What are effective strategies for the implementation of care bundles on ICUs: a systematic review

Effect of acute kidney injury care bundle on kidney outcomes in cardiac patients receiving critical care: a systematic review and meta-analysis

BACKGROUND

Cardiac surgery is a major contributor to acute kidney injury (AKI); approximately 22% of patients who undergo cardiac surgery develop AKI, and among them, 2% will require renal replacement therapy (RRT). AKI is also associated with heightened risks of mortality and morbidity, longer intensive care stays, and increased treatment costs. Due to the challenges of treating AKI, prevention through the use of care bundles is suggested as an effective approach. This review aimed to assess the impact of care bundles on kidney outcomes, mortality, and hospital stay for cardiac patients in critical care.

METHODS

PubMed, Scopus, Web of Science, and EMBASE were searched up to November 2024. Inclusion criteria were studies on individuals with cardiac diseases receiving critical care, that used AKI care bundle as the intervention, and reported outcomes related to AKI, mortality, and other kidney-related events. We used the Cochrane Collaboration's risk of bias tool 2 and the Newcastle-Ottawa scale for quality assessment. Pooled odds ratios (ORs) or risk ratios (RRs) with 95% confidence intervals (CIs) were calculated.

RESULTS

Seven studies on total 5045 subjects, including five observational and two randomized controlled trials (RCTs) were included. The implementation of care bundles significantly reduced the incidence of all-stage AKI (OR: 0.78; 95%CI: 0.61-0.99) and moderate-severe AKI (OR: 0.56; 95%CI: 0.43-0.72). Also, the implementation of care bundle increased the incidence of persistent renal dysfunction after 30 days by 2.39 times. However, there were no significant changes in RRT, major adverse kidney events, or mortality between the groups. The mean quality assessment score for observational studies was 7.2 out of ten, while there were noted concerns in the risk of bias assessment of the RCTs.

CONCLUSIONS

The application of care bundles in patients, including those undergoing cardiac surgeries as well as non-cardiac critical illness, appears to be effective in reducing AKI, particularly in moderate and severe stages. However, given the inclusion of non-cardiac patients in some studies, the observed effect may not be solely attributable to cardiac surgery cases. Future large-scale RCTs focusing specifically on cardiac surgery patients are recommended to clarify the impact of care bundles within this subgroup.

REGISTRATION ID IN PROSPERO

CRD42024498972.

The Impact of the Dialysis Event Prevention Bundle on the Reduction in Dialysis Event Rate in Patients with Catheters: A Retrospective and Prospective Cohort Study

Background: Dialysis-associated events such as bloodstream infections represent serious complications for hemodialysis patients, with the potential to increase morbidity and mortality. Aims: To assess the impact of implementing a comprehensive bundle of evidence-based practice on reducing dialysis event rates among catheter dialysis patients at Prince Mansour Military Hospital Dialysis Center. Participants and Methods: The study enrolled 111 hemodialysis participants. A comprehensive dialysis event prevention bundle consisting of 6 key components was implemented. Results: Implementation of the dialysis event prevention bundle showed a significant decrease in IV antimicrobial start (p = 0.003), positive blood culture (p = 0.039), and inflammation at the vascular access site eliminated (p = 0.004). There was a positive correlation between IV antimicrobial start and both patients' age (p = 0.005) and the permanent catheter site (p = 0.002). Positive blood culture was significantly correlated with comorbidities (p = 0.000) and patients' age (p = 0.320). A positive correlation between pus, redness, or increased swelling at the vascular access site with comorbidities (p = 0.034), patients' age (p = 0.021), and the permanent catheter site (p = 0.002) was observed. Staff compliance with the dialysis event prevention bundle components has improved regarding hemodialysis catheter disconnection, catheter exit site care, and routine disinfection. Conclusions: Implementation of a comprehensive dialysis event prevention bundle can effectively reduce dialysis event rates and enhance patient safety.

Development of a care package to prevent medical device-related pressure injuries using the Delphi Method: A maintenance care package development study

AIM

The purpose is to develop a care package for the prevention of medical device-related pressure injuries using the Delphi Method.

DESIGN

The study is a methodological.

METHOD

The care package was developed using the Delphi Method, a consensus-based technique. Two expert groups were selected to develop the care package to prevent medical device-related pressure injuries. The invitation letter and the questionnaire consisting of two questions were sent to the relevant experts via email and completed in three rounds after receiving responses. The scores from the experts were uploaded to the SPSS 25.0 software package. The range (R) was calculated as R = Q3-Q1. The differences (R) between the quartiles were examined. Items with R < 1.2 were accepted as having reached a consensus.

RESULTS

As a result of the evaluation, it was organized as 83 items. As a result of the analysis of the scores of the second round of the Delphi Method, the range values of each item were examined. In the third round of the Delphi Method, it was found that consensus was reached in the third round on items 18, 29, and 56, on which consensus could not be reached in the second round, and the care package was accepted with 83 items.

CONCLUSION

An 83-item care package was created to prevent medical device-related pressure injuries in children.

'It depends': what 86 systematic reviews tell us about what strategies to use to support the use of research in clinical practice

BACKGROUND

The gap between research findings and clinical practice is well documented and a range of strategies have been developed to support the implementation of research into clinical practice. The objective of this study was to update and extend two previous reviews of systematic reviews of strategies designed to implement research evidence into clinical practice.

METHODS

We developed a comprehensive systematic literature search strategy based on the terms used in the previous reviews to identify studies that looked explicitly at interventions designed to turn research evidence into practice. The search was performed in June 2022 in four electronic databases: Medline, Embase, Cochrane and Epistemonikos. We searched from January 2010 up to June 2022 and applied no language restrictions. Two independent reviewers appraised the quality of included studies using a quality assessment checklist. To reduce the risk of bias, papers were excluded following discussion between all members of the team. Data were synthesised using descriptive and narrative techniques to identify themes and patterns linked to intervention strategies, targeted behaviours, study settings and study outcomes.

RESULTS

We identified 32 reviews conducted between 2010 and 2022. The reviews are mainly of multi-faceted interventions (n = 20) although there are reviews focusing on single strategies (ICT, educational, reminders, local opinion leaders, audit and feedback, social media and toolkits). The majority of reviews report strategies achieving small impacts (normally on processes of care). There is much less evidence that these strategies have shifted patient outcomes. Furthermore, a lot of nuance lies behind these headline findings, and this is increasingly commented upon in the reviews themselves.

DISCUSSION

Combined with the two previous reviews, 86 systematic reviews of strategies to increase the implementation of research into clinical practice have been identified. We need to shift the emphasis away from isolating individual and multi-faceted interventions to better understanding and building more situated, relational and organisational capability to support the use of research in clinical practice. This will involve drawing on a wider range of research perspectives (including social science) in primary studies and diversifying the types of synthesis undertaken to include approaches such as realist synthesis which facilitate exploration of the context in which strategies are employed.

Clinical Outcome of Patients with Poor-Grade Aneurysmal Subarachnoid Hemorrhage with Bundled Treatments: A Propensity Score-Matched Analysis

BACKGROUND

Poor-grade aneurysmal subarachnoid hemorrhage (aSAH), defined as Hunt and Hess (HH) grades IV and V, is a challenging disease because of its high mortality and poor functional outcomes. The effectiveness of bundled treatments has been demonstrated in critical diseases. Therefore, poor-grade aSAH bundled treatments have been established. This study aims to evaluate whether bundled treatments can improve long-term outcomes and mortality in patients with poor-grade aSAH.

METHODS

This is a comparative study using historical control from 2008 to 2022. Bundled treatments were introduced in 2017. We compared the rate of favorable outcomes (modified Rankin Scale score 0-2) at 6 months and mortality before and after the introduction of the bundled treatments. To eliminate confounding bias, the propensity score matching method was used.

RESULTS

A total of 90 consecutive patients were evaluated. Forty-three patients received bundled treatments, and 47 patients received conventional care. The proportion of patients with HH grade V was higher in the bundle treatment group (41.9% vs. 27.7%). Conversely, the proportion of patients with fixed pupils on the initial examination was higher in the conventional group (30.2% vs. 38.3%). After 1:1 propensity score matching, 31 pairs were allocated to each group. The proportion of patients with 6-month favorable functional outcomes was significantly higher in the bundled treatments group (46.4% vs. 20.7%, p = 0.04). The 6-month mortality rate was 14.3% in the bundled treatments group and 27.3% in the conventional group (p = 0.01). Bundled treatments (odd ratio 14.6 [95% confidence interval 2.1-100.0], p < 0.01) and the presence of an initial pupil reflex (odd ratio 12.0 [95% confidence interval 1.4-104.6], p = 0.02) were significantly associated with a 6-month favorable functional outcome.

CONCLUSIONS

The bundled treatments improve 6-month functional outcome and mortality in patients with poor-grade aSAH.

Surgical Antibiotic Prophylaxis: A Proposal for a Global Evidence-Based Bundle

In the multimodal strategy context, to implement healthcare-associated infection prevention, bundles are one of the most commonly used methods to adapt guidelines in the local context and transfer best practices into routine clinical care. One of the most important measures to prevent surgical site infections is surgical antibiotic prophylaxis (SAP). This narrative review aims to present a bundle for the correct SAP administration and evaluate the evidence supporting it. Surgical site infection (SSI) prevention guidelines published by the WHO, CDC, NICE, and SHEA/IDSA/APIC/AHA, and the clinical practice guidelines for SAP by ASHP/IDSA/SIS/SHEA, were reviewed. Subsequently, comprehensive searches were also conducted using the PubMed®/MEDLINE and Google Scholar databases, in order to identify further supporting evidence-based documentation. The bundle includes five different measures that may affect proper SAP administration. The measures included may be easily implemented in all hospitals worldwide and are based on minimal drug pharmacokinetics and pharmacodynamics knowledge, which all surgeons should know. Antibiotics for SAP should be prescribed for surgical procedures at high risk for SSIs, such as clean-contaminated and contaminated surgical procedures or for clean surgical procedures where SSIs, even if unlikely, may have devastating consequences, such as in procedures with prosthetic implants. SAP should generally be administered within 60 min before the surgical incision for most antibiotics (including cefazolin). SAP redosing is indicated for surgical procedures exceeding two antibiotic half-lives or for procedures significantly associated with blood loss. In principle, SAP should be discontinued after the surgical procedure. Hospital-based antimicrobial stewardship programmes can optimise the treatment of infections and reduce adverse events associated with antibiotics. In the context of a collaborative and interdisciplinary approach, it is essential to encourage an institutional safety culture in which surgeons are persuaded, rather than compelled, to respect antibiotic prescribing practices. In that context, the proposed bundle contains a set of evidence-based interventions for SAP administration. It is easy to apply, promotes collaboration, and includes measures that can be adequately followed and evaluated in all hospitals worldwide.

Pressure ulcers in patients with COVID-19 acute respiratory distress syndrome undergoing prone positioning in the intensive care unit: A pre- and post-intervention study

BACKGROUND

Prone positioning has been widely used to improve oxygenation and reduce ventilator-induced lung injury in patients with severe COVID-19 acute respiratory distress syndrome (ARDS). One major complication associated with prone positioning is the development of pressure ulcers (PUs).

AIM

This study aimed to determine the impact of a prevention care bundle on the incidence of PUs in patients with COVID-19 ARDS undergoing prone positioning in the intensive care unit.

STUDY DESIGN

This was a single-centre pre and post-test intervention study which adheres to the Standards for Reporting Implementation Studies (StaRI) guidelines. The intervention included a care bundle addressing the following: increasing frequency of head turns, use of an open gel head ring, application of prophylactic dressings to bony prominences, use of a pressure redistribution air mattress, education of staff in the early identification of evolving PUs through regular and rigorous skin inspection and engaging in bedside training sessions with nursing and medical staff. The primary outcome of interest was the incidence of PU development. The secondary outcomes of interest were severity of PU development and the anatomical location of the PUs.

RESULTS

In the pre-intervention study, 20 patients were included and 80% (n = 16) of these patients developed PUs, comprising 34 ulcers in total. In the post-intervention study, a further 20 patients were included and 60% (n = 12) of these patients developed PUs, comprising 32 ulcers in total. This marks a 25% reduction in the number of patients developing a PU, and a 6% decrease in the total number of PUs observed. Grade II PUs were the most prevalent in both study groups (65%, n = 22; 88%, n = 28, respectively). In the post-intervention study, there was a reduction in the incidence of grade III and deep tissue injuries (pre-intervention 6%, n = 2 grade III, 6% n = 2 deep tissue injuries; post-intervention no grade III ulcers, grade IV ulcers, or deep tissues injuries were recorded). However, there was an increase in the number of unstageable PUs in the post-intervention group with 6% (n = 2) of PUs being classified as unstageable, meanwhile there were no unstageable PUs in the pre-intervention group. This is an important finding to consider as unstageable PUs can indicate deep tissue damage and therefore need to be considered alongside PUs of a more severe grade (grade III, grade IV, and deep tissue injuries).

CONCLUSION

The use of a new evidence-based care bundle for the prevention of PUs in the management of patients in the prone position has the potential to reduce the incidence of PU development. Although improvements were observed following alterations to standard practice, further research is needed to validate these findings.

RELEVANCE TO CLINICAL PRACTICE

The use of a new, evidence-based care bundle in the management of patients in the prone position has the potential to reduce the incidence of PUs.

Mixed-method acceptability evaluation of a co-designed bundled intervention to support communication for patients with an advanced airway in the intensive care unit during a pandemic

BACKGROUND

Although bundled communication interventions are recommended to address communication barriers for patients with an advanced airway in the intensive care unit (ICU) such interventions have not been evaluated in pandemic conditions.

AIM

To evaluate the acceptability, appropriateness, and feasibility of a co-designed bundled intervention to support communication with adult patients with an advanced airway in ICU in pandemic conditions.

STUDY DESIGN

Prospective, convergent mixed method design in a single centre medical-surgical ICU in Toronto, Canada between September 2021-March 2022. After the use of the co-designed bundled communication intervention quantitative data were collected from health care providers using validated acceptability, appropriateness, and feasibility measures and analysed using descriptive statistics. Qualitative data were collected from providers, patients and families using semi-structured interviews and analysed using content analysis applying the theoretical framework of acceptability. Joint table analysis enabled the integration of the two data sets.

RESULTS

A total of 64 (41.3%) HCPs responded to the survey: 54 (84.4%) rated the intervention acceptable; 55 (85.9%) appropriate; and 49 (76.6%) feasible for use in this context. Qualitative data (23 interviews: 13 healthcare providers, 6 families and 4 patients) and the joint table analysis extended the understanding that intervention acceptability was related to positive affective attitudes and reduced communication frustration. Appropriateness and feasibility were promoted through intervention alignment with values, ability to personalize tools, and ease of access. Recommendations to improve the acceptability included adaptation for immobilized and/or restrained patients, additional education, and integration into existing workflows.

CONCLUSIONS

This mixed method evaluation of a co-designed bundled intervention to support patient communication in the ICU during pandemic conditions demonstrated high rated and described acceptability, appropriateness, and feasibility by participants.

RELEVANCE TO CLINICAL PRACTICE

A co-designed communication intervention demonstrating stakeholder acceptability, appropriateness, and feasibility can be implemented into clinical practice in pandemic and other infection prevention and control contexts.

Use of Facebook in a quality improvement campaign to increase adherence to guidelines in intensive care: A qualitative study of nurses' and physicians' experiences

OBJECTIVES

This study aimed to explore intensive care unit nurses' and physicians' experiences with professional content provided through closed Facebook groups, as part of a quality improvement campaign to improve guideline adherence.

RESEARCH METHODOLOGY

This study used an exploratory qualitative design. In June 2018, data were collected through focus groups of intensive care nurses and physicians who also were members of closed Facebook groups. Data were analysed using reflexive thematic analysis, and the study was reported according to the consolidated criteria for reporting qualitative research.

SETTING

The study's setting was four intensive care units at Oslo University Hospital, Norway. Professional content on Facebook comprised audit and feedback on quality indicators on intensive care topics with related pictures, videos, and weblinks.

FINDINGS

Two focus groups of 12 participants were included in this study. Two main themes were identified: 'One size does not fit all ' described that quality improvement and implementation are influenced by several factors related to current recommendations and personal preferences. Various strategies are required to serve different purposes and meet individual needs. 'Matter out of place' described conflicting experiences of being offered or exposed to professional content on Facebook.

CONCLUSION

Although the audit and feedback on quality indicators presented on Facebook motivated improvements, professional content on Facebook was perceived as inappropriate. Hospital platforms with applicable features of social media, such as reach, availability, convenience, ease, and possibility for commenting, were suggested to secure professional communication about recommended practices in intensive care units.

IMPLICATIONS FOR CLINICAL PRACTICE

Social media platforms may be useful for professional communication among ICU personnel, but appropriate hospital applications with available and applicable social media features are recommended and needed. The use of several platforms may still be needed to reach all.

The Perioperative Pain Management Bundle is Feasible: Findings From the PAIN OUT Registry

OBJECTIVES

The quality of postoperative pain management is often poor. A "bundle," a small set of evidence-based interventions, is associated with improved outcomes in different settings. We assessed whether staff caring for surgical patients could implement a "Perioperative Pain Management Bundle" and whether this would be associated with improved multidimensional pain-related patient-reported outcomes (PROs).

METHODS

"PAIN OUT," a perioperative pain registry, offers tools for auditing pain-related PROs and obtaining information about perioperative pain management during the first 24 hours after surgery. Staff from 10 hospitals in Serbia used this methodology to collect data at baseline. They then implemented the "Perioperative Pain Management Bundle" into the clinical routine and collected another round of data. The bundle consists of 4 treatment elements: (1) a full daily dose of 1 to 2 nonopioid analgesics (eg, paracetamol and/or nonsteroidal anti-inflammatory drugs), (2) at least 1 type of local/regional anesthesia, (3) pain assessment by staff, and (4) offering patients information about pain management. The primary endpoint was a multidimensional pain composite score (PCS), evaluating pain intensity, interference, and side effects that was compared between patients who received the full bundle versus not.

RESULTS

Implementation of the complete bundle was associated with a significant reduction in the PCS ( P < 0.001, small-medium effect size [ES]). When each treatment element was evaluated independently, nonopioid analgesics were associated with a higher PCS (ie, poorer outcome, and negligible ES), and the other elements were associated with a lower PCS (all negligible small ES). Individual PROs were consistently better in patients receiving the full bundle compared with 0 to 3 elements. The PCS was not associated with the surgical discipline.

DISCUSSION

We report findings from using a bundle approach for perioperative pain management in patients undergoing mixed surgical procedures. Future work will seek strategies to improve the effect.

A realist review of the effective implementation of the ICU Liberation Bundle in the paediatric intensive care unit setting

OBJECTIVE

The objective of this study was to produce an evidence base of what works, for whom, and in what context when implementing the ICU Liberation Bundle into the paediatric intensive care unit (PICU).

REVIEW METHOD USED

This is a realist review (a review that considers what works, for whom, and in what context) of contemporary international literature.

DATA SOURCES

Data were collected via electronic searches of CINAHL, PubMed, EMBASE and MEDLINE, Google Scholar, and Web of Science for articles published before October 2020.

REVIEW METHOD

An initial scoping search identified the underpinning theory of the implementation of the ICU Liberation Bundle (a multifactor intervention aimed at improving patient outcomes) which was mapped onto the Consolidated Framework for Implementation Research (CFIR). We identified 547 unique citations; 12 full-text papers were included that reported eight studies. Data were extracted and mapped to the CFIR domains.

RESULTS

Data mapped to all CFIR domains. Characteristics of individuals included involvement of key stakeholders, champions, and parents and understanding of staff attitudes and perceptions of the intervention, and all bedside staff members were involved and given training. Within the inner setting, understanding of unit culture, ensuring effective support systems in place, knowledge of the baseline, and leadership support, and buy-in were important. Culture of family-centred care and alignment of the intervention to national guidelines related to the outer setting. Intervention characteristics included the number and timings of interventions, de-escalation rounding checklists, the use of age-appropriate and validated assessment tools, and local policies for the bundle. The process included set training program, senior unit/hospital team consultation on all processes, continual audit adherence to the bundle and feedback, and celebration of successes.

CONCLUSIONS

This novel realist review of the literature identified that successful implementation of the ICU Liberation Bundle into PICU settings involves the following: (i) a thorough understanding of the PICU context, including baseline metrics, resources, and staff attitudes; (ii) using contextual information to adapt the intervention elements to ensure fit; and (iii) both clinical effectiveness and implementation outcomes must be measured. Registration of review: PROSPERO 2020 CRD42020211944.

The Effectiveness of the Interventions to Reduce Sound Levels in the ICU: A Systematic Review

Excessive noise is ubiquitous in the ICU, and there is growing evidence of the negative impact on work performance of caregivers. This study aims to determine the effectiveness of interventions to reduce noise in the ICU.

DATA SOURCES

Databases of PubMed, EMBASE, PsychINFO, CINAHL, and Web of Science were systematically searched from inception to September 14, 2022.

STUDY SELECTION

Two independent reviewers assessed titles and abstracts against study eligibility criteria. Noise mitigating ICU studies were included when having at least one quantitative acoustic outcome measure expressed in A-weighted sound pressure level with an experimental, quasi-experimental, or observational design. Discrepancies were resolved by consensus, and a third independent reviewer adjudicated as necessary.

DATA EXTRACTION

After title, abstract, and full-text selection, two reviewers independently assessed the quality of each study using the Cochrane's Risk Of Bias In Nonrandomized Studies of Interventions tool. Data were synthesized according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines, and interventions were summarized.

DATA SYNTHESIS

After screening 12,652 articles, 25 articles were included, comprising either a mixed group of healthcare professionals (n = 17) or only nurses (n = 8) from adult or PICU settings. Overall, the methodological quality of the studies was low. Noise reduction interventions were categorized into education (n = 4), warning devices (n = 3), multicomponent programs (n = 15), and architectural redesign (n = 3). Education, a noise warning device, and an architectural redesign significantly decreased the sound pressure levels.

CONCLUSIONS

Staff education and visual alert systems seem promising interventions to reduce noise with a short-term effect. The evidence of the studied multicomponent intervention studies, which may lead to the best results, is still low. Therefore, high-quality studies with a low risk of bias and a long-term follow-up are warranted. Embedding noise shielding within the ICU-redesign is supportive to reduce sound pressure levels.

Effect of ICU care bundles on long-term patient-relevant outcomes: a scoping review

OBJECTIVE

Care bundles are considered a key tool to improve bedside quality of care in the intensive care unit (ICU). We explored their effect on long-term patient-relevant outcomes.

DESIGN

Systematic literature search and scoping review.

DATA SOURCES

We searched PubMed, Embase, CINAHL, APA PsycInfo, Web of Science, CDSR and CENTRAL for keywords of intensive care, care bundles, patient-relevant outcomes, and follow-up studies.

ELIGIBILITY CRITERIA

Original articles with patients admitted to adult ICUs assessing bundle implementations and measuring long-term (ie, ICU discharge or later) patient-relevant outcomes (ie, mortality, health-related quality of life (HrQoL), post-intensive care syndrome (PICS), care-related outcomes, adverse events, and social health).

DATA EXTRACTION AND SYNTHESIS

After dual, independent, two-stage selection and charting, eligible records were critically appraised and assessed for bundle type, implementation strategies, and effects on long-term patient-relevant outcomes.

RESULTS

Of 2012 records, 38 met inclusion criteria; 55% (n=21) were before-after studies, 21% (n=8) observational cohort studies, 13% (n=5) randomised controlled trials, and 11% (n=4) had other designs. Bundles pertained to sepsis (n=11), neurocognition (n=6), communication (n=4), early rehabilitation (n=3), pharmacological discontinuation (n=3), ventilation (n=2) or combined bundles (n=9). Almost two-thirds of the studies reported on survival (n=24), 45% (n=17) on care-related outcomes (eg, discharge disposition), and 13% (n=5) of studies on HrQoL. Regarding PICS, 24% (n=9) assessed cognition, 13% (n=5) physical health, and 11% (n=4) mental health, up to 1 year after discharge. The effects of bundles on long-term patient-relevant outcomes was inconclusive, except for a positive effect of sepsis bundles on survival. The inconclusive effects may have been due to the high risk of bias in included studies and the variability in implementation strategies, instruments, and follow-up times.

CONCLUSIONS

There is a need to explore the long-term effects of ICU bundles on HrQoL and PICS. Closing this knowledge gap appears vital to determine if there is long-term patient value of ICU bundles.

Multifaceted interventions are likely to be more effective to increase adherence to the ventilator care bundle: A systematic review of strategies to improve care bundle compliance

BACKGROUND

The implementation of ventilator care bundles has remained suboptimal. However, it is unclear whether improving adherence has a positive relationship with patient outcomes.

OBJECTIVES

To identify the most effective implementation strategies to improve adherence to ventilator bundles and to investigate the relationship between adherence to ventilator bundles and patient outcomes.

METHODS

A systematic review followed the PRISMA guidelines. A systematic literature search from the inception of ventilator care bundles 2001 to January 2021 of relevant databases, screening and data extraction according to Cochrane methodology.

RESULTS

In total, 6035 records were screened, and 24 studies met the eligibility criteria. The implementation strategies were provider-level interventions (n = 15), included educational activities, checklist, and audit/feedback. Organizational-level interventions include (n = 8) included change of medical record system and multidisciplinary team. System-level intervention (n = 1) had motivation and reward. The most common strategies were education, checklists, audit feedback, which are probably effective in improving adherence. We could not perform a meta-analysis due to heterogeneity of the strategies and types of adherence measurement. Most studies (n = 7) had a high risk of bias. There were some conflicting results in determining the associations between adherence and patient outcomes because of the poor quality of the studies.

CONCLUSION

Multifaceted interventions are likely to be effective for consistent improvement in adherence. It remains uncertain whether improvements in adherence have positive outcomes on patients due to limited evidence of low to moderate uncertainty. We recommend the need for robust research methodology to assess the effectiveness of implementation strategies on improving adherence and patient outcomes.

The Impact of Care Bundles on the Incidence of Surgical Site Infections: A Systematic Review

OBJECTIVE

This systematic review assesses the effects of care bundles on the incidence of surgical site infections (SSIs).

DATA SOURCES

The search was conducted between February and May 2021, using PubMed, CINAHL, SCOPUS, Cochrane, and EMBASE databases.

STUDY SELECTION

Studies were included if they used systematic review methodology, were in English, used a quantitative design, and explored the use of care bundles for SSI prevention. A total of 35 studies met the inclusion criteria, and 26 provided data conducive to meta-analysis.

DATA EXTRACTION

Data were extracted using a predesigned extraction tool, and analysis was undertaken using RevMan (Cochrane, London, UK). Quality appraisal was undertaken using evidence-based librarianship.

DATA SYNTHESIS

The mean sample size was 7,982 (median, 840) participants. There was a statistically significant difference in SSI incidence in favor of using a care bundle (SSI incidence 4%, 703/17,549 in the care bundle group vs 7%, 1,157/17,162 in the usual care group). The odds ratio was 0.55 (95% confidence interval, 0.41-0.73; P < .00001), suggesting that there is a 45% reduction in the odds of SSI development for the care bundle group. The mean validity score for all studies was 84% (SD, 0.04%).

CONCLUSIONS

The results indicate that implementing care bundles reduced SSI incidence. However, because there was clinically important variation in the composition of and compliance with care bundles, additional research with standardized care bundles is needed to confirm this finding.

Use of Care Bundles to Prevent Healthcare-Associated Infections in Intensive Care Units: Nurses' Views

Objective: The purpose of this study was to determine the views of nurses working in intensive care units regarding the use of care bundles in preventing healthcare-associated infections. Methods: This study used the focus-group interview method, which is one of the qualitative methods. Two focus-group interviews, each lasting about half an hour, were conducted with 14 intensive care unit nurses. Qualitative data obtained from the interviews were recorded on tape and in note form. The interviews were then transcribed and analyzed. The transcribed data from the focus-group discussions were grouped by theme and concept, and the statements of the participants were coded numerically according to these groupings. Three themes and six subthemes emerged in analyzing the qualitative data. Results: The nurses defined care bundles as "materials that provide integrated care for patients". They also stated that their benefits included providing a tool for self-monitoring, support and guidance for both patients and nurses. When whether they had experienced any difficulties while using care bundles, they stated that they had not experienced any. Furthermore, nurses stated that care bundles improved their perspectives, and that they were must-have items in intensive care units providing reminders rather than a waste of time. Conclusion: It is that the participation of nurses is important so that care bundles are used more widespread in order to prevent healthcare-associated infections in intensive care units.

Can systematic implementation support improve programme fidelity by improving care providers' perceptions of implementation factors? A cluster randomized trial

BACKGROUND

Investigations of implementation factors (e.g., collegial support and sense of coherence) are recommended to better understand and address inadequate implementation outcomes. Little is known about the relationship between implementation factors and outcomes, especially in later phases of an implementation effort. The aims of this study were to assess the association between implementation success (measured by programme fidelity) and care providers' perceptions of implementation factors during an implementation process and to investigate whether these perceptions are affected by systematic implementation support.

METHODS

Using a cluster-randomized design, mental health clinics were drawn to receive implementation support for one (intervention) and not for another (control) of four evidence-based practices. Programme fidelity and care providers' perceptions (Implementation Process Assessment Tool questionnaire) were scored for both intervention and control groups at baseline, 6-, 12- and 18-months. Associations and group differences were tested by means of descriptive statistics (mean, standard deviation and confidence interval) and linear mixed effect analysis.

RESULTS

Including 33 mental health centres or wards, we found care providers' perceptions of a set of implementation factors to be associated with fidelity but not at baseline. After 18 months of implementation effort, fidelity and care providers' perceptions were strongly correlated (B (95% CI) = .7 (.2, 1.1), p = .004). Care providers perceived implementation factors more positively when implementation support was provided than when it was not (t (140) = 2.22, p = .028).

CONCLUSIONS

Implementation support can facilitate positive perceptions among care providers, which is associated with higher programme fidelity. To improve implementation success, we should pay more attention to how care providers constantly perceive implementation factors during all phases of the implementation effort. Further research is needed to investigate the validity of our findings in other settings and to improve our understanding of ongoing decision-making among care providers, i.e., the mechanisms of sustaining the high fidelity of recommended practices.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03271242 (registration date: 05.09.2017).

Care bundle for family interview for pediatric organ donation

PURPOSE

to develop a care bundle for best practices in conducting the family interview for organ and tissue donation with the families of children and adolescents.

DESIGN AND METHODS

methodological study, with a qualitative approach, developed in Brazil, in three stages: literature review, qualitative study with professionals and family members, and development of the care bundle.

RESULTS

Nine studies were selected and 17 health professionals and nine family members were interviewed. With this data, the care bundle was developed in three categories: communication of death, emotional support and information about organ and tissue donation. The recommendations were evaluated by five external professionals and all of them assessed the bundle as having the highest possible quality.

CONCLUSIONS

the care bundle was built following the stages of integrative literature review and interviews with professionals working in this scenario and family members who have already gone through a family interview for organ and tissue donation of children and adolescents.

PRACTICE IMPLICATIONS

the use of this material is seen as an important resource to support the professional during the conduction of the family interview in a scenario as sensitive and challenging as the care to family members facing death and the decision of organ and tissue donation of children and adolescents. Furthermore, the care bundle can increase the quality of family interviews and impact the reduction of family refusals.

DESCRIPTORS

Practice Guideline as Topic. Tissue and Organ Procurement. Patient Care Team. Nursing. Pediatrics. Communication.

Care bundles to reduce unplanned extubation in critically ill children: a systematic review, critical appraisal and meta-analysis

OBJECTIVE

To assess the current evidence for the efficacy of care bundles in reducing unplanned extubations (UEs) in critically ill children.

DESIGN

Systematic review according to the Cochrane guidelines and meta-analysis using random-effects modelling.

METHODS

We searched MEDLINE, EMBASE, CINAHL, Web of Science, Scopus, Cochrane and SciELO databases from inception until April 2021. We conducted a quality appraisal for each study using the Newcastle-Ottawa Scale and Standards for Quality Improvement Reporting Excellence (SQUIRE) V.2.0 checklist.

MAIN OUTCOME

The primary outcome measure was UE rates per 100 intubation days.

RESULTS

We screened 10 091 records and finally included 11 studies. Six studies were pre/post-intervention studies, and five were interrupted time-series studies. The methodological quality was 'good' in 70%, and the remaining as 'fair' (30%). The most frequently used implementation strategies were staff education (100%), root cause analysis (100%), and audit and feedback (82%). Key bundle care components comprised identification of high-risk patients, endotracheal tube care and sedation protocol. Not all studies fully completed the SQUIRE V.2.0 checklist. Meta-analysis revealed a reduction in UE rate following the introduction of care bundles (rate ratio: 0.40 (95% CI: 0.19 to 0.84); p=0.02), which equates to a 60% reduction in UE rates.

CONCLUSIONS

We found that identifying high-risk patients, endotracheal tube care and protocol-directed sedation are core elements in care bundles for preventing UEs. However, there are several methodological gaps in the literature, including poor evaluation of adherence to bundle components. Future studies should address these gaps to strengthen their validity.

Use of patient-relevant outcome measures to assess the long-term effects of care bundles in the ICU: a scoping review protocol

INTRODUCTION

There is only moderate adherence to evidence-based practice in critical care. Care bundles can be used to increase adherence to best clinical practice. Components of bundle interventions, bundle implementation rates, barriers and facilitators of bundle implementation, and the effect of care bundles on short-term patient outcomes such as intensive care unit (ICU) mortality all appear to be regularly studied. However, over the last years, critical care research has turned towards long-term patient-relevant outcomes after discharge from the ICU. To our knowledge, there is no systematic overview on the long-term effect of care bundle implementation on patient-relevant outcomes. We present a protocol for a scoping review of the available literature on the effect of the implementation of care bundles in the ICU on long-term patient-relevant outcomes.

METHODS AND ANALYSIS

This scoping review will adhere to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) guidelines and the Arksey and O'Malley framework. The recommendations of the Joanna Briggs Institute for Scoping Reviews will also be followed. A systematic literature research will be performed using electronic databases (MEDLINE, EMBASE, CINAHL, PsycINFO, Web of Science, CDSR and CENTRAL). A preliminary search has been conducted on 1 September 2021, yielding 1929 entries. The main search, data extraction and charting has not been started yet. This scoping review will provide an overview of the long-term patient-relevant outcomes that have been used to assess the implementation of care bundles in the ICU. It will be the first study to summarise the long-term impact of care bundles for critically ill patients and identify research gaps to inform future research.

ETHICS AND DISSEMINATION

Due to the utilisation of already published primary studies, ethical approval is dispensable. Results of this work will be published in a peer-reviewed journal.

Effective Implementation of Ventilator Care Bundles in Improves Outcomes: A Multicenter Randomized Controlled Clinical Trial

OBJECTIVES

To evaluate the effect of 17-ventilator care bundles and different training strategies for critical care nurses on clinical outcomes.

DESIGN

A randomized controlled triple-blinded clinical trial.

SETTING

The multicenter study was conducted in four academic teaching hospitals in Tehran, Iran, from October 2011 to June 2015.

PATIENTS

A total of 1,600 adult patients (age ≥ 18 yr) who were admitted to mixed medical-surgical ICUs (> 72 hr) and received invasive ventilation (> 48 hr) were included in this study. In addition, 160 critical care nurses were recruited through letters and telephone and face-to-face invitations.

INTERVENTIONS

Seventeen-ventilator care bundles applied by four different groups of nurses.

MEASUREMENTS AND MAIN RESULTS

Clinical outcomes were compared between four groups of study which include three intervention groups (who received 17-ventilator care bundles by trained nurses) and one control group (who received routine care). According to the results, ICU length of stay, non-ICU length of stay, ventilator-associated pneumonia occurrence date, ventilator-associated pneumonia, and mortality rates were significantly higher in control group compared with other groups.

CONCLUSIONS

Critical care nurses training program to accurately implement 17-ventilator care bundles improves outcomes.

Protocol for a mixed method acceptability evaluation of a codesigned bundled COmmunication intervention for use in the adult ICU during the COVID-19 PandEmic: the COPE study

INTRODUCTION

Patients requiring invasive mechanical ventilation via an artificial airway experience sudden voicelessness placing them at risk for adverse outcomes and increasing provider workload. Infection control precautions during the COVID-19 pandemic, including the use of personal protective equipment (eg, gloves, masks, etc), patient isolation, and visitor restrictions may exacerbate communication difficulty. The objective of this study is to evaluate the acceptability of a codesigned communication intervention for use in the adult intensive care unit when infection control precautions such as those used during COVID-19 are required.

METHODS AND ANALYSIS

This three-phased, prospective study will take place in a medical surgical ICU in a community teaching hospital in Toronto. Participants will include ICU healthcare providers, adult patients and their family members. Qualitative interviews (target n: 20-25) will explore participant perceptions of the barriers to and facilitators for supporting patient communication in the adult ICU in the context of COVID-19 and infection control precautions (phase 1). Using principles of codesign, a stakeholder advisory council of 8-10 participants will iteratively produce an intervention (phase 2). The codesigned intervention will then be implemented and undergo a mixed method acceptability evaluation in the study setting (phase 3). Acceptability, feasibility and appropriateness will be evaluated using validated measures (target n: 60-65). Follow-up semistructured interviews will be analysed using the theoretical framework of acceptability (TFA). The primary outcomes of this study will be acceptability ratings and descriptions of a codesigned COmmunication intervention for use during and beyond the COVID-19 PandEmic.

ETHICS AND DISSEMINATION

The study protocol has been reviewed, and ethics approval was obtained from the Michael Garron Hospital. Results will be made available to healthcare providers in the study setting throughout the study and through publications and conference presentations.

Reducing the incidence of phlebitis in medical adult inpatients with peripheral venous catheter care bundle: a best practice implementation project

BACKGROUND

One major complication of the insertion of a peripheral venous catheter (PVC) is phlebitis, often resulting in delay of treatment, increased healthcare costs and prolonged hospitalization.

AIMS

The current study sought to evaluate the effectiveness of a standardized PVC care bundle in increasing the compliance of PVC care and assessment and reduce the occurrences of phlebitis rates.

METHODS

A pre and postimplementation audit approach was used in this study and adopted the Joanna Briggs Institute Practical Application of Clinical Evidence System and Getting Research into Practice program. This study was carried out in three phases over a 10-month period, from March 2017 to December 2017 across three medical wards in a hospital in Singapore with a sample size of 90 patients. The study involved educating nurses on phlebitis assessment, implementing a PVC care bundle and monitoring compliance. An audit tool comprising four criteria from the Joanna Briggs Institute Practical Application of Clinical Evidence System was developed.

RESULTS

One-month and 3-month postimplementation findings revealed significant improvement in Criteria 1, 3 and 4 (P < 0.001) but no significant improvement in Criterion 2 (P > 0.05). Six-month postimplementation findings showed significant improvement in all four criteria (P < 0.05). An interesting finding was that the number of reported occurrences of phlebitis increased after implementing the PVC care bundle.

DISCUSSION

The increase in phlebitis rates could be attributed to the care bundle facilitating prompt and early identification of phlebitis. Despite the initial increase in occurrences 1 month post implementation, the general effectiveness of the care bundle in reducing occurrences of phlebitis was seen 6 months post implementation. The effectiveness of the care bundle to reduce phlebitis rates may be even more evident across a longer implementation period.

CONCLUSION

The current study showed that the implementation of a standardized PVC care bundle can significantly enhance the assessment and identification process of phlebitis and can aid in reducing the incidence of phlebitis. The nurses' compliance in practicing the PVC care bundle was determined by the post and preimplementation audits, thus, the audit approach was beneficial in translating evidence into practice.

Nursing interventions for pressure injury prevention among critically ill patients: A systematic review

AIM

To systemically synthesise the evidence on the most effective nursing interventions to prevent pressure injuries among critical care patients.

BACKGROUND

Although pressure injury (PI) prevention is a focus of nursing care in critical care units, hospital-acquired pressure injuries continue to occur in these settings.

DESIGN

A systematic review of literature guided by the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) and Synthesis without meta-analysis (SWiM) guidelines.

METHODS

Four electronic databases were searched for relevant studies. Included studies were screened and then critically appraised using the appropriate Joanna Briggs Institute appraisal tool. Data were analysed and reported using a narrative synthesis.

RESULTS

The review included 14 studies. Randomised controlled trials, quasi-experimental, case series and cross-sectional studies were included. The review identified four broad categories of interventions that are the most effective for preventing pressure injuries: (a) PI prevention bundles, (b) repositioning and the use of surface support, (c) prevention of medical device-related pressure injuries and (d) access to expertise. All the included studies reported a reduction in pressure injuries following the interventions; however, the strength of the evidence was rated from moderate to very low.

CONCLUSIONS

Nurses are well qualified to lead in the prevention of pressure injuries in critical care units. Every critically ill patient requires interventions to prevent pressure injuries, and the prevention of PIs should be considered a complex intervention. Nurses must plan and implement evidence-based care to prevent all types of pressure injuries, including medical device-related pressure injuries. Education and training programmes for nurses on PI prevention are important for prevention of pressure injuries.

RELEVANCE TO CLINICAL PRACTICE

Nursing interventions should consist of evidence-based 'bundles' and be adapted to patients' needs. To prevent pressure injuries among critically ill patients, nurses must be competent and highly educated and ensure fundamental strategies are routinely implemented to improve mobility and offload pressure.

Theory-driven, rapid formative research on quality improvement intervention for critical care of patients with COVID-19 in Argentina

The challenges of implementing interventions in healthcare settings have been more apparent during the COVID-19 pandemic. This pre-implementation evaluation used a rapid qualitative approach to explore barriers and facilitators to an intervention in intensive care units in Argentina, aimed to promote the use of personal protection equipment, provide emotional support for professionals, and achieve patient flow goals. Data were collected using semi-structured interviews with health professionals of 15 public hospitals in Argentina. Normalization Process Theory was used to guide content analysis of the data. Participants identified potential barriers such as the incorporation of non-specialist staff, shortage of resources, lack of communication between groups and shifts. Potential facilitators were also identified: regular feedback and communication related to implementation, adequate training for new and non-specialist staff, and incentives (e.g., scholarships). The immediacy of the pandemic demanded rapid qualitative research, sharing actionable findings in real time.

The implementation of an infection control bundle within a Total Care Burns Unit

AIM

To evaluate the impact of the implementation of a best practice infection prevention and control bundle on healthcare associated burn wound infections in a paediatric burns unit.

BACKGROUND

Burn patients are vulnerable to infection. For this patient population, infection is associated with increased morbidity and mortality, thereby representing a significant challenge for burns clinicians who care for them.

METHODS

An interrupted time series was used to compare healthcare associated burn wound infections in paediatric burn patients before and after implementation of an infection prevention and control bundle. Prospective surveillance of healthcare associated burn wound infections was conducted from 2012 to 2014. Other potential healthcare associated infection rates were also reviewed over the study period, including urinary tract infections, pneumonia, upper respiratory tract infections and sepsis. An infection prevention and control bundle developed in collaboration between the paediatric burn unit and infection control clinicians was implemented in 2013 in addition to previous standard practice.

RESULTS

During the study period a total of 626 patients were admitted to the paediatric burns unit. Healthcare associated burn wound infections reduced from 34 in 2012 to 0 in 2014 following the implementation of the infection prevention and control bundle. Pneumonia and sepsis also reduced to 0 in 2013 and 2014, however one upper respiratory tract infection occurred in 2013 and urinary tract infections persisted in 2013.

CONCLUSION

The implementation of an infection prevention and control bundle was effective in reducing healthcare associated burn wound infections, pneumonia and sepsis within our paediatric burns unit. Urinary tract infections remain a challenge for future improvement.

Implementation of clinical practice changes in the PICU: a qualitative study using and refining the iPARIHS framework

Background

Like in many settings, implementation of evidence-based practices often fall short in pediatric intensive care units (PICU). Very few prior studies have applied implementation science frameworks to understand how best to improve practices in this unique environment. We used the relatively new integrated Promoting Action on Research Implementation in Health Services (iPARIHS) framework to assess practice improvement in the PICU and to explore the utility of the framework itself for that purpose.

Methods

We used the iPARIHS framework to guide development of a semi-structured interview tool to examine barriers, facilitators, and the process of change in the PICU. A framework approach to qualitative analysis, developed around iPARIHS constructs and subconstructs, helped identify patterns and themes in provider interviews. We assessed the utility of iPARIHS to inform PICU practice change.

Results

Fifty multi-professional providers working in 8 U.S. PICUs completed interviews. iPARIHS constructs shaped the development of a process model for change that consisted of phases that include planning, a decision to adopt change, implementation and facilitation, and sustainability; the PICU environment shaped each phase. Large, complex multi-professional teams, and high-stakes work at near-capacity impaired receptivity to change. While the unit leaders made decisions to pursue change, providers’ willingness to accept change was based on the evidence for the change, and provider’s experiences, beliefs, and capacity to integrate change into a demanding workflow. Limited analytic structures and resources frustrated attempts to monitor changes’ impacts. Variable provider engagement, time allocated to work on changes, and limited collaboration impacted facilitation. iPARIHS constructs were useful in exploring implementation; however, we identified inter-relation of subconstructs, unique concepts not captured by the framework, and a need for subconstructs to further describe facilitation.

Conclusions

The PICU environment significantly shaped the implementation. The described process model for implementation may be useful to guide efforts to integrate changes and select implementation strategies. iPARIHS was adequate to identify barriers and facilitators of change; however, further elaboration of subconstructs for facilitation would be helpful to operationalize the framework.

Trial registration

Not applicable, as no health care intervention was performed.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13012-021-01080-9.

Care bundles for improving outcomes in patients with COVID-19 or related conditions in intensive care - a rapid scoping review

BACKGROUND

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the strain of coronavirus that causes coronavirus disease 2019 (COVID-19) can cause serious illness in some people resulting in admission to intensive care units (ICU) and frequently, ventilatory support for acute respiratory failure. Evaluating ICU care, and what is effective in improving outcomes for these patients is critical. Care bundles, a small set of evidence-based interventions, delivered together consistently, may improve patient outcomes. To identify the extent of the available evidence on the use of care bundles in patients with COVID-19 in the ICU, the World Health Organization (WHO) commissioned a scoping review to inform WHO guideline discussions. This review does not assess the effectiveness of the findings, assess risk of bias, or assess the certainty of the evidence (GRADE). As this review was commissioned to inform guideline discussions, it was done rapidly over a three-week period from 26 October to 18 November 2020.

OBJECTIVES

To identify and describe the available evidence on the use of care bundles in the ICU for patients with COVID-19 or related conditions (acute respiratory distress syndrome (ARDS) viral pneumonia or pneumonitis), or both. In carrying out the review the focus was on characterising the evidence base and not evaluating the effectiveness or safety of the care bundles or their component parts.

SEARCH METHODS

We searched MEDLINE, Embase, the Cochrane Library (CENTRAL and the Cochrane COVID-19 Study Register) and the WHO International Clinical Trials Registry Platform on 26 October 2020.

SELECTION CRITERIA

Studies of all designs that reported on patients who are critically ill with COVID-19, ARDS, viral pneumonia or pneumonitis, in the ICU setting, where a care bundle was implemented in providing care, were eligible for inclusion. One review author (VS) screened all records on title and abstract. A second review author (DR) checked 20% of excluded and included records; agreement was 99.4% and 100% respectively on exclude/include decisions. Two review authors (VS and DR) independently screened all records at full-text level. VS and DR resolved any disagreements through discussion and consensus, or referral to a third review author (AN) as required.

DATA COLLECTION AND ANALYSIS

One review author (VS) extracted the data and a second review author (DR) checked 20% of this for accuracy. As the review was not designed to synthesise effectiveness data, assess risk of bias, or characterise the certainty of the evidence (GRADE), we mapped the extracted data and presented them in tabular format based on the patient condition; that is patients with confirmed or suspected COVID-19, patients with ARDS, patients with any influenza or viral pneumonia, patients with severe respiratory failure, and patients with mixed conditions. We have also provided a narrative summary of the findings from the included studies.

MAIN RESULTS

We included 21 studies and identified three ongoing studies. The studies were of variable designs and included a systematic review of standardised approaches to caring for critically ill patients in ICU, including but not exclusive to care bundles (1 study), a randomised trial (1 study), prospective and retrospective cohort studies (4 studies), before and after studies (7 studies), observational quality improvement reports (4 studies), case series/case reports (3 studies) and audit (1 study). The studies were conducted in eight countries, most commonly China (5 studies) and the USA (4 studies), were published between 1999 and 2020, and involved over 2000 participants in total. Studies categorised participant conditions patients with confirmed or suspected COVID-19 (7 studies), patients with ARDS (7 studies), patients with another influenza or viral pneumonia (5 studies), patients with severe respiratory failure (1 study), and patients with mixed conditions (1 study). The care bundles described in the studies involved multiple diverse practices. Guidance on ventilator settings (10 studies), restrictive fluid management (8 studies), sedation (7 studies) and prone positioning (7 studies) were identified most frequently, while only one study mentioned chest X-ray. None of the included studies reported the prespecified outcomes ICU-acquired weakness (muscle wasting, weight loss) and users' experience adapting care bundles. Of the remaining prespecified outcomes, 14 studies reported death in ICU, nine reported days of ventilation (or ventilator-free days), nine reported length of stay in ICU in days, five reported death in hospital, three reported length of stay in hospital in days, and three reported adherence to the bundle.

AUTHORS' CONCLUSIONS

This scoping review has identified 21 studies on care bundle use in critically ill patients in ICU with COVID-19, ARDS, viral influenza or pneumonia and severe respiratory failure. The data for patients with COVID-19 specifically are limited, derived mainly from observational quality improvement or clinical experiential accounts. Research is required, urgently, to further assess care bundle use and optimal components of these bundles in this patient cohort. The care bundles described were also varied, with guidance on ventilator settings described in 10 care bundles, while chest X-ray was part mentioned in one care bundle in one study only. None of the studies identified in this scoping review measured users' experience of adapting care bundles. Optimising care bundle implementation requires that the components of the care bundle are collectively and consistently applied. Data on challenges, barriers and facilitators to implementation are needed. A formal synthesis of the outcome data presented in this review and a critical appraisal of the evidence is required by a subsequent effectiveness review. This subsequent review should further explore effect estimates across the included studies.

Standardized Management for Hypoxemic Respiratory Failure and ARDS: Systematic Review and Meta-analysis

BACKGROUND

Treatment of hypoxemic respiratory failure (HRF) and ARDS is complex. Standardized management of HRF and ARDS may improve adherence to evidence-informed practice and improve outcomes.

RESEARCH QUESTION

What is the effect of standardized treatment compared with usual care on survival of patients with HRF and ARDS?

STUDY DESIGN AND METHODS

MEDLINE, EMBASE, Cochrane, CINAHL, Scopus, and Web-of-Science were searched (inception to 2018). Included studies were randomized clinical trials or quasi-experimental studies that examined the effect of standardized treatment (care-protocol, care-pathway, or bundle) compared with usual treatment among mechanically ventilated adult patients admitted to an ICU with HRF or ARDS. Study characteristics, pathway components, and patient outcomes were abstracted independently by two reviewers.

RESULTS

From 15,932 unique citations, 14 studies were included in the systematic review (three randomized clinical trials and 11 quasi-experimental studies). Twelve studies (including 5,767 patients) were included in the meta-analysis. Standardized management of HRF was associated with a 23% relative reduction in mortality (relative risk, 0.77; 95% CI, 0.65-0.91; I², 70%; P = .002). In studies targeting patients with ARDS (n = 8), a 21% pooled mortality reduction was observed (relative risk, 0.79; 95% CI, 0.71-0.88; I², 3.1%). Standardized management was associated with increased 28-day ventilator-free days (weighted mean difference, 3.48 days; 95% CI, 2.43-4.54 days; P < .001). Standardized management was also associated with a reduction in tidal volume (weighted mean difference, -1.80 mL/kg predicted body weight; 95% CI, -2.80 to -0.80 mL/kg predicted body weight; P < .001). Meta-regression demonstrated that the reduction in mortality was associated with provision of lower tidal volume (P = .045).

INTERPRETATION

When compared with usual treatment, standardized treatment of patients with HRF and ARDS is associated with increased ventilator-free days, lower tidal volume ventilation, and lower mortality. ICUs should consider the use of standardized treatment to improve the processes and outcomes of care for patients with HRF and ARDS.

CLINICAL TRIAL REGISTRATION

PROSPERO; No.: CRD42019099921; URL: www.crd.york.ac.uk/prospero/.

Factors associated with ABCDE bundle adherence in critically ill adults requiring mechanical ventilation: An observational design

OBJECTIVE

To identify factors associated with the ABCDEF bundle (Assess, prevent, and manage pain, Both, spontaneous awakening and breathing trials, Choice of sedation/analgesia, Delirium assess, prevent and manage, Early mobility/exercise and Family engagement/empowerment) adherence, in critically ill patients during the first 96 hours of mechanical ventilation.

DESIGN

Observational study using electronic health record data.

SETTING

15 intensive care units located in seven community hospitals in a western United States health system.

PATIENTS

977 adult patients who were on mechanical ventilation for greater than 24 hours and admitted to an intensive care unit over six months.

MEASUREMENTS AND MAIN RESULTS

Multiple regression analysis was used to examine factors contributing to bundle adherence while adjusting for severity of illness, days on mechanical ventilation, hospital site and time elapsed. ABCDEF bundle adherence was higher in patients on mechanical ventilation for less than 48 hours (p = 0.01), who received continuous sedation for less than 24 hours (p < 0.001), admitted from skilled nursing facilities (p < 0.05), and over the course of the six-month study period (p < 0.01). Bundle adherence was significantly lower for Hispanic patients (p < 0.01).

CONCLUSIONS

Our study identified potentially modifiable factors that could improve the team's performance of the ABCDEF bundle in patients requiring mechanical ventilation.

[Study protocol to improve the quality of delirium management in intensive care]

BACKGROUND

Delirium in cardiac surgery patients is common and is associated with prolonged mechanical ventilation and hospital stay as well as higher mortality. Protocols may improve outcome. In our cardiac surgery intensive care unit (ICU), patients with delirium have not received standardized treatment so far.

HYPOTHESIS

In cardiac surgery ICU patients, standardized delirium management will lead after a 4‑week introduction, compared to nonstandardized treatment, to a reduction of delirium duration.

METHODS

Prospective before/after study to evaluate a quality improvement project for delirium management over 12 weeks including 140 patients.

INCLUSION CRITERIA

(a) ≥18 years, (b) consent for research with their data.

EXCLUSION CRITERIA

(a) palliative status, (b) present during both the before/after phase, (c) pregnancy, (d) included in a competitive study, or (e) delirium not assessable. The implementation includes the introduction of a protocol with interprofessional training, bedside-teaching, pocket cards, posters, and reminders. The primary outcome is the duration of delirium, assessed four times a day with validated instruments. Secondary outcome measures include delirium incidence, duration of mechanical ventilation, length of stay in ICU and hospital, mortality, nursing/therapeutic interventions, cumulative doses of delirium-related drugs, and complications of delirium for a follow-up of 28 days. Empirical data will be analyzed with descriptive and inferential statistics.

OBJECTIVES

The purpose of the study is a reduction of the duration and frequency of delirium in cardiac ICU patients and will provide evidence of the effect size of the introduction of a delirium management.

Implementation interventions in preventing surgical site infections in abdominal surgery: a systematic review

Background

Surgical site infections (SSIs) are highly prevalent in abdominal surgery despite evidence-based prevention measures. Since guidelines are not self-implementing and SSI-preventive compliance is often insufficient, implementation interventions have been developed to promote compliance. This systematic review aims to identify implementation interventions used in abdominal surgery to prevent SSIs and determine associations with SSI reductions.

Methods

Literature was searched in April 2018 (Medline/PubMed and Web of Science Core Collection). Implementation interventions were classified using the implementation subcategories of the EPOC Taxonomy (Cochrane Review Group Effective Practice and Organisation of Care, EPOC). Additionally, an effectiveness analysis was conducted on the association between the number of implementation interventions, specific compositions thereof, and absolute and relative SSI risk reductions.

Results

Forty studies were included. Implementation interventions used most frequently (“top five”) were audit and feedback (80% of studies), organizational culture (70%), monitoring the performance of healthcare delivery (65%), reminders (53%), and educational meetings (45%). Twenty-nine studies (72.5%) used a multimodal strategy (≥3 interventions). An effectiveness analysis revealed significant absolute and relative SSI risk reductions. E.g., numerically, the largest absolute risk reduction of 10.8% pertained to thirteen studies using 3–5 interventions (p < .001); however, this was from a higher baseline rate than those with fewer or more interventions. The largest relative risk reduction was 52.4% for studies employing the top five interventions, compared to 43.1% for those not including these. Furthermore, neither the differences in risk reduction between studies with different numbers of implementation interventions (bundle size) nor between studies including the top five interventions (vs. not) were significant.

Conclusion

In SSI prevention in abdominal surgery, mostly standard bundles of implementation interventions are applied. While an effectiveness analysis of differences in SSI risk reduction by number and type of interventions did not render conclusive results, use of standard interventions such as audit and feedback, organizational culture, monitoring, reminders, and education at least does not seem to represent preventive malpractice. Further research should determine implementation interventions, or bundles thereof, which are most effective in promoting compliance with SSI-preventive measures in abdominal surgery.

Implementation of an experiential learning strategy to reduce the risk of ventilator-associated pneumonia in critically ill adult patients

Objective

We evaluated the impact of an experiential learning strategy on both the adherence to the use of bundles and the incidence of ventilator-associated pneumonia in critically ill adult patients.

Methods

Longitudinal, quasi-experimental interrupted time-series study in a tertiary teaching hospital in Buenos Aires, Argentina. Successive measurements were made before and after the intervention was implemented between January 2016 and December 2018. Our main exposure was experiential learning, which was based on a combination of play activities, simulation models, knowledge and attitude competencies, role-playing and feedback. The adherence to the bundle for the care of mechanically ventilated critically-ill adult patients and the occurrence of ventilator-associated pneumonia were the main outcomes of interest. We used generalized linear models including time as a linear spline to estimate the effect of the experiential learning strategy both on the adherence to the bundle of care and the occurrence of ventilator-associated pneumonia during long-term follow-up.

Results

The overall proportion of adequate bundle use before and after the implementation of the intervention was 60.8% (95% CI: 56.9-64.7) and 85.6% (95% CI: 81.2-90.1), respectively. The incidence rate of ventilator-associated pneumonia before and after the intervention was 6.11 (95% CI: 5.82-6.40) and 3.55 (95% CI: 2.96-4.14) every 1000 days of mechanical ventilation, respectively. The estimated baseline monthly change in the adherence to the mechanical ventilation bundle was 0.4% (95%CI: -0.3-1.2%, p = 0.31) and 1.1% (95% CI: 0.2-2.2%, p < 0.01) before and after the implementation of the intervention, respectively. These results were consistent across our statistical quality control analysis.

Conclusions

The implementation of experiential learning strategies improves the adherence to bundles in the care of mechanically ventilated critically ill adult patients. Such strategies also decrease the incidence rate of ventilator-associated pneumonia. Both effects appear to remain constant during long-term follow-up.

Ventilator Bundle and Its Effects on Mortality Among ICU Patients: A Meta-Analysis

OBJECTIVES

To assess the effectiveness of the ventilator bundle in the reduction of mortality in ICU patients.

DATA SOURCES

PubMed, Scopus, Web of Science, Cochrane Library for studies published until June 2017.

STUDY SELECTION

Included studies: randomized controlled trials or any kind of nonrandomized intervention studies, made reference to a ventilator bundle approach, assessed mortality in ICU-ventilated adult patients.

DATA EXTRACTION

Items extracted: study characteristics, description of the bundle approach, number of patients in the comparison groups, hospital/ICU mortality, ventilator-associated pneumonia-related mortality, assessment of compliance to ventilator bundle and its score.

DATA SYNTHESIS

Thirteen articles were included. The implementation of a ventilator bundle significantly reduced mortality (odds ratio, 0.90; 95% CI, 0.84-0.97), with a stronger effect with a restriction to studies that reported mortality in ventilator-associated pneumonia patients (odds ratio, 0.71; 95% CI, 0.52-0.97), to studies that provided active educational activities was analyzed (odds ratio, 0.88; 95% CI, 0.78-0.99), and when the role of care procedures within the bundle (odds ratio, 0.87; 95% CI, 0.77-0.99). No survival benefit was associated with compliance to ventilator bundles. However, these results may have been confounded by the differential implementation of evidence-based procedures at baseline, which showed improved survival in the study subgroup that did not report implementation of these procedures at baseline (odds ratio, 0.82; 95% CI, 0.70-0.96).

CONCLUSIONS

Simple interventions in common clinical practice applied in a coordinated way as a part of a bundle care are effective in reducing mortality in ventilated ICU patients. More prospective controlled studies are needed to define the effect of ventilator bundles on survival outcomes.

Inclusion of a care bundle for fever, hyperglycaemia and swallow management in a National Audit for acute stroke: evidence of upscale and spread

BACKGROUND

In the Quality in Acute Stroke Care (QASC) trial undertaken in stroke units (SUs) located in New South Wales (NSW), Australia (2005-2010), facilitated implementation of a nurse-led care bundle to manage fever, hyperglycaemia and swallowing (FeSS protocols) reduced death and disability for patients with stroke. We aimed to determine subsequent adherence to the bundled FeSS processes (reflective of the protocols) between 2013 and 2017 in Australian hospitals, and examine whether changes in adherence to these processes varied based on previous participation in the QASC trial or subsequent statewide scale-up (QASCIP-Quality in Acute Stroke Care Implementation Project) and presence of an SU.

METHODS

Cross-sectional, observational study using self-reported organisational survey and retrospective clinical audit data from the National Acute Services Stroke Audit (2013, 2015, 2017). Mixed-effects logistic regression was performed with dependent variables: (1) composite outcome measure reflecting compliance with the FeSS protocols and (2) individual FeSS processes, including the year of audit as an independent variable, adjusted for correlation of outcomes within hospital. Separate models including interaction terms between the year of audit and previous participation in QASC/QASCIP and year of audit and SU were also generated.

RESULTS

Hospital participation included the following: 2013-124 hospitals, 3741 cases; 2015-112 hospitals, 4087 cases; and 2017-117 hospitals, 4192 cases. An 80% increase in the odds of receiving the composite outcome in 2017 compared to 2013 was found (2013, 30%; 2017, 41%; OR 1.8; 95% CI 1.6, 2.0; p < 0.001). The odds of FeSS adherence from 2013 to 2017 was greater for hospitals that had participated in QASC/QASCIP relative to those that had not (participated OR 2.1; 95% CI 1.7, 2.7; not participated OR 1.6; 95% CI 1.4, 1.8; p = 0.03). Similar uptake in adherence was evident in hospitals with and without an SU between 2013 and 2017.

CONCLUSION

The use of the FeSS protocols within Australia increased from 2013 to 2017 with the inclusion of these care processes in the National Audit. Greater uptake in hospitals previously involved in QASC/QASCIP was evident. Our implementation methods may be useful for other national initiatives for improving access to evidence-based practice.

Lessons learned from a rapid implementation of a ventilator-associated pneumonia prevention bundle

Background

Ventilator-associated pneumonia (VAP) is a common avoidable healthcare associated infection in ventilated critical care patients that can have a detrimental impact on patient recovery. To increase uptake at a local level, care bundles should be designed and implemented in collaboration with the end-users who will implement the bundle into practice.

Aim/objective

The aim in this study was to evaluate critical care nurses' perceptions of the usability of a respiratory care bundle as an effective approach to VAP prevention.

Methods

An exploratory descriptive qualitative study was conducted. A respiratory care bundle consisting of five components was implemented over a 4-week period. Following implementation, a focus group and semi-structured interviews were conducted to obtain nurses' feedback on the useability of the care bundle. Seven intensive care nurses caring for ventilated patients participated in the study.

Findings/results

Participants confirmed that using a care bundle provided a structured approach to nursing care of a ventilated patient and that the use of checklist reminders at the bedside was useful in a busy practice environment. Barriers to uptake and implementation of the bundle were that the unit culture did not prioritise preventative care and the need for a structured interdisciplinary approach to sedation and weaning of mechanical ventilation.

Discussion

To successfully imbed all elements of a respiratory care bundle into practice; an interdisciplinary approach is needed in which there is a strong emphasis on preventative care. These findings highlight the advantages of involving end-users in the development of strategies to decrease VAP.

Bundle para manuseio do cateter central de inserção periférica em neonatos

Resumo Objetivo Construir um bundle para prevenção de infecção primária da corrente sanguínea relacionada a cateter que contemple cuidados de enfermagem para manuseio do cateter de acesso venoso central por inserção periférica em neonatos. Métodos Pesquisa metodológica, desenvolvida no ano de 2017 em três etapas: levantamento bibliográfico, construção do instrumento e validação de conteúdo por cinco juízes. O instrumento para validação foi composto por 21 cuidados de enfermagem selecionados na primeira etapa. O índice de validade de conteúdo acima de 80% foi utilizado para avaliar a concordância entre os juízes, esta etapa foi realizada em uma única rodada. Resultados Dos 21 itens avaliados pelos juízes, dez foram excluídos por apresentarem índice de validade de conteúdo menor que 0,80 e três foram agrupados ao demais cuidados elencados. A versão final do bundle foi composta por oito itens. Os cuidados incluídos foram relacionados a higienização das mãos antes e após as manuseio, o uso de seringas com calibre adequado, troca e desinfecção das dânulas e dos conectores com álcool 70%, teste de permeabilidade e cuidados com curativos. Conclusão O estudo permitiu elaborar e validar junto a juízes um bundle para manuseio do cateter central de inserção periférica em neonatos com vistas a redução de infecção primária da corrente sanguínea relacionada ao cateter de acesso venoso central por inserção periférica.

Barriers and facilitators to the successful development, implementation and evaluation of care bundles in acute care in hospital: a scoping review

BACKGROUND

Care bundles are small sets of evidence-based recommendations, designed to support the implementation of evidence-based best clinical practice. However, there is variation in the design and implementation of care bundles, which may impact on the fidelity of delivery and subsequently their clinical effectiveness.

METHODS

A scoping review was carried out using the Arksey and O'Malley framework to identify the literature reporting on the design, implementation and evaluation of care bundles. The Embase, CINAHL, Cochrane and Ovid MEDLINE databases were searched for manuscripts published between 2001 and November 2017; hand-searching of references and citations was also undertaken. Data were initially assessed using a quality assessment tool, the Downs and Black checklist, prior to further analysis and narrative synthesis. Implementation strategies were classified using the Expert Recommendations for Implementing Change (ERIC) criteria.

RESULTS

Twenty-eight thousand six hundred ninety-two publications were screened and 348 articles retrieved in full text. Ninety-nine peer-reviewed quantitative publications were included for data extraction. These consisted of one randomised crossover trial, one randomised cluster trial, one case-control study, 20 prospective cohort studies and 76 non-parallel cohort studies. Twenty-three percent of studies were classified as poor based on Downs and Black checklist, and reporting of implementation strategies lacked structure. Negative associations were found between the number of elements in a bundle and compliance (Spearman's rho = - 0.47, non-parallel cohort and - 0.65, prospective cohort studies), and between the complexity of elements and compliance (p < 0.001, chi-squared = 23.05). Implementation strategies associated with improved compliance included evaluative and iterative approaches, development of stakeholder relationships and education and training strategies.

CONCLUSION

Care bundles with a small number of simple elements have better compliance rates. Standardised reporting of implementation strategies may help to implement care bundles into clinical practice with high fidelity.

TRIAL REGISTRATION

This review was registered on the PROSPERO database: CRD 42015029963 in December 2015.

Effectiveness of insertion and maintenance bundles in preventing peripheral intravenous catheter-related complications and bloodstream infection in hospital patients: A systematic review

BACKGROUND

Evidence-based bundles have reduced central line bloodstream infection rates in adult intensive care units. To tackle peripheral intravenous catheter (PIVC) bloodstream infection, many hospitals have implemented PIVC insertion and maintenance bundles. However, the efficacy of PIVC bundles in preventing PIVC complications and infection in hospital patients is uncertain. The aim of this paper is to synthesize evidence on the effectiveness of PIVC insertion and maintenance bundles on preventing adverse events.

METHODS

In this systematic review, we searched multiple electronic databases, trial registries, and grey literature for eligible studies published in English (January 2000-December 2018) to identify intervention studies evaluating PIVC insertion or maintenance bundles with two or more components. Search terms: peripheral intravenous catheter/cannula, insertion, maintenance, bundle, infection, infiltration, extravasation, dislodgement, thrombosis, occlusion, and phlebitis. Two reviewers independently conducted data extraction and quality assessments using the Downs and Black checklist.

RESULTS

Of 14,456 records screened, 13 studies (6 interrupted time-series, 7 before-and-after) were included. Insertion and maintenance bundles included multiple components (2-7 items per bundle). Despite testing different bundles, 12 studies reported reductions in phlebitis and bloodstream infection, and one study reported no change in bloodstream infection and an increase in phlebitis rate. Methodological quality of all studies ranked between 'low' and 'fair'.

CONCLUSIONS

The effect of PIVC bundles on PIVC complications and bloodstream infection rates remains uncertain. Standardisation of bundle components and more rigorous studies are needed. PROSPERO registration number: CRD42017075142.

Evaluation of infection prevention and control policies, procedures, and practices: An ethnographic study

BACKGROUND

The intensive care unit (ICU) is considered the epicenter of infections, and patients in the ICU are at higher risk of infection because of their vulnerability, age, and lengthy hospitalization.

METHODS

The ethnographic design has been used to describe, examine, and evaluate the policies and procedures that are implemented to prevent and control hospital-acquired infections (HAIs) in the medical ICU in King Abdullah University Hospital. In-depth semi-structured interviews with 23 participants supported by nonparticipant observation and document analysis were carried out to collect triangulated data. The themes and subthemes were developed through a software package and hand-coding procedure.

RESULTS

Health care workers were aware but not fully engaged to prevent and control HAIs; nevertheless, they presented themselves as knowledgeable. Staff recognized the importance of involving family members and visitors. However, they had serious concern toward open visitation. The nurse to patient ratio was another challenge of infection prevention and control practices. The findings demonstrated that performing continuous prospective surveillance by highly qualified and trained staff can reduce the risk of endemic HAIs.

CONCLUSIONS

The study highlighted the importance of changing behaviors and practices of health care providers and visitors to improve adherence to infection prevention and control policies and practices.

Improving the adoption of optimal venous thromboembolism prophylaxis in critically ill patients: A process evaluation of a complex quality improvement initiative

PURPOSE

This study evaluated a complex initiative to increase evidence-based use of low molecular weight heparin for venous thromboembolism prophylaxis among adult medical-surgical ICU patients.

MATERIALS AND METHODS

This study included: quantitative survey and interviews. Participants were healthcare providers within four ICUs. Surveys collected knowledge of evidence underpinning best practice, exposure to the implementation strategies and their perceived utility, and recommendations. The interview expanded on survey topics. Descriptive statistics summarized the data and chi-squared tests were used to compare groups. Qualitative data were analyzed using a blended deductive and inductive coding approach.

RESULTS

Providers had good knowledge of the evidence (range = 58% to 94%). Pharmacist-to-physician reminders (80%), other reminders (50%), and local guidelines (50%) were the most commonly observed strategies. Local champions (76%), on-site education (74%), and computerized decision support system (69%) were perceived to be most helpful. Interviews elicited five themes: provider roles, perceptions of the implementation strategies, facilitators and barriers to uptake of best practice, and recommendations. Assessment of the implementation strategies varied by professional group.

CONCLUSIONS

The findings of this process evaluation identified implementation strategies that can improve the use of evidence-informed practices, help interpret outcomes in the context of interventions and guide future quality improvement initiatives.

"The multimodal approach for ventilator-associated pneumonia prevention"-requirements for nationwide implementation

The multimodal approach for ventilator-associated pneumonia (VAP) prevention has been shown to be a successful strategy in reducing VAP rates in many intensive care units (ICU) in some countries. The simultaneous application of several measures or "bundles" to reduce VAP rates has achieved a higher impact than the progressive implementation of the individual interventions. The ultimate objective of recommendation bundles is their integration in the culture of routine healthcare of the staff in charge of ventilated patients for accomplished rates to persist over time. The noteworthy elements of this new strategy include the selection of the individual recommendations of the bundle, education of care workers (HCW) in the culture of patient safety, audit of compliance with the recommendations, commitment of the hospital management to support implementation, nomination and empowerment of local leaders of the projects in ICUs, both physicians and nurses, and the continuous collection of VAP episodes. The implementation of this new strategy is not an easy task, as both its inherent strength and important barriers to its application have become evident, which need to be overcome for maximal reduction of VAP rates.