Marjon Borgert

110 Chapter 6 ABSTRACT Background. Care bundles have proven to be e ective in improving clinical outcomes. It is not known which strategies are the most e ective to implement care bundles. A systematic review was conducted to determine the strategies used to implement care bundles in adult intensive care units and to assess the e ects of these strategies when implementing bundles. Methods. The databases MEDLINE/PubMed, OVID/EMBASE, CINAHL and CENTRAL were searched for eligible studies until January 31, 2015. Studies with (non)randomized designs on central line, ventilator or sepsis bundles were included if implementation strategies and bundle compliance were reported. Methodological quality was assessed by using the Downs and Black checklist. Data extraction and quality assessments were independently performed by two reviewers. Results. In total, 1533 records were screened and 47 studies were nally included. In 49% pre/post designs were used, 38% prospective cohorts, and the remaining studies used retrospective designs (6%), interrupted time series (4%) and longitudinal designs (2%). The methodological quality was classi ed as ‘fair’ in 77%, and the remaining as ‘good’(13%) and‘poor’(11%). Themost frequently used strategies were education (86%), reminders (71%) and audit and feedback (63%). Our results show that compliance is in uenced by multiple factors, i.e. types and numbers of elements varied and di erent compliance measurements were reported. Furthermore, compliance was calculated within di erent time frames. Also, detailed information about compliance, such as numerators and denominators, was not reported. Therefore, recalculation of consistent monthly compliance levels was not possible. Conclusions. The three most frequently used strategies were education, reminders and audit and feedback. We conclude that the heterogeneity among the included studies was high due to the variety in study designs, number and types of elements and types of compliance measurements. Due to the heterogeneity of the data and the poor quality of the studies, conclusions about which strategy results in the highest levels of bundle compliance could not be determined. We strongly recommend that studies in quality improvement should be reported in a formalised way in order to be able to compare research ndings. It is imperative that authors follow the standards for quality improvement reporting excellence (SQUIRE) guidelines whenever they report quality improvement studies.