Yes / IMPORTANCE Patients undergoing emergency laparotomy have high mortality, but few studies exist to improve outcomes for these patients. OBJECTIVE To assess whether a collaborative approach to implement a 6-point care bundle is associated with reduction in mortality and length of stay and improvement in the delivery of standards of care across a group of hospitals. DESIGN, SETTING, AND PARTICIPANTS The Emergency Laparotomy Collaborative (ELC) was a UK-based prospective quality improvement study of the implementation of a care bundle provided to patients requiring emergency laparotomy between October 1, 2015, and September 30, 2017. Participants were 28 National Health Service hospitals and emergency surgical patients who were treated at these hospitals and whose data were entered into the National Emergency Laparotomy Audit (NELA) database. Post-ELC implementation outcomes were compared with baseline data from July 1, 2014, to September 30, 2015. Data entry and collection were performed through the NELA. INTERVENTIONS A 6-point, evidence-based care bundle was used. The bundle included prompt measurement of blood lactate levels, early review and treatment for sepsis, transfer to the operating room within defined time goals after the decision to operate, use of goal-directed fluid therapy, postoperative admission to an intensive care unit, and multidisciplinary involvement of senior clinicians in the decision and delivery of perioperative care. Change management and leadership coaching were provided to ELC leadership teams. MAIN OUTCOME AND MEASURES Primary outcomes were in-hospital mortality, both crude and Portsmouth Physiological and Operative Severity Score for the enumeration of Mortality and morbidity (P-POSSUM) risk-adjusted, and length of stay. Secondary outcomes were the changes after implementation of the separate metrics in the care bundle. RESULTS A total of 28 hospitals participated in the ELC and completed the project. The baseline group included 5562 patients (2937 female [52.8%] and a mean [range] age of 65.3 [18.0-114.0] years), whereas the post-ELC group had 9247 patients (4911 female [53.1%] and a mean [range] age of 65.0 [18.0-99.0] years). Unadjusted mortality rate decreased from 9.8% at baseline to 8.3% in year 2 of the project, and so did risk-adjusted mortality from a baseline of 5.3% to 4.5% post-ELC. Mean length of stay decreased from 20.1 days during year 1 to 18.9 days during year 2. Significant changes in 5 of the 6 metrics in the care bundle were achieved. CONCLUSIONS AND RELEVANCE A collaborative approach using a quality improvement methodology and a care bundle appeared to be effective in reducing mortality and length of stay in emergency laparotomy, suggesting that hospitals should adopt such an approach to see better patient outcomes and care delivery performance. / This study was funded by The Health Foundation, United Kingdom, as part of a Scaling Up Award.

No description available.

Background: Many nursing home residents are at risk of developing a pressure ulcer, which is an area of localised damage to the skin and/or underlying tissue due to immobility, increasing age and co-morbidities. Whilst guidelines for the prevention of pressure ulcers exist, their implementation can be sub-optimal. Care bundles are a set of research-informed practices used to facilitate the implementation of evidence into practice and incorporating psychological theory within their development may enhance their effectiveness. I aimed to co-design and assess the feasibility of implementing a theory and research-informed pressure ulcer prevention care bundle intervention in a nursing home setting. Method: This thesis comprised four separate studies as part of an overall mixed methods research design. Firstly, I conducted a systematic review and meta-analysis to determine the effects of care bundles per se on patient outcomes. I then conducted theory-informed qualitative, semi-structured interviews with nursing home care staff and NHS community-based nurses to explore the context of, and the barriers and facilitators to, pressure ulcer prevention in nursing homes. Next I co-designed a pressure ulcer prevention care bundle with 13 healthcare workers during a four hour workshop and supplemental email consultation. Using the Nominal Group Technique, we reached a consensus about the content of the care bundle. Following the steps of the Behaviour Change Wheel, I finalised the care bundle intervention. The final study involved a before-after study design where one nursing home implemented the care bundle intervention. I collected and analysed quantitative and qualitative data to gain a more holistic understanding of the feasibility issues related to the implementation. Findings: Findings from the systematic review suggested that care bundles may reduce the risk of negative outcomes in patients. These findings were based on very low quality evidence and the original study authors rarely reported adherence to the care bundle interventions. The theoretical understanding of the complexities in the prevention of pressure ulcers in nursing homes suggested there were four barriers and six facilitators, which my final care bundle intervention addressed. The co-designed care bundle intervention comprised three elements: support surfaces, skin inspection, repositioning; alongside three intervention functions and seven behaviour change techniques. In the final feasibility study, during the baseline period, there were 462 resident bed days and 5 new pressure ulcers recorded and in the intervention phase there were 1,181 resident bed days and no new pressure ulcers. The care bundle intervention appeared to be acceptable to the nursing home care staff and we have identified specific issues relating to the feasibility of implementing the care bundle intervention. Conclusions: The current research evidence-base for care bundles is poor. However, it was possible to co-design and implement a pressure ulcer prevention care bundle intervention for a nursing home setting. Further feasibility research is necessary before we can assess whether the care bundle intervention is effective in preventing pressure ulcers in nursing homes.

Introdução: As infecções primárias da corrente sanguínea associadas ao cateter venoso central (IPCS) são um grande problema nas unidades de terapia intensiva (UTI) pediátricas e neonatais em todo o mundo. Evidências sugerem que a prevenção das IPCSs é crucial para o atendimento seguro ao paciente. Uma percentagem significativa (65-70%) das IPCSs são evitáveis utilizando as estratégias baseadas em evidências, incluindo os bundles. Estas medidas têm um papel bem estabelecido em pacientes adultos.O objetivo deste estudo foi avaliar, a partir de uma ampla revisão sistemática da literatura, o benefício da implementação do bundle do cateter central na prevenção das IPCSs em pacientes pediátricos e neonatais internados em UTI. Métodos: Foram pesquisadas as bases de dados Cochrane Library, Medline, Latin American and Caribbean Health Science Literature (LILACS), Centre for Reviews and Dissemination (CRD), Embase, Scopus, Web of Science, Cumulative Index to Nursing and Allied Health Literature (CINAHL), além de busca manual e literatura cinzenta entre 1 de janeiro de 2005 até 31 de dezembro de 2015. Não houve restrição dos estudos com relação ao idioma, a data ou status de publicação. Para avaliar o benefício do bundle do cateter central, foram selecionados estudos envolvendo pelo menos dois componentes (higiene de mãos, precauções de barreira máxima, antissepsia da pele, seleção adequada do sítio do cateter, revisão diária da necessidade do cateter) como medida preventiva para pacientes com cateter venoso central (CVC). O desfecho foi o número de IPCSs por 1000 cateteres-dias antes e depois da implementação do bundle. Resultados: Foram identificados inicialmente 6369 estudos, após a exclusão dos títulos duplicados e os inelegíveis, 31 estudos preencheram os critérios de elegibilidade. Os estudos foram heterogêneos tanto na composição do bundle quanto na estratégia de implementação. A mediana da densidade de incidência de IPCS foi de 5.9 por 1000 cateteres-dias (2.6-23.1) nas unidades de terapia intensiva pediátricas (UTIP) e 4.9 por 1000 cateteres-dias (2.0-24.1) nas unidades de terapia intensiva neonatais (UTIN). Após a implementação do bundle do cateter central, a densidade de incidência de IPCS variou de 0 a 14.9 por 1000 cateteres-dias (mediana de 2.1) nas UTIPs e 0.3 a 13.9 (mediana de 2.8) nas UTINs. Conclusões: As IPCSs continuam sendo um problema significativo em unidades de terapia intensiva pediátricas e neonatais, mas a implementação do bundle do cateter central pode reduzir significativamente as taxas dessas infecções. Intervenções assistenciais com as melhores práticas baseadas em evidência permitem uma redução substancial das IPCSs pela promoção de grupos ou bundles de procedimentos e tecnologias, e pela utilização de uma estratégia multimodal para a educação, formação, implementação e divulgação. / Background: Central-line-associated bloodstream infections (CLABSIs) are a major problem in neonatal and pediatric intensive care units (ICUs) worldwide. Evidence suggests that CLABSI prevention is crucial for safe patient care. A significant percentage of CLABSIs (65- 70%) are preventable using evidenced-based guidelines. Strategies to prevent these infections have included a myriad of different preventive maneuvers gathered as “bundles”. These measures have a well established role in the adult ICU setting. We aimed to assess the benefit of the implementation of central-line bundles to prevent CLABSIs in neonatal and pediatric ICU patients, populations where their actual efficacy is yet to be proven. Methods: We searched Cochrane Library, Medline, Latin American and Caribbean Health Science Literature (LILACS), Centre for Reviews and Dissemination (CRD), Embase, Scopus, Web of Science, Cumulative Index to Nursing and Allied Health Literature (CINAHL), manual search and gray literature to identify studies reporting the implementation of central-line bundles in pediatric ICU (PICU), or neonatal ICU (NICU) patients. We searched for studies published between Jan 1, 2005, and December 21, 2015, without language restriction. To evaluate the benefit of the central line bundle were selected studies involving at least two components (hand hygiene, maximal barrier precautions, skin antisepsis, optimal catheter site selection and daily review of line necessity) as a preventive measure to patients with central venous catheter (CVC). The outcome was the number of CLABSIs per 1000 catheter-days before and after implementation. Results: We initially identified 6369 records, and after excluding duplicates and those ineligible, 31 studies met the eligibility criteria. The studies reviewed were quite heterogeneous both in bundle composition and implementation strategy. Median CLABSIs incidence were 5.9 per 1000 catheter-days (range 2.6–23.1) on PICUs and 4.9 per 1000 catheter-days (range 2.0–24.1) on NICUs. After implementation of central-line bundles the CLABSI incidence ranged from 0 to 14.9 per 1000 catheter-days (median 2.1) on PICUs and 0.3 to 14.9 (median 2.8) on NICUs. Conclusions: CLABSIs remain a significant problem in neonatal and pediatric critical care units, but implementation of catheter care bundles can significantly reduce rates of these infections. Best practice interventions allow substantial CLABSI reduction by promotion of groups or bundles of procedures and technology, and by use of a multimodal strategy for education, training, implementation, and dissemination.

Introdução: As infecções primárias da corrente sanguínea associadas ao cateter venoso central (IPCS) são um grande problema nas unidades de terapia intensiva (UTI) pediátricas e neonatais em todo o mundo. Evidências sugerem que a prevenção das IPCSs é crucial para o atendimento seguro ao paciente. Uma percentagem significativa (65-70%) das IPCSs são evitáveis utilizando as estratégias baseadas em evidências, incluindo os bundles. Estas medidas têm um papel bem estabelecido em pacientes adultos.O objetivo deste estudo foi avaliar, a partir de uma ampla revisão sistemática da literatura, o benefício da implementação do bundle do cateter central na prevenção das IPCSs em pacientes pediátricos e neonatais internados em UTI. Métodos: Foram pesquisadas as bases de dados Cochrane Library, Medline, Latin American and Caribbean Health Science Literature (LILACS), Centre for Reviews and Dissemination (CRD), Embase, Scopus, Web of Science, Cumulative Index to Nursing and Allied Health Literature (CINAHL), além de busca manual e literatura cinzenta entre 1 de janeiro de 2005 até 31 de dezembro de 2015. Não houve restrição dos estudos com relação ao idioma, a data ou status de publicação. Para avaliar o benefício do bundle do cateter central, foram selecionados estudos envolvendo pelo menos dois componentes (higiene de mãos, precauções de barreira máxima, antissepsia da pele, seleção adequada do sítio do cateter, revisão diária da necessidade do cateter) como medida preventiva para pacientes com cateter venoso central (CVC). O desfecho foi o número de IPCSs por 1000 cateteres-dias antes e depois da implementação do bundle. Resultados: Foram identificados inicialmente 6369 estudos, após a exclusão dos títulos duplicados e os inelegíveis, 31 estudos preencheram os critérios de elegibilidade. Os estudos foram heterogêneos tanto na composição do bundle quanto na estratégia de implementação. A mediana da densidade de incidência de IPCS foi de 5.9 por 1000 cateteres-dias (2.6-23.1) nas unidades de terapia intensiva pediátricas (UTIP) e 4.9 por 1000 cateteres-dias (2.0-24.1) nas unidades de terapia intensiva neonatais (UTIN). Após a implementação do bundle do cateter central, a densidade de incidência de IPCS variou de 0 a 14.9 por 1000 cateteres-dias (mediana de 2.1) nas UTIPs e 0.3 a 13.9 (mediana de 2.8) nas UTINs. Conclusões: As IPCSs continuam sendo um problema significativo em unidades de terapia intensiva pediátricas e neonatais, mas a implementação do bundle do cateter central pode reduzir significativamente as taxas dessas infecções. Intervenções assistenciais com as melhores práticas baseadas em evidência permitem uma redução substancial das IPCSs pela promoção de grupos ou bundles de procedimentos e tecnologias, e pela utilização de uma estratégia multimodal para a educação, formação, implementação e divulgação. / Background: Central-line-associated bloodstream infections (CLABSIs) are a major problem in neonatal and pediatric intensive care units (ICUs) worldwide. Evidence suggests that CLABSI prevention is crucial for safe patient care. A significant percentage of CLABSIs (65- 70%) are preventable using evidenced-based guidelines. Strategies to prevent these infections have included a myriad of different preventive maneuvers gathered as “bundles”. These measures have a well established role in the adult ICU setting. We aimed to assess the benefit of the implementation of central-line bundles to prevent CLABSIs in neonatal and pediatric ICU patients, populations where their actual efficacy is yet to be proven. Methods: We searched Cochrane Library, Medline, Latin American and Caribbean Health Science Literature (LILACS), Centre for Reviews and Dissemination (CRD), Embase, Scopus, Web of Science, Cumulative Index to Nursing and Allied Health Literature (CINAHL), manual search and gray literature to identify studies reporting the implementation of central-line bundles in pediatric ICU (PICU), or neonatal ICU (NICU) patients. We searched for studies published between Jan 1, 2005, and December 21, 2015, without language restriction. To evaluate the benefit of the central line bundle were selected studies involving at least two components (hand hygiene, maximal barrier precautions, skin antisepsis, optimal catheter site selection and daily review of line necessity) as a preventive measure to patients with central venous catheter (CVC). The outcome was the number of CLABSIs per 1000 catheter-days before and after implementation. Results: We initially identified 6369 records, and after excluding duplicates and those ineligible, 31 studies met the eligibility criteria. The studies reviewed were quite heterogeneous both in bundle composition and implementation strategy. Median CLABSIs incidence were 5.9 per 1000 catheter-days (range 2.6–23.1) on PICUs and 4.9 per 1000 catheter-days (range 2.0–24.1) on NICUs. After implementation of central-line bundles the CLABSI incidence ranged from 0 to 14.9 per 1000 catheter-days (median 2.1) on PICUs and 0.3 to 14.9 (median 2.8) on NICUs. Conclusions: CLABSIs remain a significant problem in neonatal and pediatric critical care units, but implementation of catheter care bundles can significantly reduce rates of these infections. Best practice interventions allow substantial CLABSI reduction by promotion of groups or bundles of procedures and technology, and by use of a multimodal strategy for education, training, implementation, and dissemination.

Introdução: As infecções primárias da corrente sanguínea associadas ao cateter venoso central (IPCS) são um grande problema nas unidades de terapia intensiva (UTI) pediátricas e neonatais em todo o mundo. Evidências sugerem que a prevenção das IPCSs é crucial para o atendimento seguro ao paciente. Uma percentagem significativa (65-70%) das IPCSs são evitáveis utilizando as estratégias baseadas em evidências, incluindo os bundles. Estas medidas têm um papel bem estabelecido em pacientes adultos.O objetivo deste estudo foi avaliar, a partir de uma ampla revisão sistemática da literatura, o benefício da implementação do bundle do cateter central na prevenção das IPCSs em pacientes pediátricos e neonatais internados em UTI. Métodos: Foram pesquisadas as bases de dados Cochrane Library, Medline, Latin American and Caribbean Health Science Literature (LILACS), Centre for Reviews and Dissemination (CRD), Embase, Scopus, Web of Science, Cumulative Index to Nursing and Allied Health Literature (CINAHL), além de busca manual e literatura cinzenta entre 1 de janeiro de 2005 até 31 de dezembro de 2015. Não houve restrição dos estudos com relação ao idioma, a data ou status de publicação. Para avaliar o benefício do bundle do cateter central, foram selecionados estudos envolvendo pelo menos dois componentes (higiene de mãos, precauções de barreira máxima, antissepsia da pele, seleção adequada do sítio do cateter, revisão diária da necessidade do cateter) como medida preventiva para pacientes com cateter venoso central (CVC). O desfecho foi o número de IPCSs por 1000 cateteres-dias antes e depois da implementação do bundle. Resultados: Foram identificados inicialmente 6369 estudos, após a exclusão dos títulos duplicados e os inelegíveis, 31 estudos preencheram os critérios de elegibilidade. Os estudos foram heterogêneos tanto na composição do bundle quanto na estratégia de implementação. A mediana da densidade de incidência de IPCS foi de 5.9 por 1000 cateteres-dias (2.6-23.1) nas unidades de terapia intensiva pediátricas (UTIP) e 4.9 por 1000 cateteres-dias (2.0-24.1) nas unidades de terapia intensiva neonatais (UTIN). Após a implementação do bundle do cateter central, a densidade de incidência de IPCS variou de 0 a 14.9 por 1000 cateteres-dias (mediana de 2.1) nas UTIPs e 0.3 a 13.9 (mediana de 2.8) nas UTINs. Conclusões: As IPCSs continuam sendo um problema significativo em unidades de terapia intensiva pediátricas e neonatais, mas a implementação do bundle do cateter central pode reduzir significativamente as taxas dessas infecções. Intervenções assistenciais com as melhores práticas baseadas em evidência permitem uma redução substancial das IPCSs pela promoção de grupos ou bundles de procedimentos e tecnologias, e pela utilização de uma estratégia multimodal para a educação, formação, implementação e divulgação. / Background: Central-line-associated bloodstream infections (CLABSIs) are a major problem in neonatal and pediatric intensive care units (ICUs) worldwide. Evidence suggests that CLABSI prevention is crucial for safe patient care. A significant percentage of CLABSIs (65- 70%) are preventable using evidenced-based guidelines. Strategies to prevent these infections have included a myriad of different preventive maneuvers gathered as “bundles”. These measures have a well established role in the adult ICU setting. We aimed to assess the benefit of the implementation of central-line bundles to prevent CLABSIs in neonatal and pediatric ICU patients, populations where their actual efficacy is yet to be proven. Methods: We searched Cochrane Library, Medline, Latin American and Caribbean Health Science Literature (LILACS), Centre for Reviews and Dissemination (CRD), Embase, Scopus, Web of Science, Cumulative Index to Nursing and Allied Health Literature (CINAHL), manual search and gray literature to identify studies reporting the implementation of central-line bundles in pediatric ICU (PICU), or neonatal ICU (NICU) patients. We searched for studies published between Jan 1, 2005, and December 21, 2015, without language restriction. To evaluate the benefit of the central line bundle were selected studies involving at least two components (hand hygiene, maximal barrier precautions, skin antisepsis, optimal catheter site selection and daily review of line necessity) as a preventive measure to patients with central venous catheter (CVC). The outcome was the number of CLABSIs per 1000 catheter-days before and after implementation. Results: We initially identified 6369 records, and after excluding duplicates and those ineligible, 31 studies met the eligibility criteria. The studies reviewed were quite heterogeneous both in bundle composition and implementation strategy. Median CLABSIs incidence were 5.9 per 1000 catheter-days (range 2.6–23.1) on PICUs and 4.9 per 1000 catheter-days (range 2.0–24.1) on NICUs. After implementation of central-line bundles the CLABSI incidence ranged from 0 to 14.9 per 1000 catheter-days (median 2.1) on PICUs and 0.3 to 14.9 (median 2.8) on NICUs. Conclusions: CLABSIs remain a significant problem in neonatal and pediatric critical care units, but implementation of catheter care bundles can significantly reduce rates of these infections. Best practice interventions allow substantial CLABSI reduction by promotion of groups or bundles of procedures and technology, and by use of a multimodal strategy for education, training, implementation, and dissemination.