Marjon Borgert

102 Chapter 5 by the Institute for Healthcare Improvement (IHI). 23 It is a practical tool to improve the performance of evidence based interventions. Care bundles aim to improve the reliability of care processes by grouping a small set of evidence based interventions together. All interventions should be performed together for every eligible patient to ensure patients receive the care they need. 23 Care bundles monitor professionals’bundle performance over time. Subsequent, the e ect of the bundle could then be measured by using prede ned outcome measures, i.e. quality indicators. 23,24 The quality indicator re ects a change as a result of the implementation of the care bundle. There is evidence that higher bundle compliance rates are associated with improved outcomes. 25 In this observational study we retrospectively analyzed the EN delivery in critically ill patients. We observed if patients or groups of patients were at risk of malnutrition and consideredwhether there was room for improvement. Identifying problems or potential risks within care processes is the beginning of the bundle design process according to the IHI. 23 Multiple steps follow to design an evidence based care bundle. 23,26 This process is described in detail by the IHI. 23 Further research is needed to develop and validate a care bundle for the delivery of EN. Furthermore, research should focus on determining factors to enhance the implementation and sustainability of this care bundle. By continuously monitoring the e ect of the care bundle on the prede ned quality indicators changes in the performance of professionals can be detected. This provides valuable information on the EN delivery in critically ill patients. Limitations Our study has several limitations. We analyzed the data from a single center hospital, which can a ect the generalizability of the results. We retrospective analyzed the data and therefore risk of bias could exist. We used a selected set of factors to describe the adequacy of EN intake. Other important factors a ecting adequate EN delivery described in the literature are interruptions due to (re)intubation/extubation, fasting for interventions, patient transports, intestinal intolerance, diagnostic tests and problems with feeding tubes. 2,27 In our study we were not able to assess the in uence of these factors on malnutrition. Furthermore, we were not able to identify other interfering factors for the adequate delivery of EN such as barriers in knowledge or organization. 28 Given the nature of our study, we did not nd patients with a feeding prescription and a zero EN intake.