Marjon Borgert

121 Implementation of care bundles in ICUs DISCUSSION In this systematic review we identi ed the strategies that were reported to implement care bundles in ICU settings, and subsequently, we attempted to nd the best strategies to achieve high levels of bundle compliance. Care bundles have already proven to be e ective in reducing negative clinical outcomes. 7,9,10 This reduction is associated with the compliance rates to the care bundles. 12 It is important to mention that we, therefore, focused on nding the best implementation strategy to achieve high levels of bundle compliance and not on the outcome of care processes. Although care bundles are perceived as valuable, and are proven to have an e ect on the quality of care, it is still a challenge to achieve high levels of bundle compliance. Our results show that the three most frequently used implementation strategies were education followed by reminders and A&F. These ndings are consistent with other reviews about implementation strategies in general 73,74 , in which these three strategies were commonly used to implement best practices in hospitals 73 or critical care areas. 74 In 53% of the studies, a combined strategy consisting of education, reminders and A&F were used. This combination was mainly used to implement the ventilator bundle (57%), and only used in 11% for implementing the sepsis bundle. Overall, after implementation of the bundles, compliance levels varied, ranging from 33 to 100%. However, these ndings should be interpreted with caution, because studies included in this systematic review showed a variety of designs. The majority of studies involved quality improvement initiatives with pre/post designs or prospective cohort studies without using controls. For these studies, secular trends that might have occurred at the same time were not taken into account. Furthermore, we assessed the quality of the individual studies by using the checklist of Downs and Black and the majority of the studies were classi ed as ‘fair’. 18 Remarkably, none of the studies provided more detailed information about the participants, i.e. bundle users, except for one. 50 Information about the setting was reported in all studies. Such details about the context of an intervention should be reported to determine the generalizability, or external validity, of the study. 75,76 We furthermore determined great di erences in the number and types of bundle elements between the studies, and in the measurements and calculations of bundle compliance rates. Due to this heterogeneity of data, even within the di erent subgroups (Supplementary File 5), we could not identify the most e ective implementation strategy that resulted in the highest levels of compliance. In the next paragraphs we will discuss how these factors could have in uenced the compliance levels.