**** 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

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 .