Marjon Borgert

125 Implementation of care bundles in ICUs is not always possible or suitable in quality improvement studies. Alternative designs could then be considered, such as controlled before and after trials or interrupted time series to control for confounding variables. 88 Otherwise, a combination of quantitative and qualitative designs could be conducted to assess if the intervention worked, how it worked and inwhat contexts. 83,88 Furthermore, it is imperative that studies are clearly and unambiguous reported. A clear description about the context in which the intervention was implemented should be stated, and a detailed description of the participants, i.e. the users of the intervention, should be provided. 75 These requirements are stipulated in the standards for quality improvement reporting excellence (SQUIRE) guidelines 75 which are strongly recommended when reporting quality improvement studies. To compare performance outcomes, there should be an unambiguous method for measuring compliance, i.e. the use of the AON and/or composite measurement. 24 Within current implementation research it is not only important to identify the most e ective strategy, but also to better understand why, how and when the speci c strategy works best. 89 CONCLUSIONS The three most frequently used implementation 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 design, di erence in number and types of elements, types of compliance measurements calculation. Due to the heterogeneity of the data and the poor methodological quality of the studies, conclusions about which strategy results in the highest levels of care bundle compliance could not be determined and no recommendations can be made on which strategy should be selected to get the highest levels of compliance. 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 SQUIRE guidelines whenever they report quality improvement studies.