DNP-820 Topic 4: sample paper, in real form

Reducing Delirium and Ventilator Days in a 22-Bed Medical ICU: Evidence Appraisal and a Knowledge-to-Action Translation Plan

[Author Name]

College of Nursing and Health Care Professions, Grand Canyon University

DNP-820: Translational Research and Evidence-Based Practice

Topic 4 Assignment

[Instructor Name]

August 11, 2026

Composite setting written as a model document. No real hospital, patient or clinician is described, and no practicum hours are represented.

Practice Problem, Setting, and the Clinical Question

The setting is a composite: a 22-bed adult medical ICU inside a 340-bed nonprofit teaching hospital. A 180-day baseline drawn from the electronic record covers 612 admissions and 3,104 patient-days. Delirium screening with the CAM-ICU tool was documented on 62 percent of eligible patient-days, and 41 percent of screened days were positive. Mean duration of mechanical ventilation was 6.4 days against an internal target of 4.9. Paired spontaneous awakening and breathing trials were documented on 34 percent of eligible days, continuous benzodiazepine infusions ran on 38 percent of ventilated days, and physical restraints were recorded on 27 percent of patient-days.

Two facts define the gap. The first is that the evidence for reducing delirium and ventilator days in this population is not in dispute, so this is a translation problem rather than a research problem. The second is that performance of practices already ordered is partial: screening happens on most days but not all, awakening and breathing trials are paired on a third of eligible days, and early mobility is rare, with 71 percent of ventilated patient-days recorded at bed rest or passive range of motion. Delirium in ventilated adults travels with longer ventilation, longer stay and worse function at discharge, so the gap is expensive in outcomes before it is expensive in dollars.

The clinical question, written in PICOT form: in adults receiving mechanical ventilation in a 22-bed medical ICU (P), how does full performance of the ABCDEF bundle (I), compared with current sedation and mobility practice (C), affect delirium-positive patient-days, mean ventilator days and restraint days (O) across 180 days of implementation (T)? The work is quality improvement rather than human subjects research. A written determination was requested from the institutional review board before the first data pull, because that ruling governs consent, data handling and what may later be published, and a doctoral project that skips it invites a finding it cannot undo.

Appraisal of the Evidence

The search covered PubMed, CINAHL Complete and the Cochrane Library for English-language work published between 2013 and 2025, combining sedation interruption, early mobilization, delirium screening and ICU liberation with the bundle name. It returned 214 records; 38 were read in full and 11 were retained. The retained body holds one clinical practice guideline, two systematic reviews with meta-analysis, three randomized controlled trials, four prospective cohort or multi-site improvement reports, and one instrument validation study. Each was graded for level and for quality with the Johns Hopkins tool, which keeps the strength of a design separate from the confidence a reader can place in how it was executed (Dang et al., 2022).

Two sources anchor the synthesis. The 2018 clinical practice guideline on pain, agitation and sedation, delirium, immobility and sleep disruption is a level I source of high quality, and it supports light sedation targets, avoidance of benzodiazepines as a first-line agent, routine delirium screening with a validated tool, and rehabilitation begun early in the ICU stay (Devlin et al., 2018). The largest applied report covers more than 15,000 adults across 68 ICUs and describes a dose-response pattern: as the proportion of bundle elements performed rose, the likelihood of next-day mechanical ventilation, coma, delirium, restraint use, ICU readmission and hospital death fell (Pun et al., 2019).

The limitations matter as much as the findings, because they set what may honestly be promised to a governing committee. Bundle definitions differ between studies, so a pooled effect describes a family of interventions rather than one protocol. Sedation and mobility trials cannot be blinded, which leaves performance bias inside every effect size. The strongest outcome evidence comes from prospective cohort work rather than randomization, so the dose-response pattern supports association and biological plausibility rather than causation, and most reporting sites were academic centers staffed better than this hospital. The appraisal therefore supports adoption with local measurement, not a promise that outcomes will follow on their own.

Translation Model and Implementation Plan

Knowledge-to-Action was selected as the translation model (Graham et al., 2006). Its knowledge funnel moves from primary inquiry through synthesis into usable tools, and its action cycle names the steps in order: identify the problem and select the knowledge, adapt it to the local context, evaluate barriers, tailor the intervention, monitor knowledge use, evaluate outcomes and sustain use. The Iowa Model was considered and set aside (Iowa Model Collaborative, 2017). Iowa is strongest at the front end, where a team decides whether a trigger deserves organizational priority. Here the evidence is settled and the deficit is execution, so a cycle that carries local adaptation and sustainment explicitly is the better instrument.

Adaptation began with a barrier survey returned by 96 of 128 clinical staff, a 75 percent response. Lack of time was reported by 68 percent, fear of device dislodgement during mobility by 54 percent, and uncertainty about who authorizes mobility by 49 percent. Each barrier drew a specific countermeasure rather than a general call for education. A nurse-driven protocol with written safety screens removed the authorization question, mobility was scheduled inside the existing morning care period rather than added on top of it, and a rehabilitation technician at 0.6 full-time equivalent was funded so that a first ambulation does not depend on pulling the bedside nurse away from another patient.

The implementation package is deliberately small, because packages with many parts fail in ways nobody can diagnose. Default order sets were rewritten to make light sedation with a non-benzodiazepine agent the standing choice. The daily rounding note in the electronic record was rebuilt to prompt each bundle element by name. Screening moved to a fixed twice-daily schedule at 08:00 and 20:00, and a mobility algorithm keyed to the RASS score replaced case-by-case judgment about who may sit or stand. Preparation runs 90 days and implementation 180 days, with four bedside champions per shift and audit feedback published monthly. Recurring cost is about 41,000 dollars for the technician plus 6,800 dollars for two sit-to-stand aids.

Evaluation Plan, Measures, and Sustainment

Measurement separates three families so that a rise in one cannot hide a fall in another. Process measures are the percentage of eligible patient-days on which all six bundle elements were performed, the paired awakening and breathing trial rate, twice-daily screening compliance, and the share of ventilated days reaching sitting at the edge of the bed or higher. Outcome measures are delirium-positive days per 100 screened days, mean ventilator days, ICU length of stay and restraint days per 1,000 patient-days. Balancing measures are unplanned extubation per 100 ventilator days, reintubation within 48 hours, falls during mobility, and a monthly workload rating from bedside staff.

Data come from existing documentation fields rather than hand collection, which protects the project from the reporting bias that manual quality counts invite. Monthly points are plotted on statistical process control charts, a p-chart for bundle performance and a u-chart for restraint days, and special cause is declared by standard Shewhart rules rather than by comparing one month against the last. The stated targets across 180 days are bundle performance at or above 70 percent of eligible days, delirium-positive days from 41 percent to 30 percent, and mean ventilator days from 6.4 to 5.4. Baseline and implementation periods are compared secondarily with chi-square and independent-samples t tests.

Sustainment is designed before implementation starts, because improvement work decays when its champions rotate off. Ownership passes to the shared governance council at day 180, control limits are recalculated once the process is stable, bundle performance joins the quality dashboard the critical care committee reviews each month, and the mobility algorithm and order sets are folded into orientation so the practice stops depending on memory. If bundle performance holds above 70 percent while outcome measures do not move, the next question is whether the elements are being documented rather than done, and auditing shifts from the record to direct observation at the bedside.

References

Dang, D., Dearholt, S. L., Bissett, K., Ascenzi, J., & Whalen, M. (2022). Johns Hopkins evidence-based practice for nurses and healthcare professionals: Model and guidelines (4th ed.). Sigma Theta Tau International.

Devlin, J. W., Skrobik, Y., Gelinas, C., Needham, D. M., Slooter, A. J. C., Pandharipande, P. P., Watson, P. L., Weinhouse, G. L., Nunnally, M. E., Rochwerg, B., Balas, M. C., van den Boogaard, M., Bosma, K. J., Brummel, N. E., Chanques, G., Denehy, L., Drouot, X., Fraser, G. L., Harris, J. E., . . . Alhazzani, W. (2018). Clinical practice guidelines for the prevention and management of pain, agitation/sedation, delirium, immobility, and sleep disruption in adult patients in the ICU. Critical Care Medicine, 46(9), e825-e873.

Ely, E. W. (2017). The ABCDEF bundle: Science and philosophy of how ICU liberation serves patients and families. Critical Care Medicine, 45(2), 321-330.

Graham, I. D., Logan, J., Harrison, M. B., Straus, S. E., Tetroe, J., Caswell, W., & Robinson, N. (2006). Lost in knowledge translation: Time for a map? Journal of Continuing Education in the Health Professions, 26(1), 13-24.

Iowa Model Collaborative. (2017). Iowa Model of Evidence-Based Practice: Revisions and validation. Worldviews on Evidence-Based Nursing, 14(3), 175-182.

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.