Marjon Borgert

118 Chapter 6 Implementation strategies The three most frequently used strategies to implement care bundles were: educational activities in 88% (43/49) followed by reminders in 71% (35/49) and audit and feedback (A&F) in 63% (31/49). Family participation was only adopted as a strategy to implement the ventilator bundle (Table 2). Within each study about central line implementation a minimum of one strategy was described, ranging from one to a maximum of seven strategies. In all studies of central line bundle implementation, checklists were used. Education was used in 85% (11/13) and A&F in 77% (10/13). In 54% (7/13) the time- out procedure was reported (Supplementary File 3). In studies of the implementation of the ventilator bundle, there is a great variety in the number of strategies, ranging from one to nine strategies (Table 2). The three most frequently used strategies were education (85%, 23/27), reminders (78%, 21/27) and A&F (67%, 18/27). In studies of the implementation of the sepsis bundle, education was most frequently used (89%, 8/9) followed by mass media strategies, e.g. distribution of posters (44%, 4/9). In contrast with the strategies to implement the central line and ventilator bundles, the concept of a reminder was only used in one study of the implementation of the sepsis bundle (Table 2). 66 Type of compliance measurements In the majority of the studies the AON approach was used (n=36). The composite measurement was reported in four studies. 33,46,53,63 Three studies 38,39,52 reported the lowest level of compliance, two studies 45,72 used the item-by-item measurement (Supplementary File 3) and in two studies the type of measurement was not clearly reported. In nine studies on the central line bundle implementation, the AON approach was reported to calculate the compliance levels. In two studies the composite measurement was used and in one study the lowest level of compliance. In one study the type of measurement could not be identi ed. Exline et al . reported a high level of compliance of 100%with the insertion bundle, using the AON approach. 36 In the study of Render et al . the compliance with the central line bundle was 98%at the end of the study period using the composite measurement. 33 One study 27 reported a low compliance rate of 44%, which was measured over a period of 18 months (Supplementary File 3). In the calculation of the compliance of the ventilator bundle, four types of measurements were used. One study reported the compliance per single item 46 , three studies used the composite measurement and two studies used the lowest level of compliance. In the remaining studies, the AON approach was used to measure the compliance of the ventilator bundle (Supplementary File 3).