**** very important assignment*** see attached paper to Synthesize the articles !!!!! pls synthesize, note the commonalities of the 15 articles, page length should be 8-10 pgs. pls fix corrections hi

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**** very important assignment***

see attached paper to Synthesize the articles !!!!!

the paper is already written,

I only synthesize section reworked page length should be 8-10 , I have 14 it needs to be condensed. pls fix corrections highlighted in yellow. THis is extremely important, see attached template as a reference for page length and information requesting . refer to the literature review table at the end of the manuscript for the articles.

**** very important assignment*** see attached paper to Synthesize the articles !!!!! pls synthesize, note the commonalities of the 15 articles, page length should be 8-10 pgs. pls fix corrections hi
Intensive Care Unit Liberation Bundle Impacts Length of Stay Submitted by Cathy Ann Jones A Direct Practice Improvement Project Presented in Partial Fulfillment of the Requirements for the Degree Doctor of Nursing Practice Grand Canyon University Phoenix, Arizona XXXXXX , 202x © Cathy Ann Jones, 2023 All rights reserved. GRAND CANYON UNIVERSITY Intensive Care Unit Liberation Bundle Impacts Length of Stay By Cathy Ann Jones has been approved XXXXXX X, 2023 APPROVED: ACCEPTED Christina Tedesco, DNP, DPI Project Chairperson Rosla Royal, DNP, ACNP, Project Mentor/Content Expert ACCEPTED AND SIGNED: ________________________________________ Lisa Smith, PhD, RN, CNE Dean and Professor, College of Nursing and Health Care Professions _________________________________________ Date Abstract Increased length of hospital stay (LOS) can be a concern in the healthcare setting is a concern nationwide. At the project site there was no systematic process to impact LOS so an evidence-based solution was sought. The purpose of this quality improvement project is to determine if the translation of Hsieh et al. implementing the ABCDE bundle would impact length of stay among adult patients in a long-term acute care hospital in a high observation unit. The project will be piloted over an eight-week period in urban Virginia. Virginia Henderson’s needs theory and John Kotter’s eight step change model will provide the scientific underpinnings for the DPI project. Keywords: ABCDEF bundle, length of stay, long-term acute care hospital, John Kotter’s eight-step change model, Virginia Henderson Nursing Needs Theory, patient outcomes, quality improvement project Dedication I want to thank God Almighty for everything that he has done for me and dedicate my work to him as my creator, my solid pillar, and my true inspiration. Throughout the entirety of this journey, He remained the basis of my strength, and it is only on His wings that I have been able to soar. I would also like to dedicate this undertaking to my family, who have been there for me every step of the way to offer guidance and encouragement. It will also be illogical for me to ignore the vast number of patients who have suffered in one way or another due to the shortcomings of the suggested implementation. Thanks to them, I have had an easy time understanding their grievances thus making it easy to provide a comprehensive analysis on the topic. Acknowledgments I would want to convey my profound gratitude to my mentor, who was instrumental in contributing to this motivational experience by providing me with support, direction, and expert understanding of this topic. In addition, I’d love to express my earnest appreciation to all my patients, physician colleagues and nursing staff who took part in this quality improvement project. In conclusion, I would want to take this opportunity to thank my family for the support and encouragement they have provided me with during the process of completing this terminal degree. Table of Contents Chapter 1: Introduction to the Project 13 Background of the Project 16 Organizational Needs Assessment 17 SWOT Analysis 18 Strengths 19 Weaknesses 20 Opportunities 21 Threats 22 Problem Description 23 Definition of Terms 24 Summary 26 Chapter 2: Scientific Underpinnings 28 Literature Search Strategy 28 Synthesis of Literature 29 Evidence-Based Practice Question 45 Change Recommendation: Validation of the ICU Liberation Bundle 46 Theoretical Framework 47 Nursing Theory 49 Synthesis of Nursing Theory 51 Evidence-Based Change Model 53 Synthesis of Change Model 56 Integration of the Christian Worldview 57 Summary 58 Purpose 60 Project Planning and Procedures 61 Interprofessional Collaboration 62 Project Management Plan (list required resources—delete this parenthetical note) 62 Feasibility 63 Setting and Sample Population 64 Setting 64 Population and Sample 65 Data Collection Procedures 65 Instrumentation or Data Source 66 Variables 67 Data Integrity and Storage 67 Data Management 67 Potential Bias and Mitigation 67 Ethical Considerations 68 Summary 69 Chapter 4: Data Analysis and Results 70 Data Analysis Procedures 70 Descriptive Data of Sample Population 71 Results 73 Summary 75 Chapter 5: Implications in Practice and Conclusions 76 Summary of the Project 76 Major Findings 77 Interpretation of Findings 77 Strengths and Limitations 77 Implications 77 Theoretical Implications 78 Nursing Practice Implications 78 Recommendations 78 Recommendations for Future Projects and Researchers 78 Recommendations for Sustainability 79 Plan for Dissemination 79 Conclusion and Contributions to the Profession of Nursing Practice 80 References 81 Appendix A 88 SWOT Analysis 88 Appendix B 89 Appendix C 179 Project Timeline 179 Appendix D 180 Plan for Educational Offering 180 Appendix E 181 Grand Canyon University Institutional Review Board Outcome Letter 181 Appendix F 182 Project Budget 182 Appendix G 183 Data Collection Tool for Evaluation (Use the name of the tool here) 183 Appendix H 184 Place the Permission to Use the Tool Here 184 Appendix I 185 Other Data Collection Tool and/or Permissions 185 Appendix J 186 APA Writing Style for the Direct Practice Improvement Project 186 List of Tables Table 1 A Sample Data Table Showing Correct Formatting 73 Table 2 t-Test for Equality of Emotional Intelligence Mean Scores by Gender 74 Table 3 Primary Quantitative Research – Intervention (5 Articles). 90 Table 4 Additional Primary and Secondary Quantitative Research (10 Articles) 108 Table 5 Clinical Practice Guidelines (If applicable to your project/practice) 178 List of Figures Figure 1 SWOT Analysis for Quality Improvement Project 88 Chapter 1: Introduction to the Project For patients who survive but are unable to return home following the acute hospital stay, there are three inpatient post-acute care (PAC) settings where they may receive skilled, rehabilitative care: inpatient rehabilitation facilities (IRFs), skilled nursing facilities (SNFs), and long-term acute care hospitals (LTACHs) Kumar et al., (2022). LTACHs treat patients with longer-term acute care needs due to medical complexity or illness severity and may provide rehabilitation services (MedPAC, 2019). According to Nordness (2021), patients transferred or directly admitted to a long-term acute care hospital (LTACH) to the high observation unit (HOU) may suffer from Post Intensive Care Syndrome (PICS). Patients admitted an intensive care unit can develop PICS. Post Intensive Care Syndrome is a cognitive, physical, and psychological impairment that results from ICU admission. PICS can result in deconditioning, muscle wasting, pressure ulcer formation, decreased mobility, prolonged mechanical ventilation weaning, delirium, and hospital-acquired infections. Other causes of PICS include short-term acute care readmissions or limited or no discharge destination, further prolonging their hospitalization and decreasing patient and family satisfaction (Hsieh et al., 2019). Currently, at this long-term acute care facility in Virginia, there lacks a standardized plan of care specific to this patient population to prevent long term consequences of those who suffered physical and mental health dysfunction as a result of their intensive care unit hospitalization. A standardized plan may impact the length of stay (LOS). Numerous factors can account for the increased length of stay at a healthcare facility, including poor processes, communication, and general medical errors. As the length of stay increases, the patient’s satisfaction reduces significantly. For example, the length of stay in the facility exceeds thirty and sixty days. According to Pun et al. (2019), applying for the program, especially for LTACH patients, will increase satisfaction and care delivery. The mean LOS stay of 30-60 days exceeds an LTACH average of 25-28 days (Medicare Advisory). While the increased LOS is multifactorial, implementing an evidence-based protocol may improve the throughput efficiency by impacting the length of stay and improving patient outcomes. In 2013 the Society of Critical Care Medicine initiated the Intensive Care Unit (ICU) Liberation campaign from the Prevention and Management of Pain, Agitation /Sedation, Delirium, Immobility, and Sleep Disruption (PADIS) Clinical Practice Guideline (Pun et al., 2019). The guideline was updated in 2018, now known as the ICU Liberation Bundle (A-F). The Direct Practice Improvement (DPI) Project aims to impact LOS in a long-term acute care hospital in adult patients in the high observation unit translating Hsieh et al. research implementing the ABCDE bundle to impact the length of stay. The ABCDE bundle, a validated evidence-based protocol, was initially created to improve the outcomes of patients in the ICU. As the bundle became popular and widely adopted into clinical practice, it was noted to reduce LOS (Frade-Mera et al., 2022). The interventions of the ABCDEF bundle consist of six elements starting with (A) that identifies and assess for pain using the Critical-Care Observation Tool (CPOT). The second is (B) for mechanical ventilation liberation- that assists with spontaneous awakening trials (SATs) to decrease the use of sedation and spontaneous breathing trials (SBTs) to wean patients off mechanical ventilation faster, using the Wake up and Breathe Protocol. The third is (C) that identifies the appropriate choice of sedation using the Richmond Agitation Sedation Scale (RASS). The fourth component is (D) that correctly identifies and assess for delirium screening using the Confusion Assessment Method for the ICU (CAM-ICU). The fifth component is (E) which is the early progressive mobility to decrease ICU–acquired muscle weakness (Collinsworth et al., 2021). The last component is (F) for a family was added later, further redefining the bundle, identifying the importance of family presence and involvement, and embracing patient-family-centered care (Delvin et al., 2018; Heish et al., 2019). This DPI project will to consist of five of the six bundle elements ABCDE. Background of the Project Globally, an increased length of stay in healthcare facilities is related to reduced patient satisfaction, adverse outcomes, and lower reimbursement of healthcare facilities; that is why it is significant to gradually address the issue through the promotion of quality care programs, especially for critically ill patients. LTACHs are certified acute care hospitals equipped to provide long-term (average LOS of 25-28 days) acute-level care to medically complex patients (Grevelding et al., 2022). At the clinical practice site there has been an increased length of stay beyond 25 days in 75% of the patient population over the past 60 days that have been associated with delirium, cognitive and physical impairments as well psychiatric symptoms know as post-intensive care syndrome (PICS). Patients diagnosed with PICS are often admitted to an LTACH for ongoing complex medical care needs. LTACH admissions consist of illnesses related to sepsis, strokes, encephalopathy, heart failure, and acute respiratory failure resulting in tracheostomies needing ongoing mechanical ventilation support. The syndrome of PICS, including chronic pain, significantly impacts the quality of life and the ability of ICU survivors to return to work and other daily activities, even years after illness (Nordness et al., 2021). Globally, as LOS is often viewed as a measurement of hospital care, LOS is a prime indicator of resources worldwide, such as post-acute care facilities such as skilled nursing facilities, and rehabilitation facilities (Lorenzoni & Marino, 2017). LOS can impact patient care as well as outcomes. The ABCDE bundle has been incorporated into many hospitals and healthcare organizations’ operations and protocols to improve patient outcomes and cut costs. Organizational Needs Assessment Organizational assessment is a process that can be used to assess an organization’s strengths and weaknesses. The purpose of organizational assessment is to comprehensively understand an organization’s current and potential future. The strengths, weaknesses, opportunities, and threats analysis or SWOT analysis is appropriate for this quality improvement project because it identifies the organization’s strengths, weaknesses, opportunities, and threats. In the research, it was identified that LTACH might present problems in implementing the quality improvement project. (Boehm, et al. 2017). The gap to be addressed is the role of the ABCDE bundle in reducing the length of stay in the healthcare facility. The ABCDE bundle can improve the quality of care and patient satisfaction and reduce LOS. There will be the identification of the necessary resources required, including nurses, pharmacists, and physical therapists), equipment (e.g., patient chairs), and funding for additional staff (AHRQ, 2017). SWOT Analysis SWOT is a strategic tool that identifies strengths, weaknesses, opportunities, and threats within a company’s business environment. The strengths and weaknesses perspective addressed the internal factors to the problem the company is exposed to, while the opportunities and threats identified the external factors contributing to the problem. (Chen et al. 2021). Therefore, the SWOT analysis helps pinpoint the organization’s struggles and allocate potential improvements. The SWOT analysis will be helpful to this QI project because it identifies areas within the process that could be improved or eliminated. Using SWOT to analyze the quality improvement project was instrumental in determining which elements of the process needed improvement and strategically addressing those potential barriers to the quality improvement implementation. (Benzaghta et al. 2021).  (See Appendix A). (See Figure 1). Strengths According to Collinsworth, Priest & Masica (2020), strengths are areas where an individual or organization performs well. They also include positive characters and skills related to improvement and wanted performance. The primary strength of the ABCDE bundle is the provision of a family-centered approach that boasts as one of its key pillars. By providing a holistic approach to health and health services, the ABCDEF health bundle helps to address the needs of the whole family rather than just individual members. This approach ensures that all the family members have a say and are supported in taking an active role in the decision-making progression. Secondly, the ABCDEF package effectively reduces the risk of developing delirium and facilitates the patient’s recovery in the shortest amount of time and with the fewest disruptions from the outside world (Otusanya et al., 2021). Finally, the bundle addresses various health concerns, making it a comprehensive approach to improving patient care. Similarly, the bundle is flexible and can be customized to meet the needs of specific organizations considering its well-documented and includes several tools and resources to support organizations in their efforts. Finally, the ABCDEF bundle is effective in improving patient outcomes. Weaknesses In the SWOT analysis, the weaknesses are considered as faults or areas where actions do not follow the organization’s aims. Weaknesses can be improved or worked on to meet organizational goals. Despite the tremendous clinical effects that can be achieved with the ABCDE bundle, it is not commonly adopted in practice. Several potential obstacles could prevent the ABCDE bundle from being used. The first weakness is healthcare practitioners’ unfamiliarity with the ABCDE bundle interventions and tools. Effective deployment of the ABCDE bundle necessitates several resources, including people, machines, and money for more machines and people (Collinsworth, Priest & Masica, 2020). A second weakness is a possibility that the ABCDE bundle will only partially be implemented; only utilizing certain elements per unit must yield favorable results, which presents the third challenge. Inconsistent care may be delivered between different hospitals or healthcare units if there are no established protocols. The last weakness is that the ABCDE bundle may encounter resistance from the healthcare institution’s culture. A healthcare institution’s culture is shaped by its traditions and values, which makes it challenging to bring about a shift in that culture.  There are several ways to overcome the barriers to implementing the ABCDE bundle. The first way is to increase awareness of the guideline among healthcare providers. Many providers may need to be aware of the guideline or their recommendations. Educational programs can increase awareness of the guideline among healthcare providers. Second, provide resources (e.g., personnel, equipment, funding) to healthcare facilities to implement all six interventions of the ABCDE bundle (Loberg et al., 2022). Resources needed to implement the ABCDE bundle effectively include personnel (e.g., nurses, pharmacists, physical therapists), equipment (e.g., patient monitors), and additional staff and equipment funding. A third way is to develop standardized protocols for implementing the ABCDE bundle (Loberg et al., 2022). With standardized protocols, care may be consistent across different units within a facility. Standardized protocols can ensure that care is delivered consistently across different units within a facility. Last, the culture of a healthcare facility can be changed by introducing new values and norms that support the implementation of the ABCDE bundle Opportunities Opportunities in SWOT analysis are areas that could be advanced and improved for organizational progress. They are also the circumstances that create a chance for organizational improvement. There exist multiple opportunities which can play a crucial role in improving the ABCDE bundle implementation. (Otusanya et al. 2016). The first opportunity is the preparation, skills, and competencies healthcare practitioners have will be significant in implementing the program with little investment. (Balas et al., 2022). The second opportunity is that the facility’s leaders are dedicated to reducing LOS, increasing patient satisfaction, and more reimbursement for quality delivery. Threats There are several potential threats to implementing the ABCDE bundle in an LTACH. Threats are the factors that may hinder the achievement of the project’s goals; they are also the adverse factors that limit the company from succeeding. Patients’ consent to join the research project is the central issue since most patients may be unwilling to join. However, everyone must sign an informed consent to understand engagement’s pros, cons, and risks. Another potential threat is that the ABCDE bundle could strain hospital resources which is the role of the government to ensure healthcare facilities are provided with adequate resources, including facilities, equipment, and healthcare workers hired (Bakhru et al., 2014). Finally, there is always the potential for human error when implementing any new system or procedure. It is especially true with the ABCDE bundle, as it requires high coordination and communication between staff members. If there are any lapses in this process, it could lead to severe consequences for patients. (Frade‐Mera et al. 2022). Implementing the ABCDE bundle is the proposed solution to impact the LOS of those admitted or transferred to the HOU. In order to ensure that the ABCDE bundle is effective, it is essential to consult with experts during the implementation process (DE Mellow et al., 2020). Consulting with content experts will help to ensure that the bundle meets the needs of all stakeholders. The specialists in the high observation unit in long-term acute care will be consulted to ensure that the bundle meets the needs of patients in this setting. Furthermore, this consultation will help ensure that the bundle effectively reduces the length of stay. Problem Description Over the past three years, the data shows many patients admitted to the practice site have required transfer into the HOU or have been directly admitted to the HOU upon admission to the practice site for acute complex care and management of their critical illnesses. Many of these patients suffered respiratory, neurological, or cardiovascular events warranting the HOU monitoring. Length of stay is a significant issue in our facilities since it increases complications, especially for the patients admitted to the HOU, thus increasing the cost of care. (Hsieh et al., 2019). Additionally, the length of stay affects the patient’s satisfaction and increases the risk of ulcer formation. Therefore, the project’s outcome is the gradual reduction of the LOS by assessing the patient’s situation and strategic application of the ABCDE bundle to prevent complications. Increased LOS threatens the validity of LTACHs. Reimbursement rates decrease when care related to hospital-acquired infections occurs. The longer a patient remains an inpatient, there poses the risk of delayed recovery to the prehospital state. Despite the ABCDE bundle’s clinical significance, more data regarding its effectiveness outside of short-term acute hospitals is needed. The major problem is that LTACHs need a standardized, evidence-based protocol that impacts LOS, disposition, and clinical outcomes. Definition of Terms Throughout the quality improvement project, many repetitive terms were used to illuminate the project’s key components. Below are a few of the most common terms used. ABCDEF Bundle A validated evidence-based protocol with six elements, now known as the ICU Liberation-ABCDEF bundle. (A) Assess, Protect, and Manage Pain; (B) Breathing-SAT (spontaneous awaking trial) and SBT (spontaneous breathing trial); (C) Choices of Analgesia and Sedatives; (D) Delirium Assess, Preclude, and Manage; (E) Early Movement and Exercise; (F) Family (Collinsworth et al., 2021). Delirium Delirium is a disturbance in attention and awareness that develops over a short period, represents an acute change from baseline attention and awareness, and fluctuates in severity during the day (American Psychiatric Association, 2013) Intensive Care Unit (ICU)  A multidisciplinary specialty unit committed to the comprehensive management of patients having or at risk of developing life-threatening organ dysfunction by use of technology that supports failing organ systems to prevent further physiologic deterioration (Marshall et al., 2017). Length of stay (LOS) The timeframe that a patient spends in the hospital care unit is the metric that constitutes this measurement (Pun et al., 2019). LTACH Long-term acute care hospitals- are certified acute care hospitals equipped to provide long-term (average LOS of 25-28 days) acute-level care to medically complex patients (Grevelding et al., 2022). Post Intensive Care Syndrome It is associated with delirium, cognitive and physical impairments, and psychiatric symptoms (Hsieh et al., 2019). Summary Since the ABCDE Bundle has been widely utilized across different healthcare settings locally, nationally, and globally serving the purpose of mechanical ventilation liberation, reducing the incidence of delirium, to reducing healthcare costs and length of stay. The ABCDE (Awakening and Breathing Coordination, Delirium Monitoring and Management, and Early Exercise and Mobility) bundle, a validated evidence-based protocol, was initially created to improve the outcomes of patients in the ICU (Frade-Mera et al., 2022). Reducing unnecessary healthcare costs is everyone’s responsibility. The ABCDE bundle is a cost-effective, scalable intervention. The ABCDE bundle may ameliorate the effects of PICS, reduce HAI, facilitate mechanical ventilator liberation quicker, and impact LOS; all are equally important for improving care delivery and outcomes in critically ill patients in any healthcare setting. Implementing the ABCDE bundle is a significant milestone for any institution. The ABCDE bundle consists of six elements of interventions proven to reduce the length of stay and improve patient outcomes. The ABCDE bundle gives medical practitioners access to a wider variety of treatment alternatives that can be tailored to meet the requirements of –patients and their families while improving clinical outcomes and impacting hospital length of stay. According to Pun et al. (2019), studies exist examining the effectiveness of the ABCDE bundle. These studies have shown significant reductions in delirium prevalence, ventilator days, coma days, readmission, and in-hospital mortality, and a significant increase in the number of patients who were mobilized out of bed during their ICU stay, decreased length of stay (Pun et al., 2019). Chapter 2: Scientific Underpinnings This paper reviews the current evidence regarding the Intensive Care Liberation Bundle and its impact on decreasing the length of stay among patients in a long-term acute care hospital (LTACH) admitted or transferred to a high observation unit (HOU). The goal of the review is to gain an in-depth understanding of the ABCDE bundle in decreasing the ICU length of stay, decreasing the incidence of delirium, and improving patient satisfaction after implementing the ABCDE bundle in a real-world setting. Literature Search Strategy The search strategy used the following databases: PubMed, CINAHL, and ProQuest. The search terms used were ABCDE bundle AND intensive care unit. The inclusion criteria were to have articles published in English within the last five years, full-text, and peer-reviewed articles. Articles that did not include full text, were not peer-reviewed, were published in a language other than English, were published later than 2017, and were thus excluded from the study. A total of 15 articles met the inclusion criteria and were used to support the intervention. Synthesis of Literature The first article by Hsieh et al. (2019) looks at the effect of the ABCDE bundle on specific patient costs. The objective of the study was to measure the impact of the staged implementation of complete versus virtual ABCDE bundle on mechanical ventilation (MV) duration, intensive care unit (ICU) and hospital length of stay (LOS), and cost. The prospective cohort study included 1,855 mechanically ventilated patients admitted to ICUs between July 2011 and July 2014. Based on the findings, it was established that implementing the ABCDE bundle was associated with a decrease in-hospital mortality and length of stay. It was also found that early mobilization and coordination portrayed an improvement in patients in the ICU by 30 percent. After adjustment for patient-level covariates, it was found that the implementation of the entire (B-AD-EC) versus partial (B-AD) bundle was associated with reduced mechanical ventilation duration (–22.3%; 95% CI, –22.5% to –22.0%; p < .001), ICU length of p < .05. However, this study was limited in that it was conducted in a single medical center which limited the generalizability of the findings. An unmeasured change could have affected the results, and the cross-contamination of practices between two ICUs could have further affected the findings. The study illustrates the significance of teamwork between physicians in the ICU in enhancing patients’ health and medication adherence while improving the working conditions in health facilities to safeguard the patient’s health. The article will help support a decrease in in-hospital mortality and length of stay for the DPI project by implementing the ABCDE bundle. The second article by Liu et al. (2021) had the primary outcome of the implementation rate of the ABCDE bundle. For the DPI project, the article will help support implementing the ABCDE bundle to decrease in-hospital mortality and length of stay. Secondary outcomes were the implementation rates for each element of the ABCDEF bundle, including element A (regular pain assessment), element B [both spontaneous awakening trials (SAT) and spontaneous breathing trials (SBT)], element C (regular sedation assessment), element D (regular delirium assessment), element E (early mobility and exercise), and element F (family engagement and empowerment), and an ICU diary. The ABCDE bundle and the ICU diary between patients without and with COVID-19 infections were made with the Mann-Whitney U-test for non-normally distributed continuous data, the chi-squared test, and Fisher’s exact test for categorical data. The calculated sample size with 95% power and a two-sided alpha of 0.05 was 508 patients under the assumption of the implementation rate of the entire ABCDE bundle for patients without and with COVID-19 infections.  The third article by Louzon et al. (2017) study included 436 participants. Patients managed with the ABCDE bundle and 499 patients of those with standard care in a Florida hospital in the United States. Steps to implement this program occurred in two phases. Phase 1 involved an initial pilot program to allow ICU pharmacists to directly manage sedative therapy for mechanically ventilated patients in collaboration with an insensitivity. In phase 2, that initiative was expanded to include comprehensive pharmacist PAD management and the development of a multispecialty inter-professional team to encourage the early mobilization of mechanically ventilated patients. This study used the APACHE outcomes tool for managing critical care outcomes methodology and found a reduction relative to mean hours in the standard-care cohort (p = .0025). For the DPI project, the article will help support implementing the ABCDE bundle to manage sedative therapy for mechanically ventilated patients in collaboration with an insensitivity and multispecialty inter-professional team to encourage the early mobilization of mechanically ventilated patients. The fourth article by Trogrlić et al. (2019) showed that implementing the ABCDE bundle had improved health professionals’ adherence to delirium guidelines, which was linked to reduced brain dysfunction. The ABCDE bundle was further linked to decreased ICU stay data from this study added to existing implementation literature, strongly enhancing the translatability of findings. This article aligns with this learner’s DPI project as a healthcare professional, giving tips on how best ICU delirium guidelines can be integrated to improve patient clinical adherence. The study identified improvements after the implementation pertained to delirium screening (from 35% to 96%; p < .001). The feasibility of staggered versus simultaneous implementation of the bundle elements seems strongly dependent on local resources (e.g., “local champions” vs. interprofessional implementation teams or level of previous experience with the guidelines). Additionally, the fact that “error of omission” of daily safety screens for SATs and SBTs may have precluded concurrently improved clinical outcomes, adding solid empirical support from a “real-life setting” for the effectiveness of individual ABCDE bundle elements. For the DPI project, the article will support implementing the ABCDE bundle for a decreased ICU stay. The fifth article by Ren et al. (2017) looks at the effects of the ABCDE bundle on hemodynamics in patients with mechanical ventilation. The study involved a cross-sectional overall, before-after controlled study with 143 patients on mechanical ventilation admitted at the ICU. The study found a decrease in heart rate, mean arterial pressure, and length of stay when the bundle was implemented. In addition, there was an increase in PaO2/FiO2 ratio and a decrease in ventilator-free days. The difference in the prognosis between the bundle and pre-ABCDE bundle groups was statistically significant (p < .05). The study proved that the ABCDE bundle could significantly improve the vital indicators of patients on mechanical ventilation, reduce the dose of the sedatives and pain medications used, and keep the vital indicators at levels beneficial to patients. The limitation of this study was that the study was non-randomized, which could translate to selection bias. For the DPI project, the article will support implementing the ABCDE bundle to decrease heart rate, mean arterial pressure, and length of stay on hemodynamics in patients with mechanical ventilation. The sixth article by Frade-Mera et al. (2022) looks at the impact of early intervention with the ABCDE bundle on sepsis outcomes. The study was a 4-month, prospective, observational, multi-center cohort study conducted in adult patients receiving invasive mechanical ventilation (IMV) for at least 48 hours in ICUs across Spain. The primary outcomes measured were the pain level, level of cooperation, the incidence of delirium and physical restraints, and level of mobility related to implementing bundle components A, B, C, D, and E. The secondary outcome was the drug levels of analgesia, sedatives, muscle relaxants, and antipsychotics (cumulative drug dosing by IMV days 100) associated with the implementation of bundle components A, B, C, D, and E. on the other hand, the tertiary outcome- Need for re-intubation or tracheostomy, ICU length of stay in days, IMV days, bed rest days, ICU mortality, and development of ICUAW associated with the implementation of bundle components A, B, C, D, and E. The study involved 531 patients and found a decrease in mortality and length of stay when the bundle was implemented early. It showed that patients had shorter ICU stays with bundle protocols and fewer days of IMV in ICUs with delirium and mobilization bundle components (p = .006 and p = 0.03. In addition, there was a reduction in cost per patient when the bundle was implemented. The study’s main limitation was that the Richmond agitation-sedation scale (RASS) results were not analyzed because most were recorded in ICU patients implementing protocols with analgosedation algorithms. For the DPI project, the article will support implementing the ABCDE bundle to reduce ICU length of stay, effectively manage pain, and decrease mortality. The seventh article by Negro et al. (2018) looks at the impact of the ABCDE bundle on ICU patients with systemic inflammatory response syndrome. The researchers sought to assess the feasibility and safety of an early progressive mobilization protocol, focusing on the three most advanced steps (dangling, out-of-bed, and walking) implemented without additional dedicated personnel as part of the ABCDE bundle. The study involved 482 patients and found a decrease in mortality and length of stay when the bundle was implemented. In addition, there was a reduction in cost per patient when the bundle was implemented p < .05, which is considered statistically significant. However, the study was limited because it was a descriptive study that shows the experience in a single ICU unit, and the researchers did not have control over the historical group. The descriptive study design weakens the findings and makes it imprudent to generalize them to other populations. By implementing the ABCDE bundle, the article will support early progressive mobilization protocol for ICU patients with systemic inflammatory response syndrome. The eighth article by Collinsworth et al. (2021) looks at the impact of the ABCDE bundle on ICU patients with sepsis using mixed methods. The study also sought to assess the clinicians’ perceptions regarding the ABCDE bundle and the implementation effort. The study involved eight patient adults in ICU and 84 nurses, therapists, and physicians surveyed. The study found decreased mortality and length of stay when the bundle was implemented, translating to the best care and patient outcomes. In addition, there was a reduction in cost per patient when the bundle was implemented in both interventions. Effect of Basic vs. Enhanced Intervention on Bundle Adherence ICU LOS 0.02 (0.01-0.02) <.0001a (p < .05. The data was acquired from electronic health records (EHRs). The EHR limited evaluation of some elements, such as pain and sedation, and the physicians’ responses could be biased, further limiting the study. For the DPI project, the article will support implementing the ABCDE bundle to decrease mortality and length of stay. The ninth article by van den Boogaard et al. (2020) looks at implementing the ABCDE bundle and its effect on patient outcomes by studying the association between the level of sedation and delirium occurrence in patients who are critically ill. The study included more than 1660 patients and used observation of the cohort study. It was found that there was a decrease in mortality and length of stay when the bundle was implemented; length of stay (ICU) (p < .05) was considered statistically significant. In addition, there was a reduction in cost per patient when the bundle was implemented. It was concluded that the influence of the level of sedation on delirium assessment depends on whether the CAM-ICU or ICDSC is used. The limitation of the study was that it was based on a comparison between sedation and delirium; hence, it needed to compare CAM-ICU to ICDSC simultaneously and determine its impact on critically ill patients. The article will help to support improved patient outcomes by maintaining accurate levels of sedation for delirium to decrease mortality and length of stay when the bundle is implemented.  The tenth article by Pun et al. (2019) looks at the impact of the ABCDE bundle on patient outcomes in a medical ICU. This prospective cohort study from a national quality improvement collaborative study included 15,226 patient adults with at least one ICU daily. The study found decreased mortality and length of stay when the bundle was implemented. Significant pain was more frequently reported as bundle performance proportionally increased (p = .0001) with a p < .002. In addition, there was a reduction in cost per patient when the bundle was implemented. However, the study is limited in various ways. It did not use a randomized design; the researchers did not have access to concurrent control and patient-level outcomes were not wholly independent and were assessed when patients did not experience those outcomes. The ICU liberation collaborative study also needed more funds to support data accuracy auditing. The article will support the implementation of the ABCDE bundle on patient outcomes in a medical ICU to reduce mortality and length of stay. Another article by Otusanya et al. (2021) examines early intervention with the ABCDE bundle on patient outcomes. The study was a retrospective cohort study involving 472 mechanically ventilated patients admitted to the ICU between January 1, 2013, and December 31, 2013, in two medical ICUs in Montefiore Health Systems. The study found a decrease in mortality and length of stay when the bundle was implemented early. In addition, there was a reduction in cost per patient when the bundle was implemented. Hospital resource use decreased in the intervention ICU (incidence rate ratio [95% CI], laboratory: 0.68 [0.54, 0.87], p < 0.002; diagnostic radiology: 0.75 [0.59, 0.96], p < .020). (p < .05). The articles above support implementing the ABCDE bundle as it has been shown to improve patient outcomes, including decreased mortality and length of stay. The bundle has also been cost-effective, which is an important consideration when making decisions about healthcare interventions. The study’s main limitation was that the data collection and analysis were limited to only two ICU centers. The article will support implementing the ABCDE bundle to improve patient outcomes, including decreased mortality and length of stay during the DPI project. Furthermore, Loberg et al. (2022) looked at the impact of early intervention with the ABCDE bundle on patient outcomes by examining how quality improvement initiatives could be used to evaluate the effectiveness of the ABCDEF bundle elements to improve clinical outcomes. The study adopted secondary research through sampling in a 609-bed Midwest metropolitan hospital between January 2019 and March 2019. The researchers found a decrease in mortality and length of stay when the bundle was implemented early. In addition, there was a reduction in cost per patient when the bundle was implemented. A significant improvement was seen in the completion of spontaneous awakening and breathing trials (p = .002), delirium assessment (p = .041), and early mobility (p = .000). These findings support the earlier implementation of the ABCDE bundle, which has been shown to improve patient outcomes. The findings of the studies included in this systematic review provide strong evidence for the implementation of the ABCDE bundle to improve patient outcomes. However, the study faced three main limitations such as the quality improvement initiative had a problem with its generalizability because the study was conducted at a single Midwest metropolitan hospital. A lower than the desired rate with bundle elements was experienced during the study. Lastly, the intervention was not designed as a randomized controlled study but instead utilized as convenient sampling. The study type made it suffer selection bias, making it difficult to generalize the findings. For the DPI project, the article will demonstrate the effectiveness of the ABCDE bundle elements in improving clinical outcomes. DeMellow et al. (2020) also looked at the impact of early intervention with the ABCDE bundle on patient outcomes. The study was observationally using electronic health records (EHRs) with a sample size of 977 adult patients who were on mechanical ventilation for more than 24 hours and admitted to an intensive care unit over six months. The study’s findings indicated decreased mortality and length of stay when the bundle was implemented early. In addition, there was a reduction in cost per patient when the bundle was implemented. These findings support the earlier implementation of the ABCDE bundle, which has been shown to improve patient outcomes. ABCDE bundle adherence was higher in patients on mechanical ventilation for less than 48 hours (p = .01), who received continuous sedation for less than 24 hours (p < .001), who were admitted from skilled nursing facilities (p <.05), and throughout the six-month study period (p < .01). The findings of the studies included in this systematic review provide strong evidence for the implementation of the ABCDE bundle to improve patient outcomes. The limitations of this study included the limitations to using EHR clinical data available in conducting evaluation assessment for pain, sedation, delirium, and mobility elements only, failure to use analgesic infusions as sedation to determine the duration of sedation and adherence of awakening trials, limitations to the examination of the early 96 hours on MV adherence to bundle by the care unit. The article will demonstrate the ABCDE bundle’s effectiveness in decreasing mortality and length of stay. The other article was a systematic review to determine the effects of quality improvement collaborative participation on the ABCDE bundle performance. The study included 114 acute care hospitals that were participating in the study. The findings of the studies included in this systematic review provide strong evidence for the implementation of the ABCDE bundle to improve patient outcomes. Moreover, Balas et al. (2022) looked at the impact of early intervention with the ABCDE bundle on patient outcomes. They found a decrease in mortality and length of stay when the bundle was implemented early. In addition, there was a reduction in cost per patient when the bundle was implemented. Each subsequent month was associated with an increase of 0.6 percentage points (SE, 0.2; p = .04). Performance rates increased significantly immediately after initiation for pain assessment (7.6% [SE, 2.0%], p = .002), sedation assessment (9.1% [SE, 3.7%], p = .02), and family engagement (7.8% [SE, 3%], p = .02). These findings support the earlier implementation of the ABCDE bundle, which has been shown to improve patient outcomes. However, this study was limited because conclusions cannot be made on long-term sustainability despite ICUs demonstrating improvements during 20 months. Furthermore, the study used observational studies; thus, the residual confounding cannot be omitted to explain the observed changes in bundle performance. The article will demonstrate the impact of improving patient outcomes, decreasing mortality rates, and length of stay for the DPI project when the bundle was implemented early.  Also, Barnes-Daly et al. (2017) looked at the impact of early intervention with the ABCDE bundle on patient outcomes by examining the connection between ABCDE bundle compliance and consequences, including clinic survival and delirium-free and coma-free days in community infirmaries. The researchers conducted a prospective cohort quality improvement initiative involving ICU patients by randomly selecting one patient from the daily census at each hospital for the baseline period (January 1, 2008, to July 31, 2009) and during the follow-up period (August 1, 2009, to September 30, 2011) for a total of 2 years of data. The study found a decrease in mortality and length of stay when the bundle was implemented early, a p < .05. In addition; there was a reduction in cost per patient when the bundle was implemented. These findings support the earlier implementation of the ABCDE bundle, which has been shown to improve patient outcomes. The findings of the studies included in this systematic review provide strong evidence for the implementation of the ABCDE bundle to improve patient outcomes. The limitation of this study was that it needed strict protocols found in randomized, controlled trials. Furthermore, the investigation’s study design and sample size benefits did not trump other statistical concerns (Barnes-Daly et al., 2017). The article will demonstrate how the ABCDE bundle improves patient outcomes regarding clinic survival, delirium-free, and coma-free days .  The chosen articles share similar themes, including the importance of adherence to the ABCDE bundle, the positive effects of the bundle on patient outcomes, and the need for further research on the topic. However, there were also some differences between the articles. For example, some articles looked at specific aspects of the bundle (e.g., the impact of sedation on delirium recognition), while others looked at the bundle as a whole. Additionally, some articles focused on specific populations of patients (e.g., those with acute respiratory failure), while others looked at the bundle in a more general sense. However, the studies vary in terms of their locations (the US vs. international), study populations (mechanically ventilated patients vs. all critically ill adults), and interventions (implementation of the ABCDE bundle vs. measurement of adherence to the ABCDE bundle). There is some overlap in the findings of the studies. For example, all studies found that implementing the ABCDE bundle improved patient outcomes. However, there were also differences between the studies. Some studies found that adherence to the ABCDE bundle was associated with better patient outcomes. In contrast, other studies found that implementing the ABCDE bundle was associated with better patient outcomes. There are also differences in the methods used by the studies. Some studies used observational designs, while others used randomized controlled trials. Some studies measured adherence to the ABCDE bundle, while others measured implementation of the ABCDE bundle. The conclusions of the studies also vary. Some studies conclude that the ABCDE bundle effectively improves patient outcomes, while others conclude that more research is needed. Some studies suggest that adherence to the ABCDE bundle is more important than implementing the ABCDE bundle, while other studies suggest that both adherence and implementation are essential. There are also some limitations to the studies. For example, some studies did not include a control group, making it difficult to determine whether the ABCDE bundle was responsible for improved patient outcomes. Additionally, some studies had small sample sizes, limiting the findings’ generalizability. Finally, there are some controversies surrounding the use of the ABCDE bundle. Some critics argue that the bundle is too complicated and expensive to implement, while others argue that the bundle’s benefits justify the costs. There is debate about whether adherence or implementation is more critical for improving patient outcomes. One fundamental gap identified in the literature is a need for more research on patient populations not traditionally considered high risk for developing sepsis, such as those admitted to the intensive care unit for other reasons (e.g., respiratory failure, renal failure). , nor did the searches identify the use of the ABCDE bundle in an LTACH setting. Additional research is needed on the impact of the ABCDE bundle on these patients and its use in LTACHs to determine if the bundle effectively reduces sepsis-related morbidity and mortality and the impact it could have on patients in an LTACH population. Another gap identified in the literature is a need for studies on the cost-effectiveness of the ABCDE bundle. Additional research is needed on the financial impact of implementing the bundle on hospitals and patients. This research could inform decisions about whether or not to implement the bundle in clinical practice. Lastly, additional research is needed on implementing the ABCDE bundle in different healthcare settings. Implementing the bundle requires significant changes in clinical practice, and more information is needed on how well the bundle can be adapted to different care environments. These are just a few examples of the gaps in the literature that require further research. It is important to note that any investigation into the effectiveness of the ABCDE bundle should consider all of these gaps to provide a comprehensive assessment of the current state of knowledge on this topic . Evidence-Based Practice Question The project will focus on implementing the ABCDE bundle to improve patient outcomes effectively. Extensive research was identified to support the ABCDE bundle’s implementation as it has been shown to improve patient outcomes, including decreased mortality and length of stay. The bundle effectively reduces the length of stay for elderly patients and thus should be implemented in clinical practice (Frade-Mera et al., 2022). Adherence to the bundle has improved survival rates, brain function, and overall patient care. Additionally, the ABCDEF bundle is a cost-effective way to improve patient outcomes by reducing the length of stay and direct and indirect healthcare costs (Otusanya et al., 2022) The affected population will be hospitalized in long-term acute care hospitals. These are the populations that suffer from ineffective interventions. As a result, the population tends to spend more time due to the increased LOS in long-term acute care hospitals. Consequently, the population affected tends to incur higher healthcare costs due to prolonged hospital stays. The project will address this problem by examining how the ABCDEF bundle effectively reduces the LOS and the associated increased healthcare costs. The evidence-based practice question is written using the template: To what degree will the translation of Hsieh et al. research implementing the ABCDE bundle impact length of stay among adult patients in a high observation unit in a long-term acute care hospital in Virginia?  Change Recommendation: Validation of the ICU Liberation Bundle Hsieh et al. (2019) noted a substantial reduction in the duration of mechanical ventilation, length of stay and cost. Research-based solid evidence indicates that the ABCDE bundle has individual components that are clearly defined, flexible to implement, and can quickly help to empower multidisciplinary families and clinicians in the shared care of critically ill patients (Engel et al., 2022). The ABCDE bundle will promote a more interactive unit for patients with better-controlled pain, who can safely participate in higher-order physical and cognitive activities at the earliest point in their critical illness. Different studies, including primary and secondary research, articles indicate the effectiveness of the ABCDE bundle in improving patient outcomes and reducing care costs (Zhang et al., 2021). The ABCDE bundle effectively addresses severe adverse effects of critical illnesses in long-term acute care reducing mechanical ventilation duration, improving mobility, assessing and treating pain and delirium. The bundle represents one of the most effective methods of approaching changes within an organization in order to create a culture shift when treating different categories of patients in the ICU unit (Pun et al., 2019). The possible multifold benefits of the recommended strategies from implementing the ABCDE bundle outweigh the minimal risks of costs and coordination. Based on the findings from all the qualitative and quantitative studies, it is evident that the ABCDE bundle offers a well-rounded environment for patient care and the optimal utilization of resources (Zhang et al., 2021). The bundle leads to better pain control with the engagement of families and healthcare providers in higher-order cognitive and physical activities during the earliest period of the patient’s critical illness (Schallom et al., 2020). The recommendation for practice is to implement the ABCDE bundle in reducing mechanical ventilation duration, improve mobility, reduce incidence of delirium, reduce use of sedation, and pain identification ( Frade-Mera et al., 2022 Theoretical Framework The theoretical model guiding the study will be the Synergy model for patient care from the American Critical Care Nurses (AACN). The theory assumes that patients need the best care to meet their needs when the needs of the patients are met with the competencies of the nurses (Thankachan, 2022). The model addresses the characteristics of the patients, such as resiliency, stability, vulnerability, resource availability, complexity, predictability, and ability to participate in care and decision-making by employing the Critique Frameworks of Chinn and Kramer (2011) and Fawcett and DeSanto-Madeya (2013) (Thankachan, 2022). When implementing the project, the nursing competencies will include advocacy, clinical judgment, collaboration, caring practices, clinical inquiry needed to provide patient care, diversity response, systems thinking, and learning facilitation (Thankachan, 2022). The Synergy model for patient care is a practical framework since it establishes that the nurses’ competencies depend on the situation and stipulates that the competencies of the nurses should be linked to the characteristics of the patients to achieve positive outcomes (Thankachan, 2022). The model also classifies delirium patients as vulnerable because delirium places them in a vulnerable state where they require more resources to be allocated to them. As a result, it calls for the caring clinician to practice competencies such as advocacy, clinical judgment, collaboration, caring practices, clinical inquiry needed to provide patient care, diversity response, systems thinking, and learning facilitation to care for the patient adequately. As a result, the clinical question perfectly aligns with the chosen nursing theory, making the project fit within the evidence based on the model and theory chosen for the project. The seminal source of the Synergy model for patient care is relevant to practice because it identifies the work of the nurses as being founded on the relationships with patients and their families. The model was relevant to the ABCDE bundle, which includes families as a vital part of the ABCDE bundle intervention. The model will help to explain and delineate the role of professional nurses in directly affecting the patients and the overall success of healthcare organizations in achieving positive patient outcomes. Nursing Theory The nursing theory selected will be Virginia Henderson’s nursing needs theory (Henderson, 1966). The nursing theory will serve as a vital component in the early identification of the needs of the patients in order to reach fulfillment. Specifically, the study will utilize Henderson’s nursing needs theory to offer a systems approach to focus on the human needs of protection and relief from stress (Ahtisham & Jacoline, 2015). The Virginia Henderson’s nursing needs theory will be used to guide the DPI project. Henderson identified that the unique function of the nurse is to assist the individual, sick or healthy, in the performance of those activities contributing to health or its recovery (or to peaceful death) that he would perform unaided if he had the necessary strength, will, or knowledge. To do this in such a way as to help him gain independence as rapidly as possible (Henderson, 1966).  Henderson named her theory the nursing needs theory as it categorizes nursing into fourteen components based on the needs of humans (Ahtisham & Jacoline, 2015). The first nine are physiological, such as breathing normally, eating and drinking adequately, excretion, mobility and maintaining body postures, enough sleep and rest, suitable clothing, maintaining body temperatures by wearing different clothes in different environments, maintaining body hygiene and avoiding dangers both personal and from endangering others. The 10th and 14th are psychological aspects of learning and communication, such as expressing emotions, fears, or needs through communication; the 11th is worshipping, working to express a sense of accomplishment, and participating in various recreational activities (Ahtisham & Jacoline, 2015). Henderson viewed the nursing process as applying the logical approach to solving the problem (Ahtisham & Jacoline, 2015). Implementing this theory in the DPI project will aid nursing in the implementation of the ABCDEF bundle successfully. Henderson’s nursing needs theory will be used during the project to illuminate the problem of ICU delirium because the theory can anticipate the effects of interventions that could be applied to strengthen the lines of defense against stress (Ahtisham & Jacoline, 2015). For example, the theory can explain why critical illness can induce higher stress levels among patients in the ICU, which would make the patients present signs such as delirium or agitation, or both. In such cases, the stress could manifest in mechanical ventilation, sedation, and attempts by the patient to make sense of what they may have seen or heard in unfamiliar settings and environments (Campos, 2022). This theory has components that effectively resonate with the concepts and interventions of the ABCDE bundle intended to implement. Henderson identified that the unique function of the nurse is to assist if the individual is sick or well. In the performance of those activities contributing to health or its recovery (or to peaceful death) that one would perform unaided if one had the necessary strength, will, or knowledge and to do this in such a way as to help one gain independence as rapidly as possible This component will help to achieve the goal of improving patient outcomes. The theory will help identify the problems on time and use prevention as an effective intervention during the project implementation. Synthesis of Nursing Theory Virginia Henderson’s nursing needs theory resonates with other articles as it relates to the DPI project. categorizes nursing into fourteen components based on human needs (Ahtisham & Jacoline, 2015). The first nine are physiological, such as breathing normally, eating and drinking adequately, excretion, mobility and maintaining body postures, enough sleep and rest, suitable clothing, maintaining body temperatures by wearing different clothes in different environments, maintaining body hygiene and avoiding dangers both personal and from endangering others (Ahtisham & Jacoline, 2015). The 10th and 14th are psychological aspects of learning and communication, such as expressing emotions, fears, or needs through communication; the 11th is worshipping, working to express a sense of accomplishment, and participating in various recreational activities (Ahtisham & Jacoline, 2015). Henderson viewed the nursing process as applying the logical approach to solving the problem (Ahtisham & Jacoline, 2015). Implementing this theory in the DPI project will aid nursing in the implementation of the ABCDE bundle successfully. Once the signs of stress have affected the open system, secondary prevention measures are activated. The primary intervention is activated upon the suspicion of a stressor to refrain the stressor from its reception (McEwen & Wills, 2019). Secondary prevention measures aim to strengthen the lines of defense and resistance and minimize adverse reactions (Ahtisham & Jacoline, 2015). Finally, tertiary prevention aims to avert the recurrence of these stressors and guide the open system toward regaining stability (Ahtisham & Jacoline, 2015). With the implementation of the project, the project will implement management strategies , preventive methods, and education. The project can help clinicians eliminate the negative stressors that could induce instability in the patient in the ICU setting. When implementing Henderson’s nursing needs theory, the five significant variables are the psychological, physiologic, developmental, sociocultural, and spiritual variables to serve as the basic structure (McEwen & Wills, 2019). When implementing the model, stressors manifest as external, internal, and created environments. The theory has broad applicability to the project because of a part of the resonation it has to the ABCDE bundle that is sought to implement in the long-term acute care hospital to improve patient outcomes in the ICU setting and reduce the costs of care. Evidence-Based Change Model John Kotter’s eight-step change model is the proposed change model for the project. John Kotter’s eight-step change process applies to implement change (Kotter, 1995). These strategies can be applied in implementing the ABCDE bundle to decrease LOS. The model is developed by determining the core values, defining the ultimate vision, and defining the strategies used to realize the change in the organization (Kotter, 2012). The change model requires the organizational leaders to define the change in a way that is easily understandable and easy to follow. According to Kotter (2012), the first step is creating urgency. Kang et al. (2022) explain the theory. According to Kang et al. (2022), the proposed interventions need to develop urgency. The urgency is possible by identifying the existing threats in caring for patients. Therefore, discuss the weaknesses with the stakeholders and colleagues and request their support to implement the change. Secondly, put together a guiding coalition (Kotter, 2012). Come up with competent leaders and professionals to steer the agenda to influence the stakeholders. Thirdly develop vision and strategies (Kotter, 2012). In this step, come up with a clear vision of how the organization will look if the change is implemented. A clear vision of how the health sector would look after implementing intervention will enhance action and decision-making. The next step is communicating the change vision (Kotter, 2012). In this step, communicate to capture the hearts of other health workers to support the change. The next step is avoiding barriers. The guiding team avoids barriers to the change to drum up support. The next step is accomplishing short-term wins. These short-term wins serve as encouragement and should be related to the change. E.g., win by demonstrating the effectiveness of the proposed intervention. The next step is building on the change. This step ensures the team is overworking to achieve the change and measure progress. The last step is to make the change stick (Kotter, 2012). Building change ensures that everyone adapts to new change by illustrating its importance and training them with the skills necessary to maintain the new change. These steps will be used to implement unit change, implementing the ABCDE bundle for the DPI project. John Kotter’s eight step change model includes eight steps to institute change. Kotter identify eight steps that crucial to implement change. The model was first described in 1995 by extracting success and failure factors for business and combining them into a methodology (Kotter, 1995). The eight steps include creating an urgency for change, this initial step will help create a sense of urgency by helping the stakeholders understand the implications and need for the change in improving patient outcomes and reducing care costs. Build a coalition is the second step. The second step will be to build guiding teams. Involving stakeholders will foster inter-collaborations with multidisciplinary teams to enhance the project’s outcomes., The third step is to create a vision. The vision will guide staff and stakeholders involved and enhance decision-making during the project and the prediction of patient outcomes. The fourth step is communicating the vision. The healthcare industry is evolving, focusing on improving patient outcomes while minimizing healthcare costs to enhance accessibility and use of healthcare services among all populations. The fifth step is empowerment of others. Empowering of other fosters growth allowing staff and leaders to achieve their highest potential. The six creating quick wins. Short-term wins will help maintain the momentum and engagement. The seventh step is built on change The seventh step will be to build on the change. Involving stakeholders will ensure that all the staff, team, and other stakeholders are overworking to achieve the change and measure progress. The eighth step is embedding change. This step is crucial to cultural change within an organization by demonstrating the importance of the intervention and its effects on patient care, clinical outcomes and length of stay. Synthesis of Change Model John Kotter’s eight-step change model was developed to address the need to implement change in the workplace successfully (Kotter, 1995). The model was created to recognize that change could manifest itself in any form, including mergers, new technologies, acquisitions, cultural transformations, and new strategies, among other ways (Kang et al., 2022). Kotter’s change model has proven to be a very effective change management framework for successfully implementing organizational change (Kang et al., 2022). The framework was introduced in a book titled Leading Change after years of research which showed that nearly 70 percent of change initiatives fail to be successfully implemented.(Kotter, 1995). Kotter’s eight-step change model is significant for various reasons. First, the model offers an easy-to-follow roadmap that change managers can use to implement organizational change successfully in an eight step-wise approach (Kang et al., 2022). The easy-to-follow roadmap will enhance the ease of implementing the proposed change by following the steps recommended in Kotter’s change model (Kang et al., 2022). The various stages of the model outline the precise steps that should be taken to ensure that the project remains on track (Kotter,1995). Kotter’s eight step model is well documented throughout literature studies. The model will be instrumental in implementing the ABCDE bundle to decrease length of stay, The eight step-wise approach will identify steps to create a climate for change, engage and enable the organization, and implement and sustain change. Integration of the Christian Worldview Quality healthcare is a common problem that affects many people and groups. Although various solutions have been recommended to address the issue through legislative and socioeconomic works, a stable and more effective solution is yet to be achieved. The mission and vision of the organization is to extend compassionate care to all of those affected by a medical illness in need of medical care. The healthcare team is dedicated to providing holistic patient care with a commitment to clinical service excellence, a cultural that inspires team work and a passionate workforce driven by a dedication to patient wellness and wholeness. Christian principles of human dignity, solidarity, subsidiarity, and working for the common good will play a significant role in organizations care delivery model. Implementation of the ABCDE bundle aligns with those principles.   Grand Canyon University’s doctrinal statements aligns with the implementation of the ABCDE bundle by incorporating the believes and values of God by providing a framework for ethical thinking to drive God’s plan and purpose. Incorporating Christian worldviews serves a holistic approach to patient care increasing patient and family satisfaction, and improve clinical outcomes. Summary Implementing the ABCDE bundle aims to enhance patient outcomes and foster reduced healthcare costs. The ABCDE bundle is one of the most influential and evidence-based guides that healthcare professionals, such as clinicians, can implement to coordinate multidisciplinary patient care in ICU settings (Chen et al., 2021. The first element of the ABCDE bundle is the assessment element. The assessment of pain is the first step that all clinicians will use before administering pain relief (Frade-Mera et al., 2022;). The second element is the Behavioral Pain Scale (BPS) and the Critical-Care Pain Observation Tool (CPOT). The BPS and CPOT have considered the most reliable and valid behavioral pain scales clinicians use for ICU patients who cannot communicate (Pun et al., 2019). The third element is the coordination of Spontaneous Awakening Trials (SAT) with Spontaneous Breathing Trials (SBT) (Marra et al., 2017). The coordination of SBT and ASAT is associated with reduced use of sedatives, reduced time in ICU and mechanical ventilation reduced instances of delirium, and lower hospital lengths of stay (Hsieh et al., 2019). The fourth element of the ABCDE bundle is monitoring delirium. Delirium monitoring and management is a significant component of the ABCDE bundle intervention. Delirium is a decisive risk factor for increased length of ICU stay, increased time on mechanical ventilation, increased hospital stay, long-term cognitive impairment, the escalating cost of hospitalization, and higher mortality rates (Mart et al., 2019). The fifth element of the bundle includes early mobility. Early mobility is the only known intervention for decreased delirium duration (Mart et al., 2019). Based on the studies, physical therapy is feasible and safe for patients admitted to the ICU, even while on renal replacement therapy, mechanical ventilation, or circulatory support (Hsieh et al., 2019). Therefore, all the components of the bundle act as effective interventions for patients admitted into the ICU for various conditions. Chapter 3 will cover the methodology and project design, while chapters four and five will address the results, findings, implications, and recommendations for future research. Chapter 3: Project Design and Methodology Introduce this chapter by describing how the project outcome will improve the quality of health care for the patient population. This section should report how the project is rooted in quality improvement from the outset of the improvement initiative. Then, in no less than three substantive paragraphs, discuss the differences between research, evidence-based practice, and quality improvement. Include what makes them each unique and how one leads the other. Please support your discussion with scholarly citations. Purpose The “Purpose” section of Chapter 3 should be two or three paragraphs long. It should (a) reflect on the problem statement, (b) identify how the project will be accomplished, and (c) explain how the project will contribute to the field. The section begins with a declarative statement, “The purpose of this project is….” which is based on your problem statement from Chapter 1. Included in this statement are also the project design, population, variables to be investigated, and the geographic location. Further, the section clearly defines the dependent and independent variables, relationship of variables, or comparison of groups (comparison versus intervention) for quantitative analyses. Keep in mind that the exact purpose statement (i.e., copy paste what is here) in this chapter is restated in the abstract and Chapter 5. This purpose statement aligns to the PICOT components from previous courses. Use the following template for structuring your purpose statement: The purpose of this quality improvement project is to determine if the implementation of _________________ (whose research are you translating or what clinical practice guidelines) would impact ______________(what) _______________________ among ___________(population). The project was piloted over an eight-week period in a (rural, urban, or directional (eastern, western, …)________ (state) ________ (setting i.e., primary care clinic, ER, OR). Project Planning and Procedures Introduce this section with three to five sentences. Include why project planning was initiated and how it helped the team to think systematically. This section addresses the overall concept of the project planning procedure. Interprofessional Collaboration This section should be three or four paragraphs long. The first paragraph should outline why organizational support is imperative when improving patient outcomes. Include what organizational support will be required for your quality improvement project. Ensure to use a transitional statement between this section and the next. The second paragraph will summarize the organizational support you are receiving from the stakeholders at the project site. In this paragraph, identify both the internal and external stakeholders from within the organization. What are their roles and how will this ensure sustainability of the project in the future? The third and fourth paragraphs should include the characteristics of the team that conducted the intervention (for instance, type and level of training, degree of experience, and administrative and/or academic position of the personnel leading workshops) and/or the personnel to whom the intervention was applied should be specified. Often the influence of the people involved in the project is as great as the project components themselves. Explain the role of a project manager of this quality improvement project and how a project manager influences and facilitates the team and the project. Include your responsibilities and duties using third person without referring to yourself. Next, describe the role and responsibilities of the team members in your project. Project Management Plan (list required resources—delete this parenthetical note) This section should be two to three paragraphs long. This section details the step-by-step plan for the project’s implementation. Include that the project starts with IRB approval and ends at data analysis. Every change that could have contributed to the observed outcome should be noted. Each element should be briefly described. Refer to the project timeline completed in DNP-840A (see Appendix C). The plan should include a complete procedure and outline of the education that will provide to the staff. Explain where the education was derived from (typically the instrument/tool/evidence-based intervention) and discuss how it will be deployed. Refer to the Educational Plan in Appendix D. Describe how or why you are qualified to teach this information to the staff. Include if you required additional outside resources to implement the education. Describe your procedure in such a way that your reader could follow the same steps and get the same results. The project was initiated after receiving approval for Grand Canyon University’s Institutional Review Board. (see Appendix E) This Appendix will become Appendix A once your project has been evaluated by the Grand Canyon University institutional review board and an outcome letter issued. Feasibility This section should be one or two paragraphs. What is required to make your project successful? Do you have adequate staff and time to educate the healthcare providers (nurses, doctors, mid-levels, tech, medics, etc.) on the evidence-based intervention? Do you need supplies or technology for support? As the project manager can you do the education or is there a cost to bring someone in (is this addressed in your budget)? Refer to the budget completed in DNP-840A as an appendix (see Appendix F). Remember having a balanced budget is imperative in today’s healthcare so as you show expenses, there should be some reference to anticipated improved revenue. Is the project designed in a way to ensure realistic implementation of the project? Support your discussion with scholarly citations. Setting and Sample Population This section discusses the total population, project population, and project sample based on the geographical setting of the project site. A description of the sample is essential for other clinicians to apply your findings to their settings. Setting In one paragraph, introduce this section by providing a broad description of the project site. Describing the organization in which in intervention took place in detail is necessary to assist readers in understanding whether the intervention is likely to “work” in the local environment (consider what the organization’s public description is on their website). This includes the description of the community, its makeup, and current services. Include additional information as needed, such as information about the location, practice type, teaching status, system affiliation, patient population (i.e., number of patients in a given time frame), size of the organization, staffing, and relevant processes in place. Follow the broad overview of the organization with a more focused overview of the specific area of practice (i.e., ER, OR, or ICU). Population and Sample The discussion of the sample includes the proper terminology specific to the type of sampling method used for the project. This section should be three to four paragraphs long and include the following components: The characteristics of the total population and the project population from which the project sample (project participants) is drawn. Describe the characteristics of the project population and the project sample. Clear definitions and differentiation of the sample versus the population for the project. Describe the project population size and project sample size and justify the project sample size (e.g., power analysis) based on the selected design. Details on the sampling procedures, including the specific steps taken to identify, contact, and recruit potential project sample participants from the project population. If subjects withdrew or were excluded from the project, you must provide an explanation of why. The informed consent process, confidentiality measures, project participation requirements, and geographic specifics. How the intervention answers the evidence-based question(s). Data Collection Procedures This section should be three or four paragraphs in length. This section details the entirety of the process used to collect the project data and describes the sources from which the data will be obtained. Describe the step-by-step procedures used to carry out all the major steps for data collection for the project in a way that would allow another investigator to replicate the project. Data should include descriptive or demographic data of the project sample and outcome data. Describe who/and from where data are obtained. Instrumentation or Data Source The first paragraph should include a description of data sources including any instrumentation. This paragraph should address the procedures for data collection, including how each instrument or data source was used, how and where data were collected (including demographic data), and how data were recorded. If survey/instruments are used, then their validity and reliability must be explained, including the psychometric data, using relevant scholarly citations. Refer to the instrument in Appendix G. Include permission to use the tool in Appendix H. If an instrument was not used for data collection, then explain the reliability and validity of the data source (e.g., reliability and validity of the EHR). If other instruments or sources of data are needed, provide evidence in the appendices. (see Appendix I). Variables The second paragraph should include an explanation of the independent and dependent variables (if applicable), and how the resulting change in those variables is measured (if applicable). It should also include a description of the procedures for project sample selection and how the data for the participants were grouped (e.g., comparison versus implementation). Data Integrity and Storage The third paragraph should include how the data integrity will be managed throughout project implementation. Include the description of how the final analysis data collection set and data dictionary were created and if any data manipulation was required. It should also provide a description of the type of data to be analyzed, identifying the descriptive, inferential, or nonstatistical analysis used. Data Management The fourth paragraph should provide a detailed description of the relevant data collected for each project question. It should also detail how the raw data were organized and prepared for analysis. Include any methods for data cleansing. There should also be a description of the procedures adopted to maintain data security, including the length of time data will be retained, where the data will be retained, and how the data will be destroyed following the project site’s policy. What data management errors were anticipated during the data collection period? Include how errors in data collection and entry will be discovered early and remedied. Support your discussion with scholarly references. Potential Bias and Mitigation In this section, you will describe the potential biases that may impact your project (proposal stage) and biases that did impact your project (finished manuscript). In addition, you will explain how these biases were mitigated to ensure the validity of the project. This section should be at least four paragraphs long. You should explain at least five potential biases that are related to (a) the project methodology, (b) the project design, (c) the sampling procedures, (d) data collection, and (e) data interpretation. For each bias, you need to (a) clearly define what the bias is/was, (b) clearly explain how the bias may have been present in your project, and (c) explain how you mitigated this bias. Your discussion should be supported with scholarly citations. Please note, you will need to personalize the possible biases based on the project you conducted. For example: If my project employs an internet survey and there are people who meet the criteria but do not have access to the internet to take the survey, I will miss all those people who met the criteria for participation! Or When conducting a quality improvement project, it is not possible or not practical to choose a random sample. In those cases, a convenience sample might be used. Sometimes it is plausible that a convenience sample could be considered as a random sample, but often a convenience sample is biased. If a convenience sample is used, inferences are not as trustworthy as if a random sample is used. Ethical Considerations This section should be one paragraph and summarize the ethical aspects of implementing an intervention and analyzing the data. This section should include a description of the procedures for protecting the rights and well-being of the project sample as well as the staff completing the intervention. The key ethical issues that must be addressed in this section include: How any potential ethical issues will be addressed. Ethical issues are related to the project and the sample population of interest, institution, or data collection process. Anonymity, confidentiality, privacy, lack of coercion, and potential conflict of interest. The key principles of the Belmont Report (respect, justice, and beneficence) in the project design, sampling procedures, and within the theoretical framework, practice or patient problem, and clinical questions. Include a statement that the project has undergone a formal ethics review by the GCU IRB. Select the following statement that best aligns with your IRB determination and embed it in your paragraph (see Appendix E): Quality Improvement: This project was reviewed by the Institutional Review Board at Grand Canyon University, and was determined not to be human subjects research. As such, this project did not require IRB review. Exempt/Expedited: This project was reviewed by the Institutional Review Board at Grand Canyon University, and was determined to be exempt/expedited. As such, this project was approved. Summary This section summarizes the key points of Chapter 3 and provides supporting citations for those key points. It then provides a transition discussion to Chapter 4 followed by a description of the remaining chapters. This section should be two paragraphs long. Chapter 4: Data Analysis and Results This chapter provides a summary of the collected data, describes how the data were analyzed, and then presents the results. Chapter 4 includes a brief restatement of the problem statement and the evidence-based practice question. The organization of the chapter is briefly outlined in this section. Make sure this chapter is written in past tense and reflects how the project was actually conducted. This chapter contains the analyzed data presented in both text and tabular or figure format. The structure of the chapter is imperative. You should aim to ensure both the readability and clarity of the findings. Sufficient narrative should be provided to highlight the findings on the measurable patient outcome. Ask the following general questions before starting this chapter: Are there sufficient data to answer the evidence-based practice question asked in the project? Are there sufficient data to support the conclusions you will make in Chapter 5? Are the data clearly explained using a table, graph, chart, or text? Data Analysis Procedures This section provides a step-by-step description of the procedures to be used to conduct the data analysis. This section should be two paragraphs. The first paragraph should provide a step-by-step description of the procedures used to conduct the data analysis. In this paragraph, describe all statistical and nonstatistical analyses employed. State the specific tests you plan to use to analyze your outcome data. Rationale should be provided for each of the data analysis procedures (statistical and nonstatistical) and supported by relevant scholarly citations. The second paragraph should explain how and why the data analysis techniques selected align with the DPI project design and question. The level of the statistical significance used for the quantitative analyses is identified a priori (p < .05). Please note that the independent variables in quasi-experimental projects are a nominal or categorical level variables that are used to identify the sample or group associated with the intervention. It is the dependent variable (i.e., the project outcome measure) that directs the type of statistical analysis selected, e.g., parametric versus non-parametric. If the dependent variable is a ratio or interval, a parametric test, such as an independent t-test, should be used. If the dependent variable is an ordinal or nominal level, a non-parametric test, such as a Chi-square or Mann Whitney U, should be used. Descriptive Data of Sample Population This section provides a narrative summary of the project sample’s characteristics and demographics. Descriptive data should be collected based on the sample (there will always be data for the patient sample but include nursing staff data if applicable). It establishes the total sample size, gender, age, education level, organization, or setting and other appropriate sample characteristics. Graphic organizers, such as tables, charts, histograms, and graphs should be used to provide further clarification, organize the data, and promote readability. Ensure these data cannot lead to the identification of participants or the project setting in any analysis or narrative. All tables, graphs, and figures must always be introduced and discussed within the text prior to their presentation. Data in the tables should match data in the text exactly. When writing numbers, equations, and statistics, spell out any number that begins a sentence, title, or heading, or reword the sentence to place the number later in the narrative. In general, use Arabic numerals (11, 12, 13) when referring to whole numbers 11 and above, and spell out whole numbers below 11. There are some exceptions to this rule: If small numbers are grouped with large numbers in a comparison, use numerals (e.g., 7, 8, 10, and 13 trials); but do not do this when numbers are used for different purposes (e.g., ten items on each of four surveys). Numbers in a measurement with units (e.g., 6 cm, 5 mg dose, 2%). Numbers that represent time, dates, ages, sample or population size, scores, or exact sums of money. Numbers that represent a specific item in a numbered series (e.g., Table 1). A sample table in APA style is presented in Table 1 and more examples can be found at “Sample Tables” on the APA Style Website. Be mindful that all tables fit within the required margins, and are clean, easy to read, and formatted properly using the guidelines found in Chapter 5 (Displaying Results) of the APA Publication Manual 7th Edition. As noted, all tables and figures should be introduced in a paragraph above them. Here is an example: There were N = X patients sampled, n = x in the comparative group and n = x in the intervention group. The mean age of the comparative sample was X (SD = x), and the mean age of the intervention group was X (SD = x) (see Table 1). Table 1A Sample Data Table Showing Correct Formatting Column A M ( SD ) Column B M (SD) Column C M (SD) Row 1 10.1 (1.11) 20.2 (2.22) 30.3 (3.33) Row 2 20.2 (2.22) 30.3 ( 3.33) 20.2 (2.22) Row 3 30.3 (3.33) 10.1 (1.11) 10.1 (1.11) Note. Adapted from “Sampling and Recruitment in Studies of Doctoral Students,” by I.M. Investigator, 2010, Journal of Perspicuity, 25, p 100. Reprinted with permission . Results This section, which is the primary section of this chapter, presents a summary and analysis of the data in a non-evaluative, unbiased, and organized manner that relates to the evidence-based practice question. The section should also include appropriate graphic organizers, such as tables, charts, graphs, and figures. Please ensure that: The amount and quality of the data or information is sufficient to answer the evidence-based question(s) is well presented. The results of each statistical test are presented in appropriate statistical format with tables, graphs, and charts. The p-value ( p=) and test statistics are reported. Outliers, if found, are reported. The results must be presented without implication, speculation, assessment, evaluation, or interpretation. Discussion of results and conclusions are left for Chapter 5. Both descriptive and inferential statistics are required to be reported in this section. Descriptive statistics describe or summarize data sets using frequency distributions (e.g., to describe the distribution for the IQ scores in your class of 30 pupils) or graphic displays such as bar graphs (e.g., to display increases in a school district’s budget each year for the past five years), as well as histograms (e.g., to show spending per child in school and display mean, median, modes, and frequencies), line graphs (e.g., to display peak scores for the classroom group), and scatter plots (e.g., to display the relationship between two variables). Descriptive statistics also include numerical indexes such as averages, percentile ranks, measures of central tendency, correlations, measures of variability and standard deviation, and measures of relative standing. Inferential statistics describe the numerical characteristics of data, and then go beyond the data to make inferences about the population based on the sample data. Inferential statistics also estimate the characteristics of populations about population parameters using sampling distributions, or estimation. Table 2 presents example results of an independent t-test comparing Emotional Intelligence (EI) mean scores by gender. Table 2t-Test for Equality of Emotional Intelligence Mean Scores by Gender t Df p EI 1.908 34 .065 Chapter 4 can be challenging with regard to mathematical equations and statistical symbols or variables. When including an equation in the narrative, space the equation as you would words in a sentence: x + 5 = a. Punctuate equations that are in the paragraph as you would a sentence. Remember to italicize statistical and mathematical variables, except Greek letters, and if the equation is long or complicated, set it off on its own line. Refer to your APA manual for specific details on representation of statistical information. Basic guidelines include: Statistical symbols are italicized (t, F, N, n) Greek letters, abbreviations that are not variables and subscripts that function as identifiers use standard typeface, no bolding or italicization Use parentheses to enclose statistical values (p = .026) and degrees of freedom t(36) = 3.85 or F(2, 52) = 3.85 Use brackets to enclose limits of confidence intervals 95% CIs [- 5.25, 4.95] Summary This section provides a concise summary of the project results. It briefly restates essential data and data analysis presented in the chapter, and it helps the reader see and understand the relevance of the data and analysis to the evidence-based question(s). It should summarize the statistical data and results of statistical tests in relation to the evidence-based question(s). Finally, it provides a lead or transition into Chapter 5 where the implications of the data and data analysis relative to the evidence-based question(s) will be discussed. This section should be two to three paragraphs long. Chapter 5: Implications in Practice and Conclusions Introduce Chapter 5 by providing (a) a general reminder of the problem, (b) the purpose of the project, and (c) overviewing the information that will be presented in this chapter. This section should be one to two paragraphs long. Chapter 5 is perhaps the most important chapter in the practice improvement project manuscript because it presents the project investigator’s contribution to the body of knowledge. For many who read evidence-based literature, this may be the only chapter they will read. No new data or citations should be introduced in Chapter 5; however, references should be made to findings or citations presented in earlier chapters. You should articulate new frameworks and new insights. All discussions in this chapter should be presented in the simplest possible form, making sure to preserve the conditional nature of the insights. Summary of the Project This section provides a comprehensive summary of the project by describing previous chapters in the simplest possible terms. It should recap the essential points of Chapters 1 to 3. It reminds the reader of the evidence-based question(s), the main issues being evaluated, and provides a transition, and reminds the reader of how the project was conducted. This section should be no more than two paragraphs. Major Findings Summarize the major findings (results) of your DPI project. Explain the statistical significance of your project findings. Explain the clinical significance of your project findings. This section should be no more than two paragraphs. Interpretation of Findings Describe how the findings of your DPI project align with other original research studies and/or quality improvement projects by comparing and contrasting the significance of the results. Provide possible explanations as to why your project findings confirmed or opposed previous published scholarly works. If your results did not achieve statistical significance, provide possible explanations why. This section should be no more than three to four paragraphs long. Strengths and Limitations In this section, describe the strengths of your project. In this discussion, you should consider the project design or methodology, the intervention, and the unit culture. Strengths should be presented in two paragraphs. Then, summarize the limitations of your DPI project. Limitations could be related to the project timeline, threats discussed in your SWOT, etc. Discuss the efforts that were made to minimize the limitations. Limitations should be addressed in two paragraphs. Implications In this section, you should present the “so what” (i.e., why was this important) of your project based on the project results. This section should describe the types of implications that could happen as a result of this project. It also tells the reader what the DPI project results imply both theoretically and for future nursing practice. Separate sections with corresponding headings provide proper organization. Provide a transition of three to five sentences for this new section. Theoretical Implications Theoretical implications involve the interpretation of the DPI project findings in terms of the evidence-based question(s) that guided the project. It is appropriate to evaluate the strengths and weaknesses of the project critically and include the degree to which the conclusions are credible given the method and data. It should also include a critical, retrospective examination of the framework presented in the Chapter 2 “Scientific Underpinnings” considering the practice improvement project’s new findings. In addition, you should describe whether the results of your project or the implementation process demonstrate the need to develop new or re-think current nursing theories. This section should be no more than two paragraphs. Nursing Practice Implications In this section, explore two to three ways the DPI project findings are important for nursing practice. Will it change practice? How? This section should be no more than two paragraphs. Recommendations Provide a brief transition (three to five sentences) that describes this section of the manuscript. Recommendations for Future Projects and Researchers This section should contain a minimum of four to five recommendations for future DPI projects. Project recommendations should include the areas of project that need further examination, address project or research gaps, new patient populations, or system needs. Each recommendation should be fully explained in one paragraph and should include (a) why the future project should be conducted, (b) how the project should be conducted (methodology and design), (c) what data would be collected, and (d) how the project would advance healthcare or patient outcomes. Recommendations for Sustainability This section should describe two to three recommendations for how the DPI project can be sustained. For example, does the new practice change require a policy in order for it to be sustained? Each recommendation should be fully explained in one paragraph that includes (a) what the sustainability plan is, (b) why the sustainability plan is needed, and (c) how the sustainability plan would work at the unit, organization, state, and national levels. Include any organizations or stakeholders who should be included in the sustainability discussions and what their role or involvement should be. Plan for Dissemination This section should contain a detailed plan regarding how the DPI project results will be disseminated to others in the nursing profession and other disciplines. Provide three to four specific examples of what your plan is for dissemination for your site, the community, the local nursing community, and when applicable, nationally. Describe the appropriate audience(s) for dissemination of the DPI project results. The audience(s) should be broad and should extend beyond the academic setting. Discuss informal and formal venues for electronic dissemination. Select the most appropriate peer-reviewed journal(s) in which you could publish your DPI project findings. Discuss oral dissemination opportunities (i.e., a podium or poster presentation or abstract submission). Consider presentation opportunities at regional, state, national, or international meetings. This section should be no more than three paragraphs. Conclusion and Contributions to the Profession of Nursing Practice This final section should briefly wrap up the project. Concisely describe the contributions your DPI project has made to the nursing profession. This section should be no more than two paragraphs. References Agency for Healthcare Research and Quality. [AHRQ]. (2017). Evidence behind Pain, Agitation, and Delirium: Assessments and Sedation Management: Slide Presentation: Overview. https://www.ahrq.gov/hai/tools/mvp/modules/technical/pain-mgmt-slides.html American Psychological Association. (2020). Publication manual of the American Psychological Association 2020: The official guide to APA style (7th ed.). American Psychological Association. American Psychological Association. (2021). Publication Manual, 7th edition student paper checklist. https://apastyle.apa.org/instructional-aids/ publication-manual-formatting-checklist.pdf Bakhru, R. N., Schweickert, W. D., Propert, K. J., & Kawut, S. M. (2014). C45 MECHANICAL VENTILATION: A Survey Of Abcde Bundle Protocols In Mechanically Ventilated Patients. American Journal of Respiratory and Critical Care Medicine, 189, 1. https://search.proquest.com/openview/a6d774f3dbfb8e392b1a06bc5d01e709/1?pq-origsite=gscholar&cbl=40575 Balas, M. C., Tan, A., Pun, B. T., Ely, E. W., Carson, S. S., Mion, L., Barnes-Daly, M. A., & Vasilevskis, E. E. (2022). Effects of a national quality improvement collaborative on ABCDEF bundle implementation. American Journal of Critical Care, 31(1), 54–64. https://doi-org.lopes.idm.oclc.org/10.4037/ajcc2022768 Balas, M. C., Vasilevskis, E. E., Burke, W. J., Boehm, L., Pun, B. T., Olsen, K. M., … & Ely, E. W. (2012). Critical care nurses’ role in implementing the “ABCDE bundle” into practice. Critical care nurse, 32(2), 35-47. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3375171/ Barnes-Daly, M. A., Phillips, G., & Ely, E. W. (2017). Improving hospital survival and reducing brain dysfunction at seven California community hospitals: Implementing PAD guidelines via the ABCDEF bundle in 6,064 patients. Critical Care Medicine, 45(2), 171–178. https://doi-org.lopes.idm.oclc.org/10.1097/CCM.0000000000002149 Benzaghta, M. A., Elwalda, A., Mousa, M. M., Erkan, I., & Rahman, M. (2021). SWOT analysis applications: An integrative literature review. Journal of Global Business Insights, 6(1), 55-73. https://digitalcommons.usf.edu/cgi/viewcontent.cgi?article=1148&context=globe Boehm, L. M., Dietrich, M. S., Vasilevskis, E. E., Wells, N., Pandharipande, P., Ely, E. W., & Mion, L. C. (2017). Perceptions of workload burden and adherence to ABCDE bundle among intensive care providers. American Journal of Critical Care, 26(4), e38-e47. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5089165/ Bounds, M., Kram, S., Speroni, K. G., Brice, K., Luschinski, M. A., Harte, S., & Daniel, M. G. (2016). Effect of ABCDE bundle implementation on prevalence of delirium in intensive care unit patients. American Journal of Critical Care, 25(6), 535-544. https://aacnjournals.org/ajcconline/article-abstract/25/6/535/3203 Chen, C. M., Cheng, A. C., Chou, W., Selvam, P., & Cheng, C. M. (2021). Outcome of improved care bundle in acute respiratory failure patients. Nursing in Critical Care, 26(5), 380-385. https://onlinelibrary.wiley.com/doi/pdf/10.1111/nicc.12530 Chen, T. J., Chung, Y. W., Chang, H. R., Chen, P. Y., Wu, C. R., Hsieh, S. H., & Chiu, H. Y. (2021). Diagnostic accuracy of the CAM-ICU and ICDSC in detecting intensive care unit delirium: A bivariate meta-analysis. International Journal of Nursing Studies, 113, 103782. https://doi.org/10.1016/j.ijnurstu.2020.103782 Collinsworth, A. W., Brown, R., Cole, L., Jungeblut, C., Kouznetsova, M., Qiu, T., Richter, K. M., Smith, S., & Masica, A. L. (2021). Implementation and routinization of the ABCDE bundle: A mixed methods evaluation. Dimensions of Critical Care Nursing: DCCN, 40(6), 333–344. https://doi-org.lopes.idm.oclc.org/10.1097/DCC.0000000000000495 Collinsworth, A., Priest, E., & Masica, A. (2020). Evaluating the cost-effectiveness of the ABCDE Bundle: Impact of bundle adherence on inpatient and 1-year mortality and costs of care. Critical Care Medicine, 48(12), 1752-1759. https://doi.org/10.1097/ccm.0000000000004609 DeMellow, J. M., Kim, T. Y., Romano, P. S., Drake, C., & Balas, M. C. (2020). Factors associated with ABCDE bundle adherence in critically ill adults requiring mechanical ventilation: An observational design. Intensive & Critical Care Nursing, 60. https://doi-org.lopes.idm.oclc.org/10.1016/j.iccn.2020.102873 Frade-Mera, M. J., Arias-Rivera, S., Zaragoza-García, I., Martí, J. D., Gallart, E., San José-Arribas, A., Velasco-Sanz, T. R., Blazquez-Martínez, E., & Raurell-Torredà, M. (2022). The impact of ABCDE bundle implementation on patient outcomes: A nationwide cohort study. Nursing in Critical Care. https://doi-org.lopes.idm.oclc.org/10.1111/nicc.12740. Hsieh, S. J., Otusanya, O., Gershengorn, H. B., Hope, A. A., Dayton, C., Levi, D., Garcia, M., Prince, D., Mills, M., Fein, D., Colman, S., & Gong, M. N. (2019). Staged implementation of awakening and breathing, coordination, delirium monitoring and management, and early mobilization bundle improves patient outcomes and reduces hospital costs. Critical Care Medicine, 47(7), 885–893. https://doi-org.lopes.idm.oclc.org/10.1097/CCM.0000000000003765 Kotter, J. P. (1995). Leading change: Why transformation efforts fail. Harvard Business Review, 73(2), 59–67. Kumar, R. , Zhang, W. , Evans, E. , Dams-O’Connor, K. & Thomas, K. (2022). Research Letter: Characterization of Older Adults Hospitalized With Traumatic Brain Injury Admitted to Long-Term Acute Care Hospitals. Journal of Head Trauma Rehabilitation, 37 (2), 89-95. doi: 10.1097/HTR.0000000000000685. Loberg, R. A., Smallheer, B. A., & Thompson, J. A. (2022). A quality improvement initiative to evaluate the effectiveness of the ABCDEF bundle on Sepsis outcomes. Critical Care Nursing Quarterly, 45(1), 42–53. https://doi-org.lopes.idm.oclc.org/10.1097/CNQ.0000000000000387 Marra, A., Ely, E., Pandharipande, P., & Patel, M. (2017). The ABCDEF Bundle in critical care. Critical Care Clinics, 33 (2), 225-243. https://doi.org/10.1016/j.ccc.2016.12.005 Medicare Payment Advisory Commission [MedPAC]. 2019. Long term care hospital services. In: Report to the Congress: Medicare Payment Policy. 281–300. Nordness, M. F., Hayhurst, C. J., & Pandharipande, P. (2021). Current perspectives on the assessment and management of pain in the intensive care unit. Journal of Pain Research, 14, 1733–1744. https://doi-org.lopes.idm.oclc.org/10.2147/JPR.S256406 Otusanya, O. T., Hsieh, S. J., Gong, M. N., & Gershengorn, H. B. (2022). Impact of ABCDE Bundle Implementation in the Intensive Care Unit on Specific Patient Costs. Journal of Intensive Care Medicine, 37(6), 833–841. https://doi-org.lopes.idm.oclc.org/10.1177/08850666211031813 Otusanya, O. T., Hsieh, S. J., Gong, M. N., & Gershengorn, H. B. (2016). Awakening and Breathing Coordination, Delirium Monitoring/Management and Early Mobilization (ABCDE) bundle reduces hospital Costs. In B102. STRATEGIES TO IMPROVE CARE QUALITY IN PULMONARY AND CRITICAL ILLNESS (pp. A4357-A4357). American Thoracic Society. https://www.atsjournals.org/doi/pdf/10.1164/ajrccm-conference.2016.193.1_MeetingAbstracts.A4357 Pandharipande, P., Banerjee, A., McGrane, S., & Ely, E. (2010). Liberation and animation for ventilated ICU patients: the ABCDE bundle for the back-end of critical care. Critical Care, 14(3), 1-3. https://ccforum.biomedcentral.com/articles/10.1186/cc8999 Pun, B. T., Balas, M. C., Barnes-Daly, M. A., Thompson, J. L., Aldrich, J. M., Barr, J., Byrum, D., Carson, S. S., Devlin, J. W., Engel, H. J., Esbrook, C. L., Hargett, K. D., Harmon, L., Hielsberg, C., Jackson, J. C., Kelly, T. L., Kumar, V., Millner, L., Morse, A., … Ely, E. W. (2019). Caring for critically ill patients with the ABCDEF bundle: Results of the ICU liberation collaborative in Over 15,000 adults. Critical Care Medicine, 47 (1), 3–14. https://doi-org.lopes.idm.oclc.org/10.1097/CCM.0000000000003482 Sylvia, M. L., & Terhaar, M. F. (2018). Clinical analytics and data management for the DNP. New York, NY: Springer Publishing Company, LLC Van den Boogaard, M., Wassenaar, A., van Haren, F. M. P., Slooter, A. J. C., Jorens, P. G., van der Jagt, M., Simons, K. S., Egerod, I., Burry, L. D., Beishuizen, A., Pickkers, P., & Devlin, J. W. (2020). Influence of sedation on delirium recognition in critically ill patients: A multinational cohort study. Australian Critical Care, 33(5), 420–425. https://doi-org.lopes.idm.oclc.org/10.1016/j.aucc.2019.12.002 Appendix A SWOT Analysis Figure 1SWOT Analysis for Quality Improvement Project Appendix B Learner Name: Cathy Ann Jones PICOT-D Question: In adult patients in a high observation unit in a long-term acute care hospital in Virginia, will the translation of Hsieh et al. research implementing the ABCDE bundle, compared to current practice reduce length of stay over an eight-week period? Table 3Primary Quantitative Research – Intervention (5 Articles). APA Reference (Include the GCU permalink or working link used to access the article.) Research Questions/ Hypothesis, and Purpose/Aim of Study Type of Primary Research Design Research Methodology Setting/Sample (Type, country, number of participants in study) Methods (instruments used; state if instruments can be used in the DPI project) How were the data collected? Interpretation of Data (State p-value: acceptable range is p= 0.000 to p= 0.05) Outcomes/Key Findings (Succinctly states all study results applicable to the DPI Project.) Limitations of Study and Biases Recommendations for Future Research Explanation of How the Article Supports Your Proposed Intervention Hsieh, S. J., Otusanya, O., Gershengorn, H. B., Hope, A. A., Dayton, C., Levi, D., Garcia, M., Prince, D., Mills, M., Fein, D., Colman, S., & Gong, M. N. (2019). Staged implementation of awakening and breathing, coordination, delirium monitoring and management, and early mobilization bundle improves patient outcomes and reduces hospital costs. Critical Care Medicine, 47(7), 885–893. https://doi-org.lopes.idm.oclc.org/10.1097/CCM.0000000000003765 https://lopes.idm.oclc.org/login?url=https://search.ebscohost.com/login.aspx?direct=true&db=cmedm&AN=30985390&site=eds-live&scope=site&custid=s8333196&groupid=main&profile=eds1 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6579661 Research question: Will the implementation of the ABCDE bundle decrease LOS, and mechanical ventilation? Hypothesis: The study hypothesizes that the implementation of early mobilization on a foundation of targeted sedation practices and routine delirium monitoring would improve clinical outcomes such as mechanical ventilation duration, ICU and hospital length of stay and cost. Purpose: The authors sought to determine the impact of adding early mobilization, coordination of components to breathing trial and awakening and delirium in the context of staged implementation of the ABCDE bundle in mechanically ventilated (MV) patients, Prospective cohort study The study included two medical ICUs within Montefiore Healthcare Center (Bronx, New York). The cohort consisted of all adult mechanical ventilated patients divided into two groups, a complete bundle staffed by medical residents and a partial bundle staffed by physician assistants. Participants were in the ICU for greater than 24hrs, the study period from July 2011 – June 2014, 1,855 were admitted to the full, and 819 underwent partial bundle elements. The complete bundle had younger patients, minor minorities, more comorbidities, higher severity of illness, and fewer lives at home before hospitalization. The study used unadjusted clinical outcomes and periods using descriptive statistics, non-parametric, and a multivariable regression model using the difference-in-difference (DiD) approach. Data were extracted from electronic medical records using healthcare surveillance software. The collected data were collected for 12 months after protocol implementation. The study was further divided into four phases for data collection. Phase one was collected on all ICU patients for 24 hrs. or more for two months before and two months after implementation. In phase two, data were collected monthly on 20 randomly selected patients in the ICU for three days or more for two months before and 12 months after implementation. The EHR and descriptive statistics could both be used in the DPI project. Duration of MV and ICU LOS significantly changed in the full bundle ICU but not in the partial bundle ICU across three periods ICU LOS was significantly shorter across all three periods in the full versus partial bundle ICU (p < 0.001) The primary outcome of interest was the hospital length of stay (LOS). Early mobilization and coordination (EC) portrayed improvement of patients in ICU by 30%. Implementation of full (B-AD-EC) vs (B-AD) resulted to a decrease in MV duration. The implementation of ABCDE bundle reduced total ICU and hospital cost by 24.2% and 30.2% respectively. The study experienced the challenges of unmeasured changes which could have affected the results. The study also was conducted in a single medical center hence limiting generalizability. The study also may have experienced cross-contamination of practices between two ICUs. The study was unable to compare costs between two seasonal periods due to cost-to-charge ratios changes hence study used smaller cohort for cost analyses. The study did not collect all the data in the partial bundle ICU for comparison The study identified the need for further research to include an assessment of patient-centered outcomes such as short and long-term disability and readmission rate and cost analysis identifying the benefit of the ABCDE bundle. Since this study, the (F) family has been included. Future studies must include the F and its impact on LOS and clinical outcomes. This article assessed the impact of implementing complete versus partial ABCDE bundle elements on mechanical ventilation (MV) duration, intensive care Unit (ICU)and hospital length of stay (LOS), and cost. The study demonstrates that the ABCDE bundle can be successfully early mobilization led to substantial reductions in MV duration, LOS, and hospital cost, liberated patients from restraints, and reduced iatrogenic complications. Most importantly identified that the entire bundle is more impactful than individual elements Schallom, M., Tymkew, H., Vyers, K., Prentice, D., Sona, C., Norris, T., & Arroyo, C. (2020). Implementation of an interdisciplinary AACN early mobility protocol. Critical Care Nurse, 40(4), e7–e17. https://doi-org.lopes.idm.oclc.org/10.4037/ccn2020632 https://lopes.idm.oclc.org/login?url=https://search.ebscohost.com/login.aspx?direct=true&db=ccm&AN=146029040&site=eds-live&scope=site&custid=s8333196&groupid=main&profile=eds1 Research question: how does increased mobility within the intensive care unit essential for achievement of ABCDEF bundle as an interdisciplinary protocol for specialized care in intensive care units? Hypothesis: the authors hypothesized that in critical care units, there should be mobility programs as an ABCDEF bundle to ensure quality care delivery through reduction of hospital stays, increasing patient’s mobility and reducing delirium. Purpose: The purpose of this quality improvement project is to examine the impact of an interdisciplinary mobility protocol in specialty intensive care units (ICU’s). The study is a quality improvement project using the American Association of Critical-Care Nurses mobility protocol The quality improvement (QI) project was conducted at a 1200-bed, university-affiliated level I trauma medical center in the Midwest with 132 ICU beds at project initiation. The study used a preintervention-postintervention design using a staggered approach across different units. The study used evidence-based tools such as the American Association of Critical-Care Nurses (AACN) early progressive mobility protocol, the Richmond Agitation-Sedation Scale (RASS), and the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) and the ICU Mobility Scale (IMS). All data were downloaded from REDCap into IBM SPSS Statistics, version 22, using descriptive statistics; descriptive statistics were calculated mean SD for continuous variables – dichotomous, nominal, and ordinal. The EHR was the main instrument used in this study that can also be used in this DPI project along with RASS , CAM-ICU ICU LOS decreased non significantly overall and decreased significantly in the ICUs without dedicated physical therapists (PT) at baseline. The units with dedicated PTs, had a mean (SD) decrease in LOS of more than 1 day, from 6.26 (6.05) to 5.00 (5.15) (p = .01). The study observed decreased in ICU LOS in both phases and a non-significant decrease in hospital LOS in phase two. Introduction of a standardized early mobility protocol increased the number of patients achieving ambulation and resulted in additional improved outcomes, including decreased delirium days and decreased ICU and hospital LOS. This study is not without limitations. The study design, a QI initiative, retrospective data can result in incomplete data. The data was extracted from the EMR were dependent on documentation it is contingent on accurate data entry and retrieval which may limit the final results due to inaccurate data. Another limitation is fidelity to the intervention implementation More support is needed to demonstrate the effectiveness of full bundle implementation. This study adds great significance to the DPI project as it identifies decreased length of stay in both phases of the study through the implementation of a nurse-driven early mobility Frade-Mera, M. J., Arias-Rivera, S., Zaragoza-García, I., Martí, J. D., Gallart, E., San José-Arribas, A., Velasco-Sanz, T. R., Blazquez-Martínez, E., & Raurell-Torredà, M. (2022). The impact of ABCDE bundle implementation on patient outcomes: A nationwide cohort study. Nursing in Critical Care. https://doi-org.lopes.idm.oclc.org/10.1111/nicc.12740 https://lopes.idm.oclc.org/login?url=https://search.ebscohost.com/login.aspx?direct=true&db=cmedm&AN=34994034&site=eds-live&scope=site&custid=s8333196&groupid=main&profile=eds1 Research question: what is the role of ABCDE bundle as an evidence-based practice in reducing the risks of immobility, delirium and sedation for intensive care unit patients? Hypothesis: the authors hypothesized that the ABCDE bundle is essential evidence-based practice in reduction of risks related to immobility, sedation and delirium for the intensive care unit patients thus improving the clinical experience for the patients Purpose: The purpose of this study was to investigate the association between patient outcomes (pain level, level of cooperation, patient days with delirium, patient days with physical restraint, level of mobility, drug levels of analgesia, sedatives, muscle relaxants, and antipsychotics, need for re-intubation or tracheostomy, ICU length of stay in days, IMV days, bed rest days, ICU mortality, and development of ICU acquired muscle weakness (ICUAW)) and compliance with bundle components ABC (analgosedation algorithms), D (delirium prevention and management protocol), and E (early mobilization protocol). A prospective,observational, multicenter cohort study The study included 605 patients from 80 ICUs in Spain in different Spanish multicenter ICUs receiving invasive mechanical ventilation for at least 48hrs. Patients’ data were collected from day three of the ICU stay until extubation. Categorical variables were expressed as frequency and percentage, using Fisher or Chi-squared test for between-group comparisons. Quantitative variables were expressed as mean and standard deviation (SD) or median and percentile, as 25 to 75 or 10 to 90 percentile ranges, depending on the distribution, which was analyzed with the Kolmogorov Smirnov test for large sample sizes (n ≥ 30) or the Shapiro-Wilk test for small samples (n < 30). Groups were compared using the student t-test or Mann-Whitney U test. Data were analyzed using IBM SPSS Statistics. The instruments used in this study can also be used in this DPI project, except the Kolmogorov-Smirnov test and the EHR for data collection.  Patients had shorter stays in ICUs with bundle protocols and fewer days of IMV in ICUs with delirium and mobilization bundle components (p = 0.006 and p = 0.03, Tertiary outcomes, ICU length of stay in days was decreased. The intended Richmond Agitation Sedation Scale (RASS) a valid tool of ABCDE bundle was not implemented due to use of a protocol for analgosedation algorithms. Another limitation, decrease use of the delirium scale due to its subjectively o of the observer. The spontaneous breathing trial and spontaneous awakening trial was replaced with the analgosedation protocol. because the great majority were recorded in patients in ICUs implementing protocols with analgosedation algorithms. very low implementation of delirium scales; did not analyze the use of SAT or SBT as a strategy in bundle components ABC. In this study the authors identified the need of a nurse-guided algorithm to minimize sedation and incorporating physiotherapist in ICU teams to make to initiate early mobility. This study adds merit to the DPI project as it identifies that the ABDCE bundle decreases LOS in ICU when all elements are implemented. This study adds to the growing body of evidence supporting the PICOT as it identifies that using bundle components in patients results in a shorter ICU LOS. In addition, the bundle demonstrates fewer invasive mechanical ventilation days, decreased use of analgesia, and a change in sedation strategies, with decreased use of benzodiazepines and increased use of dexmedetomidine and propofol- components of the ABCDEF bundle. Collinsworth, A., Priest, E., & Masica, A. (2020). Evaluating the Cost-Effectiveness of the ABCDE Bundle: Impact of Bundle Adherence on Inpatient and 1-Year Mortality and Costs of Care*. Critical Care Medicine, 48(12), 1752-1759. https://doi.org/10.1097/ccm.0000000000004609 Research Question: what is the role of the ABCDE bundle in improvement of the short-term and long-term care patients in the intensive care units? Hypothesis: the authors hypothesized that the ABCDE bundle is related to improvement of the cost and quality of care delivered to ICU unit patients. Additionally if reduced the overall cost of care and mortality rates for patients under the UCI units. Purpose: The research aim to determine the impact of ABCDE processes on inpatient mortality, LOS, discharge status, and direct costs of care as a basis to evaluate the cost-effectiveness of the bundle adherence. This is a prospective study The study included 2,953 patients. Patients were recruited from a large, urban tertiary referral center and five community hospitals. ICUs included medical/surgical, trauma, neurologic, and cardiac care units from July 2013 to June 2015; of those 18 years old and older with an ICU admission greater than 24hrs, mechanically ventilated greater than 24 hrs. and less than 14 days were included. Outcomes data were collected from the EHR and administrative databases. The study compared differences in continuous variables and outcomes that did not violate normality assumptions with independent t-tests and differences in categorical variables and outcomes with chi-square and Fisher exact tests. Instruments in this study can also be used in the DPI project.  Hospital LOS and direct costs were significantly higher in patients with bundle adherence greater than or equal to 60%, after risk adjustment <60% compliance vs > 60% compliance, 9.9(7.0) vs 12.3 (6.8) p<0.001 The study highlighted patients with high bundle compliance >60% had decrease mortality and decrease in LOS The limitations in this study were the study design. The severity of illness of each patient was not taken into consideration Further research is needed to obtain estimates of the bundle effect and its cost over a longer period of time. This study continues to add to the growing research that the ABCDE bundle compliance decreases mortality, decrease cost and decrease LOS. Pun, B. T., Balas, M. C., Barnes-Daly, M. A., Thompson, J. L., Aldrich, J. M., Barr, J., Byrum, D., Carson, S. S., Devlin, J. W., Engel, H. J., Esbrook, C. L., Hargett, K. D., Harmon, L., Hielsberg, C., Jackson, J. C., Kelly, T. L., Kumar, V., Millner, L., Morse, A., … Ely, E. W. (2019). Caring for critically ill patients with the ABCDEF bundle: Results of the ICU liberation collaborative in Over 15,000 adults. Critical Care Medicine, 47(1), 3–14. https://doi-org.lopes.idm.oclc.org/10.1097/CCM.0000000000003482 https://lopes.idm.oclc.org/login?url=https://search.ebscohost.com/login.aspx?direct=true&db=cmedm&AN=30339549&site=eds-live&scope=site&custid=s8333196&groupid=main&profile=eds1https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6298815 Research question: what is the relationship between ABCDEF bundle performance and having patient-centric results under the critical care units? Hypothesis: the authors hypothesize that the ABCDEF bundle would be essential for improving the quality of care for the patients under the critical care units. They challenged the old approaches like reduced access to family, sensation and immobilization of patients in critical care units. Purpose: The study aim at evaluating the relationship between ABCDEF bundle performance and patient, symptom and healthcare system related outcomes. The study hypothesized that complete and dose-related (i.e., proportional) performance of the ABCDEF bundle would be associated with improved clinical outcomes across these three domains Prospective cohort study from national quality improvement collaborative The study included 15226 adult patients on and off mechanical ventilation admitted to a participating medical, surgical, cardiac, or neurology ICU. The study included a total of 20 months of data collected per site. Data included six months of retrospectively collected data from (January 2015−June 2015) and 14 months of prospectively collected data (January 2016–March 2017) from 68 academics, community, and Veterans Administration ICUs from 29 states and Puerto Rico. Data was collected using the Research Electronic Data Capture (REDCap), a secure, web-based application for validated data entry, transmission, and storage. During the retrospective periods, five patients’ data were entered on those admitted to the ICU each month for 30 baseline patients per site. Throughout the prospective period, data was collected in the first 15 months. Data was collected for a maximum of seven ICU days. The study used Cox proportional hazards models with time-varying covariates for these outcomes. The study used R Project for Statistical Computing software version 3.4 for all analyses. The study used a specific data collection instrument. This instrument cannot be used in the DPI project. There was a consistent dose-response relationship between higher proportional bundle performance and improvements in each of the above-mentioned clinical outcomes (all p < 0.002). Significant pain was more frequently reported as bundle performance proportionally increased (p = 0.0001). Complete ABCDE bundle performance demonstrated a reduction in mortality rate within 7 days, mechanical ventilation, delirium and physical restraint use. Patients also demonstrated an increased dose response relationship between higher proportion bundle performance. Frequent pain was reported with increased bundle performance.  The study did not use a randomized study design, nor did it have access to concurrent control. ICU liberation collaborative included numerous ICU types as part of a larger effort to understand the impact of the ABCDE bundle on various types of critically ill patients while understanding the implementation strategies unique to each setting. The patient-level outcomes are not wholly independent of one another and are assessed within a short time frame during which patients did not experience those outcomes. The ICU liberation collaborative study lacked sufficient funds to support data accuracy auditing. Cohort analysis is from patient data collected within a larger QI project that collected a minimum and de-identified dataset, limiting the study’s ability to answer some questions. Physicians need to become familiarize with ABCDE bundle performance to enhance patients’ dose adherence to the critically ill adults in ICU. Physicians need to collaborate with other professionals in health sector and attend to ICU cases with open minded ready to learn from others. This large-scale study adds to the growing evidence supporting the ABCDEF bundle. The art outlined the relationship between ABCDEF bundle performance and patient-centered outcomes in critical care. Therefore, it is clear that ABCDEF bundle performance portrays significant clinical improvements in patient survival, mechanical ventilation use, coma and delirium, restraint-free care, ICU re-admissions, and post-ICU discharge disposition. Table 4Additional Primary and Secondary Quantitative Research (10 Articles) APA Reference (Include the GCU permalink or working link used to access the article.) Research Questions/ Hypothesis, and Purpose/Aim of Study Type of Primary or Secondary Research Design Research Methodology Setting/Sample (Type, country, number of participants in study) Methods (instruments used; state if instruments can be used in the DPI project) How were the data collected? Interpretation of Data (State p-value: acceptable range is p= 0.000 to p= 0.05) Outcomes/Key Findings (Succinctly states all study results applicable to the DPI Project.) Limitations of Study and Biases Recommendations for Future Research Explanation of How the Article Supports Your Proposed DPI Project Barnes-Daly, M. A., Phillips, G., & Ely, E. W. (2017). Improving hospital survival and reducing brain dysfunction at seven California community hospitals: Implementing PAD guidelines via the ABCDEF bundle in 6,064 patients. Critical Care Medicine, 45(2), 171–178. https://doi-org.lopes.idm.oclc.org/10.1097/CCM.0000000000002149 https://ubccriticalcaremedicine.ca/academic/jc_article/Improving%20Hospital%20Survival%20and%20Reducing%20Brain%20Dysfunction%20(Jan-19-17).pdf Research question: what is the relationship between implementation of the ABCDEF bundle and improvement in patient’s outcomes? Including coma and delirium free days. Hypothesis: the authors hypothesized that application of Awakening and Breathing Coordination, Choice of drugs, Delirium monitoring and management, Early mobility, and Family engagement bundle was essential for improvement of care and services delivered to the patients thus reducing survival chances of ICU patients. Purpose: The aim was to study the relationship between ABCDEF bundle compliance and outcomes including hospital survival and delirium-free and coma-free days A prospective cohort quality improvement initiative involving ICU patients. This study occurred in seven community hospitals within California’s Sutter Health System in ICUs ranging from six to 16 beds. The population consisted of medical and surgical ICU patients, ventilated and non-ventilated, between January 1, 2014, and December 31, 2014. The study enrolled 6, 6064 patients. The ABCDEF bundle was implemented on each patient every day. The study was designed to utilize an interprofessional team (IPT) model. The team consisted of a dedicated registered nurse (RN), an administrative RN, a pharmacist, a physical therapist, a respiratory care practitioner, and an ICU physician. Data were collected each day by the IPT RN in each ICU during daily rounds and entered into an electronic data collection tool (MIDAS; Kitware, Clifton Park, NY). The data was presented in monthly dashboards that tracked total and partial bundle compliance and patient outcome data. Analyses addressed the relationship between bundle compliance (independent variable) versus hospital survival and delirium-free and coma-free days (DFCFDs) (two dependent/outcome variables). The two outcomes were regressed on each independent variable (total and partial compliance). All analyses were run using Stata 14.1. The EHR was the instrument used in this study, along with a facility dashboard. While the QI project too can abstract data from the EHR, a dashboard cannot. For every 10% increase in total bundle compliance, patients had a 7% higher odds of hospital survival (odds ratio, 1.07; 95% CI, 1.04–1.11; p < 0.001). Likewise, for every 10% increase in partial bundle compliance, patients had a 15% higher hospital survival (odds ratio, 1.15; 95% CI, 1.09–1.22; p < 0.001). These results were even more striking (12% and 23% higher odds of survival per 10% increase in bundle compliance, respectively, p < 0.001) in a sensitivity analysis removing ICU patients identified as receiving palliative care. Patients experienced more days alive and free of delirium and coma with both total bundle compliance (incident rate ratio, 1.02; 95% CI, 1.01–1.04; p = 0.004) and partial bundle compliance (Incident rate ratio, 1.15; 95% CI, 1.09–1.22; p < 0.001). The evidence-based ABCDEF bundle was successfully implemented in seven community hospital ICUs using an interprofessional team model to operationalize the Pain, Agitation, and Delirium guidelines. Higher bundle compliance was independently associated with improved survival and more days free of delirium and coma after adjusting for age, severity of illness, and presence of mechanical ventilation. The authors made note of the QI project limitation, noting the project lacked randomization, or controlled trials. There was a potential risk for data integrity by the IPT nurse as one of the primary investigators. The bundle was applied to patients receiving palliative care, this may have skewed the results. There was a lack of physician buy-in and non-acceptance of patient and family to participation. The authors noted more advanced study designs should consider stepped-wedge approach that would add value to gain an understanding of the relationship among the bundle elements, compliance, and clinical outcomes. This large-scale study  demonstrated the value of implementing the PAD guidelines using a bundle of evidence-based steps through interprofessional teamwork. The study highlighted if not all bundle elements are implemented some can make a significant impact on patient outcomes. Collinsworth, A. W., Brown, R., Cole, L., Jungeblut, C., Kouznetsova, M., Qiu, T., Richter, K. M., Smith, S., & Masica, A. L. (2021). Implementation and routinization of the ABCDE bundle: A mixed methods evaluation. Dimensions of critical care nursing : DCCN, 40(6), 333–344. https://doi-org.lopes.idm.oclc.org/10.1097/DCC.0000000000000495 https://lopes.idm.oclc.org/login?url=https://search.ebscohost.com/login.aspx?direct=true&db=cmedm&AN=34606224&site=eds-live&scope=site&custid=s8333196&groupid=main&profile=eds1 Research question: what is the role of ABCDEF bundle in the reductions in delirium incidence and improved patient outcomes? Hypothesis: the authors hypothesized that adoption of the right practices when implementing the ABCDEF bundle would leader to promotion of better patient’s care and reducing the occurrence of delirium among the critically ill patients. Purpose: The objective of this mixed methods study was to determine how to facilitate ABCDE bundle adoption by examining the impact of two different implementation strategies on bundle adherence rates via basic and enhanced strategies and assessing clinicians’ perceptions of the bundle and implementation efforts. This mixed methods study This study included patients treated in 12 ICUs of eight Baylor Scott & White Health (BSWH) hospitals, including medical/surgical, trauma, neurological, and cardiac care units. A total of 84 nurses, physicians, and therapists participated in interviews and a survey to assess bundle implementation—two approaches, basic and enhanced. The basic strategy included electronic health record (EHR) modification, whereas the enhanced strategy included EHR modification plus additional bundle training, clinical champions, and staff engagement. A convenience sample was obtained to ensure varied sample schedules were on different days and times encompassing nursing, respiratory therapist, physical therapy managers, physician’s champions, and leaders were contacted via email for scheduled interviews. Interviews and surveys were the main instruments for each intervention group using the Microsoft Assess database using audio recording. Two researchers analyzed interview responses using a shared codebook. To ensure consistency in coding, both researchers coded three of the same interviews and compared coding schemes to ensure they interpreted and consistently applied the codes. This study uses a mixed method approach, qualitative and quantitative methods. The DPI project is quantitative. THE EHR is an instrument used in this project and can also be used in the DPI project. The results demonstrated the effect of basic vs enhanced strategy for bundle adherence ICU LOS estimate 0.02 95% CI (0.01-0.02) (p <0.001) Contrary to the hypothesis, the ICUs in the basic intervention group achieved higher levels of bundle adherence than ICUs in the enhanced intervention group and had the greatest change from pre-period to post-period. Although the bundle implementation process in both interventions showed improvement in bundle adherence . The authors noted data collection was time consuming. The study acquired data through the EHR hence limited to evaluating some elements such as pain and sedation Physicians’ response on bundle perception may be biased. Limitations were noted in this study—first leadership. Leadership in the basic intervention group learned about the enhanced intervention through the system-wide critical care council. This unintended exposure resulted in contamination, which made it difficult to determine the impact of the EHR modification alone on bundle implementation for ICUs in the basic intervention group. Second, this study was based on the change model chosen, Rodger’s Diffusion of Innovation theory. This change theory may have only elicited factors about implementing and adopting the bundle that was congruent with the models. Third, the authors note the differences among the ICUs that may have influenced adoption. Fourth, the convenience sample may have resulted in bias by limiting a complete representative sample of ICU staff. Other limitations included sample size, recall bias, and hesitance of respondents to reveal their true feelings about bundle implementation. Data on bundle adherence were based on what was documented in the EHR, which may not reflect actual practice. The study highlights that applying the ABCDE bundle is feasible in different healthcare settings outside the ICU. The EHR is a valuable tool in identifying bundle documentation and compliance. The ABCDE bundle is effective in reducing the length of stay. It scores that adequately implementing ABCDE bundles improves nursing care and patient outcomes. Balas, M. C., Tan, A., Pun, B. T., Ely, E. W., Carson, S. S., Mion, L., Barnes-Daly, M. A., & Vasilevskis, E. E. (2022) Effects of a national quality improvement collaborative on ABCDEF bundle implementation. American Journal of Critical Care, 31(1), 54–64. https://doi-org.lopes.idm.oclc.org/10.4037/ajcc2022768 https://aacnjournals.org/ajcconline/article-abstract/31/1/54/31644/Effects-of-a-National-Quality-Improvement?redirectedFrom=fulltext Research question: how does the participation of ABCDEF bundle performance become effective in improvement of care delivered to patients? Hypothesis: the authors hypothesized that the ABCDEF bundle was significant in improving the results of intensive care unit administration and general patient’s recovery. Although the impacts of the ABCDEF bundle are small, they play and essential part in ensuring better care advocating Purpose: The purposes of this study were to evaluate the effect of ICU Liberation Collaborative participation on ABCDEF bundle performance and explore whether bundle performance differed among participating ICUs at the end of the quality improvement collaborative (QIC). Observational study In this study, data was collected over 20 months. The data consisted of ABCDEF bundle performance data. The study included six months of baseline (pre-implementation) data from January 2015 through June 2015 and 14 months of data collected prospectively during the QIC from January 2016 through February 2017. The study consisted of 15 226 critically ill adults admitted to the 68 academic, community, and Veterans Affairs ICUs participating in the SCCM ICU Liberation Collaborative at Vanderbilt University Medical Center. Data were manually abstracted data from eligible patients’ medical records (either electronic or paper) at their institutions. The data were then entered into a Research Electronic Data Capture database, a secure web-based application for validated data entry, transmission, and storage. Data were collected for the first five patients (baseline period) or the first 15 patients (implementation period) consecutively admitted to the ICU each month. Performance data were collected for each qualifying patient for a maximum of seven ICU days or until the patient was transferred out of the ICU, was designated as having non-ICU status, or died. THE EHR was the main instrument used in this study and can also serve as a valuable instrument to the DPI project. Complete bundle performance increased by 2 percentage points (SE, 0.9; p = .06) immediately after collaborative Initiation. Each subsequent month was associated with an increase of 0.6 percentage points (SE, 0.2; p = .04). Performance rates increased significantly immediately after initiation for pain assessment (7.6% [SE, 2.0%], p = .002), sedation assessment (9.1% [SE, 3.7%], p= .02), and family engagement (7.8% [SE, 3%], p= .02) and then increased monthly at the same speed as the trend in the baseline period. Conclusion: These studies showed that the ABCDEF Bundle is associated with lower ICU and hospital mortality The first limitation is that the study involved observational studies, and residual confounding cannot be omitted as an explanation for the observed changes in bundle performance. Secondly, conclusions cannot be made on long-term sustainability despite ICUs demonstrating improvements during a 20-month period. Organizations need to develops strategic plans on how to increase compliance on bundle interventions for sedations, mechanical ventilation weaning and mobility practices. This study adds to the growing literature supporting the ABCDE bundle and its effects on patient outcomes, mortality rates. Negro, A., Cabrini, L., Lembo, R., Monti, G., Dossi, M., Perduca, A., Colombo,S., Marazzi, M., Villa,G., Manara, D., Landoni, G., & Zangrillo, A. (2018). Early progressive mobilization in the intensive care unit without dedicated personnel. Canadian Journal of Critical Care Nursing, 29(3), 26–31. https://lopes.idm.oclc.org/login?url=https://search.ebscohost.com/login.aspx?direct=true&db=ccm&AN=132043106&site=eds-live&scope=site Research question: what is the feasibility and safety of an early progressive mobilization protocol implemented without dedicated Personnel, as part of the ABCDE bundle? Hypothesis: the authors hypothesized that implementation of a progressive and early mobilization using the ABCDEF bundle is essential to promote better healthcare results for the patients under the intensive care units. Additionally the ABCDEF bundle is essential for meeting both short-term and long-term needs of the patient. Purpose: The purpose of this study was to assess the feasibility (meaning the capability of performing advanced mobilization) and safety (meaning the capability of avoiding adverse events during mobilization) of an early progressive mobilization protocol, focusing on the three most advanced steps (dangling, out of bed and walking) implemented without additional dedicated Personnel, as part of the ABCDE bundle. This is a descriptive observational study took place in a general ICU The study enrolled 482 participants in an eight-bed ICU over one year. Patients were admitted to the ICU, and 94 were mobilized. Data was collected from March 2015 to March 2016 using the electronic health record. Categorical data were presented as absolute numbers and percentages and compared by a two-tailed x2 test or Fisher’s exact test when appropriate—using the Mann-Whitney U test or t-test if data were normally distributed. Two-sided significance tests were used throughout. Patients were divided into two groups: non-mobilized patients 388 and mobilized patients 94. All statistical analyses were performed with the STATA software. The EHR, the main instrument used in the article, can be duplicated in the DPI project. Mobilized patients had longer ICU and hospital length p < 0.001 The study found that there was a significant increase over time of patients being mobilized while receiving mechanical ventilation. Mobilized patients had longer ICU and hospital length of stay and a better ICU survival rate. The study is noted limitations. The study was not generalized. It is not known if there were any adverse effects during mobilization. The authors noted a lack of control or randomization. The study did not barriers or contraindications to mobilization. The study notes further research is required to evaluate the efficacy and generalizability of our strategy and the additional nurse-workload. This study adds to the current growing body of research that supports the implementation of the ABCDEF bundle as all components were utilized with a special attention to early mobility – it supports its use as feasible, safe with the absence of PT while results demonstrated a decrease length of stay DeMellow, J. M., Kim, T. Y., Romano, P. S., Drake, C., & Balas, M. C. (2020). Factors associated with ABCDE bundle adherence in critically ill adults requiring mechanical ventilation: An observational design. Intensive & Critical Care Nursing, 60. https://doi-org.lopes.idm.oclc.org/10.1016/j.iccn.2020.102873 https://lopes.idm.oclc.org/login?url=https://search.ebscohost.com/login.aspx?direct=true&db=edselp&AN=S0964339720300768&site=eds-live&scope=site&custid=s8333196&groupid=main&profile=eds1 https://pubmed.ncbi.nlm.nih.gov/32414557/ Research question: is there a relationship between the ABCDEF bundle compliance and better healthcare results for patients including coma and delirium free days in community hospitals? Hypothesis: the authors hypothesized that the ABCDEF bundle was significant in reducing coma, delirium and overall survival rates for critical care patients in the community healthcare facilities. Purpose: The study aims at identifying factors associated with ABCDEF bundle adherence in critically ill patients during the first 96 hours of ventilation. This is an observational study This study included data from 15 ICUs in seven community hospitals between August 1, 2016, and January 31, 2017, in an extensive western United States health system. The study included 977 adult patients on mechanical ventilation for more than 24 hours admitted to an intensive care unit over six months. There were variations in ICU size, bed type, and study location. The sample included adult patients 18 years old and older. Patients with comfort care and comatose were excluded. Patient-level data were retrieved from a data warehouse for administrative data and the Cerner EHR system for bundle documentation and order entry. Data in this study were stored in a secured data repository at the health system. The study was conducted using all the statistical analyses using the SAS University Edition 9 platform software. The study used dependent and independent variables. Logistic regression analysis was used for individual bundle element adherence scores, categorized into complete (100%) vs. partial. The instruments used in this study could be implemented in the DPI project. ABCDEF bundle adherence was higher in patients on mechanical ventilation for less than 48 hours (p=0.01), who received continuous sedation for less than 24 hours (p < 0.001), admitted from skilled nursing facilities (p<0.05), And over the course of the six-month study period (p < 0.01). Bundle adherence was significantly lower for Hispanic patients (p < 0.01). The observational results from the data identified that modifiable factors improved team’s performance of the ABCDEF bundle in critically ill patients in need of mechanical ventilation. The study had limitations. The study was restricted to EHR clinical data available hence managed to only evaluate assessment for pain, sedation, delirium, and mobility elements. The study did not use analgesic infusions as sedation to determine duration of sedation and adherence of awakening trials The study was limited to the examination of the early 96hours on MV adherence to bundle by the care unit. The study identified barriers in assessing pain, delirium and mobility. The study notes more education is needed to treat patients requiring sedation to reduce sedatives in order to improve bundle adherence as well as discovering ways to implement delirium assessments in a more diverse population. This study supports the DPI project since the study identifies the factors associated with ABCDEF bundle adherence in critically ill patients during the first 96 hours of ventilation. The study supports the results that modifiable factors improve the team’s performance of the ABCDE bundle in critically ill patients in mechanical ventilation. Loberg, R. A., Smallheer, B. A., & Thompson, J. A. (2022). A quality improvement initiative to evaluate the effectiveness of the ABCDEF bundle on Sepsis outcomes. Critical Care Nursing Quarterly, 45(1), 42–53. https://doi-org.lopes.idm.oclc.org/10.1097/CNQ.0000000000000387 https://lopes.idm.oclc.org/login?url=https://search.ebscohost.com/login.aspx?direct=true&db=cmedm&AN=34818297&site=eds-live&scope=site&custid=s8333196&groupid=main&profile=eds1 https://pubmed.ncbi.nlm.nih.gov/34818297/ Research question: what is the role of compliance with the ABCDEF bundle in achievement of better clinical outcomes? Hypothesis: the authors hypothesized that critical care patients would receive higher quality and satisfactory care thus reducing the long-term negative impacts of ICU survivors. Purpose: The study aims to determine how quality improvement implementing the ABCDEF bundle can improve sepsis outcomes. Quality Improvement study This study was conducted in a 609-bed Midwest metropolitan hospital, the medical respiratory intensive care unit, and the surgical intensive care unit. The study used a pre/post-test design. The study used a convenience sample of all patients with sepsis admitted over three months. Data were collected between January 2019 and March 2019, and post implementation was collected from October 2019 to December 2019. The existing electronic health record (EHR) and the sedation and analgesia order set for patients requiring mechanical ventilation were reviewed and determined to support the needed documentation for pain and delirium. Descriptive statistics, mean (SD) or n (%), and comparative statistical test results for all study outcomes. Ventilator days and ICU and hospital LOS were compared between groups using an independent-sample t-test. The EHR served as the main instrument used in this study that can be used in the DPI project.  The ABCDEF bundle elements improved clinical outcomes. A significant improvement was seen in the completion of spontaneous awakening and breathing trials (p= .002), delirium assessment (p = .041), and early mobility (p = .000), which was associated with a reduction in mortality and 30-day readmission rates. There was a 0.5-day reduction in overall ICU LOS (p = .475) Overall hospital LOS increased by 1.1 day, but this was not significant (p = .414) The study results indicated overall implementation of ABCDEF bundle in the setting resulted to enhanced care delivery and improved clinical outcomes. The QI initiative was limited to this single center organization. The authors made note severity of illness was not taken into account. The study lacked randomization, controlled trial, rather used a convenience sample. Lower than desired rate with bundle elements was experienced The intervention was not designed as randomized controlled study but rather utilized as convenient sampling. There is need to provide nursing care education to healthcare workers to implement the ABCDEF bundle since its implementation has a direct impact on enhancing care giving and clinical outcomes. This study may show greater significance on multicenter vs one while expanding to a larger patient demographic. The article is relevant to the DPI project since it outlines the guidelines on how the ABCDEF bundle can be applied in nursing to improve clinical outcomes. The study demonstrated that bundle elements decreased ICU LOS. Otusanya, O. T., Hsieh, S. J., Gong, M. N., & Gershengorn, H. B. (2021). Impact of ABCDE bundle implementation in the intensive care unit on specific patient costs. Journal of Intensive Care Medicine, 8850666211031813. https://doi-org.lopes.idm.oclc.org/10.1177/08850666211031813 https://lopes.idm.oclc.org/login?url=https://search.ebscohost.com/login.aspx?direct=true&db=cmedm&AN=34286609&site=eds-live&scope=site&custid=s8333196&groupid=main&profile=eds1 https://pubmed.ncbi.nlm.nih.gov/34286609/#:~:text=Conclusions%3A%20Full%20ABCDE%20bundle%20implementation,increase%20in%20physical%20therapy%20costs Research question: what is the impact of partially implementing the ABCDEF bundle on some patients in ICU and implementing it fully? Hypothesis: the authors hypothesized that patients receiving the ABCDEF bundle fully would have more benefits including lowering laboratory costs, therapy costs compared to those taking it partially. Therefore advocating for the application of ABCDEF bundle fully. Purpose: The study objective is to measure the impact of full versus partial ABCDE bundle implementation on specific cost centers and related resource utilization. Retrospective cohort study This quality improvement study was conducted in two medical ICUs in Montefiore Health Systems, the medical ICU at two academic tertiary care hospitals within the Montefiore Health System in the Bronx, NY. The study compared two time periods, the B-AD from January 1, 2013-June 30, 2013, and the B-AD-CE from July 1, 2013, to December 31, 2013. They included 472 mechanically ventilated patients. The cohort was divided into the intervention ICU group, 259, and the comparison group, 226. Clinical data were obtained from health care surveillance software (Clinical Looking Glass; Emerging Health Information Technology, Yonkers, NY) and included information on demographics (age, self-reported race, and ethnicity, gender, residence prior to hospitalization) Baseline characteristics and cost per cost center were compared between ICUs (including data from both periods) using Kruskal-Wallis tests for continuous variables and chi-square tests for categorical variables. The study further used the difference-in-difference analysis to identify significant changes in outcomes associated with the completed ABCDE bundle. STATA 15 and Microsoft Excel (Microsoft, Redmond, WA) was used for all analyses. The EHR instrument used in this study can be used in the DPI project. The results identified LOS (13.9 [8.0-23.6] vs 13.6 [7.9-21.8] days, p = 0.64) were similar in both ICUs, but ICU LOS was shorter in the intervention ICU (6.1 [3.8-10.5] vs 7.2 [4.4-12.8] days, p = 0.013). There was a relationship between ABCDE bundle implementation and the cost. Relative to the comparison ICU, implementation of the entire bundle in the intervention resulted to a decrease of 27.3%in total hospital laboratory cost. Total hospital resource use resource use decreased in the intervention ICU. The limitations in this study are it design, retrospective, at a single center organization of two ICUs in one health system. The study did not include A- assessment of pain nor did it include F- family involvement. Lastly, the authors could not evaluate the impact of costs in a larger cohort more than one year. The study notes the need for additional studies identifying how total hospital cost and ICU cost are impacted by the ABCDE bundle. The article supports the DPI project as it focuses on how fully implementation of ABCDE bundle significantly reduces hospital laboratory costs decreases LOS. van den Boogaard, M., Wassenaar, A., van Haren, F. M. P., Slooter, A. J. C., Jorens, P. G., van der Jagt, M., Simons, K. S., Egerod, I., Burry, L. D., Beishuizen, A., Pickkers, P., & Devlin, J. W. (2020). Influence of sedation on delirium recognition in critically ill patients: A multinational cohort study. Australian Critical Care, 33(5), 420–425. https://doi-org.lopes.idm.oclc.org/10.1016/j.aucc.2019.12.002 https://lopes.idm.oclc.org/login?url=https://search.ebscohost.com/login.aspx?direct=true&db=ccm&AN=145414398&site=eds-live&scope=site&custid=s8333196&groupid=main&profile=eds1 https://www.australiancriticalcare.com/article/S1036-7314(19)30131-6/pdf Research Question: what is the relationship between the level of sedation and occurrence of delirium for critically ill patients if the ICDSC or CAM-ICU assessment methods were used? Hypothesis: the authors hypothesize that the level of sedation is likely to impact on the delirium screening results when either the ICDSC or CAM-ICU methods were used. Purpose: The objective of this study was to determine the association between level of sedation, as quantified by a Richmond Agitation-Sedation Scale (RASS) score, and a positive delirium assessment result in critically ill patients assessed by the ICU nurse with either the Confusion Assessment method for Intensive Care Delirium (CAM-ICU) or the intensive care delirium screening checklist (ICDSC) Prospective study The study was a secondary analysis of a previous study performed between September 2015 and June 2016. The study included seven countries and 11 ICUs. The study enrolled 1660 patients, of which 1203 (72%) were assessed with the CAM-ICU and 457 (28%) were assessed with the ICDSC. Participants were 18 years old and older. All data were collected electronically in the secured and validated data management system, CastorEDC, Amsterdam, Netherlands. Logistic regression analysis was used to determine the association between the level of sedation expressed in RASS score at the time of delirium assessment and delirium occurrence based on either a CAM-ICU or ICDSC assessment. Data were analyzed using IBM SPSS Statistics for Windows, version 25.0. The instruments used in this study cannot serve in the DPI project. The study did not show a significant difference between the CAM-ICU and ICDSC p=0.01 when used to decrease LOS. At a RASS of 0, assessment with the CAM-ICU (vs. the ICDSC) was associated with fewer positive delirium evaluations (odds ratio: 0.58; 95% confidence interval: 0.43–0.78). At a RASS of −1 or −2, no association was found between the delirium assessment method used (i.e., CAM-ICU or ICDSC) and a positive delirium evaluation. At a RASS of 0, assessment with the CAM-ICU (vs. the ICDSC) was associated with fewer positive delirium evaluations The influence of level of sedationon delirium assessment depends on whether the CAM-ICU or ICDSC is used The study based on comparison between sedation and delirium hence need to compare both CAM-ICU to ICDSC simultaneously and determine its impact on critically ill patients. There is need to compare the CAM-ICU and ICDSC simultaneously in sedated and non-sedated ICU patients There is need to offer training to nurses in intensive care units on how best sedation and delirium influence affects critically ill patients in ICU. The study is relevant since it focuses on determining the influence of sedation on delirium which aligns with DPI project as heath care personnel. Chen, C., Cheng, A., Chou, W., Selvam, P., & Cheng, C. M. (2021). Outcome of improved care bundle in acute respiratory failure patients. Nursing in Critical Care, 26(5), 380–385. https://doi-org.lopes.idm.oclc.org/10.1111/nicc.12530 https://lopes.idm.oclc.org/login?url=https://search.ebscohost.com/login.aspx?direct=true&db=a9h&AN=152166449&site=eds-live&scope=site&custid=s8333196&groupid=main&profile=eds1 Research question: what is the impact of using early mobilization in reducing respiratory failure of critical care patients using the ABCDEF bundle? Hypothesis: the authors hypothesized that the ABCDEF bundle was an essential element in reducing the negative impacts of mechanical ventilation of patients, therefore the bundle would reduce the respiratory failure for critically ill patients. Purpose: This study aim is to determine if such an improved ABCDE bundle would shorten ICU and hospital length of stay (LOS) and lower medical costs and intra-hospital mortality between phases 1 and phase 2 Pre/ post bundle. The study is a retrospective, observational, before-and-after outcome study The study included adult patients on mechanical ventilation (MV) (N = 173) admitted to a medical center ICU with 19 beds in southern Taiwan comprised of a multidisciplinary team (critical care nurse, nursing assistant, respiratory therapist, physical therapist, patient’s family). The data were retrospectively collected via medical records. The study periods were divided into two phases: phase 1 (pre-bundle), December 1, 2015, to March 31, 2016. Phase 2 (after bundle) October 1, 2016, to December 31, 2016. Data were analyzed using two independent-sample t-tests with Bonferroni correction. Categorical variables were analyzed using the chi-square or Fisher’s exact tests. The instruments used in this study can be used in the DPI project.  The patients in phase 2 had a significantly lower mean ICU LOS (8.0 vs 12.0) day p <0.05) The study demonstrated there were significant differences of MV, ICU and hospital LOS, medical cost and intra- hospital mortality before phase one and after phase two. The limitations of this study notes, this is a single ICU unit, the study did. Not take in account safety of patient mobilization, the study did not if the patient’s physical function improved pre/post bundle. Lastly the study design type, retrospective lacking randomization. This study adds the clinical outcomes (as a shortened duration of MV and ICU stays) of patients receiving an ABCDE care bundle with early mobilization and family member participation were improved. This study adds the growing body of evidence that implementing the ABCDE can decrease ICU LOS, hospital LOS, decrease cost, through early mobilization using an interprofessional team approach. Bardwell, J., Brimmer, S., & Davis, W. (2020). Implementing the ABCDE Bundle, Critical-Care Pain Observation Tool, and Richmond Agitation-Sedation Scale to Reduce Ventilation Time. AACN Advanced Critical Care, 31(1), 16-21. https://doi.org/10.4037/aacnacc2020451 Research question: what are the impacts of applying the ABCDE bundle, the Critical-Care Pain Observation Tool, and the Richmond Agitation-Sedation Scale concurrently in management of pain and reduction of delirium and over sedation? Hypothesis: the authors hypothesized that reducing oversedation, decreasing the incidence of delirium, and improving pain management would reduce LOS. Purpose: The study aimed to reduce ventilation time by reducing oversedation, decreasing the incidence of delirium, and improving pain management. Retrospective study This study was conducted at a teaching hospital within a 34-bed ICU and included patients in neurosurgical, medical, and surgical (except cardiovascular surgery) ICUs. The study was conducted from February 1, 2017, to April 30, 2017, and after bundle implementation, were for those admitted from February 1, 2018, to April 30, 2018. Analyses were conducted with spreadsheet software (Microsoft Excel). The researchers in this study used the rapid shallow breathing index (RSBI) and improved arterial blood gas values as indicators to wean patients from ventilation or to determine the extubation time. The results demonstrate the chances of reintubation. The RSBI will not be used during the DPI project. The EHR was another instrument for data collection that could also be used in the DPI project. P values less than .05 were considered statistically significant. A 2-tailed t-test was used to analyze the data. After ABCDE bundle implementation, mean ventilation time significantly decreased by nearly 50% (a difference of 1.98 days). A decrease in ventilation time was observed among all patients. p=0.02 The nursing staff bundle compliance rate was 76.5%. After ABCDE bundle implementation, mean ventilation time significantly decreased by nearly 50% (a difference of 1.98 days). A decrease in ventilation time was observed among all patients. Using the ABCDE bundle reduced sedation time by almost 50% (a difference of 1.93 days), although this finding was not significant. 33 patients were not readmitted within 30 days of hospital discharge or reintubated within 30 days of extubation. One of the limitations of the study was the non-controlled design of the study which raises the possibility of confounding variables that may have influenced study outcomes. Second, the study did not include patients with brain injuries which means that the findings may not be generalizable to neurological or trauma ICUs that care for patients with these injuries. Furthermore, the study cannot be generalized to long-term ventilator care units. The purpose of the study was to implement an international guideline and included only adults, which means that the findings should not be considered definitive and should not be generalized for children until randomized controlled studies involving children validate the results. It is recommended that future studies should include patients with brain injuries for generalizable results in other ICUs. Furthermore, randomized controlled studies should be used in future studies to validate the results. Also, future studies should include both children and adults so that the results can be extrapolated to both adults and children. The article will be used during the DPI project because it demonstrates that reducing oversedation, decreasing the incidence of delirium, and improving pain management would reduce LOS. It scores the fact that proper implementation of ABCDE bundles improves nursing care and patient outcomes. Ren, X. L., Li, J. H., Peng, C., Chen, H., Wang, H. X., Wei, X. L., & Cheng, Q. H. (2017). Effects of ABCDE bundle on hemodynamics in patients on mechanical ventilation. Medical science monitor: international medical journal of experimental and clinical research, 23, 4650–4656. https://doi.org/10.12659/msm.902872 Research question: what are the effects of ABCDE bundle on hemodynamics in patients on mechanical ventilation? Hypothesis: the authors hypothesized that the ABCDEF bundle was an essential and safe for patients under the mechanical ventilation. The ABCDEF would be essential in improving oxygenation index and hemodynamics therefore reducing patient’s mortality and enhancing prognosis. Purpose: The aim of this study is to explore the influences of ABCDE bundle on the hemodynamics and prognosis of patients on mechanical ventilation This is a cross-sectional overall, before-after controlled study The study included 143 patients in mechanical ventilation admitted to the ICU. Those admitted from May to December 2015 were classified into the pre-ABCDE bundle group (n=70) and received conventional sedation and analgesia, while those admitted from January to October 2016 were classified into the post-ABCDE bundle group (n=73) and received the ABCDE bundle. Nurses recorded intervention data in the Critical Care Record and entered it into the patient’s EHR. SPSS17.0 statistical software was used for statistical analysis. Repeated measures analysis of variance was used for comparison of repeated measurements, the t-test was used for comparison of the means of 2 groups, and the χ2 test was used to compare the rates of both groups. The instruments used in this study can be used in the DPI project.  The difference in the prognosis between the bundle and pre-ABCDE bundle groups was statistically significant. Pre bundle 9.76 post bundle 7.47 p 0.000 (p<0.05) statistical significance. The post-ABCDE bundle group had shorter duration of mechanical ventilation and length of ICU stay, as well as reduced 28-d mortality. ABCDE bundle can significantly improve the hemodynamics indicators of patients on mechanical ventilation, reduce the dose of the sedatives and analgesics used, and keep the hemodynamics indicators, including MAP, CVP, and HR, at levels beneficial to patients the ABCDE bundle is not only beneficial to the venous return, cardiac work, but also could protect the other organs, all of which could increase the oxygenation index and improve the circulatory function. The limitations of this study were lack of randomization The study highlighted patients with full bundle (ABCDE) are hemodynamically stable, have shorter LOS and shorter duration of mechanical ventilation. This study adds, the ABCDE significantly improve the hemodynamics indicators of patients on mechanical ventilation, reduce the dose of the sedatives and analgesics used, and keep the hemodynamics indicators, and has shown to reduce LOS in the vulnerable patient population. Liu, K., Nakamura, K., Katsukawa, H., Nydahl, P., Ely, E. W., Kudchadkar, S. R., Takahashi, K., Elhadi, M., Gurjar, M., Leong, B. K., Chung, C. R., Balachandran, J., Inoue, S., Lefor, A. K., & Nishida, O. (2021). Implementation of the ABCDEF Bundle for Critically Ill ICU Patients During the COVID-19 Pandemic: A Multi-National 1-Day Point Prevalence Study. Frontiers in Medicine, 8, 735860. https://doi-org.lopes.idm.oclc.org/10.3389/fmed.2021.735860 https://lopes.idm.oclc.org/login?url=https://search.ebscohost.com/login.aspx?direct=true&db=cmedm&AN=34778298&site=eds-live&scope=site&custid=s8333196&groupid=main&profile=eds1 Research question: what are impacts of ABCDEF bundle delivery for ICU patients with or without covid19? Hypothesis: the authors hypothesized that the ABCDEF bundle was significant for the intensive care unit patients to receive high quality care through mobility and reduction of infection rates for covid19 patients. Purpose: The purpose of this study is to investigate the implementation rate of evidence-based ICU care for both patients without and with COVID-19 infections and the impact of COVID-19 infections on implementation on a world-wide scale to capture the current clinical practice situation. This is a one-day point prevalence study. The study used questionnaires and surveys for data collection. The questionnaire solicited patient demographics, such as age, gender, Body Mass Index (BMI), and ICU length of stay. The questionnaire identified the use of medical devices, continuous neuromuscular blockade, vasoactive, analgesia, and sedation agents, prone positioning, and duration. In addition, the presence of a target/goal of each ICU care modality given to ICU patients on the survey date and the implementation of each element of the ABCDEF bundle and an ICU diary provided on the survey data were collected. Data was anonymous for both patients and institutions. All the data were stored online (Google Drive, Google Inc.) and managed or exported by authorized personnel. The ABCDEF bundle and the ICU diary between the groups of patients without and with COVID-19 infections were made with the Mann-Whitney U-test for non-normally distributed continuous data and the chi-squared test, and Fisher’s exact test for categorical data. The instrument used in this study, a questionnaire, can also be used in the DPI project. ICU LOS: patients without COVID19 infection 5 [2.10], patients with COVID 19 infection 9 [2-10] p<0.001 This study showed the implementation rate of the ABCDEF bundle was low regardless of COVID19 The limitation of the study noted First, the limited number of patients and participating countries (Japan accounts for 40%) could lead to selection bias and limit generalizability to other ICUs and countries. Second, the nature of a point prevalence study does not define a causal relationship and reflects the overwhelming situation at participating sites. This point prevalence study took place entirely on 1 day. Third, potential confounding factors associated with implementation, such as disease-related factors, were not investigated. Finally, an odds ratio with a relatively broad confidence interval may indicate an unstable model created by multivariate analysis. As the guideline suggests, it is important to note that evidence-based ICU care, such as the ABCDEF bundle and ICU diary, should be incorporated into clinical practice for all ICU patients regardless of their underlying diseases or the ICU length of stay. These results particularly show that a promising strategy to introduce or implement a specific element of the bundle in an ICU could vary and should be designed depending on the context and local situation in which it will be implemented. COVID- 19 infection was not a barrier to the implementation of each element of the ABCDEF bundle. This study had a different approach other than mobility, but included the use of a diary (the F) of the bundle. It added to growing evidence the use of the bundle can reduce length of stay and make noted low or incomplete implementation can result in longer hospitalization, it identified the bundle as a cohesiveness to reduce LOS Louzon, P., Jennings, H., Ali, M., & Kraisinger, M. (2017). Impact of pharmacist management of pain, agitation, and delirium in the intensive care unit through participation in multidisciplinary bundle rounds. American Journal of Health-System Pharmacy, 74(4), 253–262. https://doi-org.lopes.idm.oclc.org/10.2146/ajhp150942 https://lopes.idm.oclc.org/login?url=https://search.ebscohost.com/login.aspx?direct=true&db=a9h&AN=121191406&site=eds-live&scope=site&custid=s8333196&groupid=main&profile=eds1 Research question: how can the pharmacists increased role of care delivery reduction of length of stay, ventilator use and hospital costs? Hypothesis: the authors hypothesized that the two phase initiative was significant for more caregiver’s involvement in patient’s care delivery thus reducing use of sedatives, ventilators, the healthcare costs and length of stay in the hospital. Purpose: The study sought to improve LOS and ventilator day measures, reduce hospital expenditures, and advance pharmacists’ scope of practice within a large community teaching hospital. This is a two-phase program a retrospective cohort study This study included 436. Patients were managed with the ABCDEF bundle, and 499 patients of those with standard care. In a Florida hospital in the United States. Steps to implement this program occurred in two phases. Phase 1 involved an initial pilot program designed to allow ICU pharmacists to directly manage sedative therapy for mechanically ventilated patients in collaboration with an intensivist. In phase 2, that initiative was expanded to include comprehensive pharmacist PAD management, as well as the development of a multispecialty interprofessional team to encourage early mobilization of mechanically ventilated patients. This study used the APACHE outcomes tool for managing critical care outcomes methodology. Variables were compared between the two treatments groups using Student’s t-test for continuous data and a chi-square test of independence (Fisher’s exact test) for categorical data. The instruments used in this study can also be used in the DPI project Patients who received care via the pharmacist directed sedation management strategy were exposed to a mean of 102 fewer hours of continuous sedation, a 40.4% reduction relative to mean hours in the standard-care cohort (p = 0.0025); In the intervention-group patient had a reduction of 1.2 ventilator days, which did not reach statistical significance (mean, 8.6 days versus 7.4 days; p = 0.07); however, this was considered a clinically important difference due to the potential impact on ICU resource consumption and ICU LOS. Mean ICU LOS did not significantly change with the use of the ABCDE bundle versus standard care (4.6 days versus 4.3 days, p = 0.26), but the APACHE ratio for ICU LOS was significantly decreased, from 0.96 to 0.81 (p = 0.02). The objective was to determine the effects of pharmacist-directed sedation management on the use of continuous sedation, hospital LOS, and ventilator days. Secondary endpoints were as follows: The total amount of sedation used, ICU LOS, ventilator days, number of Richmond Agitation Sedation Scale (RASS) scores greater than +1, and reintubation rates. This study notes the previous culture of deeper sedation and continuous infusions of analgesic and sedative regimens was engrained in the daily processes of the ICU team. Introducing a new culture took intensive continuing education and daily reinforcement of concepts. Some physicians were initially hesitant to support increased pharmacist involvement in management of their patients; challenge was the need to dedicate limited ICU pharmacist resources to a new daily patient care service. Delirium screening was not fully implemented until phase 2 of the project, so comparative data on the impact of screening were not available for analysis in the cohort study; this is an area for future study. This study was significant for the number of participants in this cohort study that demonstrated the use to bundle with the assistance of a pharmacist managing sedative implementing mobility demonstrated decreased ventilation days and decreased LOS decreased hospital cost by 46%, an estimated saving of 1.2 million dollars. Sinvani, L., Kozikowski, A., Patel, V., Mulvany, C., Talukder, D., & Akerman, M. et al. (2018). Nonadherence to Geriatric-Focused Practices in Older Intensive Care Unit Survivors. American Journal Of Critical Care, 27(5), 354-361. https://doi.org/10.4037/ajcc2018363 Research question: what are the roles of geriatric-focused practices and improved intensive care unit’s patients? Hypothesis: the authors hypothesized that the application of the geriatric focused practices was essential for improving the care under intensive units. If caregivers do not adhere to the geriatric methods like using benzodiazepines, restraints and nothing by mouth would increase hospital stays and pressure ulcers. Purpose: The study aims at exploring geriatric-focused practices and associated outcomes in older intensive care survivors. This is a retrospective, cohort study The study initially used a database of 10,529 patients, focusing on 313 of that 179 who met inclusion criteria. The study was conducted at a hospital in New York 764-bed tertiary academic center. A total of 179 patients (mean age, 80.5 years) met the inclusion criteria. Data was extracted from EMR. The study’s primary focus was Geriatric practices and the screening for delirium using the CAM-ICU assessment, a component of the ABCDEF bundle, and pain agitation, using descriptive statistics. The instrument used in this study can also be used in the DPI study. Nonadherence to geriatric-focused practices, including nothing by mouth p = .004), exposure to benzodiazepines (p = .007), and use of restraints (p< .001), were associated with longer stay in the intensive care unit. Nothing by mouth (p = .002) and restraint use (p = .003) was significantly associated with longer hospital stays. The study indicated high levels of non-adherence to geriatric-focused practices was co-dependent on hospital length of stay. The limitations were, study design, The data was collected retrospectively from one site. Multiple studies in outpatients and inpatients, but not in ICU patients, have indicated better compliance with general medical best practices than with geriatric focused practices. The study identified a gap in care relating to geriatric care noting there is need to train healthcare providers geriatric focused practices to cater for the elderly. Healthcare workers need to go for a thorough training on ICU safety measures to cater for the elderly to improve clinical outcomes. Also, there is need to increase number of geriatric health care providers dedicated to the care of hospitalized older adults to meet the growing demands of the aging population. The study is relevant to the DPI project as a healthcare worker since it explores geriatric-focused practices and the associated outcomes for older adults in ICU survivors. The authors of this study highlight post-ICU syndrome (PICS) and its association with delirium and clinical outcomes. The authors aimed to use the ABCDEF bundle to assist in the management of geriatric patients. The study highlight that geriatrics were exposed to benzodiazepines, and it was associated with increased LOS. Trogrlić, Z., van der Jagt, M., Lingsma, H., Gommers, D., Ponssen, H., & Schoonderbeek, J. et al. (2019). Improved Guideline Adherence and Reduced Brain Dysfunction After a Multicenter Multifaceted Implementation of ICU Delirium Guidelines in 3,930 Patients. Critical Care Medicine, 47(3), 419-427. https://doi.org/10.1097/ccm.0000000000003596 Research question: what is the role of tailored multifaceted implementation program of ICU delirium guidelines on processes of care in improving the clinical outcomes? Hypothesis: the authors hypothesized that the tailored multifaceted implementation program of ICU delirium guidelines on processes of care was essential for ensuring a better patient’s care program especially for the critically ill since it includes baseline and delirium screening. Purpose: The study aim to evaluate the impact of a tailored multifaceted implementation program of ICU delirium guidelines on processes of care and clinical outcomes and draw lessons regarding guideline implementation. Prospective cohort study The study involved ICUs in one university hospital and five community hospitals in the Neverlands. The size of the units varied between eight and 32 ICU beds. Consecutive ICU patients 18 years old or older were included. Consecutive medical and surgical critically ill patients were enrolled between April 1, 2012, and February 1, 2015. A total of 3,930 patients were included in the study. Kruskal-Wallis was used to examine between-group differences for nonparametric analyses. Differences in clinical outcomes between the three phases were assessed with adjusted regression models. Poisson regression was used for count data (e.g., number of delirium assessments per day), logistic regression for binary outcomes, and linear regression for continuous outcomes. Data was collected using the Confusion Assessment Method for the ICU (CAM-ICU) checklist and the Intensive Care Delirium Screening Checklist (ICDSC). Study data were prospectively collected by research nurses using a data handling protocol. The instrument used in this study can be used in the DPI project. The length of mechanical ventilation, length of ICU stays, and hospital mortality, did not change ICU length of stay (d), mean (sd) PHASE 1= 1,337 4.9 (6.9) a) –0.3 (–0.8 to 0.1; p = 0.19) PHASE 2=1,399 4.3 (6.0) b) –0.1 (–0.6 to 0.3; p = 0.56) PHASE 3=,194 4.8 (5.9) c) 0.2 (–0.3 to 0.6; p = 0.49) Delirium screening increased from 35% to 93%. Continuous intravenous benzodiazepine sedation decreased from 36% to 31% to 17%. Physical therapy (PT), early mobilization of patients, sedation assessments, and light sedation improved significantly. The duration of delirium decreased over three periods after guideline implementation. Other clinical outcome measures, such as length of mechanical ventilation, length of ICU stay, and hospital mortality, did not change. The participating ICUs already applied light sedation practices in general, it was decided not to focus strongly on safety screens for Spontaneous Awakening Trials (SATs) and Spontaneous Breathing Trials (SBTs), which may have precluded improvements of the secondary outcomes, such as length of ventilation, ICU stay, or mortality. In the study, the Hawthorne effect was not avoided, seeing that delirium screening implementation alone resulted in improved adherence to several guideline recommendations. duration of delirium might be a doubtful outcome parameter due to the difference between a clinical diagnosis as assessed by chart review at baseline compared with the second and third phases. Certain changes over time may have been overestimated in the presence of secular trends Since implementation of delirium guidelines in ICUs resulted to a decrease in brain dysfunction outcome, there is need for clearer guidelines to improve clinical care adherence and overall outcome. Collaboration between healthcare professionals is also paramount to the success of the guideline’s implementation process. There is need for additional health professionals to care for the ICU patients by screening delirium to boost the clinical outcomes. This study is in line with the DPI project as it tips how best ICU delirium guidelines can be integrated to improve patients’ clinical adherence. This study demonstrated that implementing the ABCDEF bundle had improved health professionals’ adherence to delirium guidelines, which was linked to reduced brain dysfunction and decreased ICU stay. Data from this study added to existing implementation literature, strongly enhancing the translatability of findings. Zhang, S., Han, Y., Xiao, Q., Li, H., & Wu, Y. (2021). Effectiveness of Bundle Interventions on ICU Delirium: A Meta-Analysis*. Critical Care Medicine, 49(2), 335-346. https://doi.org/10.1097/ccm.0000000000004773 Research question: what is the impact of bundle interventions on ICU delirium prevalence, duration, and other patients’ adverse outcomes? Hypothesis: the authors hypothesized that the bundle intervention is significant in reduction of ICU delirium prevalence, reduction of hospital stay and overall mortality rates for the critically ill patients. Purpose: This study aim at evaluating the impact of bundle interventions on ICU delirium prevalence, duration, and other patients’ adverse outcomes. Meta-Analysis The study used a standardized data collection where two authors extracted data independently. A total of 26,384 adult participants were included in the meta-analysis. The meta-analysis included five studies; three were randomized clinical trials, and two were cohort studies. The study data sources included the Cochrane Library, PubMed, CINAHL, EMBASE, PsychINFO, and MEDLINE from January 2000 to July 2020. Data were extracted using a standardized data collection form. The quality of studies was assessed using the Modified Jadad Score Scale for randomized clinical trials and the Newcastle -Ottawa Scale for cohort studies. The instruments used in this study cannot be included in the DPI project. There were nine studies (seven RCTs and two cohort studies) reporting results on the ICU LOS. With a total of 5,184 ICU patients included in the meta-analysis using a random-effects model, the pooled result showed that the MD was 1.08 days shorter (95% CI, –2.16 to 0.00; p = 0.05) In addition, five studies (four RCTs and one cohort study) measured hospital LOS, and the meta-analysis using a fixed-effects model (I2 = 42%; p = 0.14) found that the MD of hospital LOS was 1.47 (95% CI, –2.80 to –0.15; p = 0.03) days shorter among 726 ICU patients in the intervention group compared with patients in the control group The study indicated that bundle interventions are effective in reducing the proportion of patient-days experiencing coma, hospital length of stay, 28-day mortality and mechanical ventilation. The study included both RCT and cohort studies in the current analysis, and heterogeneity was identified among studies in terms of results on the ICU delirium prevalence and duration, MV days, ICU, or hospital LOS. The number of studies included in the current analysis reporting outcomes on ICU mortality is small, which may have insufficient power to assess the differences and limited the interpretation of our pooled data. Although some studies reported coma-related outcomes, we failed to combine these data for analysis due to different presented data formats. Majority of the studies in this analysis did not include all elements of the bundle approach, the modifiable risk factors identified by the PADIS Guidelines are not fully addressed in the interventions. Further studies should be conducted to evaluate a more modifiable risk factors for ICU Delirium intervention to enhance bundle effectiveness. A more rigorous RCTs and full implementation of ABCDEF bundle should be considered to test effect of ICU intervention. Clinicians should regularly attend training on implementation of bundle intervention to improve ICU clinical outcomes. This study highlights the impacts of bundle interventions on ICU delirium prevalence, duration, and other patient adverse outcomes. The impacts highlighted in the article are vital for the DPI project in healthcare as it enhances the learner’s knowledge of how best ICU conditions can be improved to yield a positive outcome. Table 3: Theoretical Framework Aligning to DPI Project Nursing Theory Selected APA Reference – Seminal Research References (Include the GCU permalink or working link used to access each article.) Explanation for the Nursing Theory Guides the Practice Aspect of the DPI Project Virginia Henderson’s nursing needs theory Ahtisham, Y., & Jacoline, S. (2015). Integrating Nursing Theory and Process into Practice; Virginia’s Henderson Need Theory. International Journal of Caring Sciences, 8(2), 443–450. https://lopes.idm.oclc.org/login?url=https://search.ebscohost.com/login.aspx?direct=true&db=ccm&AN=102972280&site=eds-live&scope=site&custid=s8333196&groupid=main&profile=eds1 Henderson, V. (1966). The nature of nursing: A definition and its implications for practice, research, and education. Macmillan Virginia Henderson’s Nursing Needs Theory will be used to guide the DPI project. Henderson identified that the unique function of the nurse is to assist the individual, sick or healthy, in the performance of those activities contributing to health or its recovery (or to peaceful death) that he would perform unaided if he had the necessary strength, will, or knowledge. Moreover, to do this in such a way as to help him gain independence as rapidly as possible (Henderson, 1966). Henderson named her theory The Nursing Needs Theory as it categorizes nursing into fourteen components based on human needs (Ahtisham & Jacoline, 2015). The first nine are physiological, such as breathing normally, eating and drinking adequately, excretion, mobility and maintaining body postures, enough sleep and rest, suitable clothing, maintaining body temperatures by wearing different clothes in different environments, maintaining body hygiene and avoiding dangers both personal and from endangering others. The 10th and 14th are psychological aspects of learning and communication, such as expressing emotions, fears, or needs through communication; the 11th is worshipping, working to express a sense of accomplishment, and participating in various recreational activities (Ahtisham & Jacoline, 2015). Henderson viewed the nursing process as applying the logical approach to solving the problem (Ahtisham & Jacoline, 2015). Implementing this theory in the DPI project will aid nursing in the implementation of the ABCDEF bundle successfully. Change Theory Selected APA Reference – Seminal Research References (Include the GCU permalink or working link used to access each article.) Explanation for How the Change Theory Outlines the Strategies for Implementing the Proposed Intervention John Kotter’s 8 Steps for Change Kang, S.P., Chen, Y., Svihla, V., Gallup, A. K. (2022). Guiding change in higher education: an emergent, iterative application of Kotter’s change model. Studies in Higher Education, 47(2), 271-289. https://doi-org.lopes.idm.org/10.108/03075079.2020.1741540 https://lopes.idm.oclc.org/login?url=https://search.ebscohost.com/login.aspx?direct=true&db=ehh&AN=155185571&site=eds-live&scope=site&custid=s8333196&groupid=main&profile=eds1 Kotter, J. (1995). Leading change: why transformation efforts fail. Harvard Business Review, 73(2), 55-67. John Kotter’s 8 Steps for Change model applies to implement change (Kotter, 1995). These strategies can be applied in implementing the ABCDEF bundle to decrease LOS. According to Kotter (1995), the first step is creating urgency. Kang et al. (2022) explain the theory. According to Kang et al. (2022), the proposed interventions must develop urgency. Identifying accuracy is needed in identifying the existing threats in caring for patients. Therefore, discuss the weaknesses with the stakeholders and colleagues and ask for their support to implement the change. Secondly, put together a guiding coalition. Come up with competent leaders and professionals to steer the agenda to influence the stakeholders. Thirdly develop vision and strategies. In this step, come up with a clear vision of how the organization will look if the change is implemented. A clear vision of how the health sector would look after implementing intervention will enhance action and decision-making. The next step is communicating the change vision. In this step, communicate to capture the hearts of other health workers to support the change. The next step is avoiding barriers. The guiding team avoids barriers to the change to drum up support. The next step is accomplishing short-term wins. These short-term wins serve as encouragement and should be related to the change. E.g., win by demonstrating the effectiveness of the proposed intervention. The next step is building on the change. This step ensures the team is overworking to achieve the change and measure progress. The last step is to make the change stick. He re-ensures that everyone adapts to new change by illustrating its importance and training them on the skills necessary to maintain the new change. These steps will be used to implement unit change, implementing the ABCDEF bundle for the DPI project. Table 5Clinical Practice Guidelines (If applicable to your project/practice) APA Reference – Clinical Guideline (Include the GCU permalink or working link used to access the article.) APA Reference – Original Research (All) (Include the GCU permalink or working link used to access the article.) Explanation for How Clinical Practice Guidelines Align to DPI Project Place the primary quantitative research used in the clinical practice guidelines in Table 1. This is part of the primary quantitative research used to support your intervention. Legend: Appendix C Project Timeline Appendix D Plan for Educational Offering Appendix E Grand Canyon University Institutional Review Board Outcome Letter Appendix F Project Budget Appendix G Data Collection Tool for Evaluation (Use the name of the tool here) Appendix H Place the Permission to Use the Tool Here Appendix I Other Data Collection Tool and/or Permissions Appendix J APA Writing Style for the Direct Practice Improvement Project Information and resources are also available on the APA Style website. If you have questions about specific assignment guidelines or what to include in your APA Style paper, please check with your assigning instructor or chair. The DNP manuscript should be written based on the 7th edition American Psychological Association’s APA Style (7th edition). This document is based on the American Psychological Association’s Publication Manual, 7th Edition – Student Paper Checklist located at https://apastyle.apa.org/instructional-aids/publication-manual-formatting-checklist.pdf Use this checklist while writing your paper to make sure it is consistent with seventh edition APA Style. Page Header: The page header does not contain a page number until Chapter 1. The fore pages are not numbered. All pages which are numbered are included in the Table of Contents. Font and Font Size: Times New Roman 12-point Font. Use the same font and font size throughout your paper (exception: figure images require a sans serif font and can use various font sizes). Line Spacing: Double Spacing. Double-space the entire paper. Do not add extra lines before or after headings or between paragraphs. Margins: Left Margin is 1 ½ inch. 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Use clear transitions to smoothly connect sentences, paragraphs, and ideas. Conciseness: Choose words and phrases carefully and deliberately. Eliminate wordiness, redundancy, evasiveness, circumlocution, overuse of the passive voice, and clumsy prose. Do not use jargon, contractions, or colloquialisms. Avoid overusing both short, simple sentences and long, involved sentences; instead, use varied sentence lengths. Avoid both single-sentence paragraphs and paragraphs longer than one double-spaced page. Clarity: Use clear and precise language. Use a professional tone and professional language. Do not use jargon, contractions, colloquialisms, or creative literary devices. Check for anthropomorphistic language (i.e., attributing human actions to inanimate objects or nonhuman animals). Make logical comparisons using clear word choice and sentence structure. Grammar: Verb Tense: Use verb tenses consistently in the same and adjacent paragraphs. Use appropriate verb tenses for specific paper sections, e.g., future tense for proposal and past tense for final manuscript. Subject Verb Agreement: Use verbs that agree in number (i.e., singular or plural) with their subjects. Pronouns: Use first person pronouns to describe your work and your personal reactions (e.g., “I examined,” “I agreed with”), including your work with coauthors (e.g., “We conducted”). Use the singular “they” when referring to a person who uses it as their self-identified pronoun or to a person whose gender is unknown or irrelevant. Use other pronouns correctly. Otherwise, deliver the project in third person as if narrating or presenting it. Bias-free language: Eliminate biased language from your writing. 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**** very important assignment*** see attached paper to Synthesize the articles !!!!! pls synthesize, note the commonalities of the 15 articles, page length should be 8-10 pgs. pls fix corrections hi
The first article by Hsieh et al. (2019) looks at the effect of the ABCDE bundle on specific patient costs. The objective of the study was to measure the impact of the staged implementation of complete versus virtual ABCDE bundle on mechanical ventilation (MV) duration, intensive care unit (ICU) and hospital length of stay (LOS), and cost. The prospective cohort study included 1,855 mechanically ventilated patients admitted to ICUs between July 2011 and July 2014. Based on the findings, it was established that implementing the ABCDE bundle was associated with a decrease in-hospital mortality and length of stay. It was also found that early mobilization and coordination portrayed an improvement in patients in the ICU by 30 percent. After adjustment for patient-level covariates, it was found that the implementation of the entire (B-AD-EC) versus partial (B-AD) bundle was associated with reduced mechanical ventilation duration (–22.3%; 95% CI, –22.5% to –22.0%; p < .001), ICU length of p < .05. However, this study was limited in that it was conducted in a single medical center which limited the generalizability of the findings. An unmeasured change could have affected the results, and the cross-contamination of practices between two ICUs could have further affected the findings. The study illustrates the significance of teamwork between physicians in the ICU in enhancing patients’ health and medication adherence while improving the working conditions in health facilities to safeguard the patient’s health. The article will help support a decrease in in-hospital mortality and length of stay for the DPI project by implementing the ABCDE bundle. The second article by Liu et al. (2021) had the primary outcome of the implementation rate of the ABCDE bundle. For the DPI project, the article will help support implementing the ABCDE bundle to decrease in-hospital mortality and length of stay. Secondary outcomes were the implementation rates for each element of the ABCDEF bundle, including element A (regular pain assessment), element B [both spontaneous awakening trials (SAT) and spontaneous breathing trials (SBT)], element C (regular sedation assessment), element D (regular delirium assessment), element E (early mobility and exercise), and element F (family engagement and empowerment), and an ICU diary. The ABCDE bundle and the ICU diary between patients without and with COVID-19 infections were made with the Mann-Whitney U-test for non-normally distributed continuous data, the chi-squared test, and Fisher’s exact test for categorical data. The calculated sample size with 95% power and a two-sided alpha of 0.05 was 508 patients under the assumption of the implementation rate of the entire ABCDE bundle for patients without and with COVID-19 infections.  The third article by Louzon et al. (2017) study included 436 participants. Patients managed with the ABCDE bundle and 499 patients of those with standard care in a Florida hospital in the United States. Steps to implement this program occurred in two phases. Phase 1 involved an initial pilot program to allow ICU pharmacists to directly manage sedative therapy for mechanically ventilated patients in collaboration with an insensitivity. In phase 2, that initiative was expanded to include comprehensive pharmacist PAD management and the development of a multispecialty inter-professional team to encourage the early mobilization of mechanically ventilated patients. This study used the APACHE outcomes tool for managing critical care outcomes methodology and found a reduction relative to mean hours in the standard-care cohort (p = .0025). For the DPI project, the article will help support implementing the ABCDE bundle to manage sedative therapy for mechanically ventilated patients in collaboration with an insensitivity and multispecialty inter-professional team to encourage the early mobilization of mechanically ventilated patients. The fourth article by Trogrlić et al. (2019) showed that implementing the ABCDE bundle had improved health professionals’ adherence to delirium guidelines, which was linked to reduced brain dysfunction. The ABCDE bundle was further linked to decreased ICU stay data from this study added to existing implementation literature, strongly enhancing the translatability of findings. This article aligns with this learner’s DPI project as a healthcare professional, giving tips on how best ICU delirium guidelines can be integrated to improve patient clinical adherence. The study identified improvements after the implementation pertained to delirium screening (from 35% to 96%; p < .001). The feasibility of staggered versus simultaneous implementation of the bundle elements seems strongly dependent on local resources (e.g., “local champions” vs. interprofessional implementation teams or level of previous experience with the guidelines). Additionally, the fact that “error of omission” of daily safety screens for SATs and SBTs may have precluded concurrently improved clinical outcomes, adding solid empirical support from a “real-life setting” for the effectiveness of individual ABCDE bundle elements. For the DPI project, the article will support implementing the ABCDE bundle for a decreased ICU stay. The fifth article by Ren et al. (2017) looks at the effects of the ABCDE bundle on hemodynamics in patients with mechanical ventilation. The study involved a cross-sectional overall, before-after controlled study with 143 patients on mechanical ventilation admitted at the ICU. The study found a decrease in heart rate, mean arterial pressure, and length of stay when the bundle was implemented. In addition, there was an increase in PaO2/FiO2 ratio and a decrease in ventilator-free days. The difference in the prognosis between the bundle and pre-ABCDE bundle groups was statistically significant (p < .05). The study proved that the ABCDE bundle could significantly improve the vital indicators of patients on mechanical ventilation, reduce the dose of the sedatives and pain medications used, and keep the vital indicators at levels beneficial to patients. The limitation of this study was that the study was non-randomized, which could translate to selection bias. For the DPI project, the article will support implementing the ABCDE bundle to decrease heart rate, mean arterial pressure, and length of stay on hemodynamics in patients with mechanical ventilation. The sixth article by Frade-Mera et al. (2022) looks at the impact of early intervention with the ABCDE bundle on sepsis outcomes. The study was a 4-month, prospective, observational, multi-center cohort study conducted in adult patients receiving invasive mechanical ventilation (IMV) for at least 48 hours in ICUs across Spain. The primary outcomes measured were the pain level, level of cooperation, the incidence of delirium and physical restraints, and level of mobility related to implementing bundle components A, B, C, D, and E. The secondary outcome was the drug levels of analgesia, sedatives, muscle relaxants, and antipsychotics (cumulative drug dosing by IMV days 100) associated with the implementation of bundle components A, B, C, D, and E. on the other hand, the tertiary outcome- Need for re-intubation or tracheostomy, ICU length of stay in days, IMV days, bed rest days, ICU mortality, and development of ICUAW associated with the implementation of bundle components A, B, C, D, and E. The study involved 531 patients and found a decrease in mortality and length of stay when the bundle was implemented early. It showed that patients had shorter ICU stays with bundle protocols and fewer days of IMV in ICUs with delirium and mobilization bundle components (p = .006 and p = 0.03. In addition, there was a reduction in cost per patient when the bundle was implemented. The study’s main limitation was that the Richmond agitation-sedation scale (RASS) results were not analyzed because most were recorded in ICU patients implementing protocols with analgosedation algorithms. For the DPI project, the article will support implementing the ABCDE bundle to reduce ICU length of stay, effectively manage pain, and decrease mortality. The seventh article by Negro et al. (2018) looks at the impact of the ABCDE bundle on ICU patients with systemic inflammatory response syndrome. The researchers sought to assess the feasibility and safety of an early progressive mobilization protocol, focusing on the three most advanced steps (dangling, out-of-bed, and walking) implemented without additional dedicated personnel as part of the ABCDE bundle. The study involved 482 patients and found a decrease in mortality and length of stay when the bundle was implemented. In addition, there was a reduction in cost per patient when the bundle was implemented p < .05, which is considered statistically significant. However, the study was limited because it was a descriptive study that shows the experience in a single ICU unit, and the researchers did not have control over the historical group. The descriptive study design weakens the findings and makes it imprudent to generalize them to other populations. By implementing the ABCDE bundle, the article will support early progressive mobilization protocol for ICU patients with systemic inflammatory response syndrome. The eighth article by Collinsworth et al. (2021) looks at the impact of the ABCDE bundle on ICU patients with sepsis using mixed methods. The study also sought to assess the clinicians’ perceptions regarding the ABCDE bundle and the implementation effort. The study involved eight patient adults in ICU and 84 nurses, therapists, and physicians surveyed. The study found decreased mortality and length of stay when the bundle was implemented, translating to the best care and patient outcomes. In addition, there was a reduction in cost per patient when the bundle was implemented in both interventions. Effect of Basic vs. Enhanced Intervention on Bundle Adherence ICU LOS 0.02 (0.01-0.02) <.0001a (p < .05. The data was acquired from electronic health records (EHRs). The EHR limited evaluation of some elements, such as pain and sedation, and the physicians’ responses could be biased, further limiting the study. For the DPI project, the article will support implementing the ABCDE bundle to decrease mortality and length of stay. The ninth article by van den Boogaard et al. (2020) looks at implementing the ABCDE bundle and its effect on patient outcomes by studying the association between the level of sedation and delirium occurrence in patients who are critically ill. The study included more than 1660 patients and used observation of the cohort study. It was found that there was a decrease in mortality and length of stay when the bundle was implemented; length of stay (ICU) (p < .05) was considered statistically significant. In addition, there was a reduction in cost per patient when the bundle was implemented. It was concluded that the influence of the level of sedation on delirium assessment depends on whether the CAM-ICU or ICDSC is used. The limitation of the study was that it was based on a comparison between sedation and delirium; hence, it needed to compare CAM-ICU to ICDSC simultaneously and determine its impact on critically ill patients. The article will help to support improved patient outcomes by maintaining accurate levels of sedation for delirium to decrease mortality and length of stay when the bundle is implemented.  The tenth article by Pun et al. (2019) looks at the impact of the ABCDE bundle on patient outcomes in a medical ICU. This prospective cohort study from a national quality improvement collaborative study included 15,226 patient adults with at least one ICU daily. The study found decreased mortality and length of stay when the bundle was implemented. Significant pain was more frequently reported as bundle performance proportionally increased (p = .0001) with a p < .002. In addition, there was a reduction in cost per patient when the bundle was implemented. However, the study is limited in various ways. It did not use a randomized design; the researchers did not have access to concurrent control and patient-level outcomes were not wholly independent and were assessed when patients did not experience those outcomes. The ICU liberation collaborative study also needed more funds to support data accuracy auditing. The article will support the implementation of the ABCDE bundle on patient outcomes in a medical ICU to reduce mortality and length of stay. Another article by Otusanya et al. (2021) examines early intervention with the ABCDE bundle on patient outcomes. The study was a retrospective cohort study involving 472 mechanically ventilated patients admitted to the ICU between January 1, 2013, and December 31, 2013, in two medical ICUs in Montefiore Health Systems. The study found a decrease in mortality and length of stay when the bundle was implemented early. In addition, there was a reduction in cost per patient when the bundle was implemented. Hospital resource use decreased in the intervention ICU (incidence rate ratio [95% CI], laboratory: 0.68 [0.54, 0.87], p < 0.002; diagnostic radiology: 0.75 [0.59, 0.96], p < .020). (p < .05). The articles above support implementing the ABCDE bundle as it has been shown to improve patient outcomes, including decreased mortality and length of stay. The bundle has also been cost-effective, which is an important consideration when making decisions about healthcare interventions. The study’s main limitation was that the data collection and analysis were limited to only two ICU centers. The article will support implementing the ABCDE bundle to improve patient outcomes, including decreased mortality and length of stay during the DPI project. Furthermore, Loberg et al. (2022) looked at the impact of early intervention with the ABCDE bundle on patient outcomes by examining how quality improvement initiatives could be used to evaluate the effectiveness of the ABCDEF bundle elements to improve clinical outcomes. The study adopted secondary research through sampling in a 609-bed Midwest metropolitan hospital between January 2019 and March 2019. The researchers found a decrease in mortality and length of stay when the bundle was implemented early. In addition, there was a reduction in cost per patient when the bundle was implemented. A significant improvement was seen in the completion of spontaneous awakening and breathing trials (p = .002), delirium assessment (p = .041), and early mobility (p = .000). These findings support the earlier implementation of the ABCDE bundle, which has been shown to improve patient outcomes. The findings of the studies included in this systematic review provide strong evidence for the implementation of the ABCDE bundle to improve patient outcomes. However, the study faced three main limitations such as the quality improvement initiative had a problem with its generalizability because the study was conducted at a single Midwest metropolitan hospital. A lower than the desired rate with bundle elements was experienced during the study. Lastly, the intervention was not designed as a randomized controlled study but instead utilized as convenient sampling. The study type made it suffer selection bias, making it difficult to generalize the findings. For the DPI project, the article will demonstrate the effectiveness of the ABCDE bundle elements in improving clinical outcomes. DeMellow et al. (2020) also looked at the impact of early intervention with the ABCDE bundle on patient outcomes. The study was observationally using electronic health records (EHRs) with a sample size of 977 adult patients who were on mechanical ventilation for more than 24 hours and admitted to an intensive care unit over six months. The study’s findings indicated decreased mortality and length of stay when the bundle was implemented early. In addition, there was a reduction in cost per patient when the bundle was implemented. These findings support the earlier implementation of the ABCDE bundle, which has been shown to improve patient outcomes. ABCDE bundle adherence was higher in patients on mechanical ventilation for less than 48 hours (p = .01), who received continuous sedation for less than 24 hours (p < .001), who were admitted from skilled nursing facilities (p <.05), and throughout the six-month study period (p < .01). The findings of the studies included in this systematic review provide strong evidence for the implementation of the ABCDE bundle to improve patient outcomes. The limitations of this study included the limitations to using EHR clinical data available in conducting evaluation assessment for pain, sedation, delirium, and mobility elements only, failure to use analgesic infusions as sedation to determine the duration of sedation and adherence of awakening trials, limitations to the examination of the early 96 hours on MV adherence to bundle by the care unit. The article will demonstrate the ABCDE bundle’s effectiveness in decreasing mortality and length of stay. The other article was a systematic review to determine the effects of quality improvement collaborative participation on the ABCDE bundle performance. The study included 114 acute care hospitals that were participating in the study. The findings of the studies included in this systematic review provide strong evidence for the implementation of the ABCDE bundle to improve patient outcomes. Moreover, Balas et al. (2022) looked at the impact of early intervention with the ABCDE bundle on patient outcomes. They found a decrease in mortality and length of stay when the bundle was implemented early. In addition, there was a reduction in cost per patient when the bundle was implemented. Each subsequent month was associated with an increase of 0.6 percentage points (SE, 0.2; p = .04). Performance rates increased significantly immediately after initiation for pain assessment (7.6% [SE, 2.0%], p = .002), sedation assessment (9.1% [SE, 3.7%], p = .02), and family engagement (7.8% [SE, 3%], p = .02). These findings support the earlier implementation of the ABCDE bundle, which has been shown to improve patient outcomes. However, this study was limited because conclusions cannot be made on long-term sustainability despite ICUs demonstrating improvements during 20 months. Furthermore, the study used observational studies; thus, the residual confounding cannot be omitted to explain the observed changes in bundle performance. The article will demonstrate the impact of improving patient outcomes, decreasing mortality rates, and length of stay for the DPI project when the bundle was implemented early.  Also, Barnes-Daly et al. (2017) looked at the impact of early intervention with the ABCDE bundle on patient outcomes by examining the connection between ABCDE bundle compliance and consequences, including clinic survival and delirium-free and coma-free days in community infirmaries. The researchers conducted a prospective cohort quality improvement initiative involving ICU patients by randomly selecting one patient from the daily census at each hospital for the baseline period (January 1, 2008, to July 31, 2009) and during the follow-up period (August 1, 2009, to September 30, 2011) for a total of 2 years of data. The study found a decrease in mortality and length of stay when the bundle was implemented early, a p < .05. In addition; there was a reduction in cost per patient when the bundle was implemented. These findings support the earlier implementation of the ABCDE bundle, which has been shown to improve patient outcomes. The findings of the studies included in this systematic review provide strong evidence for the implementation of the ABCDE bundle to improve patient outcomes. The limitation of this study was that it needed strict protocols found in randomized, controlled trials. Furthermore, the investigation’s study design and sample size benefits did not trump other statistical concerns (Barnes-Daly et al., 2017). The article will demonstrate how the ABCDE bundle improves patient outcomes regarding clinic survival, delirium-free, and coma-free days .  The chosen articles share similar themes, including the importance of adherence to the ABCDE bundle, the positive effects of the bundle on patient outcomes, and the need for further research on the topic. However, there were also some differences between the articles. For example, some articles looked at specific aspects of the bundle (e.g., the impact of sedation on delirium recognition), while others looked at the bundle as a whole. Additionally, some articles focused on specific populations of patients (e.g., those with acute respiratory failure), while others looked at the bundle in a more general sense. However, the studies vary in terms of their locations (the US vs. international), study populations (mechanically ventilated patients vs. all critically ill adults), and interventions (implementation of the ABCDE bundle vs. measurement of adherence to the ABCDE bundle). There is some overlap in the findings of the studies. For example, all studies found that implementing the ABCDE bundle improved patient outcomes. However, there were also differences between the studies. Some studies found that adherence to the ABCDE bundle was associated with better patient outcomes. In contrast, other studies found that implementing the ABCDE bundle was associated with better patient outcomes. There are also differences in the methods used by the studies. Some studies used observational designs, while others used randomized controlled trials. Some studies measured adherence to the ABCDE bundle, while others measured implementation of the ABCDE bundle. The conclusions of the studies also vary. Some studies conclude that the ABCDE bundle effectively improves patient outcomes, while others conclude that more research is needed. Some studies suggest that adherence to the ABCDE bundle is more important than implementing the ABCDE bundle, while other studies suggest that both adherence and implementation are essential. There are also some limitations to the studies. For example, some studies did not include a control group, making it difficult to determine whether the ABCDE bundle was responsible for improved patient outcomes. Additionally, some studies had small sample sizes, limiting the findings’ generalizability. Finally, there are some controversies surrounding the use of the ABCDE bundle. Some critics argue that the bundle is too complicated and expensive to implement, while others argue that the bundle’s benefits justify the costs. There is debate about whether adherence or implementation is more critical for improving patient outcomes. One fundamental gap identified in the literature is a need for more research on patient populations not traditionally considered high risk for developing sepsis, such as those admitted to the intensive care unit for other reasons (e.g., respiratory failure, renal failure). , nor did the searches identify the use of the ABCDE bundle in an LTACH setting. Additional research is needed on the impact of the ABCDE bundle on these patients and its use in LTACHs to determine if the bundle effectively reduces sepsis-related morbidity and mortality and the impact it could have on patients in an LTACH population. Another gap identified in the literature is a need for studies on the cost-effectiveness of the ABCDE bundle. Additional research is needed on the financial impact of implementing the bundle on hospitals and patients. This research could inform decisions about whether or not to implement the bundle in clinical practice. Lastly, additional research is needed on implementing the ABCDE bundle in different healthcare settings. Implementing the bundle requires significant changes in clinical practice, and more information is needed on how well the bundle can be adapted to different care environments. These are just a few examples of the gaps in the literature that require further research. It is important to note that any investigation into the effectiveness of the ABCDE bundle should consider all of these gaps to provide a comprehensive assessment of the current state of knowledge on this topic .
**** very important assignment*** see attached paper to Synthesize the articles !!!!! pls synthesize, note the commonalities of the 15 articles, page length should be 8-10 pgs. pls fix corrections hi
Direct Practice Improvement : Title Appears in Title Case and is Centered Submitted by Insert Your Full Legal Name (No Titles, Degrees, or Academic Credentials ) Equal Spacing ~2.0” – 2.5” A Direct Practice Improvement Project Presented in Partial Fulfillment of the Requirements for the Degree Doctor of Nursing Practice Equal Spacing ~2.0” – 2.5” Grand Canyon University Phoenix, Arizona July 29, 2022 © by Your Full Legal Name (No Titles, Degrees, or Academic Credentials), 2022 All rights reserved . GRAND CANYON UNIVERSITY The Direct Practice Improvement Project Title Appears in Title Case and is Centered By Your Full Legal Name (No Titles, Degrees, or Academic Credentials), has been approved July 29, 2022 APPROVED: Full Legal Name, Ed.D., DBA, or Ph.D., DPI Project Chairperson Full Legal Name, Ed.D., DBA, or Ph.D., Project Mentor Full Legal Name, Ed.D., DBA, or Ph.D., Content Expert ACCEPTED AND SIGNED: ________________________________________ Lisa Smith, PhD, RN, CNE Dean and Professor, College of Nursing and Health Care Professions _________________________________________ Date Abstract The abstract is an accurate, nonevaluative, concise summary or synopsis of the direct practice improvement (DPI) project. It is not an introduction and is usually the last thing written. The purpose of the abstract is to assist future investigators in accessing the evidence-based materials and other vital information contained in the practice improvement project. Although only a relatively few people typically read the full practice improvement project after publication, the abstract will be read by many scholars and investigators. Consequently, great care must be taken in writing this section of the practice improvement project. The abstract is a concise statement of the nature of the project and the content of the practice improvement project. The content of the abstract covers the problem statement, evidence-based question(s), methodology, design, data analysis procedures, location, sample, theoretical foundations, results, and implications. The abstract does not appear in the Table of Contents and has no page number. Abstracts must be one paragraph, double-spaced, and no longer than 1 page. The abstract should be left justified with no indentions and no citations. Refer to the current APA Publication Manual, for additional guidelines for the development of the practice improvement project abstract. Make sure to add the keywords at the bottom of the abstract to assist future investigators. Examples and recommendations for writing this Abstract are offered in the DC Network. Keywords : Abstract, assist future investigators, limited to one page in length, vital information, include theories used, include outcomes and quality improvement Dedication An optional dedication may be included here. While a practice improvement project is an objective, scientific document, this is the place to use the first person and to be subjective. The dedication page has no page numbers and does not appear in the Table of Contents. It is only completed in the final practice improvement project and this page is a placeholder. If this page is not to be included in the final project, delete the heading, the body text, and the section break below. If you cannot see the section break, click on the ¶Show/Hide button (go to the Home tab and then ¶ Show/Hide on the Paragraph toolbar). Acknowledgments An optional acknowledgments page can be included here. This is another place to use the first person. If it applies, acknowledge and identify grants and other means of financial support. Also, acknowledge supportive colleagues who rendered assistance. The acknowledgments page has no page numbers and does not appear in the Table of Contents. This page provides a formal opportunity to thank family, friends, and faculty members who have been helpful and supportive. The acknowledgments page is only completed in the final practice improvement project and is not part of the proposal. If this page is not to be included, delete the heading, the body text, and the page break below. If you cannot see the page break, click on the ¶Show/Hide button (go to the Home tab and then to the Paragraph toolbar). Table of Contents Chapter 1: Introduction to the Project 10 Background of the Project 12 Organizational Needs Assessment 13 SWOT Analysis 13 Strengths 13 Weaknesses 13 Opportunities 13 Threats 14 Problem Description 14 Definition of Terms 14 Summary 16 Chapter 2: Scientific Underpinnings 17 Literature Search Strategy 17 Synthesis of Literature 17 Evidence-Based Practice Question 18 Change Recommendation: Validation of [Enter Name of EBP Intervention] 18 Theoretical Framework 18 Nursing Theory 19 Synthesis of Nursing Theory 19 Evidence-Based Change Model 19 Synthesis of Change Model 20 Integration of the Christian Worldview 20 Summary 21 Chapter 3: Project Design and Methodology 22 Purpose 22 Project Planning and Procedures 23 Interprofessional Collaboration 23 Project Management Plan (list required resources—delete this parenthetical note) 24 Feasibility 24 Setting and Sample Population 25 Setting 25 Population and Sample 25 Data Collection Procedures 26 Instrumentation or Data Source 26 Variables 27 Data Integrity and Storage 27 Data Management 27 Potential Bias and Mitigation 27 Ethical Considerations 28 Summary 29 Chapter 4: Data Analysis and Results 30 Data Analysis Procedures 30 Descriptive Data of Sample Population 31 Results 32 Summary 34 Chapter 5: Implications in Practice and Conclusions 35 Summary of the Project 35 Major Findings 35 Interpretation of Findings 35 Strengths and Limitations 36 Implications 36 Theoretical Implications 36 Nursing Practice Implications 37 Recommendations 37 Recommendations for Future Projects and Researchers 37 Recommendations for Sustainability 37 Plan for Dissemination 38 Conclusion and Contributions to the Profession of Nursing Practice 38 References 39 Appendix A 39 SWOT Analysis 39 Appendix B 40 Literature Evaluation Table 40 Appendix C 45 Project Timeline 45 Appendix D 46 Plan for Educational Offering 46 Appendix E 47 Grand Canyon University Institutional Review Board Outcome Letter 47 Appendix F 48 Project Budget 48 Appendix G 49 Data Collection Tool for Evaluation (Use the name of the tool here) 49 Appendix H 50 Place the Permission to Use the Tool Here 50 Appendix I 51 Other Data Collection Tool and/or Permissions 51 Appendix J 52 APA Writing Style for the Direct Practice Improvement Project 52 List of Tables Table 1 A Sample Data Table Showing Correct Formatting 32 Table 2 t-Test for Equality of Emotional Intelligence Mean Scores by Gender 33 Table 3 Primary Quantitative Research – Intervention (5 Articles) 40 Table 4 Additional Primary and Secondary Quantitative Research (10 Articles) 42 Table 5 Clinical Practice Guidelines (If applicable to your project/practice) 45 List of Figures Figure 1 SWOT Analysis for Quality Improvement Project 39 Chapter 1: Introduction to the Project The introduction of Chapter 1 provides a brief overview of (a) the project focus or practice problem, (b) states why the project is worth conducting, and (c) describes how the project will be completed. The introduction develops the significance of the project by describing how the project translates existing knowledge into practice, is new or different from other works, and how it will benefit patients at your clinical site. This section should also briefly describe the basic nature of the project and provide an overview of the contents of Chapter 1. This section should be three or four paragraphs long. Do not use single-sentence paragraphs or paragraphs longer than one double-spaced page. Keep in mind that you will write Chapters 1 through 3 as your direct practice improvement (DPI) project proposal and Chapters 1 through 5 for your final project manuscript. As you progress, changes will need to be made to the initial three chapters to enrich the content or to improve the readability of the final DPI project manuscript. In particular, after data analysis is complete, the first three chapters will need revisions to reflect a more in-depth understanding of the topic, to change the tense to past tense where appropriate, and to ensure consistency. To ensure the quality of both your proposal and your final practice improvement project and reduce the time for Academic Quality Reviews (AQR), your writing needs to reflect standards of scholarly writing from your very first draft. Each section should be well-organized, uniform, and logically presented. Each paragraph should be short, clear, and focused. A paragraph should (a) be three to eight sentences in length and (b) focus on one point, topic, or argument. If you have difficulty writing, it is recommended that you outline your paragraphs prior to writing the first draft of each chapter. Outlines should include the topic of each paragraph, evidence you would use to support this topic, explanations that connect the evidence to the topic, and a link or transition to the next paragraph. Outlining your paragraphs saves time when you’re writing and ensures coherence in your writing. In the final drafts, there should be no grammatical, punctuation, sentence structure, or American Psychological Association (APA) formatting errors. Be sure to use the check document feature in the Microsoft Word Review Menu. This feature will check for spelling errors and grammatical issues. Taking the time to put quality into each draft will save you time in all the steps of the development and review phases of the practice improvement project process. It will pay to do it right the first time. Verb tense is an important consideration throughout the manuscript drafting process. For the proposal, the learner (project manager) uses present tense (e.g., “The purpose of this project is to…”), whereas in the practice improvement final project, the chapters are revised into past tense (e.g., “The purpose of this project was to…”). However, when considering tense, you’ll want to pay attention to the conventions of grammar and APA style. For instance, when you signal the structure of a chapter, it should be written in the present or the future tense. Similarly, current or general problems should be written in the present tense. However, APA conventions stipulate referring to research studies in the past tense (i.e., “the research showed” vs. “the research shows). As a doctoral scholar, it is your responsibility to ensure the clarity, quality, and correctness of your writing and APA formatting. The DC Network provides various resources to help you improve your writing. Neither your chairperson nor your committee members will edit your documents nor will the AQR reviewers edit your documents. If you do not have outstanding writing skills, you will need to identify a writing coach, editor, or other resources, such as GrammarlyTM or ThinkingstormTM (GCU service), to help you with your writing and to edit your documents. The most important outcome is a scholarly product. Prior to submitting a draft of your proposal or practice improvement project or a single chapter to your chairperson, it is recommended that you have met previously with your Chair. Background of the Project The background section explains both (a) the history of and (b) the present state of the problem at the project site. This section should be two or three paragraphs in length. In this section, you should include your baseline data (see “Chapter 4: Using Data” in Clinical Analytics and Data Management). How many occurrences or current percentage of the problem compared to the industry have occurred over the 60 days prior to project implementation? Articulate how this “problem” has impacted or affected patient outcomes and nursing care (a) at the site, (b) the local level, (c) the national level, and (d) the global level. The section should close with a paragraph that ties these four concepts together, starting with the facility level and then adding the significance of the local, national, and global levels. Organizational Needs Assessment This section is one paragraph in length and should define what an organizational assessment is, why it is done, and that you did so utilizing a strengths, weakness, opportunities, and threats (SWOT) analysis. Explain why the SWOT analysis was appropriate for your quality improvement project. Present how you noted the gap between the current practice and the desired practice change that would improve patient outcomes at the project site. Use a transitional statement that takes you from describing the organization into the SWOT analysis. SWOT Analysis Introduce this section in one paragraph by briefly outlining the objective of performing a strengths, weaknesses, opportunities, and threats (SWOT) analysis. The SWOT analysis was created in DNP-840A. Within the weaknesses and threat, you will have barriers that emerge, so you will need to address how you mitigate them. Your SWOT should focus on the organization and the unit on which the project will be implemented (see Appendix A; see Figure 1). Strengths Concisely synthesize three to four strengths of the project site and unit that impact the successful implementation and ability to sustain this practice change. Do not implicate the site by name, be very general. Please refer to your scholarly readings and textbooks for examples. Weaknesse s Concisely synthesize three to four weaknesses, or challenges, of the project site that could negatively impact the successful implementation and ability to sustain this practice change. Again, do not implicate the site by name, be very general. Please refer to your scholarly readings and textbooks for examples. In addition, discuss the identified barriers and how you will mitigate them. Opportunities Concisely synthesize three to four potential opportunities for the organization and unit especially those to be gained from the implementation of this project. Do not implicate the site by name, be very general. Please refer to your scholarly readings and textbooks for examples. Threats Concisely synthesize three to four potential internal and external threats to the organization and unit that could impact the project’s implementation and sustainability. For instance, the COVID-19 pandemic may decrease staffing on the unit or lead to uneven patient populations seen at the project site. There may also be threats related to geographic location (urban vs. rural), patient population, or other facilities. Discuss the identified barriers and how you will mitigate them. Please refer to your scholarly readings and textbooks for examples. Problem Description This section should be two or three paragraphs long. It clearly states the problem or project focus, the problem statement, the patient population affected by the problem, the significance of the practice problem, and how the project will contribute to solving the problem. You will explain why you and your committee (project mentor/content expert) chose this problem. This section should be supported with literature and multiple examples that support why this problem was chosen and why it is both significant to the site and to current nursing practice. This section of Chapter 1 should be comprehensive, yet simple, providing the context for the practice project. A well-written problem statement begins with the big picture of the issue (macro) and works to the narrower, more specific problem (micro). It clearly communicates the significance, magnitude, and importance of the problem that will transition into the “Purpose of the Project.” The problem should be written as a declarative statement, such as “It is not known if the implementation of __________________ (specific evidence-based practice or intervention) would impact ______________ _______________ (patient outcome) among ___________ (population).” Definition of Terms The “Definition of Terms” section provides an understanding of the project constructs and a common understanding of the technical terms, jargon, variables, concepts, and other terminology used within the scope of the project. Terms should be defined in lay terms and discussed according to the context that they are used within the project. Each definition may be a few sentences to a paragraph in length. This section includes any words that may be unknown to a lay-person and taken from the evidence or literature. This section is also a good place to operationally define unique phrases specific to the project. Definitions must be supported with citations from scholarly sources. Do not use Wikipedia or general dictionaries (i.e., Merriam-Webster, Dictionary.com) to define terms. All definitions should be written in complete sentences. A lead-in paragraph is needed to introduce this section and should end with something like: “The following terms were used operationally in this project.” Project Manager Please refer do not refer yourself at all in the manuscript. It should be written in 3rd person. This term is for your reference only. Please remove this term from the Definition of Terms when writing up the project. Term Write the definition of the word. Make sure the definition is properly cited (Author, 2010). Terms often use abbreviations. According to APA (2019), abbreviations are best used only when they allow for clear communication with the audience. Standard abbreviations, such as units of measurement and names of states, do not need to be written out. Only certain units of time should be abbreviated. Abbreviate hr (hour), min (minute), ms (millisecond), ns (nanosecond), or s (second). However, do not abbreviate day, week, month, and year (APA, 2019). To form the plural of abbreviations, add “s” alone without apostrophe or italicization (e.g., vols., IQs, Eds.). The exception to this rule is not to add “s” to pluralize units of measurement (12 m not 12 ms) (APA, 2019). Besides abbreviations, the terms which may need to be defined include the outcome, the type of intervention, the sampling of data, special terminology, instruments, tool, and sources of data. Summary This section summarizes the key points of Chapter 1 and provides supporting citations for those key points. It then provides a transition discussion Chapter 2 followed by a description of the remaining chapters. This section should be two to three paragraphs. Chapter 2: Scientific Underpinnings Introduce the chapter by providing a general overview of the problem (one to two sentences). Explain the goal of the review of literature is to present an in-depth, current state of knowledge about your topic and approach to solving the problem. Literature Search Strategy This section should be one paragraph in length and should describe the search strategy used to find the applicable research articles. Include the databases that were used to search for research articles (e.g., CINAHL, Pubmed, Ovid, Google Scholar, etc.). Include the search terms or keywords that were used. Include the inclusion and exclusion criteria for relevant search strategies (e.g., last seven years, peer-reviewed, primary research, etc.) Synthesis of Literature The synthesis of literature should be no more than ten pages long and can pull from your assignment in DNP-820A. It should synthesize 15 original research studies, such as randomized control trials, synthesis of the literature with a meta-analysis, or quantitative studies. Book reviews and literature reviews should not be included. However, they should be reviewed to find sources for your literature review (i.e., hand search reference pages for applicable articles). All 15 sources should be no older than seven years. This section should reference the Literature Evaluation Table in Appendix B created in DNP-820A. This section focuses on the scientific evidence rather than the researcher(s)’s opinion of the evidence. The studies you cite in this section must relate directly to your project. Everything should be connected in a way that is evident to the reader. In your synthesis, you should address the similarities, differences, and controversies in the body of evidence. Additionally, there should be a minimum of one original research article that discusses the specific instrument, tool, or intervention that you will be implementing in your project. Another two to three articles that support the use of this intervention at other sites should also be discussed. View the following videos to assist you with writing your project: “What does it mean to synthesize in scholarly writing?” https://www.youtube.com/watch?v=CDvfwmatxjA&t=457s [links to an external site] “Writing a Literature Review” https://www.youtube.com/watch?v=jp8JKaz5VWI [links to an external site] Evidence-Based Practice Question This section should be two or three paragraphs long. It clearly states (a) the project focus, (b) the population affected, and (c) how the project will contribute to solving the problem. This section should be comprehensive, yet simple, providing context for the practice project. The evidence-based practice question is written using the template: To what degree will the implementation of _______________(intervention) impact______________(what) among _____________(population) patients in a______ (setting) in _______ (state)? Change Recommendation: Validation of [Enter Name of EBP Intervention] This section should be two paragraphs long . In this section, summarize the strength of the body of evidence (quality, quantity, and consistency), make a summary statement, and based on your conclusions drawn from the review, give a recommendation for practice change based on the scientific evidence. This section should include a brief statement about the evidence-based practice (EBP) and include the specific practice intervention, presentation, and toolkit that you will implement. Theoretical Framework This section identifies the nursing theories and EBP change models that provided the foundation for the DPI project. Describe how a theory-based evaluation is essential to address the problem. First, you should describe the main tenets (i.e., foundational concepts) of the theory. Then, you should describe how these tenets will be used to guide both the practice change (change model) and the nursing theory. Your discussions should clearly connect your theoretical foundations to the practice change you are implementing by explaining how the theories justify what is being measured as well as how those variables are related. This section also must include a discussion of how the clinical question aligns with the chosen nursing theory and illustrates how the project fits within other evidence based on the theories or models. The seminal source for each nursing theory and evidence-based change model should be identified and described. Overall, the presentation should reflect that you understand the theory or model and fully explain its relevance to the project. The discussion should also reflect knowledge and familiarity with the historical development of the theories or models. Please note models and theories are not capitalized in APA style (i.e., Lewin’s change model is correct whereas Lewin’s Change Model is incorrect). Nursing Theory This section discusses how the evidence-based question aligns with the respective nursing theory. This section should be at least three to four paragraphs long. When referring to your nursing theory, only reference the seminal sources (i.e., the original sources of the theory written by the theorist). Do not use secondary sources (i.e., criticism on the theory) or textbooks. In the first paragraph, state what the nursing theory is and how it was developed. In the second paragraph, state the main tenets of the theory. Explain what these tenets are and how they apply to nursing practice for your readers. In the third paragraph, address how one of the tenets will be used in your project. Explain the specific steps/factors that will be used to connect the nursing theory tenet to the implementation of your project. Explain how underpinning your intervention with this tenet will improve the (a) patient outcomes and (b) implementation of your project. Continue to explain all applicable nursing tenets and how they will be applied to the project. Synthesis of Nursing Theory This section synthesizes how the nursing theory has been applied in at least three other evidence-based articles, research studies, or peer-reviewed projects. These sources should be related to your particularly project topic. This section should end with a paragraph that synthesizes the literature to demonstrate the theory’s applicability to your project. This section should be two to four paragraphs long. Evidence-Based Change Model This section identifies and describes the chosen change model and the steps/factors that are included in the model. It connects those steps/factors and describe how they are being used, implemented, and/or supported in the project. Additionally, this section discusses how the evidence-based question aligns with the change model. This section should be at least four to five paragraphs long. When referring to your change model, only reference the seminal sources (i.e., the original sources of the theory written by the theorist). Do not use secondary sources (i.e., criticism on the theory) or textbooks. In the first paragraph, state what the change model is and how it was developed. In the second paragraph, state the steps of the model. Define these steps are and how they can be used to drive practice change. In the third paragraph, address how the first tenets will be used to drive the practice change. Explain the specific steps from the model that will be taken to implement the practice change. Describe (a) what you think this will look like at the proposal stage and (b) what this actually looked after the project is completed. Continue to explain all of the model steps and how they will be used to implement the project. Synthesis of Change Model This section synthesizes how the change model has been applied in at least three other evidence-based articles, research, or peer-reviewed projects on a topic similar to your project. End with a paragraph that synthesizes why the use of the model in the literature makes it applicable to your project. This section should be two to four paragraphs long. Integration of the Christian Worldview The lack of access to quality health care is a common problem in the U.S. despite various solutions offered through legislative and socioeconomic works: universal healthcare models, insurance models, and other business models. U.S. health care would be best transformed by returning to the implementation of a traditional system founded on the Christian principles of human dignity, solidarity, subsidiarity, and working for the common good. Consider diversity, equity, and inclusion and how these concepts should be considered in the project and sample population. This section should be no more than three paragraphs long. The linked article provides a good understanding of how to articulate a Christian worldview and what is relevant to Christian principles: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5375650/ Summary This section summarizes the key points of Chapter 2 and provides supporting citations for those key points. It then provides a transition discussion to Chapter 3 followed by a description of the remaining chapters. Chapter 3: Project Design and Methodology Introduce this chapter by describing how the project outcome will improve the quality of health care for the patient population. This section should report how the project is rooted in quality improvement from the outset of the improvement initiative. Then, in no less than three substantive paragraphs, discuss the differences between research, evidence-based practice, and quality improvement. Include what makes them each unique and how one leads the other. Please support your discussion with scholarly citations. Purpose The “Purpose” section of Chapter 3 should be two or three paragraphs long. It should (a) reflect on the problem statement, (b) identify how the project will be accomplished, and (c) explain how the project will contribute to the field. The section begins with a declarative statement, “The purpose of this project is….” which is based on your problem statement from Chapter 1. Included in this statement are also the project design, population, variables to be investigated, and the geographic location. Further, the section clearly defines the dependent and independent variables, relationship of variables, or comparison of groups (comparison versus intervention) for quantitative analyses. Keep in mind that the exact purpose statement (i.e., copy paste what is here) in this chapter is restated in the abstract and Chapter 5. This purpose statement aligns to the PICOT components from previous courses. Use the following template for structuring your purpose statement: The purpose of this quality improvement project is to determine if the implementation of _________________ (whose research are you translating or what clinical practice guidelines) would impact ______________(what) _______________________ among ___________(population). The project was piloted over an eight-week period in a (rural, urban, or directional (eastern, western, …)________ (state) ________ (setting i.e., primary care clinic, ER, OR). Project Planning and Procedures Introduce this section with three to five sentences. Include why project planning was initiated and how it helped the team to think systematically. This section addresses the overall concept of the project planning procedure. Interprofessional Collaboration This section should be three or four paragraphs long. The first paragraph should outline why organizational support is imperative when improving patient outcomes. Include what organizational support will be required for your quality improvement project. Ensure to use a transitional statement between this section and the next. The second paragraph will summarize the organizational support you are receiving from the stakeholders at the project site. In this paragraph, identify both the internal and external stakeholders from within the organization. What are their roles and how will this ensure sustainability of the project in the future? The third and fourth paragraphs should include the characteristics of the team that conducted the intervention (for instance, type and level of training, degree of experience, and administrative and/or academic position of the personnel leading workshops) and/or the personnel to whom the intervention was applied should be specified. Often the influence of the people involved in the project is as great as the project components themselves. Explain the role of a project manager of this quality improvement project and how a project manager influences and facilitates the team and the project. Include your responsibilities and duties using third person without referring to yourself. Next, describe the role and responsibilities of the team members in your project. Project Management Plan (list required resources—delete this parenthetical note) This section should be two to three paragraphs long. This section details the step-by-step plan for the project’s implementation. Include that the project starts with IRB approval and ends at data analysis. Every change that could have contributed to the observed outcome should be noted. Each element should be briefly described. Refer to the project timeline completed in DNP-840A (see Appendix C). The plan should include a complete procedure and outline of the education that will provide to the staff. Explain where the education was derived from (typically the instrument/tool/evidence-based intervention) and discuss how it will be deployed. Refer to the Educational Plan in Appendix D. Describe how or why you are qualified to teach this information to the staff. Include if you required additional outside resources to implement the education. Describe your procedure in such a way that your reader could follow the same steps and get the same results. The project was initiated after receiving approval for Grand Canyon University’s Institutional Review Board. (see Appendix E) This Appendix will become Appendix A once your project has been evaluated by the Grand Canyon University institutional review board and an outcome letter issued. Feasibility This section should be one or two paragraphs. What is required to make your project successful? Do you have adequate staff and time to educate the healthcare providers (nurses, doctors, mid-levels, tech, medics, etc.) on the evidence-based intervention? Do you need supplies or technology for support? As the project manager can you do the education or is there a cost to bring someone in (is this addressed in your budget)? Refer to the budget completed in DNP-840A as an appendix (see Appendix F). Remember having a balanced budget is imperative in today’s healthcare so as you show expenses, there should be some reference to anticipated improved revenue. Is the project designed in a way to ensure realistic implementation of the project? Support your discussion with scholarly citations. Setting and Sample Population This section discusses the total population, project population, and project sample based on the geographical setting of the project site. A description of the sample is essential for other clinicians to apply your findings to their settings. Setting In one paragraph, introduce this section by providing a broad description of the project site. Describing the organization in which in intervention took place in detail is necessary to assist readers in understanding whether the intervention is likely to “work” in the local environment (consider what the organization’s public description is on their website). This includes the description of the community, its makeup, and current services. Include additional information as needed, such as information about the location, practice type, teaching status, system affiliation, patient population (i.e., number of patients in a given time frame), size of the organization, staffing, and relevant processes in place. Follow the broad overview of the organization with a more focused overview of the specific area of practice (i.e., ER, OR, or ICU). Population and Sample The discussion of the sample includes the proper terminology specific to the type of sampling method used for the project. This section should be three to four paragraphs long and include the following components: The characteristics of the total population and the project population from which the project sample (project participants) is drawn. Describe the characteristics of the project population and the project sample. Clear definitions and differentiation of the sample versus the population for the project. Describe the project population size and project sample size and justify the project sample size (e.g., power analysis) based on the selected design. Details on the sampling procedures, including the specific steps taken to identify, contact, and recruit potential project sample participants from the project population. If subjects withdrew or were excluded from the project, you must provide an explanation of why. The informed consent process, confidentiality measures, project participation requirements, and geographic specifics. How the intervention answers the evidence-based question(s). Data Collection Procedures This section should be three or four paragraphs in length. This section details the entirety of the process used to collect the project data and describes the sources from which the data will be obtained. Describe the step-by-step procedures used to carry out all the major steps for data collection for the project in a way that would allow another investigator to replicate the project. Data should include descriptive or demographic data of the project sample and outcome data. Describe who/and from where data are obtained. Instrumentation or Data Source The first paragraph should include a description of data sources including any instrumentation. This paragraph should address the procedures for data collection, including how each instrument or data source was used, how and where data were collected (including demographic data), and how data were recorded. If survey/instruments are used, then their validity and reliability must be explained, including the psychometric data, using relevant scholarly citations. Refer to the instrument in Appendix G. Include permission to use the tool in Appendix H. If an instrument was not used for data collection, then explain the reliability and validity of the data source (e.g., reliability and validity of the EHR). If other instruments or sources of data are needed, provide evidence in the appendices. (see Appendix I). Variables The second paragraph should include an explanation of the independent and dependent variables (if applicable), and how the resulting change in those variables is measured (if applicable). It should also include a description of the procedures for project sample selection and how the data for the participants were grouped (e.g., comparison versus implementation). Data Integrity and Storage The third paragraph should include how the data integrity will be managed throughout project implementation. Include the description of how the final analysis data collection set and data dictionary were created and if any data manipulation was required. It should also provide a description of the type of data to be analyzed, identifying the descriptive, inferential, or nonstatistical analysis used. Data Management The fourth paragraph should provide a detailed description of the relevant data collected for each project question. It should also detail how the raw data were organized and prepared for analysis. Include any methods for data cleansing. There should also be a description of the procedures adopted to maintain data security, including the length of time data will be retained, where the data will be retained, and how the data will be destroyed following the project site’s policy. What data management errors were anticipated during the data collection period? Include how errors in data collection and entry will be discovered early and remedied. Support your discussion with scholarly references. Potential Bias and Mitigation In this section, you will describe the potential biases that may impact your project (proposal stage) and biases that did impact your project (finished manuscript). In addition, you will explain how these biases were mitigated to ensure the validity of the project. This section should be at least four paragraphs long. You should explain at least five potential biases that are related to (a) the project methodology, (b) the project design, (c) the sampling procedures, (d) data collection, and (e) data interpretation. For each bias, you need to (a) clearly define what the bias is/was, (b) clearly explain how the bias may have been present in your project, and (c) explain how you mitigated this bias. Your discussion should be supported with scholarly citations. Please note, you will need to personalize the possible biases based on the project you conducted. For example: If my project employs an internet survey and there are people who meet the criteria but do not have access to the internet to take the survey, I will miss all those people who met the criteria for participation! Or When conducting a quality improvement project, it is not possible or not practical to choose a random sample. In those cases, a convenience sample might be used. Sometimes it is plausible that a convenience sample could be considered as a random sample, but often a convenience sample is biased. If a convenience sample is used, inferences are not as trustworthy as if a random sample is used. Ethical Considerations This section should be one paragraph and summarize the ethical aspects of implementing an intervention and analyzing the data. This section should include a description of the procedures for protecting the rights and well-being of the project sample as well as the staff completing the intervention. The key ethical issues that must be addressed in this section include: How any potential ethical issues will be addressed. Ethical issues are related to the project and the sample population of interest, institution, or data collection process. Anonymity, confidentiality, privacy, lack of coercion, and potential conflict of interest. The key principles of the Belmont Report (respect, justice, and beneficence) in the project design, sampling procedures, and within the theoretical framework, practice or patient problem, and clinical questions. Include a statement that the project has undergone a formal ethics review by the GCU IRB. Select the following statement that best aligns with your IRB determination and embed it in your paragraph (see Appendix E): Quality Improvement: This project was reviewed by the Institutional Review Board at Grand Canyon University, and was determined not to be human subjects research. As such, this project did not require IRB review. Exempt/Expedited: This project was reviewed by the Institutional Review Board at Grand Canyon University, and was determined to be exempt/expedited. As such, this project was approved. Summary This section summarizes the key points of Chapter 3 and provides supporting citations for those key points. It then provides a transition discussion to Chapter 4 followed by a description of the remaining chapters. This section should be two paragraphs long. Chapter 4: Data Analysis and Results This chapter provides a summary of the collected data, describes how the data were analyzed, and then presents the results. Chapter 4 includes a brief restatement of the problem statement and the evidence-based practice question. The organization of the chapter is briefly outlined in this section. Make sure this chapter is written in past tense and reflects how the project was actually conducted. This chapter contains the analyzed data presented in both text and tabular or figure format. The structure of the chapter is imperative. You should aim to ensure both the readability and clarity of the findings. Sufficient narrative should be provided to highlight the findings on the measurable patient outcome. Ask the following general questions before starting this chapter: Are there sufficient data to answer the evidence-based practice question asked in the project? Are there sufficient data to support the conclusions you will make in Chapter 5? Are the data clearly explained using a table, graph, chart, or text? Data Analysis Procedures This section provides a step-by-step description of the procedures to be used to conduct the data analysis. This section should be two paragraphs. The first paragraph should provide a step-by-step description of the procedures used to conduct the data analysis. In this paragraph, describe all statistical and nonstatistical analyses employed. State the specific tests you plan to use to analyze your outcome data. Rationale should be provided for each of the data analysis procedures (statistical and nonstatistical) and supported by relevant scholarly citations. The second paragraph should explain how and why the data analysis techniques selected align with the DPI project design and question. The level of the statistical significance used for the quantitative analyses is identified a priori (p < .05). Please note that the independent variables in quasi-experimental projects are a nominal or categorical level variables that are used to identify the sample or group associated with the intervention. It is the dependent variable (i.e., the project outcome measure) that directs the type of statistical analysis selected, e.g., parametric versus non-parametric. If the dependent variable is a ratio or interval, a parametric test, such as an independent t-test, should be used. If the dependent variable is an ordinal or nominal level, a non-parametric test, such as a Chi-square or Mann Whitney U, should be used. Descriptive Data of Sample Population This section provides a narrative summary of the project sample’s characteristics and demographics. Descriptive data should be collected based on the sample (there will always be data for the patient sample but include nursing staff data if applicable). It establishes the total sample size, gender, age, education level, organization, or setting and other appropriate sample characteristics. Graphic organizers, such as tables, charts, histograms, and graphs should be used to provide further clarification, organize the data, and promote readability. Ensure these data cannot lead to the identification of participants or the project setting in any analysis or narrative. All tables, graphs, and figures must always be introduced and discussed within the text prior to their presentation. Data in the tables should match data in the text exactly. When writing numbers, equations, and statistics, spell out any number that begins a sentence, title, or heading, or reword the sentence to place the number later in the narrative. In general, use Arabic numerals (11, 12, 13) when referring to whole numbers 11 and above, and spell out whole numbers below 11. There are some exceptions to this rule: If small numbers are grouped with large numbers in a comparison, use numerals (e.g., 7, 8, 10, and 13 trials); but do not do this when numbers are used for different purposes (e.g., ten items on each of four surveys). Numbers in a measurement with units (e.g., 6 cm, 5 mg dose, 2%). Numbers that represent time, dates, ages, sample or population size, scores, or exact sums of money. Numbers that represent a specific item in a numbered series (e.g., Table 1). A sample table in APA style is presented in Table 1 and more examples can be found at “Sample Tables” on the APA Style Website. Be mindful that all tables fit within the required margins, and are clean, easy to read, and formatted properly using the guidelines found in Chapter 5 (Displaying Results) of the APA Publication Manual 7th Edition. As noted, all tables and figures should be introduced in a paragraph above them. Here is an example: There were N = X patients sampled, n = x in the comparative group and n = x in the intervention group. The mean age of the comparative sample was X (SD = x), and the mean age of the intervention group was X (SD = x) (see Table 1). Table 1A Sample Data Table Showing Correct Formatting Column A M ( SD ) Column B M (SD) Column C M (SD) Row 1 10.1 (1.11) 20.2 (2.22) 30.3 (3.33) Row 2 20.2 (2.22) 30.3 ( 3.33) 20.2 (2.22) Row 3 30.3 (3.33) 10.1 (1.11) 10.1 (1.11) Note. Adapted from “Sampling and Recruitment in Studies of Doctoral Students,” by I.M. Investigator, 2010, Journal of Perspicuity, 25, p 100. Reprinted with permission . Results This section, which is the primary section of this chapter, presents a summary and analysis of the data in a non-evaluative, unbiased, and organized manner that relates to the evidence-based practice question. The section should also include appropriate graphic organizers, such as tables, charts, graphs, and figures. Please ensure that: The amount and quality of the data or information is sufficient to answer the evidence-based question(s) is well presented. The results of each statistical test are presented in appropriate statistical format with tables, graphs, and charts. The p-value ( p=) and test statistics are reported. Outliers, if found, are reported. The results must be presented without implication, speculation, assessment, evaluation, or interpretation. Discussion of results and conclusions are left for Chapter 5. Both descriptive and inferential statistics are required to be reported in this section. Descriptive statistics describe or summarize data sets using frequency distributions (e.g., to describe the distribution for the IQ scores in your class of 30 pupils) or graphic displays such as bar graphs (e.g., to display increases in a school district’s budget each year for the past five years), as well as histograms (e.g., to show spending per child in school and display mean, median, modes, and frequencies), line graphs (e.g., to display peak scores for the classroom group), and scatter plots (e.g., to display the relationship between two variables). Descriptive statistics also include numerical indexes such as averages, percentile ranks, measures of central tendency, correlations, measures of variability and standard deviation, and measures of relative standing. Inferential statistics describe the numerical characteristics of data, and then go beyond the data to make inferences about the population based on the sample data. Inferential statistics also estimate the characteristics of populations about population parameters using sampling distributions, or estimation. Table 2 presents example results of an independent t-test comparing Emotional Intelligence (EI) mean scores by gender. Table 2t-Test for Equality of Emotional Intelligence Mean Scores by Gender t Df p EI 1.908 34 .065 Chapter 4 can be challenging with regard to mathematical equations and statistical symbols or variables. When including an equation in the narrative, space the equation as you would words in a sentence: x + 5 = a. Punctuate equations that are in the paragraph as you would a sentence. Remember to italicize statistical and mathematical variables, except Greek letters, and if the equation is long or complicated, set it off on its own line. Refer to your APA manual for specific details on representation of statistical information. Basic guidelines include: Statistical symbols are italicized (t, F, N, n) Greek letters, abbreviations that are not variables and subscripts that function as identifiers use standard typeface, no bolding or italicization Use parentheses to enclose statistical values (p = .026) and degrees of freedom t(36) = 3.85 or F(2, 52) = 3.85 Use brackets to enclose limits of confidence intervals 95% CIs [- 5.25, 4.95] Summary This section provides a concise summary of the project results. It briefly restates essential data and data analysis presented in the chapter, and it helps the reader see and understand the relevance of the data and analysis to the evidence-based question(s). It should summarize the statistical data and results of statistical tests in relation to the evidence-based question(s). Finally, it provides a lead or transition into Chapter 5 where the implications of the data and data analysis relative to the evidence-based question(s) will be discussed. This section should be two to three paragraphs long. Chapter 5: Implications in Practice and Conclusions Introduce Chapter 5 by providing (a) a general reminder of the problem, (b) the purpose of the project, and (c) overviewing the information that will be presented in this chapter. This section should be one to two paragraphs long. Chapter 5 is perhaps the most important chapter in the practice improvement project manuscript because it presents the project investigator’s contribution to the body of knowledge. For many who read evidence-based literature, this may be the only chapter they will read. No new data or citations should be introduced in Chapter 5; however, references should be made to findings or citations presented in earlier chapters. You should articulate new frameworks and new insights. All discussions in this chapter should be presented in the simplest possible form, making sure to preserve the conditional nature of the insights. Summary of the Project This section provides a comprehensive summary of the project by describing previous chapters in the simplest possible terms. It should recap the essential points of Chapters 1 to 3. It reminds the reader of the evidence-based question(s), the main issues being evaluated, and provides a transition, and reminds the reader of how the project was conducted. This section should be no more than two paragraphs. Major Findings Summarize the major findings (results) of your DPI project. Explain the statistical significance of your project findings. Explain the clinical significance of your project findings. This section should be no more than two paragraphs. Interpretation of Findings Describe how the findings of your DPI project align with other original research studies and/or quality improvement projects by comparing and contrasting the significance of the results. Provide possible explanations as to why your project findings confirmed or opposed previous published scholarly works. If your results did not achieve statistical significance, provide possible explanations why. This section should be no more than three to four paragraphs long. Strengths and Limitations In this section, describe the strengths of your project. In this discussion, you should consider the project design or methodology, the intervention, and the unit culture. Strengths should be presented in two paragraphs. Then, summarize the limitations of your DPI project. Limitations could be related to the project timeline, threats discussed in your SWOT, etc. Discuss the efforts that were made to minimize the limitations. Limitations should be addressed in two paragraphs. Implications In this section, you should present the “so what” (i.e., why was this important) of your project based on the project results. This section should describe the types of implications that could happen as a result of this project. It also tells the reader what the DPI project results imply both theoretically and for future nursing practice. Separate sections with corresponding headings provide proper organization. Provide a transition of three to five sentences for this new section. Theoretical Implications Theoretical implications involve the interpretation of the DPI project findings in terms of the evidence-based question(s) that guided the project. It is appropriate to evaluate the strengths and weaknesses of the project critically and include the degree to which the conclusions are credible given the method and data. It should also include a critical, retrospective examination of the framework presented in the Chapter 2 “Scientific Underpinnings” considering the practice improvement project’s new findings. In addition, you should describe whether the results of your project or the implementation process demonstrate the need to develop new or re-think current nursing theories. This section should be no more than two paragraphs. Nursing Practice Implications In this section, explore two to three ways the DPI project findings are important for nursing practice. Will it change practice? How? This section should be no more than two paragraphs. Recommendations Provide a brief transition (three to five sentences) that describes this section of the manuscript. Recommendations for Future Projects and Researchers This section should contain a minimum of four to five recommendations for future DPI projects. Project recommendations should include the areas of project that need further examination, address project or research gaps, new patient populations, or system needs. Each recommendation should be fully explained in one paragraph and should include (a) why the future project should be conducted, (b) how the project should be conducted (methodology and design), (c) what data would be collected, and (d) how the project would advance healthcare or patient outcomes. Recommendations for Sustainability This section should describe two to three recommendations for how the DPI project can be sustained. For example, does the new practice change require a policy in order for it to be sustained? Each recommendation should be fully explained in one paragraph that includes (a) what the sustainability plan is, (b) why the sustainability plan is needed, and (c) how the sustainability plan would work at the unit, organization, state, and national levels. Include any organizations or stakeholders who should be included in the sustainability discussions and what their role or involvement should be. Plan for Dissemination This section should contain a detailed plan regarding how the DPI project results will be disseminated to others in the nursing profession and other disciplines. Provide three to four specific examples of what your plan is for dissemination for your site, the community, the local nursing community, and when applicable, nationally. Describe the appropriate audience(s) for dissemination of the DPI project results. The audience(s) should be broad and should extend beyond the academic setting. Discuss informal and formal venues for electronic dissemination. Select the most appropriate peer-reviewed journal(s) in which you could publish your DPI project findings. Discuss oral dissemination opportunities (i.e., a podium or poster presentation or abstract submission). Consider presentation opportunities at regional, state, national, or international meetings. This section should be no more than three paragraphs. Conclusion and Contributions to the Profession of Nursing Practice This final section should briefly wrap up the project. Concisely describe the contributions your DPI project has made to the nursing profession. This section should be no more than two paragraphs. References American Psychological Association. (2021). Publication Manual, 7th edition student paper checklist. https://apastyle.apa.org/instructional-aids/ publication-manual-formatting-checklist.pdf American Psychological Association. (2020). Publication manual of the American Psychological Association 2020: The official guide to APA style (7th ed.). American Psychological Association. Sylvia, M. L., & Terhaar, M. F. (2018). Clinical analytics and data management for the DNP. New York, NY : Springer Publishing Company, LLC Appendix A SWOT Analysis Figure 1SWOT Analysis for Quality Improvement Project Appendix B Literature Evaluation Table Learner Name: Instructions: Use this table to evaluate and record the literature gathered for your DPI Project. Refer to the assignment instructions for guidance on completing the various sections. Empirical research articles must be published within 5 years of your anticipated graduation date. Add or delete rows as needed. PICOT-D Question: Table 3Primary Quantitative Research – Intervention (5 Articles) APA Reference (Include the GCU permalink or working link used to access the article.) Research Questions/ Hypothesis, and Purpose/Aim of Study Type of Primary Research Design Research Methodology Setting/Sample (Type, country, number of participants in study) Methods (instruments used; state if instruments can be used in the DPI project) How were the data collected? Interpretation of Data (State p-value: acceptable range is p= 0.000 to p= 0.05) Outcomes/Key Findings (Succinctly states all study results applicable to the DPI Project.) Limitations of Study and Biases Recommendations for Future Research Explanation of How the Article Supports Your Proposed Intervention Table 4Additional Primary and Secondary Quantitative Research (10 Articles) APA Reference (Include the GCU permalink or working link used to access the article.) Research Questions/ Hypothesis, and Purpose/Aim of Study Type of Primary or Secondary Research Design Research Methodology Setting/Sample (Type, country, number of participants in study) Methods (instruments used; state if instruments can be used in the DPI project) How were the data collected? Interpretation of Data (State p-value: acceptable range is p= 0.000 to p= 0.05) Outcomes/Key Findings (Succinctly states all study results applicable to the DPI Project.) Limitations of Study and Biases Recommendations for Future Research Explanation of How the Article Supports Your Proposed DPI Project Table 3: Theoretical Framework Aligning to DPI Project Nursing Theory Selected APA Reference – Seminal Research References (Include the GCU permalink or working link used to access each article.) Explanation for the Nursing Theory Guides the Practice Aspect of the DPI Project Change Theory Selected APA Reference – Seminal Research References (Include the GCU permalink or working link used to access each article.) Explanation for How the Change Theory Outlines the Strategies for Implementing the Proposed Intervention Table 5Clinical Practice Guidelines (If applicable to your project/practice) APA Reference – Clinical Guideline (Include the GCU permalink or working link used to access the article.) APA Reference – Original Research (All) (Include the GCU permalink or working link used to access the article.) Explanation for How Clinical Practice Guidelines Align to DPI Project Place the primary quantitative research used in the clinical practice guidelines in Table 1. This is part of the primary quantitative research used to support your intervention. Legend: Appendix C Project Timeline Appendix D Plan for Educational Offering Appendix E Grand Canyon University Institutional Review Board Outcome Letter Appendix F Project Budget Appendix G Data Collection Tool for Evaluation (Use the name of the tool here) Appendix H Place the Permission to Use the Tool Here Appendix I Other Data Collection Tool and/or Permissions Appendix J APA Writing Style for the Direct Practice Improvement Project Information and resources are also available on the APA Style website. If you have questions about specific assignment guidelines or what to include in your APA Style paper, please check with your assigning instructor or chair. The DNP manuscript should be written based on the 7th edition American Psychological Association’s APA Style (7th edition). This document is based on the American Psychological Association’s Publication Manual, 7th Edition – Student Paper Checklist located at https://apastyle.apa.org/instructional-aids/publication-manual-formatting-checklist.pdf Use this checklist while writing your paper to make sure it is consistent with seventh edition APA Style. Page Header: The page header does not contain a page number until Chapter 1. The fore pages are not numbered. All pages which are numbered are included in the Table of Contents. Font and Font Size: Times New Roman 12-point Font. Use the same font and font size throughout your paper (exception: figure images require a sans serif font and can use various font sizes). Line Spacing: Double Spacing. Double-space the entire paper. Do not add extra lines before or after headings or between paragraphs. Margins: Left Margin is 1 ½ inch. Margins are 1 in. on all other sides (top, bottom, and right). Paragraph Alignment and Indentation: Left-align the text (do not use full justification). Indent the first line of each paragraph 0.5 in. (one tab key). Paper Organization Chapters: Center and bold the Chapter title. Use the Level 1 heading style. Start the first line of the text one double-spaced line after the title. Headings: Use Level 2, Level 3, and Level 4 style headings for subsections. Start each new section with a heading. Write all headings in title case and bold. Also italicize Level 3. Indent Level 4 headings ½ inch and format on the same line as the text but do not include in the Table of Contents using Styles. Section Labels: Bold and center labels, including Abstract, References and Appendices. Writing Style Continuity: Check for continuity in words, concepts, and thematic development across the paper. Explain relationships between ideas clearly. Present ideas in a logical order. Use clear transitions to smoothly connect sentences, paragraphs, and ideas. Conciseness: Choose words and phrases carefully and deliberately. Eliminate wordiness, redundancy, evasiveness, circumlocution, overuse of the passive voice, and clumsy prose. Do not use jargon, contractions, or colloquialisms. Avoid overusing both short, simple sentences and long, involved sentences; instead, use varied sentence lengths. Avoid both single-sentence paragraphs and paragraphs longer than one double-spaced page. Clarity: Use clear and precise language. Use a professional tone and professional language. Do not use jargon, contractions, colloquialisms, or creative literary devices. Check for anthropomorphistic language (i.e., attributing human actions to inanimate objects or nonhuman animals). Make logical comparisons using clear word choice and sentence structure. Grammar: Verb Tense: Use verb tenses consistently in the same and adjacent paragraphs. Use appropriate verb tenses for specific paper sections, e.g., future tense for proposal and past tense for final manuscript. Subject Verb Agreement: Use verbs that agree in number (i.e., singular or plural) with their subjects. Pronouns: Use first person pronouns to describe your work and your personal reactions (e.g., “I examined,” “I agreed with”), including your work with coauthors (e.g., “We conducted”). Use the singular “they” when referring to a person who uses it as their self-identified pronoun or to a person whose gender is unknown or irrelevant. Use other pronouns correctly. Otherwise, deliver the project in third person as if narrating or presenting it. Bias-free language: Eliminate biased language from your writing. Use bias-free language to describe all people and their personal characteristics with inclusivity and respect, including age, disability, gender, participation in research , racial and ethnic identity, sexual orientation, socioeconomic status, and intersectionality. Mechanics of APA Style: Use punctuation marks correctly (periods, commas, semicolons, colons, dashes, parentheses, brackets, slashes), including in reference list entries. Use varied punctuation marks in your paper. Avoid having multiple punctuation marks in the same sentence; instead, split the sentence into multiple shorter sentences. Use one space after a period or other punctuation mark at the end of a sentence. Use a serial comma before the final element in lists of three or more items. Use parentheses to set off intext citations. Quotation Marks: Use quotation marks correctly. Place commas and periods inside closing quotation marks; place other punctuation marks (e.g., colons, semicolons, ellipses) outside closing quotation marks. Use quotation marks around direct quotations. Do not use quotation marks in the reference list. Italics: Use italics correctly to draw attention to text. Use italics for the first use of key terms or phrases accompanied by a definition. Capitalization: Use Title Case and sentence case capitalization correctly. Capitalize proper nouns, including names of racial and ethnic groups. Do not capitalize names of diseases, disorders, therapies, treatments, theories, concepts, hypotheses, principles, models, and statistical procedures, unless personal names appear within these terms. Abbreviations: Use abbreviations sparingly and usually when they are familiar to readers, save considerable space, and appear at least three times in the paper. Define abbreviations, including abbreviations for group authors, on first use. Do not use periods in abbreviations. Use Latin abbreviations only in parentheses, and use the full Latin term in the text. Do not define abbreviations listed as terms in the dictionary (e.g., AIDS, IQ) and abbreviations for units of measurement, time, Latin terms, and common statistical terms and symbols. Numbers: Use words to express numbers zero through nine in the text. Use numerals to express numbers 10 and above in the text. In all cases, use numerals in statistical or mathematical functions, with units of measurement, and for fractions, decimals, ratios, percentages and percentiles, times, dates, ages, scores and points on a scale, sums of money, and numbers in a series (e.g., Year 1, Grade 11, Chapter 2, Level 13, Table 4). Statistics: Include enough information to allow readers to fully understand any analyses conducted. Space mathematical copy the same as words, with spaces between signs. Use statistical terms in narrative text: “the means were,“ not “the Ms were.” Use statistical symbols or abbreviations with mathematical operators: “(M = 6.62),” not “(mean = 6.62).” Lists: Ensure items in lists are parallel. Use commas to separate items in simple lists. Use semicolons to separate items when any items in the list already contain commas. Tables and Figures General Guidelines: Include tables and/or figures in your manuscript. When possible, use a standard, or canonical, form for a table or figure. Do not use shading or other decorative flourishes. In the text, refer to each table or figure by its number. Explain what to look for in that table or figure by calling out the table or figure in the text (e.g., “Table 1 lists…” “As shown in Figure 1…”). Embed each table or figure in the text after it is first mentioned. Place the table or figure at either the top or the bottom of the page with an extra double-spaced line between the table or the figure and any text. Tables: Use the tables feature of your word-processing program to create tables. Number tables in the order they are mentioned in the text. Include borders only at the top and the bottom of the table, beneath column headings, and above column spanners. Do not use vertical borders or borders around every cell in the table. All tables include four basic components: number, title, column headings, and body. Write the table number above the table title and body and in bold. Write the table title one double-spaced line below the table number and in italic title case. Label all columns. Center column headings and capitalize them in sentence case. Include notes beneath the table if needed to describe the contents. Start each type of note (general, specific, and probability) on its own line, and double-space it. See sample tables on the APA Style website. Figures: Use a program appropriate for creating figures (e.g., Word, Excel, Photoshop, Inkscape, SPSS). Number figures in the order they are mentioned in the text. Within figures, check that images are clear, lines are smooth and sharp, and font is legible and simple. Provide units of measurement. Clearly label or explain axes and other figure elements. All figures include three basic components: number, title, and image. Write the figure number above the figure title and image and in bold. Write the figure title one double-spaced line below the figure number and in italic title case. Write text in the figure image in a sans serif font between 8 and 14 points. Include a figure legend if needed to explain any symbols in the image. Position the legend within the borders of the figure and capitalize it in title case. Include notes beneath the figure if needed to describe the contents. Start each type of note (general, specific, and probability) on its own line, and double-space it. See sample figures on the APA Style website. In-Text Citations: Cite only works you read and ideas you incorporated into your paper. Include all sources cited in the text in the reference list (exception: personal communications are cited in the text only). Make sure the spelling of author names and the publication dates in the in-text citations match those of the corresponding reference list entries. Paraphrase sources in your own words whenever possible. Cite appropriately to avoid plagiarism, but do not repeat the same citation in every sentence when the source and topic do not change. For guidance on appropriate citation, see the Appropriate Level of Citation page. Write author–date citations according to seventh edition guidelines: Include the author (or title if no author) and year. For paraphrases, it is optional to include a specific page number(s), paragraph number(s), or other location (e.g., section name) if the source work is long or complex. One author: Use the author surname in all intext citations. Two authors: Use both author surnames in all in-text citations. Three or more authors: Use only the first author surname and then “et al.” in all in-text citations. Use either the narrative or the parenthetical citation format for in-text citations. Parenthetical citation: Place the author name and publication year in parentheses. Narrative citation: Incorporate the author name into the text as part of the sentence and then follow with the year in parentheses. For works with two authors, ° use an ampersand (&) in parenthetical in-text citations: (Guirrez & Castillo, 2020) ° use the word “and” in narrative in-text citations: Guirrez and Castillo (2020) When citing multiple works in parentheses, place the citations in alphabetical order. When multiple parenthetical citations have the same author(s), order the years chronologically and separate them with commas (e.g., Coutlee, 2019, 2020). When the authors are different, separate the parenthetical citations with semicolons (e.g., Coutlee, 2019, 2020; Ngwane, 2020; Oishi, 2019). Quotations: Limit the use of direct quotations. Include the author (or title if no author), year, and specific part of the work (page number(s), paragraph number(s), section name) in the citation. Short quotation (less than 40 words): Use double quotation marks around the quotation. Block quotation (40 words or more): Use the block format: Indent the entire quotation 0.5 in. from the left margin and double-space it. References Start the reference list on a new page after the text. Center and bold the section label “References” at the top of the page. Double-space the entire reference list, both within and between entries. Use a hanging indent for each reference entry: First line of the reference is flush left, and subsequent lines are indented by 0.5 in. Apply the hanging indent using the paragraph formatting function of your word-processing program. All reference entries should have a corresponding in-text citation. The beginning of the reference entry (usually the first author’s surname) and year should match the corresponding in-text citation. List references in alphabetical order according to seventh edition guidelines. Do not create reference entries for personal communications and secondary sources. For a list of works to include and exclude from a reference list, see the APAstyle.org website. Each reference entry includes four elements: author, date, title, and source. List authors in the same order as the original source. Use initials for authors’ first and middle names. Put a comma after the surname and a period and a space after each initial (e.g., Lewis, C. S.). Put a comma after each author (even two authors). Use an ampersand before the last author. List up to 20 authors in the reference list. If more than 20, use ellipsis between the last author and 19th author. Capitalize titles in sentence case: Capitalize only the first word of the title, the subtitle, and any proper nouns. Format titles according to the type of work. ° Works that stand alone: Italicize the title (e.g., authored books, reports, data sets, dissertations and theses, films, TV series, albums, podcasts, social media, websites). ° Works that are part of a greater whole: Do not italicize or use quotation marks around the title (e.g., periodical articles, edited book chapters, TV and podcast episodes, songs). Write the title of the greater whole (e.g., journal or edited book) in italics in the source element. Do not include database information for works retrieved from academic research databases. Do include database information for works retrieved from databases with original, proprietary content or works of limited circulation (e.g., UpToDate). Include a DOI for any work that has one. If there is no DOI, include a URL if the work is retrieved online (but not from a database). Present DOIs and URLs as hyperlinks (beginning with “http:” or “https:”). Copy and paste DOIs and URLs directly from your web browser. Do not write “Retrieved from” or “Accessed from” before a DOI or URL. Do not add a period after a DOI or URL. Source: American Psychological Association. (2021). Publication Manual, 7th edition student paper checklist. https://apastyle.apa.org/instructional-aids/ publication-manual-formatting-checklist.pdf

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