Marjon Borgert

200 Chapter 9 timely individual A&F. The results showed that monthly A&F on team level with timely individual A&F signi cantly improved bundle compliance during implementation compared to monthly A&F on team level alone. The overall e ect of compliance during the study period was signi cantly higher with an OR of 4.05 (95% con dence interval: 1.62 to 10.08), P < 0.001. This indicates that when using the combined A&F strategy nurses are more likely to be compliant to the bundle than when monthly A&F was used alone. Providing timely individual A&F plus monthly A&F on team level might also be e ective for the implementation of other bundles in healthcare. Future research could elaborate on longer duration of the intervention, the use of information and computer technology to lower costs of the intervention and to enhance sustainability. In Chapter 8 we investigated whether the application of the transfusion bundle would reduce the number of inappropriate RBC transfusions in an ICU setting. Restrictive RBC transfusion has been widely described in transfusion guidelines. 21 However, compliance to these guidelines is often poor. 22,23 In this before and after study, we quanti ed the true e ect of the transfusion bundle by assessing, per transfusion, whether the decision to transfuse was based on a lower pre-transfusion haemoglobin (Hb) level than the patients’ individual preset Hb threshold. The primary outcome was the percentage of appropriate transfusions, referring to those transfusions that were in accordance to the patients’ individual preset Hb threshold. The results showed that the introduction of the transfusion bundle has resulted in a signi cant reduction of the percentage of inappropriate transfusions. The number of inappropriate transfusions decreased from 25% (111/439) during baseline to 15% (42/280) during implementation, a di erence of 10%; 95% CI: -0.164 to -0.042, P < 0.001. This further decreased to 12% (45/370) in the post-implementation phase. E ectively, using the transfusion bundle helps to improve compliance with transfusion guidelines in daily practice. We have not assessed whether the preset Hb threshold was considered adequate for each individual patient according to the transfusion guideline. Interestingly, our results show that inmost cases, restrictive Hb thresholds were used as stated in the transfusion guideline. 21