Using the DPI manuscript attached, pls follow the PowerPoint template - use powerpoint notes ***must follow the PowerPoint template using the attached manuscript ***

Implementing the ABCDE Bundle to Impact 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

May 31, 2023

© Cathy Ann Jones, 2023

All rights reserved.

GRAND CANYON UNIVERSITY

Implementing the ABCDE Bundle to Impact Length of Stay

By

Cathy Ann Jones

has been approved

xxxx xx, 2023

APPROVED:

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

Patients admitted to long-term acute care facilities may be at an increased risk for prolonged hospitalization related to post-intensive care syndrome (PICS). At the project site, no standardized process is in place to reduce the length of stay from the effects of PICS; therefore, an evidence-based solution was sought. This quality improvement project aims to determine if the translation of Hsieh et al.’s research on the ABCDE bundle would impact the length of stay among adult patients in a long-term acute care hospital. This quality improvement project aims to determine if implementing a translation of Hsieh et al.'s research on the ABCDE Bundle will impact the length of stay among adult patients. The project will be piloted in an urban Virginian acute care. Virginia Henderson's needs theory and John Kotter's eight-step change model will provide the scientific underpinnings for the project. Data will be collected from the electronic health record.

Keywords: ABCDE Bundle, length of stay, long-term acute care hospital, John Kotter’s eight-step change model, Virginia Henderson’s nursing needs theory, patient outcomes, quality improvement project

Dedication

I want to thank God Almighty for everything He has done for me and dedicate my work to Him as my creator, solid pillar, and inspiration. Throughout 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 would be illogical for me to ignore the vast number of patients who have suffered in one way or another due to care shortcomings. Thanks to them, I have understood their grievances, making it easy to develop a comprehensive quality improvement project.

Acknowledgments

I want to convey my profound gratitude to my mentor, who contributed to this motivational experience by providing me with support, direction, and expert understanding. In addition, I want to express my earnest appreciation to all my patients, physician colleagues, and nursing staff who participated in this quality improvement project. I would also like to take this opportunity to thank my family for the support and encouragement they have provided me during the process of completing this terminal degree.

Chapter 1: Introduction to the Project 1

Background of the Project 2

Organizational Needs Assessment 4

SWOT Analysis 4

Strengths 5

Weaknesses 5

Opportunities 6

Threats 6

Problem Description 7

Definition of Terms 8

Summary 10

Chapter 2: Scientific Underpinnings 12

Literature Search Strategy 12

Synthesis of Literature 13

Evidence-Based Practice Question 22

Change Recommendation: Validation of the ABCDE Bundle 23

Theoretical Framework 24

Nursing Theory 25

Synthesis of Nursing Theory 28

Evidence-Based Change Model 30

Synthesis of Change Model 34

Integration of the Christian Worldview 37

Summary 38

Chapter 3: Project Design and Methodology 39

Purpose 40

Project Planning and Procedures 42

Interprofessional Collaboration 42

Project Management Plan 44

Feasibility 46

Setting and Sample Population 47

Setting 47

Population and Sample 48

Data Collection Procedures 49

Data Source 50

Variables 53

Data Integrity and Storage 54

Data Management 55

Potential Bias and Mitigation 55

Ethical Considerations 57

Summary 59

Chapter 4: Data Analysis and Results 60

Data Analysis Procedures 60

Descriptive Data of Sample Population 61

Results 63

Summary 65

Chapter 5: Implications in Practice and Conclusions 66

Summary of the Project 66

Major Findings 67

Interpretation of Findings 67

Strengths and Limitations 67

Implications 67

Theoretical Implications 68

Nursing Practice Implications 68

Recommendations 68

Recommendations for Future Projects and Researchers 68

Recommendations for Sustainability 69

Plan for Dissemination 69

Conclusion and Contributions to the Profession of Nursing Practice 70

References 71

Appendix A 91

SWOT Analysis 91

Appendix B 92

Literature Evaluation Table 92

Appendix C 141

Project Timeline 141

Appendix D 146

Plan for Educational Offering 146

Appendix E 148

Grand Canyon University Institutional Review Board Outcome Letter 148

Appendix F 149

Project Budget 149

Appendix G 151

ABCDE Bundle Checklist 151

Appendix H 152

Place the Permission to Use the ABCDE Bundle Checklist 152

List of Tables

Table 1 A Sample Data Table Showing Correct Formatting 63

Table 2 t-Test for Equality of Emotional Intelligence Mean Scores by Gender 64

Table 3 Primary Quantitative Research – Intervention 92

Table 4 Additional Primary and Secondary Quantitative Research 109

Table 5 Theoretical Framework Aligning to DPI Project 136

List of Figures

Figure 1 SWOT Analysis for Quality Improvement Project 91

Some patients are unable to return home following an acute hospital stay. For these patients, there are three in-patient post-acute care (PAC) settings where they may receive skilled, rehabilitative care: in-patient rehabilitation facilities (IRFs), skilled nursing facilities (SNFs), and long-term acute care hospitals (LTACHs) (Kumar et al., 2022). Long-term acute care hospitals treat patients who require longer-term acute care due to the medical complexity or severity of their illness, and some facilities provide rehabilitation services (MedPAC, 2019). Patients transferred or directly admitted to an LTACH may suffer post-intensive care syndrome (PICS), which can result in deconditioning, muscle loss, pressure injury formation, decreased mobility, prolonged mechanical ventilation requirements, delirium, and hospital-acquired infections (Mira et al., 2017; Nordness et al., 2021). 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).

In 2013, the Society of Critical Care Medicine (SCCM) 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 (Devlin et al., 2018; Pun et al., 2019). The guideline was updated in 2018 and included recommendations for reducing PICS and length of stay (LOS) in the ABCDE Bundle. This bundle is a valid, evidence-based protocol that can help guide treatment decisions (Balas et al., 2022). The ABCDE Bundle consists of six elements: Assessing pain using the Critical-Care Observation Tool (CPOT), Breathing or spontaneous awakening trials (SATs), Choice of sedation using the Richmond Agitation Sedation Scale (RASS), Delirium screening using the Confusion Assessment Method for the ICU (CAM-ICU), and Early progressive mobility to decrease ICU–acquired muscle weakness (Chen et al., 2021; Collinsworth et al., 2021). The proposed project site lacks a standardized plan to manage PICS-related LOS. While increased LOS are multifactorial, implementing an evidence-based protocol may improve throughput efficiency at the project site and ensure patients receive evidence-based care. This chapter explores the project's background, including the results of an organizational needs assessment and the identified problem.

Patients diagnosed with PICS are often admitted to an LTACH for ongoing complex medical care needs related to sepsis, strokes, encephalopathy, heart failure, and acute respiratory failure resulting in tracheostomies needing ongoing mechanical ventilation support (Mira et al., 2017). Post-intensive care syndrome increases a patient’s risk of chronic pain, significantly impacting their quality of life and the ability to return to work and other daily activities (Nordness et al., 2021). This syndrome also increases patients’ LOS and readmissions to acute care.

Globally, LOS is viewed as a measurement of hospital care (Kumar et al., 2018). Longer LOS equates to poorer care perception and increased patient dissatisfaction (Kumar et al., 2018). Length of stay among adult patients in long-term acute care can also impact patient outcomes. An increased LOS among adult patients in LTACHs has been correlated to reduced patient satisfaction, adverse effects, and lower reimbursement from government agencies and insurance companies. Long-term acute care hospitals are certified to provide long-term acute-level care to medically complex patients for 25 to 28 days (Grevelding et al., 2022). There has been an increased LOS among adult patients receiving long-term acute care at the clinical practice site. In the past 60 days, 75% of patients have had a LOS longer than 25 days due to delirium, cognitive and physical impairments, and psychiatric symptoms related to PICS. The ABCDE Bundle has been incorporated into many hospitals and healthcare organizations’ operations and protocols to improve patient outcomes and cut costs (Hsieh et al., 2019). However, it has not been incorporated into practice at the project site.

An organizational assessment is a process that reviews an organization’s strengths and weaknesses. The purpose of organizational assessment is to understand an organization’s current and potential future comprehensively. A strengths, weaknesses, opportunities, and threats (SWOT) analysis is one method for assessing needs. The research indicated that factors inherent in LTACHs might present problems when implementing quality improvement projects; therefore, a SWOT analysis was performed to identify and address possible issues early (Boehm et al., 2017).

A SWOT analysis is a strategic tool for identifying strengths, weaknesses, opportunities, and threats within an organization’s business environment (Edwards et al., 2023). The strengths and weaknesses address the internal factors affecting quality improvement efforts, while opportunities and threats refer to external factors (Edwards et al., 2023). The following SWOT analysis helped pinpoint the organization’s strengths and struggles so that appropriate resources could be allocated for this quality improvement effort. Further, the SWOT analysis was instrumental in determining which elements of the organization’s processes needed strategically addressed improvement before and during the quality improvement project (Benzaghta et al., 2021). The discussion below summarizes the SWOT analysis results, and Figure 1 in Appendix A illustrates the findings.

According to Collinsworth et al. (2020), strengths are areas where an individual or organization performs well. They include positive characters and skills related to improvement and performance. The organization has been serving the community for more than 40 years, is well-respected, and can attract and retain high-quality staff despite shortages in healthcare, particularly in nursing. The ICU nursing and specialist teams function well together and are an asset to the organization. Hospital management is supportive and believes in continuous improvement based on evidence-based recommendations.

Weaknesses are considered faults or areas where actions do not follow the organization’s aims. Weaknesses can be improved or worked on to meet organizational goals. One weakness is the current nursing staff shortages. New nurses will be hired throughout the project, making training time for quality improvement efforts challenging to fit into the schedule. The nursing shortage also results in double shifts at times, which further reduces opportunities for groups of nurses to find time for training. This weakness will be mitigated by offering multiple educational opportunities throughout the week to meet the needs of nurses.

Opportunities are areas that could be advanced and improved for organizational progress. They are also the circumstances that create a chance for organizational improvement. One opportunity of this project is that healthcare practitioners will receive preparation and training in evidence-based skills and competencies, which will enhance their growth and development to undertake quality improvement projects in the future (Balas et al., 2022). The second opportunity is that the facility's leaders are dedicated to reducing LOS, increasing patient satisfaction, and obtaining reimbursement for quality care delivery. Leadership support throughout this project will demonstrate a caring culture and offer guidance and support.

Threats are the factors that may hinder the achievement of the project's goals. One threat to implementing this project is poor communication between interdisciplinary team members. The ABCDE Bundle requires high coordination and communication between staff members. Effective clinician communication is critical in the hospital environment (Wu et al., 2012). Thus, communication between clinicians is critical in providing high-quality and safe patient care (Coiera, 2000). In a study conducted by Flynn et al. (2018), nurses reported improved communication between team members, including physicians and other allied healthcare providers. The ability to use smartphone technology improves efficiency in communication and facilitates immediate contact with colleagues (Flynn et al., 2018). To enhance communication, the facilities utilizes ASCOM phones. An ASCOM phone is the brand name of the smartphone used at the project site that promotes accessibility allowing for constant communication among staff members. To mitigate the communication threat, all staff members will be assigned an ASCOM phone at the beginning of their shift. A second threat is the use of contract nursing staff. Due to the recent pandemic, contract nurses are in total demand. While hiring contract nursing staff has been a good-faith effort for hospitals to ensure patient care is not interrupted, it is equally essential to ensure contract nursing staff have complete orientation and support to be successful in their workplace to carry out the mission of the organization. To mitigate this threat, it is essential to ensure all contract nurses receive proper orientation and training on the bundle elements, including the project's goal. Upon onboarding, an indepth orientation will be specifically for contract nursing staff.

Length of stay is a significant issue in healthcare facilities since it increases complications associated with increased mechanical ventilation duration, skin ulcer formation, patient well-being, and cost of care (Hsieh et al., 2019). Data from management at the LTACH indicated that patients admitted to the long-term acute care units frequently require or are transferred to the facility's high observation unit (HOU) upon admission. Many of these patients suffer respiratory, neurological, or cardiovascular events, warranting HOU monitoring. These patients frequently develop PICS, and 75% have required a LOS longer than the national average of 25 days.

It is unknown if implementing a translation of Hsieh et al.’s research on the ABCDE Bundle will impact LOS among adult patients. Longer LOS increases a patient’s risk for hospital-acquired infections, which leads to patient dissatisfaction and reduced reimbursement from Medicare and insurers. A longer LOS also increases a patient’s risk of delayed recovery to their prehospital state and development of PICS. Despite recommendations from the Society of Critical Care Medicine concerning the use of the ABCDE Bundle, more data regarding its effectiveness outside of short-term acute hospitals is needed. Further, LTACHs need standardized, evidence-based protocols that impact patient LOS, which can then improve their long-term clinical outcomes.

The terms defined below outline the project's key components. These terms are used operationally throughout the project.

ABCDE Bundle

The ABCDE Bundle is a valid, evidence-based protocol with five elements that can reduce ICU LOS. The first letter stands for Assess, Protect, and Manage Pain. The second letter stands for Breathing-spontaneous awaking trial (SAT) and spontaneous breathing trial (SBT). The third letter identifies choices of analgesia and sedatives. The “D” stands for delirium, including assessment and management. The “E” stands for early movement and exercise. The Society of Critical Medicine has recently expanded the ABCDE Bundle to the ABCDEF Bundle, where the “F” stands for family (Collinsworth et al., 2021). However, only the first five elements will be implemented in this project.

Delirium

Delirium is a disturbance in attention and awareness that develops quickly. It represents an acute change from baseline attention and awareness and fluctuates in severity during the day (American Psychiatric Association, 2021).

Intensive Care Unit (ICU)

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

Length of Stay (LOS)

Length of stay refers to a patient's time in a hospital care unit from admission to discharge (Pun et al., 2019). This is the dependent variable for the project.

Long-Term Acute Care Hospital (LTACH)

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

Post-Intensive Care Syndrome (PICS)

Post-intensive care syndrome is associated with delirium, cognitive and physical impairments, and psychiatric symptoms (Hsieh et al., 2019).

While the ABCDE Bundle has been widely utilized in ICUs and short-term acute care settings, it has not been used in LTACHs. Evidence showed that the ABCDE Bundle can reduce the length of mechanical ventilation, the incidence of delirium, healthcare costs, and LOS among adult patients needing acute care (Frade-Mera et al., 2022). The LOS among patients needing long-term acute care at the project site is increasing; therefore, an evidence-based, standardized protocol was sought. Due to the need to reduce LOS to improve reimbursement and patient satisfaction, the ABCDE Bundle was selected to address the problem at the project site. An organizational needs assessment demonstrated the strengths, weaknesses, opportunities, and threats that might affect implementing the ABDCE Bundle at the LTACH.

Chapter 2 describes the results of a literature review to develop this project. It also includes an overview of the nursing theory and change model to guide bundle implementation. Chapter 3 outlines the methodology that will be used to conduct the project, while Chapters 4 and 5 present the results and implications of the project for future practice, respectively.

This quality improvement project aims to impact the increasing LOS among patients needing long-term acute care at an LTACH. Long LOS in acute care facilities can lead to poor patient outcomes and reduced hospital reimbursement. Evidence showed that the ABCDE Bundle could effectively reduce LOS, among other conditions, in short-term acute care facilities. Still, more literature needs to focus on its use in long-term care. This chapter aims to provide an in-depth understanding of the ABCDE Bundle’s efficacy by reviewing scholarly literature concerning its impact on delirium, pain management, mechanical ventilation needs, and mobility. In addition, this chapter provides an overview of the theoretical foundations that will inform this project and how it will advance a Christian worldview.

The following databases were searched for relevant literature: PubMed, CINAHL, and ProQuest. The search terms used were ABCDE Bundle and intensive care unit. The inclusion criteria were articles published in English within the last five years that were available in full-text and peer-reviewed. Articles not available in full text, were not peer-reviewed, were published in a language other than English, and were published later than 2017 were excluded from consideration. A total of 15 articles met the inclusion criteria and were used to support the intervention.

The ABCDE Bundle effectively reduces patient costs, especially for critical care patients. When implemented appropriately, the ABCDE Bundle can guide healthcare professionals in using delirium protocols, thus reducing healthcare costs (Loberg et al., 2022). The literature established that implementing the ABCDE Bundle is associated with a decrease in in-hospital mortality and LOS among adult patients in long-term acute care (Barnes-Daly et al., 2017). Hsieh et al. (2019) evaluated the impact of the staged performance of complete versus virtual ABCDE Bundle on mechanical ventilation (MV) duration, ICU and hospital LOS, and cost among adult patients in long-term acute care. This study used a prospective cohort design and included 1,855 MV patients admitted to ICUs. The findings showed that early mobilization and coordination (EC) improved patients in the ICU by 30%. Implementation of the entire (B-AD-EC) vs. (B-AD) resulted in a decrease in MV duration. Implementing the ABCDE bundle reduced total ICU and hospital costs by 24.2% and 30.2%, respectively. The study's primary limitation was the concentration on a single medical center, thus limiting the generalizability of the findings. The recommendations included carrying the same research out in different facilities to observe the impacts of the ABCDE Bundle on patient costs.

The ABCDE Bundle's first element is pain assessment, which should be performed before administering pain relief medications (Frade-Mera et al., 2022). This element includes the Behavioral Pain Scale (BPS) and the Critical-Care Pain Observation Tool (CPOT), which are considered the most reliable and valid behavioral pain scales for ICU patients who cannot communicate (Pun et al., 2019). The first element coincides with the second element, which is the breathing trials, spontaneous awakening trials (SAT) with spontaneous breathing trials (SBT) (Marra et al., 2017). The coordination of SBT and SAT has been associated with reduced use of sedatives, reduced time in ICU and MV, reduced instances of delirium, and lower hospital LOS (Hsieh et al., 2019).

The third element is the coordination of the first and second elements. Bardwell et al. (2020) conducted a retrospective study at a teaching institution in a 34-bed ICU implementing the ABCDE Bundle to wean mechanical ventilation. A 2-tailed t-test was used to analyze the data. After ABCDE bundle implementation, mean ventilation time significantly decreased by nearly 50% (a difference of 1.98 days). A decrease in ventilation time was observed among all patients p=0.02. Bardwell et al.’s study highlights care coordination demonstrated that less sedation reduced the incidence of delirium, and improved pain management, thus decreasing LOS. The fourth element of the ABCDE Bundle is monitoring and managing delirium, which is significant components. Delirium is a risk factor for increased length of ICU stay, increased time on MV, increased hospital stays, long-term cognitive impairment, higher hospital costs, and higher mortality rates (Collinsworth et al., 2021).

A study conducted by Trogrlić et al. (2019) conducted a retrospective cohort study. The study involved ICUs in one university hospital and five Neverland community hospitals. The size of the units varied between eight and 32 ICU beds. The study included a total of 3,930 patients. The results demonstrated that delirium screening increased from 35% to 93% after implementing the bundle’s delirium screening. The fifth element of the bundle outlines processes for early mobility. Early mobility is one intervention that can decrease delirium duration and improve other patient outcomes (Schallom et al., 2020). Chen et al. (2021) conducted a retrospective study in southern Taiwan. The study was conducted in two phases. Phase one was pre-ABCDE Bundle and phase two was post-ABCDE Bundle. The study demonstrated significant differences in hospital LOS among patients in phase two. Patients in phase two had a significantly lower ICU LOS ( 8.0 vs. 12.0) day p <0.05. The study highlighted the clinical outcome of shortened MV duration among those patients in phase two who received the ABCDE Bundle intervention was impacted by early mobilization.

The ABCDE Bundle significantly reduces sepsis-related outcomes among critically ill patients (Hsieh et al., 2019). Mortality rates, especially in critical care units, are high; thus, properly implementing the ABCDE Bundle may decrease in-hospital mortality and LOS (Liu et al., 2021). Liu et al. (2021) recommended that secondary outcomes involve the implementation rates for each element of the ABCDEF Bundle. Further, the ABCDE bundle is related to effective care; therefore, managing a patient's care using the ABCDE Bundle has an influential role in proper care delivery (Louzon et al., 2017). Proper bundle use has been shown to reduce mortality rates and LOS among adult patients in long-term acute care by establishing an effective and quality care delivery process (Liu et al., 2021).

There are several significant steps to follow when implementing the ABCDE Bundle, according to Louzon et al. (2017). Phase 1 should involve a pilot program allowing ICU pharmacists to directly manage sedative therapy for MV patients in collaboration with an intensivist. In Phase 2, an interactive initiative that includes comprehensive pharmacist management and the development of a multispecialty inter-professional team to encourage the early mobilization of MV patients should be established (Louzon et al., 2017). Understanding how to manage patient care using bundle elements, including sedative therapy and early mobilization activities, will support the quality improvement project (Schallom et al., 2020).

Healthcare professionals' understanding of regulations and standards is essential to promoting quality care in critical care units. Evidence showed a correlation between implementing the ABCDE Bundle and improved adherence to delirium guidelines among healthcare professionals (Trogrlić et al., 2019). The official bundle implementation plans also include practitioner evaluation programs, thus promoting efficiency when the ABCDE Bundle is implemented and increasing success in care delivery (Louzon et al., 2017). These evaluation programs will be used in this project.

The ABCDE Bundle has been shown to improve care for MV patients with fluctuating hemodynamics (Ren et al., 2017). A cross-sectional before and after the study was performed with 143 patients on MV admitted to an ICU (Ren et al., 2017). The ABCDE Bundle was implemented, and the researchers found a decrease in heart rate, mean arterial pressure, and LOS post-implementation (Ren et al., 2017). Another study by Frade-Mera et al. (2022) found that employing interventions from the ABCDE Bundle early can effectively reduce the negative impacts of sepsis. As such, early interventions following the ABCDE Bundle elements may help reduce LOS among adult patients in the HOU at the project site. It may also lead to effective pain management and decreased mortality.

It is essential to understand the impact of the ABCDE bundle on ICU patients (Negro et al., 2018). The ABCDE bundle is feasible and safe as an early progressive mobilization protocol (Frade-Mera et al., 2022). With proper implementation of the bundle, mortality rates and LOS among adult patients in long-term acute care decrease (Collinsworth et al., 2020). Proper ABCDE Bundle implementation can also reduce the incidence of sepsis (Collinsworth et al., 2020). Consequently, when implemented and used as standard practice, the bundle can reduce care costs per patient (Liu et al., 2021).

Evidence showed a relationship between the level of sedation and delirium incidence in patients who are critically ill (van den Boogaard et al., 2020). The ABCDE Bundle can address these problems and reduce delirium incidence by improving proper sedation. Additionally, research showed decreased mortality and LOS when the bundle is implemented (Pun et al., 2019). Some authors may also focus on specific populations of patients (e.g., those with acute respiratory failure) or look at bundle implementation in a more general sense (Hsieh et al., 2019). The results may differ according to the location (the US vs. International), target population (MV patients vs. all critically ill adults), and outcome measures (implementation of the ABCDE Bundle vs. measurement of adherence to the ABCDE Bundle) (Liu et al., 2021).

Otusanya et al. (2022) performed a retrospective cohort study involving MV patients admitted to an ICU. The findings showed that it is practical, reliable, and valid (Otusanya et al., 2022). Further, Pun et al. (2019) asserted that the ABCDE Bundle effectively promotes quality and routine care, thus promoting an effective recovery process. Barnes-Daly et al.'s (2017) study showed a gradual decrease in mortality and LOS when implementing the bundle for critically ill patients. Therefore, implementing the ABCDE bundle is appropriate for this quality improvement project since it has been shown to improve patient outcomes, including LOS.

Loberg et al. (2022) asserted that quality improvement initiatives could be used to evaluate the effectiveness of the ABCDEF Bundle elements on different clinical outcomes. Early interventions based on the ABCDE Bundle elements also promote positive patient results and patient satisfaction (Balas et al., 2022; DeMellow et al., 2020; Otusanya et al., 2022). However, for accurate and reliable results, a systematic review of multiple studies focused on implementing the ABCDE Bundle is required (Otusanya et al., 2022). A major limitation of the current literature related to bundle implementation is the poor generalizability of results since most studies were conducted at a single site.

Another limitation to the generalizability of the findings is the use of different methodologies. Some studies used observational designs, while others used randomized controlled trials (Balas et al., 2022; Zhang et al., 2021). Some studies also showed that the ABCDE Bundle effectively improves patient outcomes, while others conclude that more research is needed (van den Boogaard et al., 2020). Some studies suggested that adherence to the ABCDE bundle is more important than implementing the ABCDE Bundle, while other studies suggested that both adherence and implementation are essential (Boehm et al., 2017; DeMellow et al., 2020).

In addition, some studies did not include a control group, making it difficult to determine whether the ABCDE Bundle was responsible for improved patient outcomes (van den Boogaard et al., 2020). Other studies had small sample sizes, limiting the generalizability of the findings (Loberg et al., 2022). Finally, there are some controversies surrounding the use of the ABCDE Bundle. Some researchers have argued that the bundle is too complicated and expensive to implement, while others assert that the benefits justify the costs (Hsieh et al., 2019).

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 an ICU for other reasons (e.g., respiratory failure, renal failure) (Frade-Mera et al., 2022). No studies have examined using the ABCDE Bundle in an LTACH setting. Additional research is needed on the impact of the ABCDE Bundle on patients without sepsis and in LTACHs to determine the applicability of the bundle in other patient populations and settings (Collinsworth et al., 2020).

Applying the ABCDE Bundle is a practical EBP that can improve outcomes for patients requiring acute care. Research showed that the EBP approaches in the bundle can significantly improve pain management and reduce over-sedation and delirium incidence (Bardwell et al., 2020). This multidisciplinary process involves physical therapists, respiratory therapists, nurses, and nurse assistants to achieve holistic, high-quality patient care (Chen et al., 2021).

It was essential to review the literature concerning the ABCDE Bundle and understand the impacts of EBP on reducing sleep deprivation, agitation, immobility, and delirium among patients in critical care units. Nurses can use the ABCDE assessment tools to develop patient-oriented care plans that recognize the patient's needs, thereby increasing confidence, autonomy, and recovery rates (Sinvani et al., 2018). Predicting and preventing delirium among critical care patients is possible. Proper and timely delirium management can significantly reduce adverse healthcare outcomes and LOS (Zhang et al., 2021). This quality improvement project will add to the current literature and may demonstrate the effectiveness of the ABCDE Bundle elements on clinical outcomes.

The quality improvement project will focus on implementing the ABCDE Bundle to impact LOS. Extensive research was identified that supported implementing the ABCDE Bundle in an LTACH. Research showed that adherence to the bundle has improved acute care patients’ survival rates, brain functioning, and overall patient care (Barnes-Daly et a., 2017). It has improved patient outcomes and can decrease mortality rates and LOS. The bundle effectively reduces the length of stay for elderly patients and thus should be implemented in clinical practice (Frade-Mera et al., 2022).

Additionally, the ABCDEF Bundle is a cost-effective way to improve patient outcomes by reducing direct and indirect healthcare costs (Otusanya et al., 2022). The evidence-based practice question is: To what degree will the translation of Hsieh et al.'s research on the ABCDE Bundle impact the length of stay among adult patients in a high observation unit in a long-term acute care hospital in urban Virginia? To what degree will the implementation of a translation of Hsieh et al.’s research on the ABCDE Bundle impact LOS among adult patients in a long-term acute care hospital in urban Virginia?

The affected population will be hospitalized adult patients in the HOU of an LTACH. This population can suffer from ineffective interventions, which increases adverse outcomes related to their illnesses. As a result, the population tends to have an increased LOS, which incurs higher healthcare costs. The project will address this problem by examining how the ABCDE Bundle impact LOS among patients needing long-term acute care in an HOU.

Multiple primary and secondary research studies demonstrated that the ABCDE Bundle could improve patient outcomes and reduce care costs (Zhang et al., 2021). In their study, Hsieh et al. (2019) noted a substantial reduction in the duration of MV, LOS, and cost after implementing the ABCDE Bundle. Evidence also indicated that the ABCDE Bundle’s components are clearly defined, flexible, and can quickly empower multidisciplinary teams to share the care of critically ill patients (Boehm et al., 2017). The ABCDE Bundle will promote interaction across the unit, which will increase pain control and help patients safely participate in higher-order physical and cognitive activities earlier.

The ABCDE Bundle has been shown to address the adverse effects of critical illnesses by reducing MV duration, improving early mobility, and ensuring timely assessment and treatment of pain and delirium. The bundle represents one of the most effective methods for creating a culture shift when treating various categories of patients in an ICU (Pun et al., 2019). Based on the findings from current qualitative and quantitative studies, it is evident that the ABCDE Bundle offers a well-rounded method for improving patient care and optimizing research utilization (Zhang et al., 2021). The bundle improves pain control by increasing family and patient engagement and healthcare providers' use of higher-order cognitive and physical activities (Schallom et al., 2020). Therefore, It is recommended to implement the ABCDE Bundle to reduce MV duration, improve mobility, reduce the incidence of delirium, reduce the use of sedation, and improve pain identification (Frade-Mera et al., 2022). This project will focus on the patient outcome of reduced LOS.

Nurses promote health, especially when patients lack knowledge, strength, or willingness to observe healthcare needs. Nurses also provide patients with spiritual, physical, and biological therapy. Nursing theories help nurses meet patient needs by assisting nurses to understand their role in healthcare (Brown, 1964). Nursing theories provide the foundations of nursing practice, generate knowledge, and indicate which direction nursing should develop in the future (Brown, 1964). Theories also provide rational and scientific reasoning for nurses' care (Dziak, 2023). Nursing theories often guide knowledge development and direct education, research, and practice (Fitzpatrick & Whall, 1996).

Virginia Henderson’s nursing will guide the implementation of the ABCDE Bundle needs theory. Henderson (1966) was a nursing theorist who developed a blueprint to ensure that nursing practice is fine-tuned to meet patients’ interests. Henderson’s theory outlines the importance of patient autonomy in improving care delivery in the healthcare facility. According to Henderson (1966), healthcare practitioners should understand basic human needs and how nurses can meet them, promoting care delivery. Henderson's theory provides a solid foundation for nursing practice and fosters ongoing growth and knowledge geared toward addressing patients’ needs.

For the effective implementation of this project, there must be a collaboration between patients and healthcare providers so that the identified needs align with the patient's goals and expectations. While quality improvement is challenging, Kotter's eight-step change model can facilitate implementation procedures. Kotter (1995) asserted that change is related to a positive culture, urgency, strategy, vision, and motivation; therefore, using Kotter's theory can encourage nurses to implement evidence-based practices (EBP) to promote the care delivery process and patient satisfaction. In the change process, communication is paramount, especially between nurses and other healthcare professionals. Various stakeholders will be required to support the implementation of the ABCDE Bundle to impact the LOS of adult patients needing long-term acute care.

Nurses help patients gain knowledge and independence to address their needs as rapidly as possible (Henderson, 1966). Virginia Henderson's (1966) nursing needs theory will serve as a vital component in the early identification of the needs of the patients. Specifically, Henderson's nursing needs theory will offer a systems approach to focus on the human need for protection and relief from stress (Ahtisham & Jacoline, 2015). Henderson (1966) identified that the unique function of a nurse is to assist an individual, sick or healthy, in performing activities that contribute to health or recovery (or to peaceful death). These actions would be performed unaided if the patient had the strength, will, or knowledge.

Henderson viewed nursing as applying logical approaches to solving a problem (Ahtisham & Jacoline, 2015). The theory categorizes nursing into 14 components based on the needs of humans (Ahtisham & Jacoline, 2015). The first nine are physiological: breathing normally, eating and drinking adequately, excretion, mobility and maintaining body postures, getting enough sleep and rest, wearing suitable clothing, maintaining body temperatures by wearing different clothes in different environments, maintaining body hygiene, and avoiding dangers and endangering others. The tenth and fourteenth components are psychological aspects of learning and communication, explicitly expressing emotions, fears, or needs through communication. The eleventh is worshipping, working to convey a sense of accomplishment, and participating in various recreational activities (Ahtisham & Jacoline, 2015). Using this theory in the quality project will aid nursing in implementing the ABCDEF Bundle.

Henderson's nursing needs theory will be used during the project to illuminate the problem of longer LOS associated with PICS because the theory can anticipate the effects of interventions that can be applied to strengthen the lines of defense against stress (Ahtisham & Jacoline, 2015). This theory has components that effectively resonate with the concepts and interventions of the ABCDE Bundle. For example, the theory can explain why critical illness can induce higher stress levels among patients in the HOU, making the patients present with signs of delirium and agitation. In such cases, a patient’s stress may manifest during mechanical ventilation or sedation, and patients may attempt to make sense of what they have seen or heard in unfamiliar settings and environments (Chen et al., 2021). Henderson (1966) identified that the unique function of the nurse is to assist individuals who are sick or well. Henderson’s nursing needs theory highlights the basic human needs and how nurses can meet those needs. This component will help to achieve the goal of improving patient outcomes. Using the theory during the ABCDE Bundle implementation will help nurses identify patients’ problems on time and use prevention measures, which can reduce LOS and improve patient outcomes.

Henderson’s needs theory has been used in multiple studies to improve patient outcomes by focusing specifically on the needs of patients. For instance, Fernandes et al. (2016) applied Henderson's theory to a working elderly individual using the nursing process. The study employed nursing diagnoses, outcomes, and interventions based on Henderson's fundamental human needs theory. The study revealed that nursing diagnoses predominantly centered on the biological dimension. At the same time, interventions comprised one-on-one counseling and educational undertakings aimed at fulfilling the fundamental human requirements of the elderly individual. The application of Henderson's theory highlights its significance in enhancing the welfare and contentment of employed older adults. Fernandes et al. (2016) demonstrated the potential benefits of utilizing Henderson's theory in the nursing process for elderly individuals who are employed. This approach can enhance their physical health and overall well-being and satisfaction. Henderson's theory underscores the holistic approach to meeting the basic human needs of the elderly workforce by prioritizing individual counseling and educational activities.

Two other researchers who used Henderson’s theory are Nicely and DeLario ( 2011) and Armijo (2012). Nicely and DeLario (2011) utilize Henderson's theory to examine organ donation for transplantation. Organ donation coordinators typically registered nurses, are essential in managing organ donor, their family and friends, and caregivers. Healthcare professionals can improve the quality of care during the organ donation process by addressing the physiological, psychological, and social needs of the individuals involved, as suggested by Henderson's concepts. Henderson's theory is applied to the specific field of organ donation for transplantation by Nicely and DeLario (2011). The authors emphasize organ donation coordinators' crucial function, mainly registered nurses, in delivering comprehensive care to organ donors, their relatives, acquaintances, and caregivers. Healthcare professionals can enhance the quality of care and support during organ donation by incorporating Henderson's principles, encompassing physiological, psychological, and social needs. This approach benefits all parties involved. Armijo (2012) examines the use of Henderson's theory in providing advanced nursing care in a pediatric ward. The author acknowledges the need for a theoretical framework to quantify nursing workload beyond medical diagnoses. The research indicates that pediatric ward nurses utilize Henderson's 14 basic needs as a framework for patient evaluation. However, they prioritize the initial nine needs when devising and executing care plans. Implementing Henderson's nursing theory and training nurses on its application can facilitate the effective delivery of advanced nursing care in the pediatric ward. Armijo (2012) demonstrated the necessity of a theoretical framework to measure nursing workload in advanced pediatric nursing care by implementing Henderson's theory. Nurses in the pediatric ward recognize Henderson's 14 basic needs during the patient assessment but prioritize the first nine needs in their care planning and implementation. The successful performance of advanced nursing care for pediatric patients can be achieved by integrating a nursing plan based on Henderson's theory and providing training to support nurses in utilizing the model. This approach promotes patient-centered and holistic care delivery.

The studies demonstrate the practical application of Virginia Henderson's nursing theory in diverse healthcare settings. Based on the literature, Henderson’s theory is a practical framework for ensuring quality nursing care. Integrating the principles of the ABCDE bundle into quality improvement initiatives can enhance patient outcomes and overall care quality by addressing their physiological, psychological, and social needs. Henderson's theory can guide the nursing process, including diagnosis, assessment, planning, evaluation, and implementation, to deliver comprehensive, patient-centered care.

John Kotter's eight-step change model will guide the implementation of the ABCDE Bundle. The framework was introduced in a book titled Leading Change, which showed that nearly 70% of change initiatives fail (Kotter, 1995). Kotter's (1995) model outlines eight steps that can be applied in implementing organizational change. The model was first developed in 1995 and outlined how to ensure success and reduce failure in business (Kotter, 1995). Kotter identifies eight steps that are crucial to implementing change. The model was developed by determining the core values, the ultimate vision, and the strategies necessary to realize organizational change (Guzman et al., 2011). The change model requires the organizational leaders to define a change in a way that is easily understandable and easy to follow.

Kang et al. (2022) stated that urgency needs to be developed before implementing proposed interventions. According to Kotter (2012), urgency refers to identifying the existing threats and discussing weaknesses with the stakeholders and colleagues to support an intervention. The second step is creating a guiding coalition, or producing competent leaders and professionals to steer the agenda and influence staff involved in the implementation process. Third, the team develops a vision and strategies (Kotter, 2012). In this step, a clear vision of how the organization will look if the change is implemented is developed and disseminated. The next step is communicating the change vision and avoiding barriers (Kotter, 2012). Then, short-term wins related to the change are outlined to encourage buy-in (Kotter, 2012). The next step is building the change, which ensures the team works to achieve the change and measure progress. Building change ensures everyone adapts to a new process by illustrating its importance and training them with the skills necessary to maintain the new requirements. The last step is to make the change stick (Kotter, 2012). These steps will be used to implement the ABCDE Bundle.

First, urgency will be created. This initial step will help stakeholders understand the implications of longer LOS and the need to improve patient outcomes and reduce care costs. The project manager developed the patient/population, intervention, comparison, and outcomes question (PICO) during this stage. Building a coalition is the second step. During this step, the project manager will meet with key stakeholders to formulate quality improvement buy-in from those who could directly support the bundle's implementation. Involving stakeholders will foster interdisciplinary collaboration and may enhance the project's outcomes. When creating a vision, the project developed a proposed future for the HOU based on predictions of the patient outcome that will guide the staff and stakeholders involved and enhance decision-making processes. During this stage, the project manager will create an interdisciplinary team that includes a nurse, respiratory therapist, physical therapist, and physician who will serve as bundle champions.

According to Kotter (2012), the fourth step is communicating the vision. During this stage, the project manager will inform all staff members of the bundling initiative and desired outcomes, including how they can help the organization and patients. The fifth step is empowering others, which fosters growth, thereby allowing staff and leaders to achieve their highest potential. During this stage, the project management plans to help clinical staff identify which bundle elements are most important to them. They can then serve as a resource to others, leading to the sixth step: creating quick wins. Short-term wins will help maintain momentum and engagement. Weekly announcements will be made on the project's progress during day and night shift safety huddles.

The seventh step is building on the change. This step will involve stakeholders to ensure all staff and team members work to achieve the change and measure progress. During this stage, the bundle champions will be acknowledged for their contributions (Guzman et al., 2011). Throughout the project, the bundle champions will identify the necessary resources, distribute roles among the staff, and report directly to the project manager. The eighth step is embedding change. This step is crucial to cultural change within an organization by demonstrating the importance of an intervention and its effects on patient care and clinical outcomes, specifically LOS. In this stage, project findings will be disseminated throughout the HOU and LTACH to determine if the continued implementation of the ABCDE Bundle is warranted.

The intricate nature of organizational change demands meticulous planning and execution. Integrating quality improvement interventions, such as the ABCDE bundle, can substantially enhance patient care and outcomes in the healthcare industry. The scholarly works authored by Kuo and Chen (2019), Sorensen et al. (2016), and Eller et al. (2023) have made noteworthy contributions to the existing body of literature on the application of Kotter's eight-step model in the execution of organizational change endeavors, with a specific emphasis on the healthcare industry.

In a research study on age-friendly hospital (AFH) accreditation, Kuo and Chen (2019) used Kotter's change model to assess how workers' attitudes toward the elderly and their understanding of aging had changed. According to the article, the success of AFH certification was mainly due to the selection of a chief executive officer, the creation of a steering committee, interdepartmental and multidisciplinary collaboration, and the solicitation of support from all workers. The research used Kotter's framework to show how the model may direct the use of the ABCDE bundle by highlighting the significance of leadership, collaboration, and employee engagement. Kuo and Chen (2019) looked at the implementation of the age-friendly hospital (AFH) accreditation and how it affected the knowledge and attitudes of workers in their research. They determined crucial elements for a successful AFH certification by using Kotter's change model, including selecting a CEO, creating a steering committee, encouraging collaboration, and enlisting the help of all staff members. These results show the importance of leadership, teamwork, and employee involvement in fostering positive change and guaranteeing the effective adoption of the ABCDE bundle in healthcare settings. They also directly relate to the implementation of the ABCDE bundle.

Sorensen et al. (2016) investigated how medication management services were implemented in six Minnesota health systems. The research used Kotter's eight-step model to pinpoint the themes connected to the effective integration of medication management programs. The themes of the three phases of Kotter's model—creating an environment for change, including empowering the whole company and executing and maintaining change—were grouped together. This study emphasizes the value of creating a welcoming atmosphere, supporting team-based care, and overcoming obstacles while implementing the ABCDE bundle. According to Sorensen et al. (2016), Kotter's eight-step model should be followed to create an environment for change, including the whole organization, and execute sustainable changes for medication management services to be successfully integrated into Minnesota's health systems. The research stressed the significance of fostering team-based care, creating a supportive culture, and overcoming implementation difficulties. These results are directly related to the ABCDE bundle's deployment since they highlight the need for an encouraging corporate culture, provider engagement, and proactive problem-solving for the bundle's successful adoption.

Eller et al. (2023) focused on the sustenance of In Situ Simulation (ISS) programs, which offer healthcare organizations benefits in terms of enhancing patient safety. Kotter's theory of change management served as the basis for the "longitudinal pre-brief," a theoretical framework created by the researchers. This project's goal was to provide a strategic plan for the successful implementation and ongoing viability of the International Space Station (ISS) program. The framework for leadership in the context of organizational transformation consists of eight distinct phases. The procedure involves determining the goals of essential stakeholders, creating a group vision, inspiring participants, and incorporating simulation into the business culture. By using this approach, healthcare organizations may successfully deploy and maintain the ABCDE bundle by promoting active involvement, getting the needed resources, and fostering a culture of continuous improvement.

The three articles provide light on how to use Kotter's eight-step model for conducting healthcare-related organizational change efforts. The research shows that quality improvement initiatives, like the ABCDE bundle, need strong leadership, teamwork, employee buy-in, and a receptive organizational culture. Improved patient outcomes and quality of treatment are possible when healthcare companies use Kotter's methodology to successfully negotiate the complexity of change.

A lack of quality healthcare is a widespread problem that affects many people and groups. Although various solutions have been recommended to address the issue through legislative and social works, a stable and more effective solution is yet to be achieved. A healthcare team should be dedicated to holistic patient care and committed to clinical service excellence. Interventions that inspire passion in the workforce and a dedication to patient wellness and wholeness are required. The mission and vision of the organization where this project will take place are to extend compassionate care to all those affected by a medical illness who need medical care. The Christian principles of human dignity, solidarity, subsidiarity, and working for the typical good play a significant role in the organization's care delivery model (Moorman, 2015). Implementing the ABCDE Bundle aligns with those principles through the relief of suffering and the promotion of wholeness.

Further, Grand Canyon University's doctrinal statement aligns with implementing the ABCDE Bundle. According to the doctrinal statement, students trained at the university can incorporate the beliefs and values of God into practice. They can provide a framework for ethical thinking to drive God's plan and purpose when initiating change. Incorporating Christian worldviews into this quality improvement project will serve a holistic approach to patient care, increasing patient and family satisfaction and improving clinical outcomes.

Implementing the ABCDE Bundle can enhance patient outcomes and reduce healthcare costs. The ABCDE Bundle comprises EBPs that healthcare professionals can implement to coordinate multidisciplinary patient care in ICUs (Chen et al., 2021). All the components of the bundle act as effective interventions for patients admitted to acute care settings; however, more research is needed on the bundle’s use outside of the ICU. This project will address this gap in practice. Henderson’s nursing will guide its needs theory and Kotter’s eight-step change model. Chapter 3 outlines the project’s methodology and design, while Chapters 4 and 5 present the results and how these results add to the current literature.

Long stays in acute care facilities can increase an individual’s PICS risk. Length of stay also indicates care quality, with longer LOS denoting poorer quality. This quality improvement project intends to improve the quality of health care for patients needing long-term acute care by implementing strategies that may reduce the length of stay. According to the literature, quality improvement initiatives can reduce adverse events and unnecessary hospitalizations (Ballard, 2019).

The Magnet Recognition Program® and the Magnet Model guide professional practice care quality, disseminate best practices on nursing services, and identify excellence in healthcare delivery (Petto et al., 2022). These goals can be met by research, determining and implementing evidence-based practices (EBPs), or instituting a quality improvement initiative. Research provides empirical evidence to support nursing practice and help provide optimal patient care (Altman, 2020). Evidence-based practice ensures that clinical practices follow the best evidence available (Ginex et al., 2021).

Research generates new knowledge and validates existing knowledge. Scientific methods ensure that the results are valid, credible, and reliable. Alternately, EBP is the unique outcome of the research. When determining an EBP, the goal is to seek, not develop, new knowledge. EBP contributes to a healthcare system's mission and vision by making care decisions using the best evidence available (Mukerji et al., 2019). Determining EBP relies on clinical expertise, patient values, and preferences to deliver holistic care (Hagle et al., 2020).

Quality improvement projects are distinct from research and EBP but related to both practices. Quality improvement initiatives use principles and strategies from organizational philosophies to ensure systematic, data-guided approaches to improve health outcomes and processes are implemented (Dziak, 2023). Quality improvement focuses on improving patient outcomes by implementing research-driven EBP, such as the ABCDE Bundle. When performing a quality improvement project, a project team defines the desired outcomes, identifies how they will be measured, and then develops a plan to implement an evidence-based intervention. This project is a quality improvement initiative, and this chapter outlines the planning and implementation process that will be employed.

The purpose of this quality improvement project is to determine if the implementation of a translation of Hsieh et al.'s research on the ABCDE Bundle will impact the length of stay among adult patients. The project will be piloted over eight weeks in an urban Virginian long-term acute care hospital. Length of stay is a significant concern for patients and healthcare organizations. Longer LOS increases healthcare costs, patients’ risk of developing hospital-acquired infections, and mortality rates (Moraes et al., 2022). The LOS has been increasing at the project site among patients needing long-term acute care. Seventy-five percent of the 60 days before this project had a LOS longer than the national average of 25 days. There is no standardized protocol in place for reducing LOS. This quality improvement project addresses this problem by determining if implementing the ABCDE Bundle impacts LOS.

The average LOS will be collected from the electronic health record (EHR) for a comparative and implementation group of patients. The average LOS of these two groups will be compared following a quantitative, quasi-experimental design to determine the project’s clinical or statistical significance. The project will contribute to nursing practice by supporting the best EBP nurses can employ to address LOS in acute care facilities. The ABCDE Bundle involves assessing a patient's needs, involving the patient and their family in a care plan, and implementing patient-centered approaches to improve care and reduce adverse outcomes from PICS. Research has shown that the ABCDE Bundle can reduce LOS among adult patients in short-term acute care, and this project demonstrates if this intervention is appropriate and feasible for long-term care settings (Boltey et al., 2019; Moraes et al., 2022).

Project planning is vital to systematic thinking and was initiated to determine the necessary steps for the project. In this project planning phase, the project team developed the goals and timeline and considered ways to mitigate risks during project implementation. During the project planning phase, contextual factors that will influence the project were considered to understand best how to bring about and deliver the change. Project planning included interprofessional collaboration, project management plan development, and feasibility analysis.

According to Li-Hui et al. (2021), organizational support is considered one of the most critical factors affecting nurse practitioners' (NPs) job satisfaction. Healthcare administrators must, therefore, promote and advocate for organizational support when implementing a change initiative to improve patient outcomes (Li-Hui et al., 2021). Supportive leadership enhances engagement and trust in an organization, which mediates overall job satisfaction (Meng & Berger, 2018). The stakeholders at the project site will offer organizational support in various ways. First, all leaders in the designated units will create a positive, supportive environment to ensure nurses’ engagement in the implementation of the project. A positive work environment will increase satisfaction with the task at hand to ensure the completion of the project (Li-Hui et al., 2021). Internal stakeholders, including administration, seek ways to improve patient care and reduce costs by lowering LOS. The administration will be informed of the project to ensure engagement in the designated units, and they will support sustaining the project if the results are positive. Frontline staff members, such as nurses, pharmacists, respiratory therapists, and physical and occupational therapists, were involved in planning the quality improvement project. The primary care providers, such as nurses, NPs, nurse bundle champions, and physicians, will be responsible for implementing the project.

When nurse leaders use nurse champions in a structured change process, staffing resources are maximized without incurring additional costs, which makes quality improvement initiatives more feasible and sustainable (Mount & Anderson, 2015). Nurse bundle champions will be in charge of monitoring the ABCDE Bundle deployment. They will collect the bundle checklists and ensure complete documentation and implementation of the bundle elements. Bundle champions will be ideal for leading the intervention due to their training, experience, skillset, and competencies. Furthermore, bundle champions are skilled in coordination and effective communication, which will enhance teamwork in the targeted units to achieve a smooth implementation of the ABCDE Bundle. Nurses are also integral to the project's implementation because they are frontline staff providing day-to-day care. Mount and Anderson (2015) asserted that bedside nurses are empowered through peer-to-peer collaboration throughout the change process. Bedside nurses will be responsible for initiating and documenting the individual bundle elements.

A project manager oversees a project (Aubry & Lavoie-Tremblay, 2018). In this project, the project manager will lead and manage the implementation team by facilitating interactions among implementation team members, frontline staff, and administration. The implementation team members will offer the necessary expertise in the subject and collaborate with frontline staff to ensure the successful integration of the ABCDE Bundle into the daily workflows on the target unit.

The project will begin after approval from the Grand Canyon University Institutional Review Board (IRB) (see Appendix E) and end with data analysis. After approval, staff will be educated about the project purpose and implementation process. Nurses, certified nursing assistants, respiratory therapists, critical care physicians, hospitalists, pharmacists, and physical and occupational therapists will be invited to attend a mandatory in-service. The in-service training will require approximately 20 minutes and be held at a mandatory annual skills fair. The sessions will be available for two weeks from 6:00 a.m. to 9:00 a.m. on Monday, Wednesday, Friday, Saturday, and Sunday. The training will include a pre-assessment, a PowerPoint presentation on using the bundle components, a bedside rounding checklist, a delirium assessment worksheet, and a mobility chart (see Appendix D). Handouts will be provided, and then a post-test will occur. Posters and flipcharts will be available in the target unit to visually remind participants about the project and the bundle process.

After completing the training, the ABCDE Bundle will be implemented for eight weeks. All patients who meet the inclusion criteria and are admitted to the HOU will be included in the implementation group. Nurses will assess patients’ need for bundle elements and use any elements required indicated by the assessments. The assessments and elements will be documented on a bedside ABCDE Bundle checklist daily (see Appendix G). The ABCDE Bundle checklist follows the task of each bundle element. The bedside nurses will be required to complete the checklist and if applicable, make comments for un-checked items. Completed checklists will be stored in a designated folder located in the nursing supervisor’s office. Quantitative data on LOS and patients’ demographics will be collected from the electronic health record (EHR) for the eight weeks before and after initiating the project. The data will consist of the ages, genders, primary diagnosis, and LOS. Retrospective data will be collected and included two months before implementation. The project will ensure nurses optimize sedation levels, monitor for delirium, and plan for routine sedation interruptions, pain management, and early mobility.

Six healthcare staff will be selected to act as bundle champions. They will help in the rollout and implementation of the project. The champions will be tasked with ensuring the project's success. Adequate staff is available to carry out the bundle initiatives and for the ongoing time needed to educate other healthcare providers, such as bedside nurses, doctors, mid-level managers, technicians, and pharmacists. Access to patient health information (PHI) and Statistical Package for the Social Sciences (SPSS) version 28 software will also be required to measure the project's outcomes. The EHR does not guarantee that testing will be valid or that patients receive appropriate and timely action after test results become available (Murphy et al., 2019). To enable efficient data extraction, a validated process must be used (Joseph et al., 2022). It will be necessary that all PHI is uniformly documented by caregivers in the EHR. Staff will be trained to ensure documentation is uniform and standard.

Project costs include paid staff training, printing educational materials (i.e., handouts, poster boards, and flip charts), and capital equipment purchases, such as stretcher chairs (see Appendix F). The estimated cost of conducting the project is $5150.00. This increased cost is justified since the successful implementation of the ABCDE Bundle has been shown to reduce LOS in prior research, and reduced LOS decreases the costs incurred by care delivery (Otusanya et al., 2022).

The project site is an LTACH located in an urban city in Virginia. The facility treats critically-ill adult patients seeking surgical, medical, cardiac, neurological, and long-term respiratory management. Long-term respiratory management includes mechanical ventilator support, high-flow oxygen, and tracheostomy care. The LTACH staff can perform minor surgical interventions and provide rehabilitation services.

The project site is a free-standing, 60-bed LTACH in urban Virginia with single and double occupancy rooms. Staff includes physicians, NPs, registered nurses, licensed practical nurses, certified nursing assistants, respiratory therapists, and physical and occupational therapists. The LTACH provides on-site emergent care services such as mechanical intubation. Approximately two to five patients are admitted daily from surrounding short-term acute care hospitals, with varying long-term care needs. There are 46 designated high observation unit (HOU) beds for patients who are hemodynamically unstable and require acute care monitoring. The average daily census is approximately 43 to 50.

The project population will include all eligible adults admitted or transferred to the HOU. The HOU cares for patients hospitalized in an ICU for three days or more who require ongoing long-term acute services related to their hospitalization. Inclusion criteria are patients 18 or older admitted to the HOU and requiring active life-saving support and monitoring. The exclusion criteria are patients younger than 18 who are not admitted to the HOU and do not require life-saving measures. The sample will include a comparative and an implementation group. The comparative group will consist of all individuals admitted to the HOU in the eight weeks before the project begins. The implementation group will include all patients admitted to the HOU eight weeks after implementing the ABCDE Bundle.

The sample size was obtained by using a sample size calculator. The HOU admits an average of five patients per week. For a confidence level of 95% and a 5% margin of error, the sample should be 32 (Calculator.net, 2022). A sample of 32 will be adequate to detect a clinically or statistically significant change in LOS.

A purposive sampling procedure includes defining the research problem, determining the population, defining the characteristics of the sample, collecting data, and analyzing and interpreting the results (Campbell et al., 2020). A convenience sample of patients who meet the inclusion criteria will be purposively selected using the EHR. Informed consent will not be required in this project. The informed consent process involves educating participants about an intervention's benefits, risks, and alternatives; it is a legal and ethical obligation during a study (Arifin, 2018). Confidentiality measures, including not disclosing participants' identities, personal information, and responses to the public without their explicit consent, will be followed. Data will be collected on LOS from the EHR for a comparative and implementation sample, reported in aggregate form, stored according to the data retention policy at the site, and destroyed three years after the findings have been published. Collecting and comparing LOS data will indicate if implementing the ABCDE Bundle impacted this patient outcome.

Data collection will only occur once IRB is received. A hospital administrator will extract comparative data from the EHR after the ABCDEF Bundle educational intervention. The same data administrator will also extract implementation LOS data. Demographic data will also be collected to characterize the sample. The demographic data will include patients’ ages, genders, and primary diagnoses. The primary diagnosis will include surgical, medical, trauma, neurosurgical, cardiac, and neurological options. Codes will be assigned to identify the patients, and the data will then be organized using SPSS version 28 for analysis.

This DPI project will rely on secondary data from the facility's EHR. A data administrator will extract de-identified comparative and implementation data from the site's data tracking spreadsheet on LOS and patient demographics. The EHR will serve as a valuable tool for data extrapolation. While EHRs can potentially improve communication by managing the delivery of electronic test orders and facilitating the delivery of essential findings to a clinician, they do not guarantee that testing will be completed promptly or that patients will receive appropriate and timely action after test results become available (Murphy et al., 2019). The EHR is password protected to safeguard the privacy of patients.

Validity and reliability are essential in research. Validity refers to the extent to which an instrument measures the intended construct (Leedy et al., 2019). Reliability and validity are concepts used to evaluate the quality of research (Hassey et al., 2001). Altman et al. (2018) conducted a study to evaluate the accuracy of information obtained from an EHR system for obstetric research. For several perinatal parameters, including birth type, labor induction, labor augmentation, cervical ripening, vertex presentation, and postpartum hemorrhage, the research compares data collected via automated EHR reporting with manually extracted data. The researchers used data from 3,250 women who gave birth at a significant hospital in the Pacific Northwest to perform the study (Altman et al., 2018). The authors discovered that the EHR data and manual chart abstraction for delivery techniques (including vacuum-assisted, forceps-assisted, cesarean, and spontaneous vaginal births) were in virtually perfect agreement. A study by van Melle et al. (2018) evaluated the dependability and accuracy of a medical record review process for detecting transitional safety incidents (TSIs) within healthcare environments. The investigation aimed to assess the efficacy of the measuring instrument employed in detecting TSIs and to appraise the concurrence between appraisers and a benchmark standard of TSIs that can be identified objectively. A retrospective study utilized the medical records of 301 primary and secondary care patients in the Netherlands (van Melle et al., 2018). The medical records were evaluated for TSIs by a group of six proficient reviewers comprising general practitioners and specialists. Two reviewers evaluated The inter-rater reliability through the independent review of 10% of the medical records. The TSIs that were identified were subjected to a validity assessment by comparing them to a reference standard consisting of three TSIs that were objectively identifiable. The study's findings indicate that the reviewers were able to detect Transitional Safety Incidents (TSIs) in approximately 17.3% of the transitional medical records. However, there was considerable variability observed between the reviewers. The inter-rater agreement in detecting a TSI was found to be 0%, with Cohen's kappa coefficient, a statistical measure of agreement, indicating low reliability at -0.15. The reviewers' identification of objectively identifiable TSIs was limited to only 22%, suggesting a significant proportion of TSIs needed to be noticed (van Melle et al., 2018). The study's results indicate that the measurement tool employed by clinicians to identify TSIs in transitional medical records had low reliability, leading to the conclusion that the tool's effectiveness is questionable. However, the clinical professionals were able to identify some valid TSIs, but a considerable proportion of them were overlooked. According to the research findings, it is imperative to restructure the record review process to enhance the dependability and accuracy of detecting Transitional Safety Incidents (TSIs) in healthcare transitions. The research acknowledges certain constraints, such as utilizing a suboptimal reference standard and involving a heterogeneous group of reviewers (van Melle et al., 2018).

A study conducted by Chan et al. (2010) reviewed empirical studies on the quality of EHR data, with a particular emphasis on attributes pertinent to quality measurement. The meta-analysis encompassed a total of 35 scholarly articles that were published subsequent to January 2004. The research investigated diverse facets of data quality, wherein 66% of the studies scrutinized data precision, 57% analyzed data entirety, and 23% evaluated data similarity (Chan et al., 2010). The reviewed studies exhibited various data elements, study settings, populations, health conditions, and EHR systems. The study underscores the significance of comprehending the factors linked to inadequate or inconsistent data quality in EHRs. The authors concluded that enhancing the accuracy and reliability of health data used for measurement and decision-making is contingent upon improving EHR data quality. While EHRs present many prospects for enhancing healthcare and conducting research, obstacles to the credibility and consistency of the data are present. To tackle these obstacles, it is imperative to adopt methodological strategies, conduct validation research, and foster cooperation among diverse stakeholders. The assurance of the dependability and accuracy of electronic health record (EHR) data is of utmost importance in generating sound research outcomes, augmenting patient safety, and advancing the standard of healthcare.

The independent variable is the translation of Hsieh et al.'s research on the ABCDE Bundle, and the dependent variable is LOS in the HOU. Length of stay will be calculated by noting a patient’s day of admission and discharge. LOS data will be calculated as the mean LOS for a comparative and implementation group of patients. The comparative group will include all patients meeting the eligibility criteria admitted to the HOU eight weeks before the project’s implementation. The implementation group will include all patients who meet the inclusion criteria and receive the ABCDE Bundle elements.

Data will be collected by a data management expert at the project site. The data management expert will perform a retrospective review of the EHR using the eligibility criteria and pull data on patients’ LOS in the HOU and demographics. The data management expert will de-identify and input the information into a Microsoft Excel spreadsheet. Data will then be transferred to SPSS version 28 for analysis. LOS will be analyzed using an independent t-test. A Student’s t-test is an inferential test used to determine whether the difference in means between two samples is statistically different (Leedy et al., 2019). A t-test is a parametric procedure measuring differences in numerical data (Leedy et al., 2019). Descriptive statistics will also calculate the mean LOS and analyze patients’ demographics. According to Knapp (2018), researchers use descriptive statistics to summarize findings. A p-value of less or equal to 0.05 will indicate statistical significance (Schober et al., 2018).

The methods used for data cleansing will include removing duplicates, filtering out unwanted outliers, and validating the input information (Setiyanto & Setiawan, 2022). Data security will be ensured by storing the data on a password-protected hard drive in a locked vault. Comparative and implementation data will be extracted from the EHR by a data analyst who will provide the information in an Excel spreadsheet. All PHI will be removed from the file dataset. The data will be retained for three years, and then hard copies of the checklists will be destroyed following the project site's policy of shredding and cross-shredding, while electronic data will be destroyed by degaussing.

This quality improvement project is not exempt from bias. Primarily, the project is not a randomized controlled trial. Randomized controlled trials provide strong evidence because randomizing a sample to treatment and control groups can account for confounding variables (Noyes et al., 2019). This project will use a convenience sample, a non-probability sample of individuals selected based on availability (Stratton, 2021). This approach allows researchers to gather data that would not have been possible otherwise but is prone to bias (Stratton, 2021). This bias will be mitigated using clear, objective eligibility criteria to select participants.

Sampling bias occurs when a sample does not represent the larger population. It happens when the group involved needs to represent the needs and expectations of the target population. For example, the sample selected from the HOU may not represent the target population of adults needing long-term care. Selection bias is a significant issue in the design since it is difficult to determine the traits of those involved in the quality improvement project and those not involved. This bias can be mitigated by expanding the quality improvement project to additional departments in the LTACH in the future.

Further, data collection is another potential bias because of the limitations of the data. Researchers should recognize that all data has errors and that no data set is perfect (Dórea & Revie, 2021). This project seeks to improve the quality of care and reduce LOS among adult patients in an LTACH. According to Watt et al. (2019), bias during a quality improvement project occurs when the process is manipulated to ensure that a specific outcome or result is achieved. Bias occurs when the researcher influences or controls the research process to achieve specific results (Flyvbjerg, 2021). In the data interpretation stage, confirmation bias may affect the results. Confirmation bias refers to ignoring specific results due to preexisting hypotheses. It is crucial to focus on the desired outcome, not the hypothesis, to avoid this bias.

Last, the various basic principles of data interpretation are important to consider when translating outcomes into practice. First, it is essential to think about the validity of the data. Data validity means determining whether the data is accurate and representative of the population it is supposed to be measuring (Leonelli, 2019). In a quality improvement project, there are numerous ways to avoid bias, including ensuring that the data is collected from numerous sources and that there is data verification. Before analysis, one should confirm their sources and other related data. Finally, peer review is essential to ensure that other people can revisit the process and identify bias that could have occurred before publication.

The safeguarding of individuals' rights and privacy in the healthcare and research domains is addressed by two notable frameworks, namely the HIPAA Privacy Rule and the Belmont Report. The Health Insurance Portability and Accountability Act of 1996 (HIPAA) established the HIPAA Privacy Rule, which imposes national standards for safeguarding health information. This rule applies to covered entities that participate in healthcare. Conversely, the Belmont Report, which emerged from the National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research, furnishes ethical tenets and directives for investigating human participants. Both frameworks aim to safeguard the security and privacy of individuals and their data within healthcare and research environments.

Parasidis et al. (2019) state that the Belmont Report stipulates principles and guidelines for protecting human subjects involved in behavioral and biomedical research projects. Researchers follow the principles described in the Belmont Report to inform the ethical conduct of their research (Jefferson et al., 2021). The Belmont Report principles are respect, justice, and beneficence, which were used to guide the development of the project design and sampling procedures (National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research, 1979).  Respect will be demonstrated by explaining confidentiality procedures, and potential conflicts of interest will be explained to the study participants before the project. Justice will be observed by not withholding the interventions from eligible patients, and beneficence will be achieved by ensuring that the nurses involved in the project follow the principle of “do no harm.” Further, the interventions in the ABCDE Bundle have been shown to improve patients’ outcomes and reduce the adverse effects of PICS, aligning with the goals of beneficence. The Grand Canyon University IRB will review the project and be determined as a quality improvement initiative.

The LOS of adult patients in long-term acute care is a significant concern as it increases individuals’ risk of adverse outcomes and hospital costs. Patient outcomes have been linked to increased LOS in long-term acute care (Boltey et al., 2019; Moraes et al., 2022). This quality improvement project aims to improve health care quality in the HOU of an LTACH by implementing the ABCDE Bundle. The sample will include patients who need acute care eight weeks before or after the implementation of the project. The ABCDE Bundle will be implemented after nurses are trained on the project. Data will be extracted from the EHR and then input into SPSS version 28 for analysis. The project will follow the principles outlined in the Belmont Report to ensure ethical considerations are maintained throughout implementation. Chapters 4 and 5 present the results of data analysis and explore how to sustain bundle implementation in clinical practice at the LTACH.

Chapter 4: Data Analysis and Results

This chapter summarizes the collected data, describes how the data were analyzed, and then presents the results. Chapter 4 briefly restates the problem statement and the evidence-based practice question. The organization of the chapter is briefly outlined in this section. Ensure this chapter is written in the past tense and reflects how the project was 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.

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Figure 1
SWOT Analysis for Quality Improvement Project

Table 3
Primary Quantitative Research – Intervention

Table 4
Additional Primary and Secondary Quantitative Research

Table 5
Theoretical Framework Aligning to DPI Project

Lesson Plan for Educational Offering on the ABCDE Bundle

This lesson plan will act as a blueprint of activities to guide nurses’ implementation of the ABCDE Bundle in a long-term acute care in urban Virginia. The lesson will follow the following activities: pre-assessment, in-service at a mandatory job skill fair, educational offering with handouts and PowerPoint presentation, and a post-assessment. In addition, portable flipcharts and posters will be posted in the project unit to act as visual reminders of the education.

Lesson Objectives

• By the end of the lesson, learners will be able to define the elements and interventions of the ABCDE bundle and its importance in promoting quality care in long-term acute care setting

• By the end of the lesson the learner will recite why it’s essential to engage patients and caregivers’ example, family members, during the implementation of the ABCDE bundle. (Kram et al., 2015).

• By the end of the lesson, the learner will identify the benefits of implementing the ABCDE bundle in the long-term acute care hospital, including ensuring improved patient outcomes and role in reducing length of stay. According to Bounds et al. (2016), the bundle is associated with delirium occurrence reduction, patient care improvements in understanding LTACHs, and lowering the financial demands of patients in critical care units. Comprehension of the learning will be evaluated in the post-assessment, passing score of 80% for demonstration of the intervention.

Methods

In-Person In-Service at a Mandatory Job Skills Fair: An initial in-service will be performed by the primary investigator at the mandatory skills fair. All staff members will be is required to attend the yearly skills fair. The primary investigator will present the ABCDE Bundle via poster presentation, with handouts at the skills fair. For those who did not attend the yearly skills fair, an in-service will be held.

Educational Offering: During the initial training, a PowerPoint presentation will be used to summarize the main points of ABCDE Bundle implementation. The presentation will begin after a post-test assessment. The educational offering will include how to use and document the ABCDE Bundle elements, including how to use and score the CAM-ICU and RASS. The presentation will end with a post-test assessment. Handouts will be provided at the educational offering, which will include:

• Pre- and Post-Test Assessments

• “Wake Up and Breathe” Protocol Handout

• Bedside Treatments for ABCDE Protocol

• CAM-ICU Worksheet

• Richmond Agitation-Sedation Scale

• Johns Hopkins Mobility Goal Calculator

Visual Reminders: Posters of the bundle elements will be on display in each break room and two portable sheet protected flip charts will be housed on each unit. The flipcharts will be of the initial PowerPoint presentation to act as a reminder of the information in the education.

On-Going Education: The bundle elements will be reviewed during the daily safety huddles on the unit held at 7 am for the day shift and 7 pm for the night shift. The unit nursing supervisor will act as the bundle champion and provide the daily just-in-time education on the bundle elements.

Delirium, Vanderbilt University. Available at www.ICUdelerium.org