could publish your DPI project findings. Discuss oral dissemination opportunities (i.e., a podium or poster presentation or abstract submission). Consider presentation opportunities at regional, state, national, or international meetings. This section should be no more than three paragraphs.

This final section should briefly wrap up the project. Concisely describe the contributions your DPI project has made to the nursing profession. This section should be no more than two paragraphs.

Agency for Healthcare Research and Quality. [AHRQ]. (2017). Evidence behind Pain, Agitation, and Delirium: Assessments and Sedation Management: Slide Presentation: Overview. https://www.ahrq.gov/hai/tools/mvp/modules/technical/pain-mgmt-slides.html

American Psychological Association. (2020). Publication manual of the American Psychological Association 2020: The official guide to APA style (7th ed.). American Psychological Association.

American Psychological Association. (2021). Publication Manual, 7th edition student paper checklist. https://apastyle.apa.org/instructional-aids/ publication-manual-formatting-checklist.pdf

Bakhru, R. N., Schweickert, W. D., Propert, K. J., & Kawut, S. M. (2014). C45 MECHANICAL VENTILATION: A Survey Of Abcde Bundle Protocols In Mechanically Ventilated Patients. American Journal of Respiratory and Critical Care Medicine, 189, 1. https://search.proquest.com/openview/a6d774f3dbfb8e392b1a06bc5d01e709/1?pq-origsite=gscholar&cbl=40575

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

Balas, M. C., Vasilevskis, E. E., Burke, W. J., Boehm, L., Pun, B. T., Olsen, K. M., ... & Ely, E. W. (2012). Critical care nurses’ role in implementing the “ABCDE bundle” into practice. Critical care nurse, 32(2), 35-47. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3375171/

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

Benzaghta, M. A., Elwalda, A., Mousa, M. M., Erkan, I., & Rahman, M. (2021). SWOT analysis applications: An integrative literature review. Journal of Global Business Insights, 6(1), 55-73. https://digitalcommons.usf.edu/cgi/viewcontent.cgi?article=1148&context=globe

Boehm, L. M., Dietrich, M. S., Vasilevskis, E. E., Wells, N., Pandharipande, P., Ely, E. W., & Mion, L. C. (2017). Perceptions of workload burden and adherence to ABCDE bundle among intensive care providers. American Journal of Critical Care, 26(4), e38-e47. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5089165/

Bounds, M., Kram, S., Speroni, K. G., Brice, K., Luschinski, M. A., Harte, S., & Daniel, M. G. (2016). Effect of ABCDE bundle implementation on prevalence of delirium in intensive care unit patients. American Journal of Critical Care, 25(6), 535-544. https://aacnjournals.org/ajcconline/article-abstract/25/6/535/3203

Chen, C. M., Cheng, A. C., 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://onlinelibrary.wiley.com/doi/pdf/10.1111/nicc.12530

Chen, T. J., Chung, Y. W., Chang, H. R., Chen, P. Y., Wu, C. R., Hsieh, S. H., & Chiu, H. Y. (2021). Diagnostic accuracy of the CAM-ICU and ICDSC in detecting intensive care unit delirium: A bivariate meta-analysis. International Journal of Nursing Studies, 113, 103782. https://doi.org/10.1016/j.ijnurstu.2020.103782

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

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

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

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.

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

Kotter, J. P. (1995). Leading change: Why transformation efforts fail. Harvard Business Review, 73(2), 59–67.

Kumar, R. , Zhang, W. , Evans, E. , Dams-O'Connor, K. & Thomas, K. (2022). Research Letter: Characterization of Older Adults Hospitalized With Traumatic Brain Injury Admitted to Long-Term Acute Care Hospitals. Journal of Head Trauma Rehabilitation, 37 (2), 89-95. doi: 10.1097/HTR.0000000000000685.

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

Marra, A., Ely, E., Pandharipande, P., & Patel, M. (2017). The ABCDEF Bundle in critical care. Critical Care Clinics, 33 (2), 225-243. https://doi.org/10.1016/j.ccc.2016.12.005

Medicare Payment Advisory Commission [MedPAC]. 2019. Long term care hospital services. In: Report to the Congress: Medicare Payment Policy. 281–300.

Nordness, M. F., Hayhurst, C. J., & Pandharipande, P. (2021). Current perspectives on the assessment and management of pain in the intensive care unit. Journal of Pain Research, 14, 1733–1744. https://doi-org.lopes.idm.oclc.org/10.2147/JPR.S256406

Otusanya, O. T., Hsieh, S. J., Gong, M. N., & Gershengorn, H. B. (2022). Impact of ABCDE Bundle Implementation in the Intensive Care Unit on Specific Patient Costs. Journal of Intensive Care Medicine, 37(6), 833–841. https://doi-org.lopes.idm.oclc.org/10.1177/08850666211031813

Otusanya, O. T., Hsieh, S. J., Gong, M. N., & Gershengorn, H. B. (2016). Awakening and Breathing Coordination, Delirium Monitoring/Management and Early Mobilization (ABCDE) bundle reduces hospital Costs. In B102. STRATEGIES TO IMPROVE CARE QUALITY IN PULMONARY AND CRITICAL ILLNESS (pp. A4357-A4357). American Thoracic Society. https://www.atsjournals.org/doi/pdf/10.1164/ajrccm-conference.2016.193.1_MeetingAbstracts.A4357

Pandharipande, P., Banerjee, A., McGrane, S., & Ely, E. (2010). Liberation and animation for ventilated ICU patients: the ABCDE bundle for the back-end of critical care. Critical Care, 14(3), 1-3. https://ccforum.biomedcentral.com/articles/10.1186/cc8999

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

Sylvia, M. L., & Terhaar, M. F. (2018). Clinical analytics and data management for the DNP. New York, NY: Springer Publishing Company, LLC

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

Figure 1
SWOT Analysis for Quality Improvement Project

Learner Name: Cathy Ann Jones

PICOT-D Question: In adult patients in a high observation unit in a long-term acute care hospital in Virginia, will the translation of Hsieh et al. research implementing the ABCDE bundle, compared to current practice reduce length of stay over an eight-week period?

Table 3
Primary Quantitative Research – Intervention (5 Articles).

Table 4
Additional Primary and Secondary Quantitative Research (10 Articles)

Table 3: Theoretical Framework Aligning to DPI Project

Table 5
Clinical Practice Guidelines (If applicable to your project/practice)

Legend:

Information and resources are also available on the APA Style website. If you have questions about specific assignment guidelines or what to include in your APA Style paper, please check with your assigning instructor or chair.

The DNP manuscript should be written based on the 7th edition American Psychological Association’s APA Style (7th edition). This document is based on the American Psychological Association’s Publication Manual, 7th Edition - Student Paper Checklist located at https://apastyle.apa.org/instructional-aids/publication-manual-formatting-checklist.pdf

Use this checklist while writing your paper to make sure it is consistent with seventh edition APA Style.

Page Header: The page header does not contain a page number until Chapter 1. The fore pages are not numbered. All pages which are numbered are included in the Table of Contents.

Font and Font Size: Times New Roman 12-point Font. Use the same font and font size throughout your paper (exception: figure images require a sans serif font and can use various font sizes).

Line Spacing: Double Spacing. Double-space the entire paper. Do not add extra lines before or after headings or between paragraphs.

Margins: Left Margin is 1 ½ inch. Margins are 1 in. on all other sides (top, bottom, and right).

Paragraph Alignment and Indentation: Left-align the text (do not use full justification). Indent the first line of each paragraph 0.5 in. (one tab key).

Paper Organization

Chapters: Center and bold the Chapter title. Use the Level 1 heading style. Start the first line of the text one double-spaced line after the title.

Headings: Use Level 2, Level 3, and Level 4 style headings for subsections. Start each new section with a heading. Write all headings in title case and bold. Also italicize Level 3. Indent Level 4 headings ½ inch and format on the same line as the text but do not include in the Table of Contents using Styles.

Section Labels: Bold and center labels, including Abstract, References and Appendices.

Writing Style

Continuity: Check for continuity in words, concepts, and thematic development across the paper. Explain relationships between ideas clearly. Present ideas in a logical order. Use clear transitions to smoothly connect sentences, paragraphs, and ideas.

Conciseness: Choose words and phrases carefully and deliberately. Eliminate wordiness, redundancy, evasiveness, circumlocution, overuse of the passive voice, and clumsy prose. Do not use jargon, contractions, or colloquialisms. Avoid overusing both short, simple sentences and long, involved sentences; instead, use varied sentence lengths. Avoid both single-sentence paragraphs and paragraphs longer than one double-spaced page.

Clarity: Use clear and precise language. Use a professional tone and professional language. Do not use jargon, contractions, colloquialisms, or creative literary devices. Check for anthropomorphistic language (i.e., attributing human actions to inanimate objects or nonhuman animals). Make logical comparisons using clear word choice and sentence structure.

Grammar:

Verb Tense: Use verb tenses consistently in the same and adjacent paragraphs. Use appropriate verb tenses for specific paper sections, e.g., future tense for proposal and past tense for final manuscript.

Subject Verb Agreement: Use verbs that agree in number (i.e., singular or plural) with their subjects.

Pronouns: Use first person pronouns to describe your work and your personal reactions (e.g., “I examined,” “I agreed with”), including your work with coauthors (e.g., “We conducted”). Use the singular “they” when referring to a person who uses it as their self-identified pronoun or to a person whose gender is unknown or irrelevant. Use other pronouns correctly. Otherwise, deliver the project in third person as if narrating or presenting it.

Bias-free language: Eliminate biased language from your writing. Use bias-free language to describe all people and their personal characteristics with inclusivity and respect, including age, disability, gender, participation in research , racial and ethnic identity, sexual orientation, socioeconomic status, and intersectionality.

Mechanics of APA Style: Use punctuation marks correctly (periods, commas, semicolons, colons, dashes, parentheses, brackets, slashes), including in reference list entries. Use varied punctuation marks in your paper. Avoid having multiple punctuation marks in the same sentence; instead, split the sentence into multiple shorter sentences. Use one space after a period or other punctuation mark at the end of a sentence. Use a serial comma before the final element in lists of three or more items. Use parentheses to set off intext citations.

Quotation Marks: Use quotation marks correctly. Place commas and periods inside closing quotation marks; place other punctuation marks (e.g., colons, semicolons, ellipses) outside closing quotation marks. Use quotation marks around direct quotations. Do not use quotation marks in the reference list.

Italics: Use italics correctly to draw attention to text. Use italics for the first use of key terms or phrases accompanied by a definition.

Capitalization: Use Title Case and sentence case capitalization correctly. Capitalize proper nouns, including names of racial and ethnic groups. Do not capitalize names of diseases, disorders, therapies, treatments, theories, concepts, hypotheses, principles, models, and statistical procedures, unless personal names appear within these terms.

Abbreviations: Use abbreviations sparingly and usually when they are familiar to readers, save considerable space, and appear at least three times in the paper. Define abbreviations, including abbreviations for group authors, on first use. Do not use periods in abbreviations. Use Latin abbreviations only in parentheses, and use the full Latin term in the text. Do not define abbreviations listed as terms in the dictionary (e.g., AIDS, IQ) and abbreviations for units of measurement, time, Latin terms, and common statistical terms and symbols.

Numbers: Use words to express numbers zero through nine in the text. Use numerals to express numbers 10 and above in the text. In all cases, use numerals in statistical or mathematical functions, with units of measurement, and for fractions, decimals, ratios, percentages and percentiles, times, dates, ages, scores and points on a scale, sums of money, and numbers in a series (e.g., Year 1, Grade 11, Chapter 2, Level 13, Table 4).

Statistics: Include enough information to allow readers to fully understand any analyses conducted. Space mathematical copy the same as words, with spaces between signs. Use statistical terms in narrative text: “the means were,“ not “the Ms were.” Use statistical symbols or abbreviations with mathematical operators: “(M = 6.62),” not “(mean = 6.62).”

Lists: Ensure items in lists are parallel. Use commas to separate items in simple lists. Use semicolons to separate items when any items in the list already contain commas.

Tables and Figures

General Guidelines: Include tables and/or figures in your manuscript. When possible, use a standard, or canonical, form for a table or figure. Do not use shading or other decorative flourishes. In the text, refer to each table or figure by its number. Explain what to look for in that table or figure by calling out the table or figure in the text (e.g., “Table 1 lists…” “As shown in Figure 1…”). Embed each table or figure in the text after it is first mentioned. Place the table or figure at either the top or the bottom of the page with an extra double-spaced line between the table or the figure and any text.

Tables: Use the tables feature of your word-processing program to create tables. Number tables in the order they are mentioned in the text. Include borders only at the top and the bottom of the table, beneath column headings, and above column spanners. Do not use vertical borders or borders around every cell in the table. All tables include four basic components: number, title, column headings, and body. Write the table number above the table title and body and in bold. Write the table title one double-spaced line below the table number and in italic title case. Label all columns. Center column headings and capitalize them in sentence case. Include notes beneath the table if needed to describe the contents. Start each type of note (general, specific, and probability) on its own line, and double-space it. See sample tables on the APA Style website.

Figures: Use a program appropriate for creating figures (e.g., Word, Excel, Photoshop, Inkscape, SPSS). Number figures in the order they are mentioned in the text. Within figures, check that images are clear, lines are smooth and sharp, and font is legible and simple. Provide units of measurement. Clearly label or explain axes and other figure elements. All figures include three basic components: number, title, and image. Write the figure number above the figure title and image and in bold. Write the figure title one double-spaced line below the figure number and in italic title case. Write text in the figure image in a sans serif font between 8 and 14 points. Include a figure legend if needed to explain any symbols in the image. Position the legend within the borders of the figure and capitalize it in title case. Include notes beneath the figure if needed to describe the contents. Start each type of note (general, specific, and probability) on its own line, and double-space it. See sample figures on the APA Style website.

In-Text Citations: Cite only works you read and ideas you incorporated into your paper. Include all sources cited in the text in the reference list (exception: personal communications are cited in the text only). Make sure the spelling of author names and the publication dates in the in-text citations match those of the corresponding reference list entries. Paraphrase sources in your own words whenever possible.

Cite appropriately to avoid plagiarism, but do not repeat the same citation in every sentence when the source and topic do not change. For guidance on appropriate citation, see the Appropriate Level of Citation page.

Write author–date citations according to seventh edition guidelines: Include the author (or title if no author) and year. For paraphrases, it is optional to include a specific page number(s), paragraph number(s), or other location (e.g., section name) if the source work is long or complex.

One author: Use the author surname in all intext citations.

Two authors: Use both author surnames in all in-text citations.

Three or more authors: Use only the first author surname and then “et al.” in all in-text citations.

Use either the narrative or the parenthetical citation format for in-text citations. Parenthetical citation: Place the author name and publication year in parentheses.

Narrative citation: Incorporate the author name into the text as part of the sentence and then follow with the year in parentheses. For works with two authors, ° use an ampersand (&) in parenthetical in-text citations: (Guirrez & Castillo, 2020) ° use the word “and” in narrative in-text citations: Guirrez and Castillo (2020)

When citing multiple works in parentheses, place the citations in alphabetical order. When multiple parenthetical citations have the same author(s), order the years chronologically and separate them with commas (e.g., Coutlee, 2019, 2020). When the authors are different, separate the parenthetical citations with semicolons (e.g., Coutlee, 2019, 2020; Ngwane, 2020; Oishi, 2019).

Quotations: Limit the use of direct quotations. Include the author (or title if no author), year, and specific part of the work (page number(s), paragraph number(s), section name) in the citation. Short quotation (less than 40 words): Use double quotation marks around the quotation. Block quotation (40 words or more): Use the block format: Indent the entire quotation 0.5 in. from the left margin and double-space it.

References

Start the reference list on a new page after the text. Center and bold the section label “References” at the top of the page. Double-space the entire reference list, both within and between entries. Use a hanging indent for each reference entry: First line of the reference is flush left, and subsequent lines are indented by 0.5 in. Apply the hanging indent using the paragraph formatting function of your word-processing program. All reference entries should have a corresponding in-text citation. The beginning of the reference entry (usually the first author’s surname) and year should match the corresponding in-text citation. List references in alphabetical order according to seventh edition guidelines.

Do not create reference entries for personal communications and secondary sources. For a list of works to include and exclude from a reference list, see the APAstyle.org website. Each reference entry includes four elements: author, date, title, and source.

List authors in the same order as the original source. Use initials for authors’ first and middle names. Put a comma after the surname and a period and a space after each initial (e.g., Lewis, C. S.). Put a comma after each author (even two authors). Use an ampersand before the last author. List up to 20 authors in the reference list. If more than 20, use ellipsis between the last author and 19th author.

Capitalize titles in sentence case: Capitalize only the first word of the title, the subtitle, and any proper nouns. Format titles according to the type of work. ° Works that stand alone: Italicize the title (e.g., authored books, reports, data sets, dissertations and theses, films, TV series, albums, podcasts, social media, websites). ° Works that are part of a greater whole: Do not italicize or use quotation marks around the title (e.g., periodical articles, edited book chapters, TV and podcast episodes, songs). Write the title of the greater whole (e.g., journal or edited book) in italics in the source element.

Do not include database information for works retrieved from academic research databases. Do include database information for works retrieved from databases with original, proprietary content or works of limited circulation (e.g., UpToDate).

Include a DOI for any work that has one. If there is no DOI, include a URL if the work is retrieved online (but not from a database). Present DOIs and URLs as hyperlinks (beginning with “http:” or “https:”). Copy and paste DOIs and URLs directly from your web browser. Do not write “Retrieved from” or “Accessed from” before a DOI or URL. Do not add a period after a DOI or URL.

Source: American Psychological Association. (2021). Publication Manual, 7th edition student paper checklist. https://apastyle.apa.org/instructional-aids/ publication-manual-formatting-checklist.pdf