Marjon Borgert

112 Chapter 6 used to implement care bundles in adult ICU settings and to assess the e ects of these strategies when implementing care bundles. We addressed the following questions: which strategies were used to implement the three most used care bundles, i.e. central line, ventilator and sepsis bundle, on adult ICUs and which implementation strategy or strategies lead to the highest levels of compliance? METHODS Study design A systematic review was conducted to determine the strategies used to implement care bundles in adult ICU settings and to assess the e ects of these strategies when implementing care bundles. The protocol for the systematic review was not registered. Selection criteria We included studies of any design which implemented one of the three mostly used care bundles, i.e. central line, ventilator or sepsis bundle, on ICUs for adult patients. Studies were only included if a description of the implementation strategy was given, and if the level of compliance of the whole bundle or either compliance for each bundle element was reported separately. Studies written in non-English language were excluded. Protocols, abstracts, letters, commentaries or editorials were also not eligible. Search strategy Systematic and comprehensive searches were developed with a clinical librarian and designed for optimal retrieval. The electronic databases MEDLINE/PubMed, OVID EMBASE, CINAHL and CENTRAL were searched for literature until January 31, 2015. The complete list of search terms and strategy of MEDLINE/PubMed can be found in Supplementary File 1. Additionally, the reference lists of included articles were checked. Inclusion of relevant studies Two reviewers independently selected the studies (MB/DD or MB/AG). In case of discrepancies in study selections we reached consensus through discussion. A third reviewer (DD or AG) was involved in case of disagreement. Studies were selected if they reported about: 1) central line, ventilator or sepsis bundle; 2) implementation strategies used; and if 3) compliance levels for the whole care bundle was reported or for each bundle intervention separately. Two criteria for selecting studies, i.e. compliance rates and implementation strategies, were not (clearly) reported in abstracts, while these criteria could be well described in the full text. Therefore, if there was uncertainty