Pls fill in table ( must interpret p-value in tables , table is attached with articles

Pls fill in table ( must interpret p-value in tables , table is attached with articles
Literature Evaluation Table – DPI Intervention Learner Name: Instructions: Use this table to evaluate and record the literature gathered for your DPI Project. Refer to the assignment instructions for guidance on completing the various sections. Empirical research articles must be published within 5 years of your anticipated graduation date. Add or delete rows as needed. PICOT-D Question: In adult patients in a high observation unit in a long-term acute care hospital in Virginia, will the translation of Hsieh et al. research implementing the ABCDEF bundle, compared to current practice reduce length of stay over an eight-week period? Table 1: Primary Quantitative Research – Intervention (5 Articles) complete table with listed articles APA Reference (Include the GCU permalink or working link used to access the article.) Research Questions/ Hypothesis, and Purpose/Aim of Study Type of Primary Research Design Research Methodology Setting/Sample (Type, country, number of participants in study) Methods (instruments used; state if instruments can be used in the DPI project) How was the data collected? Interpretation of Data (State p-value: acceptable range is p= 0.000 – p= 0. 05 ) Outcomes/Key Findings (Succinctly states all study results applicable to the DPI Project.) Limitations of Study and Biases Recommendations for Future Research Explanation of How the Article Supports Your Proposed Intervention Hsieh, S. J., Otusanya, O., Gershengorn, H. B., Hope, A. A., Dayton, C., Levi, D., Garcia, M., Prince, D., Mills, M., Fein, D., Colman, S., & Gong, M. N. (2019). Staged implementation of awakening and breathing, coordination, delirium monitoring and management, and early mobilization bundle improves patient outcomes and reduces hospital costs. Critical Care Medicine, 47(7), 885–893. https://doi-org.lopes.idm.oclc.org/10.1097/CCM.0000000000003765 https://lopes.idm.oclc.org/login?url=https://search.ebscohost.com/login.aspx?direct=true&db=cmedm&AN=30985390&site=eds-live&scope=site&custid=s8333196&groupid=main&profile=eds1 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6579661/ The research question aimed at measuring the impact of staged implementation of complete versus virtual ABCDE bundle on mechanical ventilation (MV) duration, intensive care unit (ICU) and hospital length of stay(LOS), and cost Prospective cohort study The study included two medical ICUs within Montefiore Healthcare Center (Bronx, New York). The study also included 1855 mechanically ventilated patients admitted to ICUs between July 2011 – July 2014. After early coordination (EC) was implemented (period 2), 65% of patients stood, 54% walked at least once during their ICU stay, and ICU-acquired pressure ulcers and physical restraint use decreased (period 1 vs 2: 39% vs 23% of patients; 30% vs 26% patient days, respectively; p < 0.001 for both). After adjustment for patient-level covariates, implementation of the full (B-AD-EC) versus partial (B-AD) bundle was associated with reduced mechanical ventilation duration (–22.3%; 95% CI, –22.5% to –22.0%; p < 0.001), ICU length of p<0.05 Early mobilization and coordination (EC) portrayed improvement of patients in ICU by 30% Implementation of full (B-AD-EC) vs (B-AD) resulted to a decrease in MV duration. Implementation of ABCDE bundle reduced total ICU and hospital cost by 24.2% and 30.2% respectively. The study experienced the challenge of unmeasured changes which could have affected the results The study also was conducted in a single medical center hence limiting generalizability. The study also may have experienced cross-contamination of practices between two ICUs The study was unable to compare costs between two seasonal periods due to cost-to-charge ratios changes hence study used smaller cohort for cost analyses. The study did not collect all the data in the partial bundle ICU for comparison There is need for physicians to acquire training on implementing ABCDE bundle to improve patient’s conditions on ICU and reduce length of hospital stay. There is need for teamwork between physicians in ICU to enhance patient’s health and medication adherence. There is need for improvement of working conditions in health facilities to safeguard patient’s health. This article accessed the impact of implementing complete versus virtual ABCDE bundle on mechanical ventilation (MV) duration, intensive care Unit (ICU)and hospital length of stay (LOS), and cost. However, the article has also determined that early mobilization and structured condition of ABCDE bundle results to a spontaneous awakening, breathing, and delirium management leading to reduced mechanical duration (MV), length of hospital stay and the cost. Schallom, M., Tymkew, H., Vyers, K., Prentice, D., Sona, C., Norris, T., & Arroyo, C. (2020). Implementation of an interdisciplinary AACN early mobility protocol. Critical Care Nurse, 40(4), e7–e17. https://doi-org.lopes.idm.oclc.org/10.4037/ccn2020632 https://lopes.idm.oclc.org/login?url=https://search.ebscohost.com/login.aspx?direct=true&db=ccm&AN=146029040&site=eds-live&scope=site&custid=s8333196&groupid=main&profile=eds1 To examine the impact of an interdisciplinary mobility protocol in 7 specialty intensive care units that previously implemented other bundle components. quality improvement project using the American Association of Critical-Care Nurses mobility protocol The project was conducted at a 1200-bed, university affiliated level I trauma medical center in the Midwest with 132 ICU beds at project initiation. QI preintervention-postintervention design was used The American Association of Critical-Care Nurses (AACN) early progressive mobility protocol was used, The Richmond Agitation-Sedation Scale (RASS) The Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) was also used. All data were downloaded from REDCap into IBM SPSS Statistics, version 22 using descriptive statistics Level of significance for pre-implementation post implementation differences was set at a = 0.05. (p <0.05) In phase 1, the mean (SD) mobility level increased in all intensive care units, from 1.45 (1.03) before to 1.64 (1.03) after implementation (P < .001). Mean (SD) ICU Mobility Scale scores increased on initial evaluation from 4.4 (2.8) to 5.0 (2.8) (P = .01) and at intensive care unit discharge from 6.4 (2.5) to 6.8 (2.3) (P = .04). Complications occurred in 0.2% of patients mobilized. In phase 2, 84% of patients had out-of-bed activity after implementation. The time to achieve mobility levels 2 to 4 decreased (P = .05). Intensive care unit length of stay decreased significantly in both phases. QI initiatives using retrospective reviews of medical records The data we extracted from the EMR were dependent on documentation quality. Another limitation is fidelity to the intervention implementation. Implementing the ABCDEF bundle can produce significant impact on pt outcomes. Implementing the E and produce greater results This study adds great significance to my DPI project as it clearly identifies implementation of the ABCDEF bundle can reduce length of stay in the ICU setting. Fill in table Frade-Mera, M. J., Arias-Rivera, S., Zaragoza-García, I., Martí, J. D., Gallart, E., San José-Arribas, A., Velasco-Sanz, T. R., Blazquez-Martínez, E., & Raurell-Torredà, M. (2022). The impact of ABCDE bundle implementation on patient outcomes: A nationwide cohort study. Nursing in Critical Care. https://doi-org.lopes.idm.oclc.org/10.1111/nicc.12740 https://lopes.idm.oclc.org/login?url=https://search.ebscohost.com/login.aspx?direct=true&db=cmedm&AN=34994034&site=eds-live&scope=site&custid=s8333196&groupid=main&profile=eds1 * Collinsworth, A. W., Brown, R., Cole, L., Jungeblut, C., Kouznetsova, M., Qiu, T., Richter, K. M., Smith, S., & Masica, A. L. (2021). Implementation and routinization of the ABCDE bundle: A mixed methods evaluation. dimensions of critical care nursing : DCCN, 40(6), 333–344. https://doi-org.lopes.idm.oclc.org/10.1097/DCC.0000000000000495 https://lopes.idm.oclc.org/login?url=https://search.ebscohost.com/login.aspx?direct=true&db=cmedm&AN=34606224&site=eds-live&scope=site&custid=s8333196&groupid=main&profile=eds1 The study determines how to facilitate ABCDE bundle adoption by analyzing different implementation strategies on bundle adherence rates. The study also aims at assessing clinician’s perception of the bundle and the implementation effort. Mixed method eval The study examined effect of 2 bundle implementation on 8 patient adults in ICU. Electronic Health Record(EHR) modification was used as the primary strategy while enhanced strategy uses HER plus additional bundle training 84 nurses, therapists and physicians participated in the survey. Effect of Basic vs Enhanced Intervention on Bundle Adherence ICU LOS 0.02 (0.01-0.02) <.0001a (p <0.05 The response from the participants show that bundle use resulted in best care and patient outcomes. After bundle implementation process, ICUs in both interventions showed improvement in bundle adherence ICUs in the basic intervention outperformed others after initiating own implementation strategies. Data collection was time consuming The study acquired data through HER hence limited to evaluating some elements such as pain and sedation Physicians response on bundle perception may be biased. There is need for adequate training for physicians on how best to implement ABCDE bundle to improve care for patients Promote teamwork to enhance coordination between healthcare professionals for easier implementation of ABCDE bundle. The article highlights the effects of applying ABCDE bundle in healthcare for the patients in ICU It scores the fact that proper implementation of ABCDE bundles results to improvement in nursing care and patient outcomes. Pun, B. T., Balas, M. C., Barnes-Daly, M. A., Thompson, J. L., Aldrich, J. M., Barr, J., Byrum, D., Carson, S. S., Devlin, J. W., Engel, H. J., Esbrook, C. L., Hargett, K. D., Harmon, L., Hielsberg, C., Jackson, J. C., Kelly, T. L., Kumar, V., Millner, L., Morse, A., … Ely, E. W. (2019). Caring for critically ill patients with the ABCDEF bundle: Results of the ICU liberation collaborative in Over 15,000 adults. Critical Care Medicine, 47(1), 3–14. https://doi-org.lopes.idm.oclc.org/10.1097/CCM.0000000000003482 https://lopes.idm.oclc.org/login?url=https://search.ebscohost.com/login.aspx?direct=true&db=cmedm&AN=30339549&site=eds-live&scope=site&custid=s8333196&groupid=main&profile=eds1https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6298815 The study aim at evaluating the relationship between ABCDEF bundle performance and patient-centered outcomes in critical care. Prospective cohort study from national quality improvement collaborative The research collected a 20-month period data on 68 academics, community, and federal ICUs The study also included 15226 patient adults and at least one ICU every day. There was a consistent dose-response relationship between higher proportional bundle performance and improvements in each of the above-mentioned clinical outcomes (all p < 0.002). Significant pain was more frequently reported as bundle performance proportionally increased (p = 0.0001). p < 0.002 Complete ABCDE bundle performance demonstrated a reduction in mortality rate within 7 days, mechanical ventilation, delirium and physical restraint use. Patients also demonstrated an increased dose response relationship between higher proportion bundle performance. Frequent pain was reported with increased bundle performance.  The study did not use a randomized study design, nor did it have access to concurrent control. ICU liberation collaborative included numerous ICU types as part of a larger effort to understand the impact of the ABCDE bundle on various types of critically ill patients while understanding the implementation strategies unique to each setting. The patient-level outcomes are not wholly independent of one another and are assessed within a short time frame during which patients did not experience those outcomes.   The ICU liberation collaborative study lacked sufficient funds to support data accuracy auditing. Cohort analysis is from patient data collected within a larger QI project that collected a minimum and de-identified dataset, limiting the study’s ability to answer some questions. Physicians ought to familiarize with ABCDE bundle performance to enhance patients’ dose adherence to the critically ill adults in ICU. Physicians need to collaborate with other professionals in health sector and attend to ICU cases with open minded ready to learn from others. The article analyzes measures to take in caring for the critically ill patients in ICU with ABCDEF bundle with reference to the results of the ICU liberation collaborative of over 15000 adults. The article however outlined the relationship between ABCDEF bundle performance and patient centered outcomes in critical care. Therefore, it is clear that ABCDEF bundle performance portray significant clinical improvements in patient survival, mechanical ventilation use, coma and delirium, restraint free care, ICU re-admissions and post ICU discharge disposition. Table 2: Additional Primary and Secondary Quantitative Research (10 Articles) complete table with listed articles APA Reference (Include the GCU permalink or working link used to access the article.) Research Questions/ Hypothesis, and Purpose/Aim of Study Type of Primary or Secondary Research Design Research Methodology Setting/Sample (Type, country, number of participants in study) Methods (instruments used; state if instruments can be used in the DPI project) How was the data collected? Interpretation of Data (State p-value: acceptable range is p= 0.000 – p= 0.05) Outcomes/Key Findings (Succinctly states all study results applicable to the DPI Project.) Limitations of Study and Biases Recommendations for Future Research Explanation of How the Article Supports Your Proposed DPI Project Barnes-Daly, M. A., Phillips, G., & Ely, E. W. (2017). Improving hospital survival and reducing brain dysfunction at seven California community hospitals: Implementing PAD guidelines via the ABCDEF bundle in 6,064 patients. Critical Care Medicine, 45(2), 171–178. https://doi-org.lopes.idm.oclc.org/10.1097/CCM.0000000000002149 https://ubccriticalcaremedicine.ca/academic/jc_article/Improving%20Hospital%20Survival%20and%20Reducing%20Brain%20Dysfunction%20(Jan-19-17).pdf The research question was tailored on tracking compliance by an interprofessional team with the (ABCDEF) bundle in enforcing the Agitation, Pain, and Delirium procedures. The aim was to examine the connection between ABCDEF bundle compliance and consequences, including clinic survival and delirium-free and coma-free days in community infirmaries A prospective cohort quality improvement initiative involving ICU patients. 1. Random selection of 1 patient from the daily census at each hospital 2. Study included patients who were 66 years or older with a diagnosis of AMI. Exclusion criteria included age <66 years, primary diagnosis of a noncardiac etiology (e.g., sepsis), and a transfer from another acute care hospital. Data collection Data on patient characteristics, processes of care, and outcomes were collected during the baseline period (January 1, 2008, to July 31, 2009) and during the follow-up period (August 1, 2009, to September 30, 2011) for a total of 2 years of data. For every 10% increase in total bundle compliance, patients had a 7% higher odds of hospital survival (odds ratio, 1.07; 95% CI, 1.04–1.11; p < 0.001). Likewise, for every 10% increase in partial bundle compliance, patients had a 15% higher hospital survival (odds ratio, 1.15; 95% CI, 1.09–1.22; p < 0.001). These results were even more striking (12% and 23% higher odds of survival per 10% increase in bundle compliance, respectively, p < 0.001) in a sensitivity analysis removing ICU patients identified as receiving palliative care. Patients experienced more days alive and free of delirium and coma with both total bundle compliance (incident rate ratio, 1.02; 95% CI, 1.01–1.04; p = 0.004) and partial bundle compliance (incident rate ratio, 1.15; 95% CI, 1.09–1.22; p < 0.001). P < 0.05  The mortality rate for patients with sepsis was decreased by 42 percent (from 20.7 percent to 12.1 percent) in the 23 months after implementation of the ABCDEF bundle, compared with the 21 months before the institution of the bundle. Mortality rates for patients with pneumonia were also lower after bundle implementation (35.4 percent before the intervention vs. 28 percent afterward) The number of days’ patients spent in the intensive care unit within 30 days after arriving at the hospital was reduced by an average of 1.7 days for patients who had sepsis, and by an average of 1.5 days for those with pneumonia The number of brain dysfunction events (such as coma, seizures, and infection) within 30 days after an ICU admission dropped by 36 percent improving Hospital Survival and Reducing Brain Dysfunction at Seven California Community Hospitals: Implementing PAD Guidelines Via the ABCDEF Bundle in 6,064 Patients. First, this QI project lacked the strict protocols found in randomized, controlled trials. The design and sample size benefits of the investigation did not trump other statistical concerns. - Physicians need further education on guidelines and protocols, as well as how to collaborate with other physicians and experts. - Physical environment needs to be improved along with an organized system for transferring patients. - Physicians should be more open to changing their thought process. - Better communication between nurse and physician needs to be encouraged, as well as between physicians and experts such as cardiologists. The article describes the implementation of acute care for older adults’ guidelines at seven California community hospitals and has been used to determine whether a regional quality improvement initiative is associated with improved hospital survival, functional status, and intensive care unit (ICU) length of stay after acute myocardial infarction (AMI). The article also determined whether a regional quality improvement initiative is associated with improved hospital survival, functional status, and ICU length of stay after AMI. Balas, M. C., Tan, A., Pun, B. T., Ely, E. W., Carson, S. S., Mion, L., Barnes-Daly, M. A., & Vasilevskis, E. E. (2022) Effects of a national quality improvement collaborative on ABCDEF bundle implementation. American Journal of Critical Care, 31(1), 54–64. https://doi-org.lopes.idm.oclc.org/10.4037/ajcc2022768 https://aacnjournals.org/ajcconline/article-abstract/31/1/54/31644/Effects-of-a-National-Quality-Improvement?redirectedFrom=fulltext What are the effect of quality improvement collaborative participation on ABCDEF bundle performance? This study examined the NQIC's impact on the implementation of the six components of the ABCDEF Bundle in four types of hospitals: The authors hypothesized that with an increase in safety culture, there would be an increased implementation of the ABCDEF Bundle. The purpose of this study was to determine whether the ABCDEF Bundle could be implemented in a variety of hospitals across the United States with a focus on safety culture. Quasi-experimental design This study used a non-experimental design to determine the impact of the ABCDEF Bundle on safety culture, defined as the degree to which a system is characterized by attention to safety in tasks, relationships, and attitudes. The study included 114 acute care hospitals that were participating in the NQIC. In the ARISE and ProCESS trials, ABCDEF Bundle reduced ICU mortality by 12.6% (P=0.04) and hospital mortality by 15.1% (P=0.007) Complete bundle performance increased by 2 percentage points (SE, 0.9; P = .06) immediately after collaborative initiation. Each subsequent month was associated with an increase of 0.6 percentage points (SE, 0.2; P = .04). Performance rates increased significantly immediately after initiation for pain assessment (7.6% [SE, 2.0%], P = .002), sedation assessment (9.1% [SE, 3.7%], P = .02), and family engagement (7.8% [SE, 3%], P = .02) and then increased monthly at the same speed as the trend in the baseline period. P <0.05  Conclusion: These studies showed that the ABCDEF Bundle is associated with lower ICU and hospital mortality The first limitation is that the study involved observational studies, and residual confounding cannot be omitted as an explanation for the observed changes in bundle performance. Secondly, conclusions cannot be made on long-term sustainability despite ICUs demonstrating improvements during a 20-month period. Authors should use an experimental research design The language used should be simplified for easier understanding by all audience The article provides information on reducing the use of common potentially preventable complications (PPCs) in acute care hospitals, connected to my DPI project. The Central Line Bundle demonstrated a 19% reduction in complications, and the ABCDEF Bundle demonstrated a 21% reduction. The ABCDEF Bundle can be implemented in various hospitals across the United States with a focus on safety culture, defined as the degree to which a system is characterized by attention to safety in tasks, relationships, and attitudes. Fill in table Negro,A., Cabrini, L., Lembo, R., Monti, G., Dossi, M., Perduca, A., Colombo,S., Marazzi, M., Villa,G., Manara, D., Landoni, G., & Zangrillo, A. (2018). Early progressive mobilization in the intensive care unit with out dedicated personnel. Canadian Journal of Critical Care Nursing, 29(3), 26–31. https://lopes.idm.oclc.org/login?url=https://search.ebscohost.com/login.aspx?direct=true&db=ccm&AN=132043106&site=eds-live&scope=site DeMellow, J. M., Kim, T. Y., Romano, P. S., Drake, C., & Balas, M. C. (2020). Factors associated with ABCDE bundle adherence in critically ill adults requiring mechanical ventilation: An observational design. Intensive & Critical Care Nursing, 60. https://doi-org.lopes.idm.oclc.org/10.1016/j.iccn.2020.102873 https://lopes.idm.oclc.org/login?url=https://search.ebscohost.com/login.aspx?direct=true&db=edselp&AN=S0964339720300768&site=eds-live&scope=site&custid=s8333196&groupid=main&profile=eds1 https://pubmed.ncbi.nlm.nih.gov/32414557/ The study aim at identifying factors associated with ABCDEF bundle adherence in critically ill patients during the first 96hours of ventilation. Observational using electronic health record data The study used 15 ICUs located in seven community hospitals in western United States The study also included 977 adult patients who were on mechanical ventilation for more than 24hours and admitted to an intensive care unit over the six months. 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). (p <0.05) The observational results from the data identified that modifiable factors improved team’s performance of the ABCDEF bundle in critically ill patients in need of mechanical ventilation. The study was restricted to EHR clinical data available hence managed to only evaluate assessment for pain, sedation, delirium, and mobility elements. The study did not use analgesic infusions as sedation to determine duration of sedation and adherence of awakening trials. The study was limited to the examination of the early 96hours on MV adherence to bundle by the care unit. There is need for openness in data sharing among the physicians to develop a complete system that can identify all the factors associated with ABCDEF bundle adherence in severely ill patients The article supports my DPI project since the article identifies the factors associated with ABCDEF bundle adherence in critically ill patients during the first 96 hours of ventilation. The article supports the results that modifiable factors improve team’s performance of the ABCDE bundle in critically ill patients in mechanical ventilation. Loberg, R. A., Smallheer, B. A., & Thompson, J. A. (2022). A quality improvement initiative to evaluate the effectiveness of the ABCDEF bundle on Sepsis outcomes. Critical Care Nursing Quarterly, 45(1), 42–53. https://doi-org.lopes.idm.oclc.org/10.1097/CNQ.0000000000000387 https://lopes.idm.oclc.org/login?url=https://search.ebscohost.com/login.aspx?direct=true&db=cmedm&AN=34818297&site=eds-live&scope=site&custid=s8333196&groupid=main&profile=eds1 https://pubmed.ncbi.nlm.nih.gov/34818297/ The study aims to determine how quality improvement initiative can evaluate the effectiveness of the ABCDEF bundle elements to improve clinical outcomes Quality Improvement Secondary research through sampling Interventions was done in (609-bed) Midwest metropolitan hospital. Pre-implementation data were collected between January 2019 and March 2019. A pre/posttest design was used, and a convenience sample of all patients with sepsis admitted ABCDEF bundle elements and improve clinical outcomes. A significant improvement was seen in the completion of spontaneous awakening and breathing trials (P = .002), delirium assessment (P = .041), and early mobility (P = .000), which was associated with a reduction in mortality and 30-day readmission rates. (p <0.05 The study results indicated overall implementation of ABCDEF bundle in the setting resulted to enhanced care delivery and improved clinical outcomes. The QI initiative has problem with its generalizability Lower than desired rate with bundle elements was experienced The intervention was not designed as randomized controlled study but rather utilized as convenient sampling. There is need to provide nursing care education to healthcare workers to implement the ABCDEF bundle since its implementation has a direct impact on enhancing care giving and clinical outcomes. The government should support the implementation of the QI initiative to enhance quality care for patients. The article is relevant to my DPI project since it outlines the guidelines on how best ABCDEF bundle can be applied in nursing to improve clinical outcomes. Otusanya, O. T., Hsieh, S. J., Gong, M. N., & Gershengorn, H. B. (2021). Impact of ABCDE bundle implementation in the intensive care unit on specific patient costs. Journal of Intensive Care Medicine, 8850666211031813. https://doi-org.lopes.idm.oclc.org/10.1177/08850666211031813 https://lopes.idm.oclc.org/login?url=https://search.ebscohost.com/login.aspx?direct=true&db=cmedm&AN=34286609&site=eds-live&scope=site&custid=s8333196&groupid=main&profile=eds1 https://pubmed.ncbi.nlm.nih.gov/34286609/#:~:text=Conclusions%3A%20Full%20ABCDE%20bundle%20implementation,increase%20in%20physical%20therapy%20costs. The study objective is to measure the impact of full versus partial ABCDE bundle implementation on specific cost centers and related resource utilization. Retrospective cohort study The study was conducted in two medical ICUs in Montefiore Health Systems The study also involved 472 mechanically ventilated patients admitted in the ICU between 1st January 2013 and 31st December 2013. Relative to the comparison ICU, implementation of the entire bundle in the intervention ICU was associated with a 27.3% (95% CI: 9.9%, 41.3%; P   0.004) decrease in total hospital laboratory costs and a 2,888.6% (95% CI: 77.9%, 50,113.2%; P   0.018) increase in total hospital physical therapy costs. Cost of total hospital medications, diagnostic radiology and respiratory therapy were unchanged. Relative to the comparison ICU, total hospital resource use decreased in the intervention ICU (incidence rate ratio [95% CI], laboratory: 0.68 [0.54, 0.87], P   0.002; diagnostic radiology: 0.75 [0.59, 0.96], P   0.020). (p <0.05) There was a relationship between ABCDE bundle implementation and the cost Relative to the comparison ICU, implementation of the entire bundle in the intervention resulted to a decrease of 27.3%in total hospital laboratory cost Total hospital resource use resource use decreased in the intervention ICU. The research data collection and analysis was only limited to two ICU centers. There is need for teamwork between professionals in nursing to fully implement ABCDE bundle intervention to increase ICU discharges and reduce total hospitalization cost Physicians also need conducive environment and support to fully implement ABCDE bundle in health centers The article supports my DPI project as it focuses on how fully implementation of ABCDE bundle significantly reduces hospital laboratory costs and the hospital resource use also decreased. van den Boogaard, M., Wassenaar, A., van Haren, F. M. P., Slooter, A. J. C., Jorens, P. G., van der Jagt, M., Simons, K. S., Egerod, I., Burry, L. D., Beishuizen, A., Pickkers, P., & Devlin, J. W. (2020). Influence of sedation on delirium recognition in critically ill patients: A multinational cohort study. Australian Critical Care, 33(5), 420–425. https://doi-org.lopes.idm.oclc.org/10.1016/j.aucc.2019.12.002 https://lopes.idm.oclc.org/login?url=https://search.ebscohost.com/login.aspx?direct=true&db=ccm&AN=145414398&site=eds-live&scope=site&custid=s8333196&groupid=main&profile=eds1 https://www.australiancriticalcare.com/article/S1036-7314(19)30131-6/pdf The study aim to determine the association between level of sedation and delirium occurrence in critically ill patients Observation of cohort study. Patients aged above 18years from multinational ICUs participated since ICU patients are at risk of developing outcome of interest and delirium. The study was a secondary analysis of a multinational prospective cohort study performed in 9 ICUs in different countries Patients were assessed either through CAM-ICU or ICDSC 1660 patients were involved in the study. Length of stay (ICU) (p <0.05) At a RASS of 0, assessment with the CAM-ICU (vs. the ICDSC) was associated with fewer positive delirium evaluations The influence of level of sedation on delirium assessment depends on whether the CAM-ICU or ICDSC is used The study based on comparison between sedation and delirium hence need to compare both CAM-ICU to ICDSC simultaneously and determine its impact on critically ill patients. There is need to compare the CAM-ICU and ICDSC simultaneously in sedated and non-sedated ICU patients There is need to offer training to nurses in intensive care units on how best sedation and delirium influence affects critically ill patients in ICU. The article is relevant since it focuses on determining the influence of sedation on delirium which aligns with DPI project as heath care personnel. Part 2 (3-09-2022) Chen, C., Cheng, A., Chou, W., Selvam, P., & Cheng, C. M. (2021). Outcome of improved care bundle in acute respiratory failure patients. Nursing in Critical Care, 26(5), 380–385. https://doi-org.lopes.idm.oclc.org/10.1111/nicc.12530 https://lopes.idm.oclc.org/login?url=https://search.ebscohost.com/login.aspx?direct=true&db=a9h&AN=152166449&site=eds-live&scope=site&custid=s8333196&groupid=main&profile=eds1 This study aim is to determine if such an improved ABCDE bundle would shorten ICU and hospital length of stay (LOS) and lower medical costs and intra-hospital mortality between phases 1 and 2 Pre/ post bundle. retrospective, observational, before-and-after outcome study The study included adult patients on MV (N = 173) admitted to a medical center ICU with 19 beds in southern Taiwan comprised of a multidisciplinary team (critical care nurse, nursing assistant, respiratory therapist, physical therapist, patient's family) performed ABCDE with early mobilization. The data were retrospectively collected. The study periods were divided into phase 1 (before ABCDE bundle, from December 1, 2015 to March 31, 2016 phase 2 (after application of the ABCDE bundle, from October 1st to December 31st, 2016). Continuous data were compared using two independent-sample t-tests with Bonferroni correction. Categorical variables were analysed using the chi-square or Fisher's exact tests. Significance was set at (p<0.05) The patients in phase 2 had a significantly lower mean ICU length of stay (8.0 vs 12.0 days) but a similar MV duration (170.2 vs 188.1 hours), hospital stays (21.1 vs 23.3 days) with reduced costs (22.1 vs 31.7   104 NT$), and intra-hospital mortality (8.3 vs. 36.6%). The ABCDE care bundle improved the outcome of acute renal failure patients with MV, especially shortening ICU stays and lowering medical costs and hospital mortality. First, findings are based on the experience in a single ICU. Second, safety or feasibility of early mobilization was considered. Third, physical function before and after implementation of the care bundle was not measured and fourth, this study was based on a retrospective design This study adds the clinical outcomes (as a shortened duration of MV and ICU stays) of patients receiving an ABCDE care bundle with early mobilization and family member participation were improved. This study adds the growing body of evidence that implementing An ABCDE care bundle with an inter-professional, evidence-based, multicomponent ICU management strategy can reduce unnecessary ICU and general hospital stays, hospital expenditure, and mortality among ARF patients on MV. Collinsworth, A., Priest, E., & Masica, A. (2020). Evaluating the Cost-Effectiveness of the ABCDE Bundle: Impact of Bundle Adherence on Inpatient and 1-Year Mortality and Costs of Care*. Critical Care Medicine, 48(12), 1752-1759. https://doi.org/10.1097/ccm.0000000000004609 The research aim to determine the impact of ABCDE processes on inpatient mortality, LOS, discharge status, and direct costs of care Retrospective Cohort study The study included 2,953 patients, 18 years and above, with an ICU stay greater than 24 hours, who were on a ventilator for more than 24 hours and less than 14 days. It also included 12 adult ICUs in six hospitals belonging to a large, integrated healthcare delivery system. The Unadjusted and Adjusted Effect of Bundle Adherence on Inpatient Outcomes Length of stay (d) 0.64 (0.51–0.76)a 0.57 (0.45–0.69)a (p <0.05) Higher levels of bundle adherence significantly decreased inpatient discharge status and mortality. Hospital survival increased by 7% of every 10% compliance. Higher bundle adherence resulted to an increase LOS and in patient direct cost Differences in patient characteristics may have influenced bundle adherence rates, potentially overestimating the impact of improved bundle adherence on outcomes. All patients in this study were critically ill, and it is difficult to differentiate levels of illness severity within this population with existing measures. Physicians need support to fully implement ABCDE bundle since it is cost effective in reducing mortality rate in ICUs. Programs on ABCDE bundle application should be integrated with curriculum to equip physicians with the skills. My proposed DPI project focuses on the impact of ABCDE bundle on inpatient mortality LOS, discharge and its cost effectiveness which the article clearly outlines. Marra, A., Ely, E., Pandharipande, P., & Patel, M. (2017). The ABCDEF Bundle in Critical Care. Critical Care Clinics, 33(2), 225-243. https://doi.org/10.1016/j.ccc.2016.12.005 The study objective is to review the core evidence and features behind the ABCDEF bundle Retrospective cohort study. The study involved a multicenter cohort of 821 critically ill patients, with respiratory failure or shock Add interpretation (p <0.05) Deep sedation in the first 48 hours of an ICU stay has been associated with delayed time to extubation, higher need for tracheostomy, increased risk of hospital and long term death Deep sedation was associated with increased mortality. Daily SBT proved to be effective and superior to all other techniques to ventilator weaning. The consequence of physical dysfunction in critically ill patients can be profound and long-term with significant reduction in functional status being observed even 1 year and 5 years after ICU discharge ABCDEF bundle implementation faces lack of close collaboration and coordination with medicine, nursing, and physical therapists is fundamental for an efficacy and safe strategy There is need to mobilize coordination between family members and healthcare workers to take part in ICU care for critically ill patients to improve bundle adherence. Sensitization of the need for implementing ABCDEF bundle both in ICU and after discharge to enhance clinical adherence of the patients. Prosper coordination between healthcare professionals and caregivers is crucial in implementing ABCDEF bundle. This article supports my proposed DPI project by analyzing the basic core evidence and features behind ABCDEF bundle adherence for critically ill patients . Fill in table Liu, K., Nakamura, K., Katsukawa, H., Nydahl, P., Ely, E. W., Kudchadkar, S. R., Takahashi, K., Elhadi, M., Gurjar, M., Leong, B. K., Chung, C. R., Balachandran, J., Inoue, S., Lefor, A. K., & Nishida, O. (2021). Implementation of the ABCDEF Bundle for Critically Ill ICU Patients During the COVID-19 Pandemic: A Multi-National 1-Day Point Prevalence Study. Frontiers in Medicine, 8, 735860. https://doi-org.lopes.idm.oclc.org/10.3389/fmed.2021.735860 https://lopes.idm.oclc.org/login?url=https://search.ebscohost.com/login.aspx?direct=true&db=cmedm&AN=34778298&site=eds-live&scope=site&custid=s8333196&groupid=main&profile=eds1 Fill in table Louzon, P., Jennings, H., Ali, M., & Kraisinger, M. (2017). Impact of pharmacist management of pain, agitation, and delirium in the intensive care unit through participation in multidisciplinary bundle rounds. American Journal of Health-System Pharmacy, 74(4), 253–262. https://doi-org.lopes.idm.oclc.org/10.2146/ajhp150942 https://lopes.idm.oclc.org/login?url=https://search.ebscohost.com/login.aspx?direct=true&db=a9h&AN=121191406&site=eds-live&scope=site&custid=s8333196&groupid=main&profile=eds1 Sinvani, L., Kozikowski, A., Patel, V., Mulvany, C., Talukder, D., & Akerman, M. et al. (2018). Nonadherence to Geriatric-Focused Practices in Older Intensive Care Unit Survivors. American Journal Of Critical Care, 27(5), 354-361. https://doi.org/10.4037/ajcc2018363 The study aim at exploring geriatric-focused practices and associated outcomes in older intensive care survivors. retrospective, cohort study The study included 179 older adults with a mean age of 80.2 years Bladder catheters were associated with hospital-acquired pressure injuries. (P<.05) Add interpretation The study indicated high levels of non-adherence to geriatric-focused practices depending on hospital length of stay. Bladder catheters were associated with hospital-acquired pressure injuries. The data was collected retrospectively from one site. Multiple studies in outpatients and inpatients, but not in ICU patients, have indicated better compliance with general medical best practices than with geriatric focused practices. Since half of the ICUs are occupied by older adults, there is need to train healthcare providers geriatric focused practices to cater for the elderly. Healthcare workers need to go for a thorough training on ICU safety measures to cater for the elderly to improve clinical outcomes. There is need to increase number of geriatric health care providers dedicated to the care of hospitalized older adults to meet the growing demands of the aging population. The article is relevant to my DPI project as a healthcare worker since it explores geriatric-focused practices and the associated outcomes for older adults in ICU survivors. The practices can be used to care for the elderly adults visiting ICUs to improve their medical adherence . Trogrlić, Z., van der Jagt, M., Lingsma, H., Gommers, D., Ponssen, H., & Schoonderbeek, J. et al. (2019). Improved Guideline Adherence and Reduced Brain Dysfunction After a Multicenter Multifaceted Implementation of ICU Delirium Guidelines in 3,930 Patients. Critical Care Medicine, 47(3), 419-427. https://doi.org/10.1097/ccm.0000000000003596 The study aim to evaluate the impact of a tailored multifaceted implementation program of ICU delirium guidelines on processes of care and clinical outcomes and draw lessons regarding guideline implementation. Prospective cohort study The study involved ICUs in one university hospital and five community hospitals. Consecutive medical and surgical critically ill patients were enrolled between April 1, 2012, and February 1, 2015. A total of 3,930 patients were included in the study. (P<.05) Add interpretation Delirium screening increased from 35% to 93% Continuous IV benzodiazepine sedation decreased from 36% to 31% to 17%. Physical therapy (PT), early mobilization of patients, sedation assessments, and light sedation improved significantly. The duration of delirium decreased over three periods after guideline implementation. In the study, the Hawthorne effect was not avoided, seeing that delirium screening implementation alone resulted in improved adherence to several guideline recommendations. duration of delirium might be a doubtful outcome parameter due to the difference between a clinical diagnosis as assessed by chart review at baseline compared with the second and third phases. Certain changes over time may have been overestimated in the presence of secular trends Since implementation of delirium guidelines in ICUs resulted to a decrease in brain dysfunction outcome, there is need for clearer guidelines to improve clinical care adherence and overall outcome. Collaboration between healthcare professionals is also paramount to the success of the guidelines implementation process. There is need for additional health professionals to care for the ICU patients by screening delirium to boost the clinical outcomes. This article is in line with my DPI project as healthcare professional as it gives tips on how best ICU delirium guidelines can be integrated to improve patient’s clinical adherence . Zhang, S., Han, Y., Xiao, Q., Li, H., & Wu, Y. (2021). Effectiveness of Bundle Interventions on ICU Delirium: A Meta-Analysis*. Critical Care Medicine, 49(2), 335-346. https://doi.org/10.1097/ccm.0000000000004773 This study aim at evaluating the impact of bundle interventions on ICU delirium prevalence, duration, and other patients’ adverse outcomes. Meta-Analysis The study involved using a standardized data collection where two authors extracted data independently A total of 26,384 adult participants were included in the meta-analysis. The study data sources included, the Cochrane Library, PubMed, CINAHL, EMBASE, PsychINFO, and MEDLINE from January 2000 to July 2020. (P<0.05) Add interpretation The two cohort studies that applied bundle interventions lowered the ICU delirium prevalence by 8% but no significant differences were detected. The study indicated that bundle interventions are effective in reducing the proportion of patient-days experiencing coma, hospital length of stay, 28-day mortality and mechanical ventilation. In ICU Delirium Duration, there was no difference identified between participants in the bundle intervention group The study included both RCT and cohort studies in the current analysis, and heterogeneity was identified among studies in terms of results on the ICU delirium prevalence and duration, MV days, ICU, or hospital LOS. The number of studies included in the current analysis reporting outcomes on ICU mortality is small, which may have insufficient power to assess the differences and limited the interpretation of our pooled data. Although some studies reported coma-related outcomes, we failed to combine these data for analysis due to different presented data formats. Majority of the studies in this analysis did not include all elements of the bundle approach, the modifiable risk factors identified by the PADIS Guidelines are not fully addressed in the interventions. Further studies should be conducted to evaluate a more modifiable risk factors for ICU Delirium intervention to enhance bundle effectiveness. A more rigorous RCTs and full implementation of ABCDEF bundle should be considered to test effect of ICU intervention. Clinicians should regularly attend training on implementation of bundle intervention to improve ICU clinical outcomes. This study highlights the impacts of bundle interventions on ICU delirium prevalence, duration and other patient’s adverse outcomes. The impacts highlighted in the article are vital for my DPI project in healthcare as it enhances my knowledge on how best ICU conditions can be improved to yield a positive outcome. Table 3: Theoretical Framework Aligning to DPI Project Nursing Theory Selected APA Reference – Seminal Research References (Include the GCU permalink or working link used to access each article.) Explanation for the Nursing Theory Guides the Practice Aspect of the DPI Project Virginia Henderson’s Nursing Needs Theory Ahtisham, Y., & Jacoline, S. (2015). Integrating Nursing Theory and Process into Practice; Virginia’s Henderson Need Theory. International Journal of Caring Sciences, 8(2), 443–450. https://lopes.idm.oclc.org/login?url=https://search.ebscohost.com/login.aspx?direct=true&db=ccm&AN=102972280&site=eds-live&scope=site&custid=s8333196&groupid=main&profile=eds1 Virginia Henderson came up with a modern nursing theory named ‘need theory.’ Virginia named her theory need to emphasize the importance of increasing the patient's independence to ensure the nursing progress can continue even after hospitalization. Virginia further categorized nursing into fourteen components based on human needs. In her theory, Virginia described the nurse’s role as a substitute doing on behalf of the patient, helper, and working for the patient to help the patient become independent. According to Virginia, a nurse’s role is to assist the person sick or healthy in performing activities that contribute to healthy recovery that the person would have performed individually if they had the strength to do it. In her theory on individual care, Virginia emphasized assisting individuals with essential activities to maintain health or help the person attain a peaceful death. Henderson, in her fourteen components of nursing, the first nine are physiological, 10th and 14th are psychological aspects of learning and communication, 11th as spiritual and moral while the remaining she categorized them as sociological oriented to work and recreation. The fourteen components effective for nursing, according to Henderson, included breathing normally, eating and drinking adequately, excretion, mobility and maintaining body postures, enough sleep and rest, suitable clothing, maintaining body temperatures by wearing different clothes in different environments, maintaining body hygiene and avoiding dangers both personal and from endangering others, expression of emotions, fears or needs through communication, worshipping, working in a way to express a sense of accomplishment, participating in various recreational activities and lastly the curiosity to discover and learn Change Theory Selected APA Reference - Seminal Research References (Include the GCU permalink or working link used to access each article.) Explanation for How the Change Theory Outlines the Strategies for Implementing the Proposed Intervention John Kotter’s Change Model Kang, S. P., Chen, Y., Svihla, V., Gallup, A., Ferris, K., & Datye, A. K. (2022). Guiding change in higher education: an emergent, iterative application of Kotter’s change model. Studies in Higher Education, 47(2), 270–289. https://doi-org.lopes.idm.oclc.org/10.1080/03075079.2020.1741540 https://lopes.idm.oclc.org/login?url=https://search.ebscohost.com/login.aspx?direct=true&db=ehh&AN=155185571&site=eds-live&scope=site&custid=s8333196&groupid=main&profile=eds1 Kotter came up with 8 step change processes applied to implement change successfully. These strategies can be applied in implementing proposed interventions in nursing. The first step is creating urgency. First, there is a need to develop urgency for the proposed interventions. This is possible by identifying the existing threats caring for patients in ICUs. Therefore, discuss the weaknesses with the stakeholders and colleagues and ask for their support to implement the change. Secondly, put together a guiding coalition. Come up with a group of competent leaders and professionals to steer the agenda to influence the stakeholders. Thirdly develop vision and strategies. In this step, come up with a clear vision of how the organization will look if the change is implemented. A clear vision of how the health sector would look after implementing intervention will enhance action and decision-making. The next step is communicating the change vision. In this step, communicate to capture the hearts of other health workers to support the change. The next step is avoiding barriers. The guiding team avoids barriers from the change to drum up support for the change. The next step is accomplishing short-term wins. These short-term wins serve as encouragement and should be related to the change. E.g., win by demonstrating the effectiveness of the proposed intervention. The next step is building on the change. This step ensures the team is overworking to achieve the change and measure progress. The last step is to make change stick. Here ensure that everyone adapts to new change by illustrating its importance, training them the skills necessary to maintain the new change. Table 4: Clinical Practice Guidelines (If applicable to your project/practice) APA Reference - Clinical Guideline (Include the GCU permalink or working link used to access the article.) APA Reference - Original Research (All) (Include the GCU permalink or working link used to access the article.) Explanation for How Clinical Practice Guidelines Align to DPI Project © 2022. Grand Canyon University. All Rights Reserved. Pls fill in table ( must interpret p-value in tables , table is attached with articles Downloaded from<004B005700570053001D00120012004D00520058005500510044004F00560011004F005A005A001100460052005000120046 00460050004D00520058005500510044004F> by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on02/27/2022 Downloadedfrom<004B005700570053001D00120012004D00520058005500510044004F00560011004F005A005A001100460052005000120046 00460050004D00520058005500510044004F> by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on02/27/2022Copyright © 2018 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved. Critical Care Medicine www.ccmjournal.org 419 1Department of Intensive Care Adults, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands. 2Department of Public Health, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands. 3Department of Intensive Care, Albert Schweitzer Hospital, Dordrecht, The Netherlands. 4Department of Intensive Care, Ikazia Hospital, Rotterdam, The Nether-lands. 5Department of Intensive Care, IJsselland Hospital, Rotterdam, The Neth-erlands. 6Department of Intensive Care, Franciscus Gasthuis & Vlietland, Rot-terdam, The Netherlands. 7Department of Intensive Care, Maasstad Hospital, Rotterdam, The Neth-erlands. 8Department of Pulmonology and Critical Care, New York University – Langone, New York, NY. 9Department of Pulmonology and Critical Care, Columbia University Med-ical Center – New York Presbyterian, New York, NY. 10Department of Intensive Care, Pontificia Universidad Catolica de Chile, Santiago, Chile. 11Department of Pediatric Surgery, Intensive Care Unit, Erasmus MC – Sophia Children’s Hospital University Medical Center Rotterdam, Rot- terdam, The Netherlands. Drs. van der Jagt and Ista supervised the study and contributed equally. Supplemental digital content is available for this article. Direct URL cita- tions appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (http://journals.l ww.com/ ccmjournal). Supported, in part, by grant No. 171203008 from The Netherlands Orga- nization for Health Research and Development (ZonMw). ZonMw had no role in the statistical analyses or publication decisions. This work was performed at Department of Intensive Care Adults, Erasmus MC University Medical Center Rotterdam; Department of Intensive Care, Albert Schweitzer Hospital Dordrecht; Department of Intensive Care, Ika- zia Hospital Rotterdam; Department of Intensive Care, IJsselland Hospital Rotterdam; Department of Intensive Care, Sint Franciscus Gasthuis Rot- terdam; and Department of Intensive Care, Maasstad Hospital Rotterdam, all in the Netherlands. Drs. Trogrlic’s and van der Jagt’s institutions received funding from The Netherlands Organization for Health Research and Development (ZonMw) with the grant number: 171203008 awarded to Drs. van der Jagt and Ista. Drs. Verbrugge’s and Bakker’s institutions received funding from ZonMW. The remaining authors have disclosed that they do not have any potential conflicts of interest. Address requests for reprints to: Zoran Trogrlić , RN, MSc, Department of Intensive Care Adults, Erasmus MC University Medical Center Rotterdam‘s Gravendijkwal 230, P.O. Box 2040, 3000CA Rotterdam, the Netherlands, office: Ne-405. E-mail: [email protected] Objectives: Implementation of delirium guidelines at ICUs is sub- optimal. The aim was to evaluate the impact of a tailored mul- tifaceted implementation program of ICU delirium guidelines on processes of care and clinical outcomes and draw lessons re- garding guideline implementation. Design: A prospective multicenter, pre-post, intervention study. Setting: ICUs in one university hospital and five community hospitals. Patients: Consecutive medical and surgical critically ill patients were enrolled between April 1, 2012, and February 1, 2015. Interventions: Multifaceted, three-phase (baseline, delirium screening, and guideline) implementation program of delirium guidelines in adult ICUs. Measurements and Main Results: The primary outcome was adherence changes to delirium guidelines recommendations, based on the Pain, Agitation and Delirium guidelines. Secondary outcomes were brain dysfunction (delirium or coma), length of ICU stay, and hospital mortality. A total of 3,930 patients were included. Improvements after the implementation pertained to delirium screening (from 35% to 96%; p < 0.001), use of benzodiazepines for continuous sedation (from 36% to 17%; p < 0.001), light sedation of ventilated patients (from 55% to 61%; p < 0.001), physiotherapy (from 21% to 48%; p < 0.001), and early mobilization (from 10% to 19%; p < 0.001). Brain dys- function improved: the mean delirium duration decreased from 5.6 to 3.3 days (–2.2 d; 95% CI, –3.2 to –1.3; p < 0.001), and DOI: 10.1097/CCM.0000000000003596 Improved Guideline Adherence and Reduced Brain Dysfunction After a Multicenter Multifaceted Implementation of ICU Delirium Guidelines in 3,930 Patients Zoran Trogrlić, RN, MSc 1; Mathieu van der Jagt, MD, PhD 1; Hester Lingsma, PhD 2; Diederik Gommers, MD, PhD 1; Huibert H. Ponssen, MD 3; Jeannette F. J. Schoonderbeek, MD, PhD 4; Frodo Schreiner, MD 5; Serge J. Verbrugge, MD, PhD 6; Servet Duran, MD 7; Jan Bakker, MD, PhD 1,8,9,10 ; Erwin Ista, RN, PhD 11 Copyright © 2018 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved. Copyright © 2018 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved. 420 www.ccmjournal.org March 2019 • Volume 47 • Number 3 coma days decreased from 14% to 9% (risk ratio, 0.5; 95% CI, 0.4–0.6; p < 0.001). Other clinical outcome measures, such as length of mechanical ventilation, length of ICU stay, and hospital mortality, did not change. Conclusions: This large pre-post implementation study of delir- ium-oriented measures based on the 2013 Pain, Agitation, and Delirium guidelines showed improved health professionals’ adher- ence to delirium guidelines and reduced brain dysfunction. Our findings provide empirical support for the differential efficacy of the guideline bundle elements in a real-life setting and provide les- sons for optimization of guideline implementation programs. (Crit Care Med 2019; 47 :419–427) Key Words: critical care; delirium; guideline adherence; intensive care units D elirium is a common form of vital organ dysfunc- tion in critically ill adults, associated with increased morbidity, mortality, and long-term cognitive deteri- oration (1–3). Adequate delirium management is therefore an important component of intensive care—as substantiated in the Pain, Agitation, and Delirium (PAD) guidelines (4). Suc- cessful implementation of guidelines into daily practice is chal- lenging (5) although multifaceted implementation programs have the potential to facilitate success (6). Implementation of the PAD guidelines has had beneficial effects on pain, brain dysfunction, durations of mechanical ventilation and ICU stay, early mobilization, long-term cognitive dysfunction, func- tional recovery, and mortality in the critically ill (7–9). Still, “real-life” prospective multicenter implementation studies fo- cused on these delirium-oriented guidelines in hospitals with low use of the guidelines at baseline are needed to bring clinical evidence into practice on a wider scale, given the suboptimal implementation of these guidelines worldwide (10). We therefore performed the prospective multicenter “ICU DElirium in Clinical PracTice Implementation Evaluation” study (11), designed to evaluate the effectiveness of a multifac- eted implementation program tailored to improving adherence to delirium guidelines and to study patient-related benefits. MATERIALS AND METHODS Study Design and Participants We conducted a prospective, multicenter, before-after imple- mentation study in six ICUs in the Netherlands—one uni- versity and five community hospitals (three teaching and two nonteaching hospitals) (11). The size of the units varied be- tween eight and 32 ICU beds. Consecutive ICU patients 18 years old or older were included. Exclusion criteria were a primary neurologic diagnosis, home mechanical ventilation for chronic respiratory insufficiency, and burn injuries. The intervention, an implementation program focused at the im- plementation of the delirium-oriented recommendations de- rived from Dutch ICU Delirium Guidelines (12), and the PAD guidelines of the Society of Critical Care Medicine (4) was aimed at all ICU physicians and nurses. Results of this study were reported using the Standards for Quality Improvement Reporting Excellence guidelines (13). The study protocol was reviewed by the Medical Ethical Committees of participating hospitals (MEC-2012–063). Patients’ informed consent was not necessary according to Dutch legislation (14). The study was registered at ClinicalTrials.gov (Identifier: Nct01952899 2017). Procedures, Outcomes, and Data Collection The study duration was 36 months and consisted of three measurement periods between April 2012 and February 2015 (Fig. 1). The Implementation Model of Change of Grol and Wensing (15) was used to structure the guideline implemen- tation. This model is a seven steps approach and starts with identifying the problem and defining the aim of change fol- lowed by identification of potential barriers and facilitators for implementation; development of an implementation plan based on these barriers and facilitators; and finally execution, evaluation, and sustaining of the implementation plan. Phase I. The baseline phase started with a 4-month data collection period. To avoid the Hawthorne effect (11), staff of the participating ICUs were not informed about the study during data collection, with the exception of the local inten- sivist (principal investigator) and research nurses. Next, we performed an analysis of barriers and facilitators for delirium guideline adherence by means of a survey (16) and focus group interviews with stakeholders and development of the imple- mentation program (Fig. 1). We identified more than 30 bar - riers and facilitators for guideline adherence, to which we then tailored the implementation program following the model of Grol and Wensing and change theories (6, 11, 17) (Supple- mental Digital Content 1 and 2, http://links.lww.com/CCM/ E227). Important facilitators were realizing that delirium is a major problem, that treatment is essential, and that delirium is often underdiagnosed. The most important barriers were in- sufficient knowledge for screening, no integral delirium pro- tocol with a link to screening results (16). The implementation program consisted of different implementation strategies in accordance to the Effective Practice and Organization of Care (EPOC) group classification, mainly on organizational and professionals levels (18, 19). See details in Table 1 and Figure 1. Phase II. This phase was dedicated to reliable delirium screening, for which all nurses and physicians compulsory completed an e-learning program. We formally appointed an intensivist and research nurse at each site to act as local champions during this and subsequent phases and encour - aged them to involve other ICU nurses or ICU physicians as “ambassadors”. Additional clinical lessons and bedside educa- tion were provided by the local implementation teams, which also performed delirium screening spot checks. Three of the ICUs preferred the Confusion Assessment Method for the ICU (CAM-ICU) (20); the other three preferred the Intensive Care Delirium Screening Checklist (ICDSC) (21). All implementa- tion elements are briefly explained in Table 1 and were catego- rized according to the Cochrane EPOC (18) and study phase. Trogrli et al Copyright © 2018 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.Neurologic Critical Care Critical Care Medicine www.ccmjournal.org 421 Phase III. This phase consisted of 8 months of implemen- tation followed by 4 months of data collection (Fig. 1). The nurses and physicians now completed a second e-learning pro- gram focused on the guideline. Everyone received a laminated pocket card summarizing the integrated measures based on the PAD guidelines (Supplemental Digital Content 3, a and b, http://links.lww.com/CCM/E227). Throughout the implementation phase, we regularly did bedside reliability spot checks on delirium screening, distrib- uted delirium screening adherence feedback posters, issued newsletters on study progression and practical experiences, assessed the perceived level of implementation of bundle elements, and the deployment of implementation elements as another feedback tool to the local implementation teams. Furthermore, experiences with the implementation program were shared in repeated focus group sessions. Outcomes The primary outcome was changes in adherence to guideline recommendations from before to after implementation. Sec- ondary outcomes were presence of brain dysfunction defined as days with delirium or coma, duration of mechanical venti- lation, ICU length of stay (LOS), ICU and hospital mortality. Study data were prospectively collected by research nurses at each site, using a data handling protocol (Supplemental Digital Content 4, http://links.lww.com/CCM/E227). Guideline ad- herence was measured using seven performance indicators ( Supplemental Digital Content 5, http://links.lww.com/CCM/ E227). During phase I, the presence of delirium was defined as treatment with any antipsychotic drug or documentation of a de- lirium diagnosis in the medical or nursing chart. During phases II and III, delirium was diagnosed with the CAM-ICU or ICDSC (20, 21). Coma was defined as a sedation level compatible with a Richmond Agitation-Sedation Scale (RASS) score (22) of –4 or –5 or a Ramsay Sedation Scale score (23) less than 5 or a Critically Ill Assessment score (24) less than 7. A “delirium day” was defined as at least one recorded delirium diagnosis in a 24-hour period. A coma day was defined as documented presence of coma with absence of documented delirium during a 24-hour period. Statistical Analysis Demographics are presented as numbers and percentages, medi- ans and interquartile ranges (IQRs), or means and sds where ap- propriate. differences in guideline adherence between the three phases, as expressed by crude numbers and percentages, were assessed with a chi-square test. To examine between-group dif- ferences, we used Kruskal-Wallis test for nonparametric analyses. differences in clinical outcomes between the three phases were assessed with adjusted regression models. Poisson regression was used for count data (e.g., number of delirium assessments per day), logistic regression for binary outcomes, and linear re- gression for continuous outcomes. Guideline adherence and presence of brain dysfunction were analyzed on day level, with random effect models with a random intercept for patient. du- ration of mechanical ventilation, ICU LOs, ICU and hospital mortality were analyzed on patient level with xed effect models. The adjusted models used severity of illness score Acute Phys- iology and Chronic Health Evaluation-II, hospital, age and ad- mission diagnosis (elective or acute surgery vs medical diagnosis) as covariables. differences between the periods were expressed as adjusted rate ratios, adjusted odds ratios (ORs), or betas. Miss- ing baseline data were imputed using single imputation with the Figure 1. Timeline ICU DElirium in Clinical PracTice Implementation Evaluation Study. See text for further details. Copyright © 2018 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved. 422 www.ccmjournal.org March 2019 • Volume 47 • Number 3 AregImpute function in R. Two-sided p values less than 0.05 were considered statistically significant. All analyses were performed with computer software programs R (extension packages: for - eign, lme4, and rms; R Foundation for Statistical Computing, Vienna, Austria; http://www.R-project.org/) and IBM SPSS Sta- tistics Version 23.0 (IBM Corp., Armonk, NY). RESULTS In total 4,853 patients were admitted during the three data col- lection periods. As 923 patients had to be excluded (Supple- mental Digital Content 6, http://links.lww.com/CCM/E227), data of 3,930 patients, with a total of 18,288 patient-days, were analyzed. Demographics are presented in Table 2. The e-learn- ing programs in phases II and III were completed by 90% of physicians (73/81) and 91% of nurses (374/409). Primary Outcomes—Guideline Adherence Figure 2 and Supplemental Digital Content 7 (http://links. lww.com/CCM/E227) show the crude performance indicator metrics presented as percentages. Delirium screening increased from 35% to 93% (p < 0.001) to 96% (p < 0.001). Contin- uous IV benzodiazepine sedation decreased from 36% to 31% TABLE 1. Description of Implementation Strategies Used, According to Effective Practice and Organization of Care classification Implementation Strategy InterventionPhase IIPhase III Audit and feedback Repeated evaluation of implementation process strategies used and level of perceived adherence to guideline recommendations. + a + Monitoring the performance of the delivery of healthcare Posters with delirium screening adherence and delirium incidence. ++ Educational materials Reader development and dissemination; interactive website e-learning (with instructional videos, e.g., on the use of screening instruments Confusion Assessment Method for ICU/ Intensive Care Delirium Screening Checklist). + + Educational meetings Education of expert teams at each hospital/ICU Education sessions. + + Educational outreach visits or academic detailing Interactive workshop sessions: education about the severity and impact of delirium on patient outcomes on short and long term. The importance of why screening for delirium is important and what may work as pre- ventive measures. + + Clinical Practice Guidelines Construction of general delirium guideline protocol by several “con- sensus group”—meetings with representatives from each ICU (physi- cians, nurses). During the sessions, various local protocols (if any) from each ICU would be made visible when discussing the interpretation and translation of the guideline into a workable and widely endorsed protocol among participating centers. – b + Interprofessional education Spot checks for screening were first done by expert-team members, but later by all nurses, checking and discussing each other’s delirium assessments. + – Local consensus processes Yes, see previous point under “Clinical Practice Guidelines”. –+ Local opinion leaders Medical and nursing stakeholders were recruited and involved in the stud y and its execution. They had the task to appeal to people, encourag- ing colleagues to work according to the guidelines (e.g., during daily rounds/visits). We appointed one participating intensivist and a dedi- cated research nurse as local opinion leaders/champion. + + Patient-mediated interventions Family involvement was encouraged: Delirium information poster and info booklet placed in family room. Instructions by nurses to family members on participation in daily care and communication in case of delirium. – + Reminders Operationalization of existing PDMS for integration of delirium guideline protocol. Reminders for screening was preferentially incorporated. One of the hospitals did not have a digital PDMS system which hampered the implementation process. + + Tailored interventions Yes: based on preimplementation assessment of barriers and facilitators. ++ PDMS = Patient Data Management System. a Plus (+) and and b minus (–) signs indicate whether individual implementation strategies were used (+) or not used (–) during: the phase II or phase III (Fig. 1). Trogrli et al Copyright © 2018 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.Neurologic Critical Care Critical Care Medicine www.ccmjournal.org 423 (p < 0.001) to 17% (p < 0.001). Administration of daily inter - mittent benzodiazepines boluses had not consistently increased over the three phases. The amounts given (mean of 0.22– 0.48 mg/d of diazepam equivalent; see legend of Supplemental Digital Content 7, http://links.lww.com/CCM/E227) seemed negligible compared with usual daily dosages of continuous IV benzodiazepines. Although the daily use of midazolam, fen- tanyl, and morphine had decreased, that of propofol, dexme- detomidine, and remifentanil had increased (Supplemental Digital Content 8, http://links.lww.com/CCM/E227). Applica- tion of physical therapy (PT), early mobilization of patients, sedation assessments, and light sedation improved signifi- cantly. The medians of all available daily maximum RASS scores in mechanically ventilated patients were significantly different between the study phases (p < 0.001), indicating less deep sedation after the implementation (Supplemental Dig- ital Content 9, http://links.lww.com/CCM/E227). Supplemental Digital Content 10 (http://links.lww.com/ CCM/E227) shows the adjusted effect changes of the per - formance indicators. Implementation of delirium screening resulted in a significant improvement in adherence to delirium screening, sedation assessments, light sedation, less use of continuous IV benzodiazepine sedation, and performing PT compared with the baseline period. These ORs indicate, for example, that for a random patient on a random admission day, the odds of getting sedated with continuous IV benzodi- azepines was 0.5 (or two times smaller) after implementation of delirium screening. These improvements in adherences rel- ative to the baseline period were maintained after implemen- tation of the guideline. Early mobilization (as opposed to PT) only improved after guideline implementation but not after screening implementation. Guideline implementation resulted in additional improvements compared with the screening im- plementation phase for delirium screening, use of benzodi- azepines, performing PT, and performing early mobilization when feasible. Secondary Outcomes—Clinical Outcomes Table 3 shows crude and adjusted clinical outcomes changes per study phase. The duration of delirium decreased over three periods from 5.6 days to 2.9 days (Beta: – 2.6 d; 95% CI, –3.5 to –1.6 d; p < 0.001) and to 3.3 days after guideline implementation TABLE 2. Patient Demographics and Baseline Clinical Characteristics Characteristics Data Collection Period a Phase I: Baseline Phase II: Screening Implementation Phase III: Guideline Implementation Number of patients, n 1,337 1,399 1,194 Number of ICU days, n 6,527 6,086 5,675 Gender, n (%) Male 775 (58)789 (56) 710 (60) Female 562 (42)610 (44) 484 (40) Age (yr), median (IQR) 66 (54–75)66 (53–75) 65 (5–74) Admission status, n (%) Elective surgery 401 (30)432 (31) 339 (28) Emergency surgery 188 (14)200 (14) 167 (14) Medical 748 (56)767 (55) 688 (58) Acute Physiology and Chronic Health Evaluation -II b, median (IQR) 16 (11–22)15 (10–21) 16 (11–21) Mechanically ventilated patients, n (%) 560 (42) 541 (39) 593 (50) Hospital, n (%) 1 145 (11)155 (11) 195 (16) 2 247 (19)248 (18) 242 (20) 3 231 (17)251 (18) 249 (18) 4 158 (12)166 (12) 76 (6) 5 251 (19)271 (19) 216 (18) 6 305 (23)308 (22) 216 (18) IQR = interquartile range .a See Figure 1 for further explanation.b Acute Physiology and Chronic Health Evaluation-II range is 0–71. Copyright © 2018 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved. 424 www.ccmjournal.org March 2019 • Volume 47 • Number 3 (Beta: –2.2 d; 95% CI, –3.2 to –1.3 d; p < 0.001). Implemen- tation of delirium screening resulted in 6% more patients detected with delirium in the third study period compared with the baseline period (OR, 1.4; 95% CI, 1.2–1.7; p < 0.001). Sup- plemental Digital Content 11 (http://links.lww.com/CCM/ E227) shows the cumulative proportions of delirium- and coma(-free) days as changes in percentages for the three study periods. In the adjusted analysis (Supplemental Digital Con- tent 12, http://links.lww.com/CCM/E227), only the coma days were significantly reduced in phases II and III relative to phase I (from 14% to 12%; OR, 0.6; 95% CI, 0.4–0.8; p < 0.001, and from 14% to 9%; OR, 0.5; 95% CI, 0.4–0.6; p < 0.001). There were no significant changes for the other study outcomes. DISCUSSION In this study, the implementation of delirium monitoring and other elements of delirium care recommended in the 2013 PAD guideline recommendations was associated with modest, although significant, improvements in six of the seven studied care processes, corresponding with fewer delirium or coma days. On the assumption that the participating ICUs already applied light sedation practices in general, we decided not to focus strongly on safety screens for Spontaneous Awakening Trials (SATs) and Spontaneous Breathing Trials (SBTs), which may have precluded improvements of the secondary outcomes, such as length of ventilation, ICU stay, or mortality. We found that delirium screening resulted in slightly higher delirium detection rates, probably on account of the phe- nomenon that the use of a vali- dated delirium screening tool increases the detection rate, es- pecially of hypoactive delirium (25). This may also explain that the cumulative number of de- lirium and coma free days in the entire population did not decrease significantly in spite of decreased mean duration of delirium and days with coma per patient. Several previous studies on delirium screening implementation (26–29) and PAD guidelines (7, 30–32) also have reported improvement in delirium screening adherence. Further, a recent systematic re- view reported that adherence to delirium screening was assessed in 15 of 21 implementation studies, 13 of which found improved adherence, with rates ranging from 14% to 92% (6). In a previous trial (SLEAP trial), SATs/SBTs did not have additional benefit for LOS or mortality in settings with rel- atively light sedation practices (33). The sedation levels we found (RASS –1 [IQR, –3 to 0) more closely resembled those of patients in the SLEAP trial (RASS between –2 and –1) than those of patients in the Awakening and Breathing Controlled trial (RASS between –4 and –1), which indeed found a positive effect on mortality (34). On the other hand, the implementa- tion studies by Balas et al (7, 35), that bared many methodo- logical similarities to our study, but was a single-center study, also had a mean RASS of –1 indicating light sedation rates, but still established lower length of mechanical ventilation, apply- ing awakening and breathing trials. Our lack of focus on SATs and SBTs may also be illustrative for the tension between the premises of the PAD guidelines (with moderate emphasis on SATs/SBTs), the Assess, Prevent, and Manage Pain, Both SAT and SBT, Choice of analgesia and sedation, Delirium: Assess, Prevent, and Manage, Early mobility and Exercise, and Family engagement concept (with strong emphasis) and more recent insights such as provided by the SLEAP study and as substanti- ated in the early Comfort using Analgesia, minimal Sedatives and maximal Humane care (eCASH) concept that has even questioned the value of daily sedation stops as opposed to goal- directed sedation (36). Furthermore, our results on patient outcomes are in line with a recent meta-analysis reporting that interventions that reduced delirium duration did not neces- sarily translate into reduced short-term mortality (37). Figure 2. Adherence to guideline recommendations. This figure graph shows adherence percentage per performance indicator for the three data collection periods. See Supplem ental Digital Content 7 (http://links. lww.com/CCM/E227) for crude numbers. *Indicates a significant change relative to the baseline period. #Indicates a significant change after guideline implementation relative to the screening implement ation period. For adjusted analyses: see Supplemental Digital Content 10 (http://links .lww.com/CCM/E227). LOS = length of stay, PT = physical therapy. Trogrli et al Copyright © 2018 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved.Neurologic Critical Care Critical Care Medicine www.ccmjournal.org 425 From an implementation perspective, we learned several lessons on evidence-to-practice translation. First, our implicit assumption that other improvements such as SATs and SBTs would follow next to our efforts to implement delirium-ori- ented measures, not specifically aimed at safety screens, has been falsified. Second, ICU teams less experienced with use of the guideline bundles or relying solely on “local champions” rather than interprofessional implementation teams should not try to implement all PAD/ABCDE bundle elements “si- multaneously” within a limited time frame. Of note, our study deployed one or two local champions (intensivist or research nurse), but limited funding precluded appointment of full interprofessional teams (IPTs), existing of all relevant stakeholders, such as residents, respiratory therapists, physical therapists, and other dedicated healthcare workers. Deploying such IPTs has been shown in other implementation studies to be essential for multibundle implementation within a limited timeframe (7, 38, 39). A graded or phased implementation seems much more feasible in such relatively resource-limited settings, and we learned that “integration” of bundle elements should not be confused with their “simultaneous” adoption. Third, not only the caregivers but also the dedicated “role models” have a learning curve for providing education and the feedback, so patience is of the essence. Fourth, successful im- plementation of bundle elements requires taking into account the baseline situation and contextual issues, such as existing barriers and facilitators, because many have been identified and not all are pertinent to all settings (40). The strengths of our study include the prospective design, use of tailored multifaceted implementation strategies, the largest cohort to date outside of the United States, and the representative mix of ICU types supporting the translatability of our findings. Further, we deployed a pragmatic approach: implementation as part of daily clinical practice instead of deployment in a controlled research setting, which is also in contrast to most published studies. Several limitations need to be addressed. First, the Hawthorne effect was not avoided, seeing that delirium screening implementation alone resulted in improved adherence to several guideline recommendations. Second, duration of delirium might be a doubtful outcome pa- rameter due to the difference between a clinical diagnosis as assessed by chart review at baseline compared with the second and third phases (based on validated screening instruments). Long-term outcomes, such as cognition or posttraumatic stress disorder, may be more relevant outcomes. Last, certain changes over time may have been overestimated in the pres- ence of secular trends (41). In conclusion, this largest pre-post implementation study outside of the United States of delirium-oriented measures based on the 2013 PAD guidelines showed that implementa- tion had improved health professionals’ adherence to delirium guidelines, which was linked to reduced brain dysfunction. TABLE 3. Secondary (Clinical) Outcomes Outcomes Crude analysis Adjusted a Effect Values Phase I: Baseline Phase II: Screening Implementation Phase III: Guideline Implementation Adjusted OR/Rate Ratio/Beta a (95% CI; p) a) Phase I vs Phase II b) Phase I vs Phase III c) Phase II vs Phase III Patients (n) Patients (n) Patients (n) Delirium duration (d), mean ( sd) 2 74 5.6 (8.6) 3002.9 (3.3) 3193.3 (4.5) a) 2.6 3.5 to 1.6; p < 0.001) b) –2.2 (–3.2 to –1.3; p < 0.001) c) 0.3 (–0.6 to 1.2; p = 0.46) Patients with delirium during ICU admission, n (%) 1,337 274 (21) 1,399300 (21) 1,194319 (27) a) 1.2 (0.9–1.4; p = 0.16) b) 1.4 (1.2–1.7; p < 0.001) c) 1.2 (1.0–1.5; p = 0.25) Duration of mechanical ventilation (d), mean ( sd) 560 4.6 (8.2) 5414.9 (6.4) 5934.7 (6.5) a) 0.5 0.3 to 1.3; p = 0.23) b) 0.4 (–0.4 to 1.2; p = 0.36) c) –0.1 (–0.9 to 0.7; p = 0.75) ICU length of stay (d), mean ( sd) 1,337 4.9 (6.9) 1,3994.3 (6.0) 1,1944.8 (5.9) a) 0.3 0.8 to 0.1; p = 0.19) b) –0.1 (–0.6 to 0.3; p = 0.56) c) 0.2 (–0.3 to 0.6; p = 0.49) ICU mortality, n (%) 1,337 135 (10.1) 1,399140 (10.0) 1,194126 (10.6) a) 1.3 (1.0–1.7; p = 0.08) b) 1.3 (0.9–1.7; p = 0.13) c) 1.0 (0.7–1.3; p = 0.88) Hospital mortality, n (%) 1,337 216 (16.2) 1,399226 (16.2) 1,194194 (16.2) a) 1.3 (1.0–1.6; p = 0.057) b) 1.1 (0.9–1.5; p = 0.31) c) 0.9 (0.7–1.1; p = 0.39) OR = odds ratio.a Differences are expressed as adjusted OR or adjusted rate ratios with the Phase I: Baseline (for a and b) and Phase II: After screening implementation (for c) as the reference. Adjusted for Acute Physiology and Chronic Health Evaluati on-II, hospital, age, and admission type. Copyright © 2018 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved. 426 www.ccmjournal.org March 2019 • Volume 47 • Number 3 Our data add to existing implementation literature due to the non-U.S. setting, strongly enhancing translatability of findings. Furthermore, implementation lessons learned that are unique for our study pertain to 1) the feasibility of staggered versus simultaneous implementation of bundle elements, that seem strongly dependent on local resources (e.g., “local champions” vs interprofessional implementation teams or level of previous experience with the guidelines), and 2) the fact that our “error of omission” of daily safety screens for SATs and SBTs may have precluded concurrently improved clinical outcomes, adding strong empirical support from a “real-life setting” for effective- ness of individual ABCDE bundle elements. 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