Marjon Borgert

199 Summary and future perspectives The delivery of care, such as the delivery of enteral nutrition (EN), consist of a complex series of interactions between physicians, nurses, patients and medical interventions. 18 Monitoring and systematically analysing these interactions can be helpful in identifying those areas where optimal care is potentially at risk. The identi cation of those risks is important in nding opportunities in improving the quality of care. 18 And thus, an area were care bundles could be e ective. Malnutrition is a serious problem in critically ill patients. 19,20 We do, however, not exactly know to what extent patients are at risk in receiving adequate EN therapy. In Chapter 5 we conducted a retrospective cohort study, in which we identi ed patients who were at risk for malnutrition in order to nd ways of improving the quality of care. Patients admitted to the ICU from January 2012 to December 2014 were included. Ideal calorie intake was calculated as 25 Kcal/kg/day. Ideal protein intake as 1.2 to 1.5 g/kg/day. Multilinear regression was used to describe the factors of success of EN intake. The results showed that, the delivery of EN in critically ill patients was moderate to high in the majority of the patients. However, a substantial part of the EN delivery was still suboptimal during admission and need to be improved. This implies a strong argument to support ICU sta in the adequate delivery of EN. This could be facilitated by a nutritional care bundle to support guideline uptake and thereby improve the delivery of EN. In Chapter 6 a systematic review was performed to determine the strategies used to implement care bundles in adult ICUs. Furthermore, we assessed the e ect of these strategies when implementing bundles. The electronic databases, PubMed, Ovid Embase, CINAHL and CENTRAL, were searched for eligible studies. Themost frequently used strategies were education (86%), reminders (71%) and audit and feedback (A&F) (63%). Our results showed that compliance was in uenced by multiple factors, i.e. types and numbers of elements varied and di erent compliance measurements were reported. Furthermore, compliance was calculated within di erent time frames. Also detailed information about compliance, such as numerators and denominators, was not reported. Therefore, recalculation of consistent monthly compliance levels was not possible. We concluded that the heterogeneity among the included studies was high, caused by the variety in study designs, number and types of elements and types of compliance measurements. Due to the heterogeneity of the data and the poor quality of the studies, conclusions could not be determined about which strategy results in the highest levels of bundle compliance. Therefore, it is recommended that studies in quality improvement should be reported in a formalised way in order to be able to compare research ndings. In Chapter 7 we developed and implemented a transfusion care bundle for the delivery of red blood cells (RBCs). In this implementation study, with a quasi-experimental study design, we investigated 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