Marjon Borgert

158 Chapter 7 The implementation of care bundles is challenging. Di erent implementation strategies are described with varying success rates. 17 A frequently used strategy is Audit and Feedback (A&F). Although A&F tends to be e ective, there is a great variability in the e ectiveness on implementation. 18 Several frameworks and theories have been designed in order to understand how A&F could change professionals’ behaviour. Zajonc showed that the combination of A&F strategies on group and individual level has positive e ects on performance. 19 Hysong et al. developed a model in which it is postulated that feedback should be given timely, individualized and non-punitive in order to be e ective. 20 An important di erence between our study and the study of Hysong et al. is that they have chosen a month as a threshold for timely feedback. We considered timely feedback as given within a maximum time span of 72 hours. The reason behind this shorter time span is that it would ensure nurses to clearly remember their actions and gave them the possibility to change their behaviour before the next transfusion occurred. This is in line with Sinu et al. who also found that the timeliness of feedback is an important factor in changing behaviour. 21 Ivers et al. suggested that implementation studies should focus on comparing di erent A&F strategies and on how to optimize their e ectiveness. 22 In this present study, we aim to investigate the di erence in e ect on transfusion bundle compliance between monthly team level A&F versus monthly team level A&F with the addition of timely individual A&F. METHODS This implementation study with a quasi-experimental comparative study design was conducted from May to December 2014. We implemented the transfusion bundle from May to August. This implementation period denotes the transition period and post-implementation refers to the period in which the intervention is considered fully implemented as intended. Context The study was conducted in a 28-bed mixed medical-surgical ICU of a university hospital. The ICU is a ‘closed format’ department with four units in which patients are under the direct care of the ICU team. The ICU team consists of 10 full-time intensivists, 8 subspecialty fellows, 12 residents and 125 ICU nurses. The ICU has a stable nursing sta and all nurses were quali ed as critical care nurses. Fellows rotate on a yearly basis and