Follow the instructions in the “DPI Project Template” for the specified content and required length and formation for each page or section. Chapter 3 – The main headings in Chapter 3 include: Chapte
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.
Follow the instructions in the “DPI Project Template” for the specified content and required length and formation for each page or section. Chapter 3 – The main headings in Chapter 3 include: Chapte
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 Hseih et al. research ABCDEF bundle_________________ (whose research are you translating or what clinical practice guidelines) would impact Length of stay_____________(what) _______________________ among adult patients admitted to a long-term acute care hospital ___________(population). The project was piloted over an eight-week period in a (rural, urban, or directional (eastern, western, …) Virginia________ (state) _high observation unit_______ (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) write full explanation to be determined and/or the personnel to whom the intervention was applied should be specified. As the project has not started. 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) ( I will attach). 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. Population (patients 18 years and older, sample to be determined, setting HOU in a LTACH in urban city in Virginia) Setting In one paragraph, introduce this section by providing a broad description of the project site. 60 bed hospital full time services of resp therapy, rehab, pharm department, radiology services, off site lab service – physician staff 24/7, two floors, continuous cardiac monitoring capability, private and semi private. 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)- (Vibra Hospital of Richmond) 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. (extrapolated from EHR –surveys etc) be creative here 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,( be creative here) 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 four discusses This chapter provides a summary of the collected data, describes how the data were analyzed, and then presents the results.
Follow the instructions in the “DPI Project Template” for the specified content and required length and formation for each page or section. Chapter 3 – The main headings in Chapter 3 include: Chapte
Intensive Care Unit Liberation Bundle Implemented at A Long-term Acute Care Hospital 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 November 1, 2023 © by Cathy Ann Jones, 2023 All rights reserved. GRAND CANYON UNIVERSITY Intensive Care Unit Liberation Bundle Implemented at A Long-term Acute Care Hospital By Cathy Ann Jones has been approved xxxxx xx, 2023 APPROVED: Brandi Wilford, 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) is a concern nationwide in all healthcare settings. Long-term acute care hospitals (LTACHs) are certified acute care hospitals equipped to provide long-term care for an average (LOS) of 25-28 days. The purpose of this direct project improvement (DPI) quasi-experimental project is to determine 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 ABCDEF bundle compared to current practice impact length of stay over an eight-week period? The ABCDEF bundle is a set of six evidence-based interventions that, when implemented together, can significantly improve the quality of care for any patient in any healthcare setting and impact LOS. The nursing theory of Virginia Henderson’s Nursing Needs Theory and John Kotter’s Eight Step Change Model, an evidence-based practice model, was the scientific underpinnings for the DPI project. Data were extrapolated from the facility’s electronic health record using descriptive statistics of adult patients 18 and older. The sample size is 32, n=32. An independent t-test was run to analyze the data indicating clinical and statistical significance in LOS. The p= Value of >0.05 was used to determine statistical significance. Therefore, patients’ outcomes enhance by implementing the ABCDEF bundle, which decreases their LOS. Recommendations include increasing sample size and ensuring all six components are implemented to further impact length of stay and improve overall clinical outcomes.  Keywords: ABCDEF bundle, length of stay, long-term acute care hospital, 8-step model, 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 14 Background of the Project 16 Organizational Needs Assessment 18 SWOT Analysis 19 Strengths 19 Weaknesses 20 Opportunities 22 Threats 22 Problem Description 23 Definition of Terms 24 Summary  26 Chapter 2: Scientific Underpinnings 28 Literature Search Strategy 28 Synthesis of Literature 28 Evidence-Based Practice Question 44 Change Recommendation: Validation of [The ABCDEF bundle]  45 Theoretical Framework 46 Nursing Theory 48 Synthesis of Nursing Theory 50 Evidence-Based Change Model 51 Synthesis of Change Model 54 Integration of the Christian Worldview 55 Summary  57 Purpose 59 Project Planning and Procedures 60 Interprofessional Collaboration 60 Project Management Plan (list required resources—delete this parenthetical note) 61 Feasibility 62 Setting and Sample Population 62 Setting 62 Population and Sample 63 Data Collection Procedures 64 Instrumentation or Data Source 64 Variables 65 Data Integrity and Storage 65 Data Management 65 Potential Bias and Mitigation 66 Ethical Considerations 67 Summary 67 Chapter 4: Data Analysis and Results 69 Data Analysis Procedures 69 Descriptive Data of Sample Population 70 Results 72 Summary 74 Chapter 5: Implications in Practice and Conclusions 75 Summary of the Project 75 Major Findings 75 Interpretation of Findings 76 Strengths and Limitations 76 Implications 76 Theoretical Implications 76 Nursing Practice Implications 77 Recommendations 77 Recommendations for Future Projects and Researchers 77 Recommendations for Sustainability 78 Plan for Dissemination 78 Conclusion and Contributions to the Profession of Nursing Practice 78 References 79 Appendix A 87 SWOT Analysis 87 Appendix B 89 Literature Evaluation Table 89 Appendix C 164 Project Timeline 164 Appendix D 165 Plan for Educational Offering 165 Appendix E 166 Grand Canyon University Institutional Review Board Outcome Letter 166 Appendix F 167 Project Budget 167 Appendix G 168 Data Collection Tool for Evaluation (Use the name of the tool here) 168 Appendix H 169 Place the Permission to Use the Tool Here 169 Appendix I 170 Other Data Collection Tool and/or Permissions 170 Appendix J 171 APA Writing Style for the Direct Practice Improvement Project 171 List of Tables Table 1 A Sample Data Table Showing Correct Formatting 72 Table 2 t-Test for Equality of Emotional Intelligence Mean Scores by Gender 73 Table 3 Primary Quantitative Research – Intervention (5 Articles) 89 Table 4 Additional Primary and Secondary Quantitative Research (10 Articles) 108 Table 5 Clinical Practice Guidelines (If applicable to your project/practice) 163 List of Figures Figure 1 SWOT Analysis for Quality Improvement Project 87 Chapter 1: Introduction to the Project Patients transferred or directly admitted to a long-term acute care hospital (LTACH) to the high observation unit (HOU) may have suffer from Post Intensive Care Syndrome (PICS). PICS is a cognitive, physical, and psychological impairment that results from ICU admission (Nordness, 2021). PICS can result in deconditioning, muscle wasting, pressure ulcer formation, decreased mobility, prolonged mechanical ventilation weaning, delirium, and hospital-acquired infections (Nordness, 2021). 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 is a gap in care delivery of patients admitted or transferred to the HOU, impacting length of stay (LOS) and clinical outcomes. As a result, the mean LOS stay of 30-60 days exceeds an LTACH average LOS of 25-28 days. While the increased length of stay 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 ICU Liberation campaign from the PAD Clinical Practice Guideline. The guideline was updated in 2018, now known as the ICU Liberation-ABCDEF bundle. This learner’s 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 ABCDEF bundle to impact the 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 intensive care unit (ICU). As the bundle became popular and widely adopted in to clinical practice it was noted to reduce LOS (Pun et al., 2019; Heish et al., 2019; Frade-Mera et al., 2022). The bundle consists of six interventions, (A) identifying and assessing for using the Critical-Care Observation Tool (CPOT), (B) mechanical ventilation liberation- assisting 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. (C) identifying the appropriate choice of sedation, using the Richmond Agitation Sedation Scale (RASS), (D) to correctly identify and assess for delirium screening using the Confusion Assessment Method for the ICU (CAM-ICU), (E) early progressive mobility to decrease ICU–acquired muscle weakness (Collinsworth et al., 2021). The (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).  Individually these interventions have impacted patient comes such as reductions in the incidence and duration of delirium using the evidence-based tool CAM-ICU (Chen et al., 2021; Delvin et al., 2018). Delvin et al., 2018 & Nordness et al., 2022. identified and treated pain using CPOT. The ABCDEF bundle interventions have impacted clinical outcomes, patient and family satisfaction, resulted in shorter duration of mechanical ventilation, impacted ICU and hospital LOS, (Pun et al., 2019; Frade-Mera et al., 2022, Hsieh et al., 2019). There continues to be significant supportive evidence that the ABCDEF bundle is considered the gold standard of care, adopted in several healthcare settings across the globe.  Background of the Project The increased length of hospital stay is a concern nationwide in all healthcare settings. 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 this LTACH, in Virginia, there has been an increased length of stay beyond 25-28 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 tracheostomies needing ongoing mechanical ventilation support. The syndrome of PICS including chronic pain, has a significant impact of 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). Prolonged LOS is felt locally, nationally, and globally. Locally, surrounding hospitals struggle discharging to LTACHS due to limited bed availability, which puts an undue strain on the surrounding healthcare systems to admit or divert critically ill patients to other surrounding localities. Nationally, LOS affects cost, as it affects clinical and economic outcomes determining where federal funds are allocated, and overall impacts mortality rates impacting resources supplied by the government. 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).  Directly LOS can impact patient care. The ABCDEF bundle has partially or entirely incorporated many hospitals and healthcare organizations into their operations and protocols to improve patient outcomes and cut costs. Most of the ABCDEF bundle elements are relatively well established and have been demonstrated to improve patient outcomes while reducing costs. A critical part of the ABCDEF bundle is its development and widespread use. The use of clinical pathways may help to standardize and improve the treatment of patients across various medical specialties and departments within hospitals. The development of standardized clinical practice guideline allows for consistent treatment protocols across the organization and gives patients a greater chance of receiving high-quality care (Marra et al., 2017).  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 understand an organization’s current and potential future comprehensively. The ultimate goal of the assessment process is to identify areas for improvement so an organization can move forward and grow. As with any quality improvement project, there are threats to the implementation of the project. The SWOT analysis was appropriate for this quality improvement project because it identified the organization’s strengths, weaknesses, opportunities, and threats. This learner identified that LTACH might present challenges to implementing the quality improvement project. There are several potential reasons. One is the need for more familiarity with the guideline among healthcare providers—two, limited resources available at the clinical site to implement all six interventions of the ABCDEF bundle. Resources needed to implement the ABCDEF bundle effectively include personnel (e.g., nurses, pharmacists, physical therapists), equipment (e.g., patient monitors), and funding for additional staff and equipment (AHRQ, 2017). Third, the need for a standardized protocol for implementing the ABCDEF bundle. Without standardized protocols, care may be inconsistent within a facility—lastly, the organization’s culture. The culture of a healthcare facility is defined by its values and norms, and it can take time to change the culture. This DPI project aims to identify and assess challenges that may present. The assessment was conducted using a SWOT analysis.  SWOT Analysis SWOT is a strategic tool that identifies opportunities and threats within a company’s business environment. The SWOT analysis was helpful in our study because it identified 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.  (see Appendix A; see Figure 1). Strengths The ABCDEF bundle implementation provides 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. The ABCDEF package is essential in reducing the risk of developing delirium and facilitating the patient’s recovery in the shortest amount of time and with the fewest disruptions from the outside world (Otusanya et al., 2021). The bundle is designed to address 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 has been shown to be effective in improving patient outcomes. Weaknesses Despite the tremendous clinical effects that can be achieved with the ABCDEF bundle, it is not commonly adopted in practice. Several potential roadblocks could prevent the ABCDEF package from being used. The first obstacle is healthcare practitioners’ unfamiliarity with the ABCDEF bundle interventions and tools. Effective deployment of the ABCDEF bundle necessitates several resources, including people, machines, and money for more machines and people (Collinsworth, Priest & Masica, 2020). There is also the possibility that the ABCDEF bundle will only partially be implemented; only utilizing certain elements per unit needs to yield favorable results, which presents the third challenge. Inconsistent care may be delivered between different units in a hospital or other healthcare facility if there are no established protocols. Lastly, the ABCDEF 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 ABCDEF 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 ABCDEF bundle (Loberg et al., 2022). Resources needed to implement the ABCDEF 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 ABCDEF bundle (Loberg et al., 2022). With standardized protocols, care may be consistent across different units within a facility. Standardized protocols can help 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 ABCDEF bundle. Opportunities There exist multiple opportunities which can play a crucial role in improving the ABCDEF bundle implementation. To begin with, the need to educate health care professionals about the guideline considering that most physicians may need to learn about the guideline, thus limiting the program’s efficiency (Balas et al., 2022). It is also recommended that adequate resources should be provided to healthcare organizations in order to perform all six ABCDEF interventions. Many hospitals cannot perform all six ABCDEF treatments. Personnel, technology, and finance are required to implement ABCDEF successfully. Lastly, standardizing ABCDEF implementation protocols can also be handy as it will ensure consistent care throughout a facility’s units. Threats There are several potential threats to implementing the ABCDEF bundle in an LTACH. One of the most significant is that it could lead to an increase in the length of stay for patients. The bundle requires that patients be monitored more closely, which could lead to more frequent interventions and testing. The ABCDEF bundle could, in turn, lead to patients staying in the hospital for more extended periods (Hsieh et al., 2019). Another potential threat is that the ABCDEF bundle could strain hospital resources. The strain on hospital resources requires more staff time and attention, as well as more equipment and supplies subsequently, which could lead to increased costs for the hospital, which could eventually be passed on to patients and their families. Finally, there is always the potential for human error when implementing any new system or procedure. It is especially true with the ABCDEF 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. Implementation of the ABCDEF bundle is the proposed solution to impact LOS of those admitted or transferred to the HOU. In order to ensure that the ABCDEF 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 this LTACH have required transfer to the HOU or direct admission for acute complex care and management of their critical illnesses. Many of these patients suffered respiratory, neurological, or cardiovascular events warranting the HOU monitoring. Care provided to this vulnerable population was disjointed; lack of a standardized approach impacting LOS, increased skilled nursing facility (SNF) admissions, increased infection rates, caused or worsened delirium, increased pressure ulcer formation, and decreased patient and family satisfaction. As a result, disposition to inpatient rehabilitation facilities or home rates decreased. 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 a risk of delayed recovery to the prehospital state. Despite the ABCDEF bundle’s clinical significance, there is limited data regarding its effectiveness outside of short-term acute hospitals. LTACHs lack a standardized, evidence-based protocol that impacts LOS, disposition, and clinical outcomes. The clinical question of this DPI “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 ABCDEF bundle compared to current practice impact length of stay over eight weeks? 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. 1.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). 2. 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) 3. Direct Project Improvement (DPI) – a translation of existing knowledge or new clinical guidelines into clinical practice that will have a direct and measurable patient outcome. (GCU.EDU)  4. 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). 5. Lengths 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). 6. 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). 7. PICS- Post Intensive Care Syndrome- associated with delirium, cognitive and physical impairments, and psychiatric symptoms (Hsieh et al., 2019). Summary  In 2013 the Society of Critical Care Medicine initiated the ICU Liberation campaign from the PAD Clinical Practice Guideline. The guideline was updated in 2018, now known as the ICU Liberation-ABCDEF bundle. 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 intensive care unit (ICU). Since the ABCDEF 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 (Heish et al., 2019; Frade-Mera et al., 2022). Reducing unnecessary healthcare costs is everyone’s responsibility. The ABCDEF bundle is a cost-effective, scalable intervention. The ABCDEF 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 ABCDEF bundle is a significant milestone for any institution. The ABCDEF bundle consists of six elements of interventions proven to reduce the length of stay and improve patient outcomes. The ABCDEF 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 aims to review the current evidence regarding the ABCDEF 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 ABCDEF bundle in decreasing the ICU length of stay, decreasing the incidence of delirium, and improving patient satisfaction after implementing the ABCDEF 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 the English language 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 and were published later than 2017 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 entire ABCDEF 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 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 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 ABCDEF 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 ABCDEF 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 as it gives tips on how best ICU delirium guidelines can be integrated to improve patient clinical adherence. 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. Patients had shorter stays in ICUs 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 the great majority were recorded in patients in ICUs 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 a decrease in 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, which was a further limitation of 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 both 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 a decrease in 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. Patient-level outcomes were not wholly independent and were assessed quickly 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) looks at 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 the implementation of 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. First, the quality improvement initiative had a problem with its generalizability because the study was conducted at a single Midwest metropolitan hospital. Second, a lower than the desired rate with bundle elements was experienced during the study. Thirdly, 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 ABCDEF bundle elements in improving clinical outcomes. Additionally, DeMellow et al. (2020) looked at the impact of early intervention with the ABCDE bundle on patient outcomes. The study was an observational study conducted 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 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. These findings support the earlier implementation of the ABCDE bundle, which has been shown to improve patient outcomes. ABCDEF 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 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 ABCDEF 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 ABCDEF 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 as an explanation for the observed changes in bundle performance. For the DPI project, the article will demonstrate the impact on improving patient outcomes, decreasing mortality rates, and length of stay 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 ABCDEF 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 lacked the strict protocols found in randomized, controlled trials. Furthermore, the study design and sample size benefits of the investigation did not trump other statistical concerns (Barnes-Daly et al., 2017). The article will demonstrate how the ABCDEF 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 ABCDEF 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 ABCDEF bundle vs. measurement of adherence to the ABCDEF bundle). There is some overlap in the findings of the studies. For example, all studies found that implementing the ABCDEF bundle improved patient outcomes. However, there were also differences between the studies. Some studies found that adherence to the ABCDEF bundle was associated with better patient outcomes. In contrast, other studies found that implementation of the ABCDEF 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 ABCDEF bundle, while others measured implementation of the ABCDEF bundle. The conclusions of the studies also vary. Some studies conclude that the ABCDEF bundle effectively improves patient outcomes, while others conclude that more research is needed. Some studies suggest that adherence to the ABCDEF bundle is more important than implementing the ABCDEF 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 ABCDEF 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 ABCDEF 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 ABCDEF 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 the bundle 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 the feasibility of implementing the ABCDE bundle in different healthcare settings. Implementation of 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 ABCDEF 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. 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 at an LTACH by reducing the length of stay and direct and indirect healthcare costs. 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 ABCDEF 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 ABCDEF bundle]  All the articles identified consistently support the validity of the ABCDEF bundle in improving patient outcomes. Research-based solid evidence indicates that the ABCDEF 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). From past literature, it is evident that the ABCDEF bundle will be very instrumental in guiding optimal resource utilization and well-rounded patient care. The ABCDEF 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, are qualitative and quantitative research articles that indicate the effectiveness of the ABCDEF bundle in improving patient outcomes and reducing the costs of care.  The ABCDEF bundle effectively addresses severe adverse effects of critical illnesses in long-term acute care hospitals. 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. The possible multifold benefits of the recommended strategies from implementing the ABCDEF 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 ABCDEF bundle offers a well-rounded environment for patient care and the optimal utilization of resources. 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. The recommendation for practice is to implement the ABCDEF bundle in reducing sepsis-related morbidity and mortality among high-risk populations such as those admitted to the intensive care unit for conditions like respiratory failure, renal failure, and other conditions based on the scientific evidence from the sources identified.  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 ABCDEF bundle which includes families as a key part of the ABCDEF 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 (Ahtisham & Jacoline, 2015). The nursing theory will help to serve as the 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). 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 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. Henderson’s nursing needs theory will be used during the project to illuminate the problem of ICU delirium because the theory has the potential to 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 levels of stress 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 ABCDEF bundle intended to implement. 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 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 ABCDEF 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 with the goal of refraining 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 same 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. The five significant variables when implementing Henderson’s nursing needs theory are the psychological, physiologic, developmental, sociocultural, and spiritual variables to serve as the basic structure (McEwen & Wills, 2019, p. 157). When implementing the model, stressors manifest themselves in the form of external, internal, and created environments. The theory has broad applicability to the project because a part of the resonation it has to the ABCDEF 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 change model is the proposed change model for the project. John Kotter’s 8-step change process applies to implement change (Kotter, 2012). These strategies can be applied in implementing the ABCDEF 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), there is a need to develop urgency for the proposed interventions. The urgency is possible by 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 (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 ABCDEF bundle for the DPI project. The change model will guide the various steps that will be implemented when instituting the change. The first 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. 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 will be to develop the vision of the project. The vision will guide the stakeholders involved and enhance decision-making during the project. The next step will involve communicating with the stakeholders for buy-in. The healthcare industry is evolving with the core focus being on improving patient outcomes while minimizing healthcare costs to enhance accessibility and use of healthcare services among all populations. The fifth step will be to eliminate barriers. Eliminating barriers will help to enhance support for the change and thus reduce resistance to the proposed change. Resistance to change would only yield poor project outcomes. The next step is to accomplish short-term wins. Short-term will help all the stakeholders understand the proposed intervention’s effectiveness. 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 final step will be to make the proposed change stick. The leaders will incorporate the proposed changes into the organization’s culture by demonstrating the importance of the intervention and training the employees to gain the skills necessary to maintain the new change. These measures will make the change very appealing to the stakeholders at the proposal stage. When the change is implemented as a project, the interventions will actually be practical and achievable when the project is completed. Synthesis of Change Model John Kotter’s change model was developed to successfully address the need to implement change in the workplace. The model was created to recognize the fact 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. The book discussed the mistakes that organizations make when implementing change. Kotter’s 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. The easy-to-follow roadmap will enhance the ease of implementing the proposed change by simply 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, 2012). Integration of the Christian Worldview The lack of access to quality health care is not an uncommon issue in the United States. Quality healthcare is a common problem that affects many people and groups. Despite the various solutions recommended to address the issue through legislative and socioeconomic works, a stable and more effective solution is yet to be achieved. The United States has seen insurance, universal healthcare, and other business models developed to enhance quality healthcare services to all people, but in vain. Some populations are more vulnerable to inadequate healthcare services based on various factors (Woods-Giscombe et al., 2016). For instance, factors such as age, race/ethnicity, sexual orientation, gender identity, and levels of income have been shown to immensely affect the accessibility to some types of healthcare services (Woods-Giscombe et al., 2016). However, the transformation of US health care 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 will play a significant role in addressing the adversaries experienced in the healthcare industry.  Low-income social groups are one of the groups affected immensely by the lack of quality healthcare services in the United States (Cuellar De la Cruz & Robinson, 2017). This burdens the urgent care centers and emergency departments, necessitating the need to implement a universal healthcare model by observing a Christian worldview. Universal health coverage (UHC) has been recommended by the World Health Organization (WHO) to increase accessibility to healthcare services by all populations (Park & Canaway, 2019). The equitable distribution of resources has enhanced accessibility to quality healthcare services. UHC is one of the measures that has also been implemented to enhance the inclusion of minority and vulnerable groups in the healthcare system and decision-making (Park & Canaway, 2019). Diversity would ensure that the healthcare professionals or at least one of the healthcare professionals are conversant with the other groups’ norms, beliefs, cultures, practices, and traditions. Diversity education allows trained professionals to understand and help minority and vulnerable groups despite prevailing differences (Park & Canaway, 2019). Therefore, diversity, equity, and inclusion are essential Christian worldviews for the project and sample population increasing accessibility to healthcare services in order to improve health outcomes among the patients through the Christian principles of ensuring good for all. Summary  The implementation of the ABCDEF bundle will play a vital role in enhancing patient outcomes and fostering reduced healthcare costs. The ABCDEF 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; Liu et al., 2021; Louzon et al., 2017). The first element of the ABCDEF 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; Louzon et al., 2017). 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 ABCDEF bundle is monitoring delirium. Delirium monitoring and management is a significant component of the ABCDEF bundle intervention. Delirium is a strong risk factor for increased length of ICU stay, increased time on mechanical ventilation, increased hospital stay, long-term cognitive impairment, escalating cost of hospitalization, and higher mortality rates (Mart et al., 2019). The fifth element of the bundle includes early mobility. Early mobility is currently the only known intervention linked to a decrease in 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 the remaining chapters 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 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. Amador, L. A. (2021). Theory Application Paper: Preventing ICU delirium. Theoretical Foundation in Advanced Practice Nursing, 1(1), p.5. 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. 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 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 Campos, C. P. A. (2022). Nursing care for patients with Kounis syndrome. Enfermería Clínica (English Edition), 32(3), 203-209. https://doi.org/10.1016/j.enfcle.2021.12.004 Chen, C., Cheng, A., Chou, W., Selvam, P., & Cheng, C. M. (2021). The 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 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 Cuellar De la Cruz, Y., & Robinson, S. (2017). Answering the call to access quality health care for all using a new model of local community not-for-profit charity clinics: A return to Christ-centered care of the past. The Linacre Quarterly, 84(1), 44-56. Engel, J., von Borell, F., Baumgartner, I., Kumpf, M., Hofbeck, M., Michel, J., & Neunhoeffer, F. (2022). Modified ABCDEF-Bundles for Critically Ill Pediatric Patients-What Could They Look Like? Frontiers in Pediatrics, 654. https://doi.org/10.3389/fped.2022.886334 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 Kang, S. P., Chen, Y., Svihla, V., Gallup, A., Ferris, K., & Datye, A. K. (2022). Guiding change in higher education: an emergent, iterative application of Kotter’s change model. Studies in Higher Education, 47(2), 270–289. https://doi-org.lopes.idm.oclc.org/10.1080/03075079.2020.1741540 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 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 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 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 Mart, M. F., Brummel, N. E., & Ely, E. W. (2019). The ABCDEF bundle for the respiratory therapist. Respiratory care, 64(12), 1561-1573. McEwen, M., & Wills, E.M. (2019). Theoretical Basis for Nursing (5th ed.). Philadelphia: Wolters Kluwer/Lippincott Williams & Wilkins. ISBN 978-1-4963-5120-3 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. 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. (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 Park, Y. L., & Canaway, R. (2019). Integrating traditional and complementary medicine with national healthcare systems for universal health coverage in Asia and the Western Pacific. Health Systems & Reform, 5(1), 24-31. https://doi.org/10.1080/23288604.2018.1539058 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 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 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 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 Sylvia, M. L., & Terhaar, M. F. (2018). Clinical analytics and data management for the DNP. New York, NY : Springer Publishing Company, LLC Thankachan, A. (2022). Synergy model for patient care. TNNMC Journal of Nursing Education and Administration, 10(1), 30-33. 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 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 Woods-Giscombe, C., Robinson, M. N., Carthon, D., Devane-Johnson, S., & Corbie-Smith, G. (2016). Superwoman schema, stigma, spirituality, and culturally sensitive providers: Factors influencing African American women’s use of mental health services. Journal of best practices in health professions diversity: research, education, and policy, 9(1), 1124. 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 Appendix A SWOT Analysis Figure 1SWOT Analysis for Quality Improvement Project Appendix B Literature Evaluation Table 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 ABCDEF 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/ The research question aimed at measuring the impact of 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 Prospective cohort study The study included two medical ICUs within Montefiore Healthcare Center (Bronx, New York). The study also included 1855 mechanically ventilated patients admitted to ICUs between July 2011 – July 2014. After early coordination (EC) was implemented (period 2), 65% of patients stood, 54% walked at least once during their ICU stay, and ICU-acquired pressure ulcers and physical restraint use decreased (period 1 vs 2: 39% vs 23% of patients; 30% vs 26% patient days, respectively; p < 0.001 for both). After adjustment for patient-level covariates, implementation of the full (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 < 0.001), ICU length of p 0.05 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. implement on of ABCDE bundle reduced total ICU and hospital cost by 24.2% and 30.2% respectively. The study experienced the challenge of unmeasured changes which could have affected the results The study also as 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 There is need for physicians to acquire training on implementing ABCDE bundle to improve patient’s conditions on ICU and reduce length of hospital stay. There is need for teamwork between physicians in ICU to enhance patient’s health and medication adherence. There is need for improvement of working conditions in health facilities to safeguard patient’s health. This article accessed the impact of implementing complete versus virtual ABCDE bundle on mechanical ventilation (MV) duration, intensive care Unit (ICU)and hospital length of stay (LOS), and cost. However, the article has also determined that early mobilization and structured condition of ABCDE bundle results to a spontaneous awakening, breathing, and delirium management leading to reduced mechanical duration (MV), length of hospital stay and the cost. 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 To examine the impact of an interdisciplinary mobility protocol in 7 specialty intensive care units that previously implemented other bundle components. quality improvement project using the American Association of Critical-Care Nurses mobility protocol The project was conducted at a 1200-bed, university affiliated level I trauma medical center in the Midwest with 132 ICU beds at project initiation. QI preintervention-postintervention design was used The American Association of Critical-Care Nurses (AACN) early progressive mobility protocol was used, The Richmond Agitation-Sedation Scale (RASS) The Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) was also used. All data were downloaded from REDCap into IBM SPSS Statistics, version 22 using descriptive statistics Level of significance for pre-implementation post implementation differences was set at =0.05. (p <0.05) In phase 1, the mean SD) mobility level increased in all intensive care units, from 1.45 (1.03) before to 1.64 (1.03) after implementation P < .001). Mean (SD) ICU Mobility Scale scores increased on initial evaluation from 4.4 (2.8) to 5.0 (2.8) (P = .01) and at intensive care unit discharge from 6.4 (2.5) to 6.8 (2.3) (P = .04). Complications occurred in 0.2% of patients mobilized. In phase 2, 84% of patients had out-of-bed activity after implementation. The time to achieve mobility levels 2 to 4 decreased (P = .05). Intensive care unit length of stay decreased significantly in both phases. QI initiatives using retrospective reviews of medical records The data we extracted from the EMR were dependent on documentation quality. Another limitation is fidelity to the intervention implementation. Implementing the ABCDEF bundle can produce significant impact on pt outcomes. Implementing the E and produce greater results This study adds great significance to my DPI project as it clearly identifies implementation of the ABCDEF bundle can reduce length of stay in the ICU setting. 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 The aim 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 4-month, prospective, observational,multicentre cohort study was conducted in adult patients receiving IMV for at least 48 h in ICUs across Spain. 531 patients Data were collected from day 3 of the ICU stay until extubation A Spanish multicentre cohort study of adult patients receiving invasive mechanicalventilation (IMV) for ≥48 h until extubation.Primary outcome Pain level, level of cooperation, incidence of delirium and physical restraints, and level of mobility related to the implementation of bundle components ABC, D, and E. secondary outcome-Drug levels of analgesia, sedatives, muscle relaxants, and antipsychotics (cumulative drug dosing by IMV days 100) associated with implementation of bundle components ABC, D, and E. Opioids were calculated with morphine equivalents, and benzodiazepines with midazolam equivalents 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 implementation of bundle components ABC, D, and E. The following indices and scores were applied: Charlson, Barthel, Acute Physiology And Chronic Health Evaluation II (APACHE II),and Sequential Organ Failure Assessment (SOFA). Categorical variables were expressed as frequency and percentage, using Fisher or Chi-squared test for between-group comparisons.Groups were compared using the Student t test or Mann-Whitney U test, depending on whether data followed a normal or non-normal distribution; Data were analysed using IBM SPSS Statistics 21.0 forWindows (SPSS Inc., Chicago IL, USA). 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, The implementation rate of ABCDE bundle components was very low in our Spanish setting, but when implemented, patients had a shorter ICU stay, more analgesia dosing, and lighter sedation. unable to analyse the Richmond agitation-sedation scale (RASS) results because the great majority were recorded in patients in ICUs implementing protocols with analgosedation algorithms. very low implementation of delirium scales; did not analyse the use of SAT or SBT as a strategy in bundle components ABC. Applying some but not all the bundle components improve the quality of care and the clinical outcome of critically ill patients.; agitation-sedation and delirium monitoring should be reinforced, physiotherapists need to be incorporated into ICU teams to make early mobilization more efficient and effective. patients in ICUs that apply protocols have shorter ICU stays, this study adds to the growing body of evidence that supports my PICOT as it identifies that the use of bundle components in patients resulted in a shorter ICU stay, fewer IMV days,greater 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. 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 The study determines how to facilitate ABCDE bundle adoption by analyzing different implementation strategies on bundle adherence rates. The study also aims at assessing clinician’s perception of the bundle and the implementation effort. Mixed method eval The study examined effect of 2 bundle implementation on 8 patient adults in ICU. Electronic Health Record (EHR) modification was used as the primary strategy while enhanced strategy uses HER plus additional bundle training 84 nurses, therapists and physicians participated in the survey. Effect of Basic vs Enhanced Intervention on Bundle Adherence ICU LOS 0.02 (0.01-0.02) <.0001a (p <0.05 The response from the participants show that bundle use resulted in best care and patient outcomes. After bundle implementation process, ICUs in both interventions showed improvement in bundle adherence ICUs in the basic intervention outperformed others after initiating own implementation strategies. Data collection was time consuming The study acquired data through EHR hence limited to evaluating some elements such as pain and sedation Physicians response on bundle perception may be biased. There is need for adequate training for physicians on how best to implement ABCDE bundle to improve care for patients Promote teamwork to enhance coordination between healthcare professionals for easier implementation of ABCDE bundle. The article highlights the effects of applying ABCDE bundle in healthcare for the patients in ICU It scores the fact that proper implementation of ABCDE bundles results to improvement in nursing care and patient outcomes. 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 The study aim at evaluating the relationship between ABCDEF bundle performance and patient-centered outcomes in critical care. Prospective cohort study from national quality improvement collaborative The research collected a 20-month period data on 68 academics, community, and federal ICUs The study also included 15226 patient adults and at least one ICU every day. 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). P < 0.002 Complete ABCDE bundle performance demonstratea 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 ought to 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. The article analyzes measures to take in caring for the critically ill patients in ICU with ABCDEF bundle with reference to the results of the ICU liberation collaborative of over 15000 adults. The article however outlined the relationship between ABCDEF bundle performance and patient centered outcomes in critical care. Therefore, it is clear that ABCDEF bundle performance portray 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 The research question was tailored on tracking compliance by an interprofessional team with the (ABCDEF) bundle in enforcing the Agitation, Pain, and Delirium procedures. The aim was to examine the connection between ABCDEF bundle compliance and consequences, including clinic survival and delirium-free and coma-free days in community infirmaries A prospective cohort quality improvement initiative involving ICU patients. Random selection of 1 patient from the daily census at each hospital Study included patients who were 66 years or older with a diagnosis of AMI. Exclusion criteria included age <66 years, primary diagnosis of a noncardiac etiology (e.g., sepsis), and a transfer from another acute care hospital. Data collection Data on patient characteristics, processes of care, and outcomes were collected during 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 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). P < 0.05  The mortality rate for patients with sepsis was decreased by 42 percent (from 20.7 percent to 12.1 percent) in the 23 months after implementation of the ABCDEF bundle, compared with the 21 months before the institution of the bundle. Mortality rates for patients with pneumonia were also lower after bundle implementation (35.4 percent before the intervention vs. 28 percent afterward) The number of days’ patients spent in the intensive care unit within 30 days after arriving at the hospital was reduced by an average of 1.7 days for patients who had sepsis, and by an average of 1.5 days for those with pneumonia The number of brain dysfunction events (such as coma, seizures, and infection) within 30 days after an ICU admission dropped by 36 percent improving Hospital Survival and Reducing Brain Dysfunction at Seven California Community Hospitals: Implementing PAD Guidelines Via the ABCDEF Bundle in 6,064 Patients. First, this QI project lacked the strict protocols found in randomized, controlled trials. The design and sample size benefits of the investigation did not trump other statistical concerns Physicians need further education on guidelines and protocols, as well as how to collaborate with other physicians and experts. – Physical environment needs to be improved along with an organized system for transferring patients. Physicians should be more open to changing their thought process. – Better communication between nurse and physician needs to be encouraged, as well as between physicians and experts such as cardiologists. The article describes the implementation of acute care for older adults’ guidelines at seven California community hospitals and has been used to determine whether a regional quality improvement initiative is associated with improved hospital survival, functional status, and intensive care unit (ICU) length of stay after acute myocardial infarction (AMI). The article also determined whether a regional quality improvement initiative is associated with improved hospital survival, functional status, and ICU length of stay after AMI. 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 What are the effect of quality improvement collaborative participation on ABCDEF bundle performance? This study examined the NQIC’s impact on the implementation of the six components of the ABCDEF Bundle in four types of hospitals: The authors hypothesized that with an increase in safety culture, there would be an increased implementation of the ABCDEF Bundle. The purpose of this study was to determine whether the ABCDEF Bundle could be implemented in a variety of hospitals across the United States with a focus on safety culture. Quasi-experimental design This study used a non-experimental design to determine the impact of the ABCDEF Bundle on safety culture, defined as the degree to which a system is characterized by attention to safety in tasks, relationships, and attitudes. The study included 114 acute care hospitals that were participating in the NQIC. In the ARISE and ProCESS trials, ABCDEF Bundle reduced ICU mortality by 12.6% (P=0.04) and hospital mortality by 15.1% (P=0.007) 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. P <0.05  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. Authors should use an experimental research design The language used should be simplified for easier understanding by all audience The article provides information on reducing the use of common potentially preventable complications (PPCs) in acute care hospitals, connected to my DPI project. The Central Line Bundle demonstrated a 19% reduction in complications, and the ABCDEF Bundle demonstrated a 21% reduction. The ABCDEF Bundle can be implemented in various hospitals across the United States with a focus on safety culture, defined as the degree to which a system is characterized by attention to safety in tasks, relationships, and attitudes. 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 with out 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 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 observational study took place in the general ICU 482 of a 8 bed ICU over a one year period patients were admitted in the ICU and 94(19.5%) were mobilized. Non-mobilized patients were more frequently surgical patients. We conducted 356 mobilization sessions a teaching hospital in Italy. Nurse led- mobility protocol, The protocol was entirely nurse-led and mobilization was performed only with patients passing the safety checklist derived from the original ABCDE protocol The mobilizations were considered “early” only when the patient was mobilized for the first time within 48 hours of admission using a mobilization diary; data was collected from March 2015 to March 2016: Categorical data are presented as absolute numbers and percentages and compared by two tailed yl 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. A P-value less than 0.05 was considered statistically significant. All statistical analyses were performed with the STATA software (ver. 13; Texas USA). A P-value less than 0.05 was considered statistically significant. All statistical analyses were performed with the STATA software (ver. 13; Texas USA). Hospital length of stay, days mobilized 11(6-19) Non-mobilized 25 (11-47) <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. To note no adverse event took place after the first three months, despite a growing number of patient who were mobilized even while ventilated. the implementation of an early and progressive mobilization program in a mixed ICU proved feasible and safe even in its more advanced steps despite the lack of additional personnel dedicated to mobilization, but the number of mobilized patients was low This study is a descriptive study that shows the experience in a single ICU. Therefore, these results cannot be generalized. lack of a historical control group weakens the studys finding 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/ The study aim at identifying factors associated with ABCDEF bundle adherence in critically ill patients during the first 96hours of ventilation Observational using electronic health record data The study used 15 ICUs located in seven community hospitals in western United States The study also included 977 adult patients who were on mechanical ventilation for more than 24hours and admitted to an intensive care unit over the six months. Multiple regression analysis was used to examine factors contributing to bundle Adherence while adjusting for severity of illness, days on mechanical ventilation, hospital site and time elapsed. 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). (p <0.05) 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 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. There is need for openness in data sharing among the physicians to develop a complete system that can identify all the factors associated with ABCDEF bundle adherence in severely ill patients The article supports my DPI project since the article identifies the factors associated with ABCDEF bundle adherence in critically ill patients during the first 96 hours of ventilation. The article supports the results that modifiable factors improve 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/ The study aims to determine how quality improvement initiative can evaluate the effectiveness of the ABCDEF bundle elements to improve clinical outcomes Quality Improvement Secondary research through sampling Interventions was done in (609-bed) Midwest metropolitan hospital. Pre-implementation data were collected between January 2019 and March 2019. A pre/posttest design was used, and a convenience sample of all patients with sepsis admitted ABCDEF bundle elements and improve 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. (p <0.05 The study results indicated overall implementation of ABCDEF bundle in the setting resulted to enhanced care delivery and improved clinical outcomes. The QI initiative has problem with its generalizability 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. The government should support the implementation of the QI initiative to enhance quality care for patients The article is relevant to my DPI project since it outlines the guidelines on how best ABCDEF bundle can be applied in nursing to improve clinical outcomes. 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. 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 The study was conducted in two medical ICUs in Montefiore Health Systems The study also involved 472 mechanically ventilated patients admitted in the ICU between 1st January 2013 and 31st December 2013. Relative to the comparison ICU, implementation of the entire bundle in the intervention ICU was associated with a 27.3% (95% CI: 9.9%, 41.3%; P   0.004) decrease in total hospital laboratory costs and a 2,888.6% (95% CI: 77.9%, 50,113.2%; P  0.018) increase in total hospital physical therapy costs. Cost of total hospital medications, diagnostic radiology and respiratory therapy were unchanged. Relative to the comparison ICU, total 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   0.020). (p <0.05) 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 research data collection and analysis was only limited to two ICU centers There is need for teamwork between professionals in nursing to fully implement ABCDE bundle intervention to increase ICU discharges and reduce total hospitalization cost Physicians also need conducive environment and support to fully implement ABCDE bundle in health centers The article supports my DPI project as it focuses on how fully implementation of ABCDE bundle significantly reduces hospital laboratory costs and the hospital resource use also decreased. 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 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 2 Pre/ post bundle. retrospective, observational, before-and-after outcome study The study included adult patients on 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) performed ABCDE with early mobilization. The data were retrospectively collected. The study periods were divided into phase 1 (before ABCDE bundle, from December 1, 2015 to March 31, 2016 phase 2 (after application of the ABCDE bundle, from October 1st to December 31st, 2016). Continuous data were compared using two independent-sample t-tests with Bonferroni correction. Categorical variables were analysed using the chi-square or Fisher’s exact tests. Significance was set at (p<0.05) The ABCDE care bundle improved the outcome of acute renal failure patients with MV, especially shortening ICU stays and lowering medical costs and hospital mortality. The patients in phase 2 had a significantly lower mean ICU length of stay (8.0 vs 12.0 days) but a similar MV duration (170.2 vs 188.1 hours), hospital stays (21.1 vs 23.3 days) with reduced costs (22.1 vs 31.7   104 NT$), and intra-hospital mortality (8.3 vs. 36.6%). First, findings are based on the experience in a single ICU. Second, safety or feasibility of early mobilization was considered. Third, physical function before and after implementation of the care bundle was not measured and fourth, this study was based on a retrospective design 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 An ABCDE care bundle with an inter-professional, evidence-based, multicomponent ICU management strategy can reduce unnecessary ICU and general hospital stays, hospital expenditure, and mortality among ARF patients on MV. 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 The research aim to determine the impact of ABCDE processes on inpatient mortality,LOS, discharge status, and direct costs of care Retrospective Cohort study The study included 2,953 patients, 18 years and above, with an ICU stay greater than 24 hours, who were on a ventilator for more than 24 hours and less than 14 days. It also included 12 adult ICUs in six hospitals belonging to a large, integrated healthcare delivery system. The Unadjusted and Adjusted Effect of Bundle Adherence on Inpatient Outcomes Length of stay (d) 0.64 (0.51–0.76)a 0.57 (0.45–0.69)a (p <0.05) Differences in patient characteristics may have influenced bundle adherence rates, potentially overestimating the impact of improved bundle adherence on outcomes. Physicians need support to fully implement ABCDE bundle since it is cost effective in reducing mortality rate in ICUs. Programs on ABCDE bundle application should be integrated with curriculum to equip physicians with the skills. My proposed DPI project focuses on the impact of ABCDE bundle on inpatient mortality LOS, discharge and its cost effectiveness which the article clearly outlines. 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 to explore the influences of ABCDE bundle on the hemodynamics and prognosis of patients on mechanical ventilation cross-sectional overall, before-after controlled study 143 patients on mechanical ventilation admitted at 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 ABCDE bundle. 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 for comparison of the rates of both groups. P<0.05 was considered statistically significant. (p <0.05) The difference in the prognosis between the bundle and pre-ABCDE bundle groups was statistically significant (P<0.05), as 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. Non randomized few studies have assessed the effects of hemodynamics more studies of this caliber need to be conducted to determine the hemodynamic affect the ABCDE bundle can have ABCDE was implemented identifying significant substantial differences in pre/post bundle implementation that demonstrated to 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 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. We sought to identify ICU-related factors associated with implementation in the ICU. 1-day point prevalence study, The primary outcome was the implementation rate of the entire ABCDEF bundle. 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 ABCDEF bundle, and the ICU diary between the groups of patients with out 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 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 ABCDEF bundle for patients without and with COVID-19 infections The p-value was reported as two-sided and p < 0.05 was considered statistically significant. Multidisciplinary rounds were conducted significantly less frequently for patients with COVID-19 infections (p = 0.004). Compared to before the pandemic, family visting hours to patients both without and with COVID- 19 infection were reduced (<0.001 and p = 0.004, respectively), and more stringent restrictions imposed on families of patients with COVID-19 infections (p < 0.001). There were significant differences in the demographics of the two groups for ICU length of stay, age, BMI, gender, use of mechanical ventilation (49 vs. 66%) Comparison of delirium incidence, 28-d survival, mechanical ventilation duration, and length of ICU stay between 2 groups showed that the delirium incidence in the pre-ABCDE bundle group was higher than in the post-ABCDE bundle group, while the prognostic indicators in the post-ABCDE bundle group were better than in the pre-ABCDE bundle group, and the difference was statistically significant (P<0.05, 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 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 sought to improve LOS and ventilator day measures, reduce hospital expenditures, and advance pharmacists’ scope of practice within a large community teaching hospital. A two-phase program a retrospective cohort study This study included 436. Patients manged with the ABCDEF bundle and 499 patients of those with standard care. In. Florida hospital in the US. 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 treatment groups using Student’s t test for continuous data and a chi-square test of independence (Fisher’s exact test) for categorical data. P < 0.05 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); intervention-group patients 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 use of continuous sedation, hospital LOS, and ventilator days. Secondary endpoints were as follows: total amount of sedation used, ICU LOS, ventilator days, number of Richmond Agitation Sedation Scale (RASS) scores greater than +1, and reintubation rates 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 pharmacisy 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 or its number of participants in this cohort study that demonstrated the use to bundle with the assist of pharmacist managing sedative implementing mobility demonstrated decrease ventilation days and decrease LOS decrease hospital cost by 46% an estimatd saving of 1.2million 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 The study aim at exploring geriatric-focused practices and associated outcomes in older intensive care survivors retrospective, cohort study The study included 179 older adults with a mean age of 80.2 years In a total of 179 patients (mean age, 80.5 years) met inclusion criteria. 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) were significantly associated with longer hospital stays. (P<.05) The study indicated high levels of non-adherence to geriatric-focused practices depending on hospital length of stay. 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. Since half of the ICUs are occupied by older adults, 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. 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 article is relevant to my DPI project as a healthcare worker since it explores geriatric-focused practices and the associated outcomes for older adults in ICU survivors. The practices can be used to care for the elderly adults visiting ICUs to improve their medical adherence. The aim of the ABCDEF bundle is to improve adherence to best practices, they are geared to the general adult population, in this study it was used to manage specific needs of geriatric patients. This study foion the geriatric population of ICU survivors to assess the association between nonadherence to geriatric focused practices such as delirium, early mobility and clinic outcomes one being LOS 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 focused practices and associated outcomes in older intensive care survivors. Bladder catheters were associated with hospital-acquired pressure injuries. In A total of 179 patients (mean age, 80.5 years) met inclusion criteria. 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) were significantly associated with longer hospital stays. (P<.05) adherence to geriatric-focused practices depending on hospital length of stay. 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. 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. 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. for older adults in ICU survivors. The practices can be used to care for the elderly adults visiting ICUs to improve their medical adherence. The aim of the ABCDEF bundle is to improve adherence to best practices, they are geared to the general adult population, in this study it was used to manage specific needs of geriatric patients. This study foion the geriatric population of ICU survivors to assess the association between nonadherence to geriatric focused practices such as delirium, early mobility and clinic outcomes one being 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 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. 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. To examine between-group differences, The stude used Kruskal-Wallis test 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. (P<.05) The primary outcome was adherence changes to delirium guidelines recommendations, based on the Pain, Agitation and Delirium guidelines. Secondary outcomes were brain dysfunction (delirium or coma), length of ICU stay, and hospital mortality. A total of 3,930 patients were included. Improvements after the implementation pertained to delirium screening (from 35% to 96%; p < 0.001), use of benzodiazepines for continuous sedation (from 36% to 17%; p < 0.001), light sedation of ventilated patients (from 55% to 61%; p < 0.001), physiotherapy (from 21% to 48%; p < 0.001), and early mobilization (from 10% to 19%; p < 0.001). Brain dysfunction improved: the mean delirium duration decreased from 5.6 to 3.3 days (–2.2 d; 95% CI, –3.2 to –1.3; p < 0.001), and coma days decreased from 14% to 9% (risk ratio, 0.5; 95% CI, 0.4–0.6; p < 0.001). Other clinical outcome measures, such as length of mechanical ventilation, length of ICU stay, and hospital mortality, did not change ICU length of stay (d), mean (sd) PHASE 1= 1,337 4.9 (6.9) PHASE 2=1,399 4.3 (6.0) PHASE 3=,194 4.8 (5.9) ADJUSTED OR.RATE RATIO BETAa a) –0.3 (–0.8 to 0.1; p = 0.19) b) –0.1 (–0.6 to 0.3; p = 0.56) c) 0.2 (–0.3 to 0.6; p = 0.49) Delirium screening increased from 35% to 93% Continuous IV 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 guidelines implementation process. There is need for additional health professionals to care for the ICU patients by screening delirium to boost the clinical outcomes. This article is in line with my DPI project as healthcare professional as it gives tips on how best ICU delirium guidelines can be integrated to improve patient’s clinical adherence. This study showed that the implementation of the ABCDEF bundle had improved health professionals’ adherence to delirium guidelines, which was linked to reduced brain dysfunction which link to decrease ICU stay data from this study added to existing implementation literature strongly enhancing translatability of findings. the feasibility of staggered versus simultaneous implementation of bundle elements, that seem strongly dependent on local resources (e.g., “local champions” vs interprofessional implementation teams or level of previous experience with the guidelines), and 2) the fact that our “error of omission” of daily safety screens for SATs and SBTs may have precluded concurrently improved clinical outcomes, adding strong empirical support from a “real-life setting” for effectiveness of individual ABCDE bundle elements. 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 This study aim at evaluating the impact of bundle interventions on ICU delirium prevalence, duration, and other patients’ adverse outcomes. Meta-Analysis The study involved using a standardized data collection where two authors extracted data independently A total of 26,384 adult participants were included in the meta-analysis. The study data sources included, the Cochrane Library, PubMed, CINAHL, EMBASE, PsychINFO, and MEDLINE from January 2000 to July 2020. (P<0.05) Add interpretation 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 (Table 2), 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 two cohort studies that applied bundle interventions lowered the ICU delirium prevalence by 8% but no significant differences were detected. 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. In ICU Delirium Duration, there was no difference identified between participants in the bundle intervention group 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’s adverse outcomes. The impacts highlighted in the article are vital for my DPI project in healthcare as it enhances my knowledge on 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 Virginia Henderson Nursing Needs Theory will be used to guide the DPI project. Henderson identified the unique function of the nurse is to assist the individual, sick or well, 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. And 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 such as (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 in expression of emotions, fears or needs through communication, the11th is worshipping, working in a way to express a sense of accomplishment, participating in various recreational activities (Ahtisham & Jacoline, 2015). Henderson viewed the nursing process as an application of the logical approach to the solution of 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 Change Model Kang, S. P., Chen, Y., Svihla, V., Gallup, A., Ferris, K., & Datye, A. K. (2022). Guiding change in higher education: an emergent, iterative application of Kotter’s change model. Studies in Higher Education, 47(2), 270–289. https://doi-org.lopes.idm.oclc.org/10.1080/03075079.2020.1741540 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 John Kotter’s 8 step change processes applies to implement change (Kotter, 2012). These strategies can be applied in implementing the ABCDEF bundle to decrease LOS. According to Kotter (2012) the first step is creating urgency. Kang et al., (2022) provides an explanation of the theory. According to Kang et al., (2022) first, there is a need to develop urgency for the proposed interventions. This is possible by identifying the existing threats 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 a group of 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 from the change to drum up support for the change. 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 change stick. He re-ensure that everyone adapts to new change by illustrating its importance, training them 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. 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