Implementing multi-modal nursing strategies to reduce catheter-associated urinary tract infections in adult inpatients: a scoping review.

To map the current literature on interventions designed to enhance Family Centred Care (FCC) in Neonatal Intensive Care Units (NICUs) and identify gaps in the existing literature. Following Arksey and O'Malley's scoping review framework, a comprehensive search was conducted on November 10th, 2023, and updated on the 20th May 2025. Four databases were searched: Medline via OVID, CINAHL via EBSCO-Host, OVID Embase and PROQUEST. Studies were included if they described interventions targeting FCC in NICUs. Two reviewers independently conducted the screening at both phases with conflicts resolved by a third reviewer. The review identified 31 studies outlining 26 interventions, categorised into four categories: Family centred care bundles; Educational interventions; Communication interventions; and Environmental interventions. Study participants included mothers, fathers, families, and healthcare workers, often restricted to specific languages and cultures. Most outcome measures predominantly reflected the perspectives of mothers and nurses. Many interventions were associated with improvement in family engagement and satisfaction. However, evidence was limited on long-term neonatal and parental outcomes and sustainability of the FCC practices. While some interventions, such as Family Integrated Care (FiCare) and The Close Collaboration Program, have been extensively studied, others have been examined only to a limited extent. This review investigated interventions to enhance FCC in the NICU. The findings highlighted a range of interventions designed to improve family experiences and neonatal outcomes. This review underscores the need for standardised implementation studies on FCC interventions in NICUs. While numerous interventions successfully increased parental involvement and positively influenced staff perspectives, their effectiveness often hinges on the implementation strategies employed, as well as the support from institutions and healthcare providers. Understanding FCC interventions implemented worldwide will broaden the application of FCC within the NICU. Further investigation into these interventions across various NICUs is necessary, involving diverse family members and healthcare professionals in assessing outcomes.

Sleep health is an overlooked but important part of children's health and development. The health consequences associated with poor sleep health may impact recovery during critical illness. Explore sleep health among children in the pediatric intensive care unit (PICU) receiving usual care or a nurse-led chronotherapeutic care bundle. Secondary analysis of the RESTORE Resilience (R2) trial. Parent-reported baseline sleep health was compared with PICU sleep health, including compliance with baseline sleep behaviors, alertness levels, and actigraphy-based measures of sleep timing, efficiency, and duration. In 52 R2 participants (6 months to 17 years), 49 provided prehospital sleep data and 22/49 (45%) had atypical baseline sleep health. Participants had irregular PICU sleep behaviors and spent ≥ 25% of PICU days sedated. Children experienced little daytime activity consolidation and short, fragmented sleep episodes. Total sleep time was within 1 hour of baseline on 23 (11%) study days. There were few associations between baseline and PICU sleep health or between R2 bundle implementation and PICU sleep health. Critically ill children demonstrated disrupted sleep health. Results will inform nurse-led interventions to promote sleep in the PICU.

To test whether a unit-level nutrition care bundle that accelerates enteral feed and optimises early caloric delivery improves in-hospital growth in preterm infants. Single-centre pre-post observational study. Tertiary neonatal intensive care unit. Infants born at less than 32 weeks' gestation admitted during two epochs: baseline (1 January 2023-30 April 2024) and post-quality improvement (QI) (1 May 2024-31 August 2025). Complete cases were analysed for each endpoint (growth velocity (GV) cohort: pre n=163, post n=149). A multicomponent nutrition care bundle promoting earlier initiation and advancement of enteral feeds, protocolised fortification and higher early energy delivery. Primary outcome was infant-level average GV (g/kg/day) calculated from weekly GV from week 3 onwards. Secondary outcomes included week-specific GV, change in weight Z-score from birth to discharge (Δ weight Z), discharge anthropometry, feeding process measures (time to full feeds, week 1 calories) and safety outcomes (feeding intolerance and necrotising enterocolitis). Average GV increased from 12.52±2.49 pre-QI to 15.50±2.30 g/kg/day post-QI (mean difference+2.98, 95% CI 2.45 to 3.52; p<0.001). Weekly GV was higher post-QI across weeks 3-12, with the largest difference at week 8 (+4.31 g/kg/day, 95% CI 2.34 to 6.27; p<0.001). Δ weight Z was less negative post-QI (-1.21±0.75 vs -1.43±0.81; difference+0.22, 95% CI 0.05 to 0.39; p=0.012). Discharge weight was higher post-QI (+152 g, 95% CI 13 to 290; p=0.033), while discharge length and head circumference Z-scores were similar between epochs. Time to full feeds decreased by 6.05 days (95% CI -11.77 to -0.33), and mean week 1 caloric intake increased by 11.38 kcal/kg/day (95% CI 6.16 to 16.60). Feeding intolerance and necrotising enterocolitis rates did not differ between periods. Implementation of a care bundle was associated with improved GV and earlier feeding milestones without increased feeding intolerance or necrotising enterocolitis.

In resource-constrained healthcare settings such as in India, effective infection prevention and control (IPC) practices are essential for reducing healthcare-associated infections (HAIs) and enhancing patient outcomes. This study aimed to evaluate a customized IPC model implemented in Indian hospitals to address these challenges and improve patient safety. The model was designed to be replicable by other hospitals with similar objectives. The multicenter pre-post quality improvement study was conducted across 11 Indian private tertiary hospitals from January 2022 to June 2023, with a 6 months preintervention phase (January-June 2022) and a 12 months intervention phase (July 2022-June 2023). Following the World Health Organization (WHO) guidelines, the study employed a stepwise methodology, including induction, HAI data collection, baseline assessments using WHO's Infection Prevention and Control (IPC) Assessment Framework (IPCAF) tool to evaluate IPC level, team formation, training, surveillance, and audit protocols. The intervention phase focused on comprehensive IPC training, virtual courses, and IPC surveillance. The project utilized the IPC model to enhance the methodology of implementing IPC, enabling transition over an 18-month duration. Significant improvements were observed in IPC assessment scores, hand hygiene compliance, and adherence to IPC care bundles during the intervention phase. IPC assessment scores remarkably improved from a median of 78-97% (p = 0.004), with hospitals remaining in the advanced IPC level both pre and post intervention. Compliance toward hand hygiene improved from a median of 65% in the preintervention phase to 88% in the postintervention phase (p = 0.004). Significant improvement in compliance with IPC care bundles were observed for CAUTI (p = 0.016), CLABSI (p = 0.004), SSI (p = 0.010), and VAP (p = 0.037).Overall, HAI incidence rates remained consistently low during the study period with no statistically significant difference (p > 0.05) between preintervention and postintervention rates; however, variability across individual hospitals highlights differences in settings and indicates further strengthening and standardization of IPC practices. This quality improvement initiative highlights that a structured, WHO-aligned IPC approach can be practically adopted across Indian hospitals and can strengthen key IPC practices such as hand hygiene and care bundle compliance. With HAI rates already low at baseline and remaining stable over the study period, the findings primarily highlight the feasibility and scalability of such IPC programs across diverse healthcare settings.

Delirium is a frequent complication of critical illness and remains an important cause of short- and long-term morbidity for patients admitted to ICUs. Delirium is associated with prolonged mechanical ventilation; extended ICU and hospital stay; and longer-term health issues. Development is associated with patient (e.g. severe physiological derangement); clinical (e.g. sedation); and environmental factors (e.g. loss of day/night variation and sleep deprivation). This review provides an overview of the current understanding of ICU delirium and its implications for critical care practice. We undertook a narrative review of the contemporary literature and synthesised evidence related to epidemiology, pathophysiology, risk factors, diagnostic tools and preventive and therapeutic strategies, with an aim of developing a practical resource for clinicians. Delirium impacts approximately one-third of patients admitted to general ICUs, with higher rates among older adults and those requiring mechanical ventilation. Diagnosis relies on clinical assessment supported by validated instruments, each with limitations for the critically ill population. Pharmacological interventions have not shown consistent benefit to prevent or treat delirium. In contrast, multicomponent non-pharmacological approaches (e.g. optimal sedation, early mobilisation, re-orientation, sleep hygiene and family engagement) are associated with a reduced incidence of delirium and improved functional outcomes. Delirium contributes to the long-term psychological and cognitive burden of critical illness and structured follow-up and ICU diaries may support recovery. Delirium in the ICU is common and important for patients and multidisciplinary critical care providers. The most effective strategies for prevention and management are non-pharmacological and require co-ordinated, multidisciplinary delivery. Sustained improvements in outcomes require consistent implementation of evidence-based care bundles and better integration of follow-up services for survivors.

Hospital-acquired infections (HAIs) are a leading cause of morbidity and mortality in intensive care units (ICUs), largely driven by invasive devices, immunosuppression, and prolonged hospitalization. Despite available guidelines, prevention strategies remain inconsistently applied across settings. This narrative review synthesized evidence from PubMed (2020-2025) and key guideline documents (World Health Organization, Centers for Disease Control and Prevention, Infectious Diseases Society of America, Society for Healthcare Epidemiology of America), focusing on staff-level, patient-level, and systemic interventions for ICU infection prevention. Eligible sources included systematic reviews, clinical trials, consensus statements, and implementation studies. Effective staff-level strategies include strict hand hygiene, correct use of personal protective equipment, vaccination, and decontamination of personal devices, supported by audits and feedback. Patient-level care bundles targeting ventilator-associated pneumonia, central line-associated bloodstream infection, and catheter-associated urinary tract infection reduce device-related complications, though real-world adherence varies. Systemic measures such as closed ICU models, adequate nurse-to-patient ratios, triage protocols, and single-patient rooms, further mitigate infection risks. Implementation barriers include resource limitations, compliance gaps, and ethical considerations regarding futile care. Preventing ICU-acquired infections requires coordinated, multifaceted strategies embedded into daily practice. Sustained progress depends on leadership, continuous education, auditing, and adaptation of international frameworks to local contexts.

Post-sternotomy mediastinitis (PSM) is a rare but life-threatening complication of cardiac surgical procedures. This study evaluated the impact of a structured multi-disciplinary post-discharge care bundle on PSM incidence. A single-center, retrospective cohort study compared the incidence of PSM two years before and after implementation of a care bundle led by a multi-disciplinary team. The intervention included telephonic monitoring, a specialized wound-care clinic, and a standardized two-phase wound management protocol incorporating single-use negative pressure wound therapy. Outcomes were assessed using chi-square tests and logistic regression adjusted with propensity scores and inverse probability weighting. To rule out a temporal trend in newly identified wound infections, we performed a linear regression using bimonthly incident counts as the outcome. A total of 1,197 patients underwent median sternotomy between May 1, 2018, and April 30, 2022. The crude incidence of PSM was 3.32% in the pre-implementation group and 1.56% in the post-implementation group (p = 0.058). After adjustment with inverse probability of treatment weighting, the care bundle was associated with a significant reduction in PSM rate (absolute risk difference 1.96%, 95% confidence interval [CI]: 0.54-3.87; p = 0.044; relative reduction 59%, 95% CI: 16.3%-116%), despite a higher baseline surgical risk in the post-implementation cohort (higher EuroSCORE II, more urgent procedures, greater need for vasoactive support). The rate of newly identified wound infections did not exhibit a significant time trend (β = -0.43; p = 0.299). Implementation of a multi-disciplinary care bundle is significantly associated with a reduction in PSM incidence in cardiac sternotomy patients, underscoring the importance of structured outpatient wound surveillance.

Chronic obstructive pulmonary disease (COPD) affects more than 16 million US adults, many of whom experience high rates of acute care revisits (emergency department and hospital) after initial hospitalization. These frequent exacerbations, often due to failures in transitions of care (TOC), lead to lung function decline and premature mortality. While effective interventions exist to reduce readmissions, wide-scale implementation of COPD TOC programs remains limited. The National Institutes of Health-funded Reducing Respiratory Emergency Visits Using Implementation Science Interventions Tailored to Settings (REVISITS) study was designed to address this implementation gap by developing and implementing bundled COPD TOC programs across diverse US hospitals. This study aimed to conduct pre-implementation contextual assessments at US hospitals to guide the development of site-specific, evidence-based COPD TOC programs. We conducted pre-implementation contextual assessments using a novel semi-structured interview format that integrated the Consolidated Framework for Implementation Research (CFIR) with human-centered design approaches (ethnographic interviewing) to capture real-world experiences of COPD care across inpatient, outpatient, and home settings. We used a sequential explanatory mixed methods design in which pre-interview survey data completed by site leads informed and shaped the subsequent semi-structured interviews. Site leads, clinicians, organizational leaders, patients, and caregivers were interviewed. Interviews explored baseline COPD TOC practices, local resources, opportunities for improvement, as well as participant priorities from a menu of 12 evidence-based interventions (eg, pulmonary rehabilitation, patient navigation, and inhaler teaching). Rapid analysis methods identified intervention priorities across participant groups, along with perceived barriers and facilitators to implementation. Findings were shared with site leads to help guide their development of tailored COPD TOC programs. Among 194 participants from 21 sites (42 site leads, 29 organizational leaders, 105 clinicians, and 18 patients or caregivers), the highest priority interventions identified during interviews were post-emergency department follow-up visits, education (inhaler technique, disease management, and action plan), and pulmonary rehabilitation. Reported barriers included clinician-level challenges (limited training, staffing, and time), patient-level challenges (social needs and physical burden of COPD), and system-level challenges (lack of standardization, limited resources, and cost). Key facilitators included the presence of dedicated staff and the availability of pre-existing programs or infrastructure. The 3 most commonly chosen interventions for implementation were patient education (eg, inhaler education and COPD action plans), medication reconciliation, and post-discharge care (eg, post-discharge visits and pulmonary rehabilitation). This study demonstrates how the integration of implementation science and human-centered design approaches can yield valuable insights, beyond what either field could obtain separately, during the pre-implementation phase of COPD TOC program implementation development. Contextual assessments that capture diverse views are instrumental in designing feasible and relevant interventions. Future work will explore how pre-implementation insights relate to post-implementation outcomes across participating sites.

Patients living in rural settings are among the least likely to receive care, contributing to excess deaths in rural communities from respiratory conditions. We examine barriers that impede implementation of a care bundle for chronic obstructive pulmonary disease (COPD) management that was widely implemented across rural communities in the USA. 17 rural medical centres implementing the care bundle in the US Department of Veteran Affairs (VA). Medical centres were located across 13 states, with 3 VA medical centres (VAMC) in the Southeast, 4 in the South, 9 in the Midwest and 1 in the Northwest. Clinician participants engaged in programme implementation included pharmacy leaders, hired clinical pharmacists, nurse care managers and pharmacy technicians. Participation was offered to all clinicians engaged in the implementation process and was voluntary. This evaluation identifies barriers that impede implementation of a care bundle for COPD management. To guide our analysis, we identified challenges that strongly aligned with work system factors within the Systems Engineering Initiative for Patient Safety (SEIPS) 2.0 model. Challenges experienced during the implementation of a COPD service in rural settings included (1) limited staff availability, (2) fragmentation of care, (3) technology challenges, (4) limited referral opportunities, (5) competing demands on pharmacist time and (6) clinician apprehension regarding their ability to manage a new disease state. This evaluation furthers what is understood regarding barriers to implementing care bundles within rural healthcare contexts. Our findings suggested that clinicians in rural settings felt constrained in their ability to take on new tasks and expand their practice models due to staffing shortages and heavy workload demands. Some clinicians reported approaches they used to address barriers they encountered, such as leveraging relationships with other healthcare practitioners to enhance communication and minimise technology limitations.

Care Bundles to Reduce Stillbirths and Improve Pregnancy Outcome.

Acute kidney injury (AKI) is a devastating complication of acute illness that affects adults and children across multiple settings worldwide and is associated with the development and progression of chronic kidney disease, increased mortality and increased resource utilization. Over the past two decades, standardization of criteria for AKI diagnosis and staging and the publication of multicentre studies have led to improved understanding of the AKI spectrum and provided insights into the heterogeneity of patient characteristics, processes of care and the environmental and sociodemographic factors that influence care delivery and outcomes. Substantial advances have been made in the utilization of electronic health records, biomarkers and care bundles- structured sets of evidence-based treatment practices- to improve the clinical management of AKI. The emerging fields of artificial intelligence and digital health may also provide ways to reduce the burden of this disease. However, these developments have occurred mainly in high-income countries and have yet to improve care delivery or outcomes in low-resource regions. Progress in the development of specific treatments for AKI is limited, and important gaps in knowledge and clinical practice remain, particularly in relation to the 5R framework (risk, recognition, response, renal support and rehabilitation) for managing AKI. An urgent need exists to address the wide variation and inequities in AKI management worldwide.

The objective of this scoping review will be to identify and describe the characteristics and outcome measures of indwelling urinary catheter care bundles in adult populations. The use of indwelling urinary catheters carries an inherent risk of infection, leading to the development of catheter-associated urinary tract infections, particularly antimicrobial-resistant infections, which are the most common. These infections can increase the risk of other complications, such as increased morbidity, mortality, hospitalization, length of stay, and hospital costs. The prevention of catheter-associated urinary tract infections has been explored through the use of care bundles; however, the best use case for these bundles remains unknown. This review will include primary qualitative, quantitative, and mixed methods research, systematic reviews, and gray literature examining care bundles for indwelling urethral or suprapubic urinary catheters in adult populations. All care settings will be included where care bundles are delivered by health professionals. A search limit of 2015 onward will be set. This review will follow the JBI methodology for scoping reviews and will be reported against the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRIMSA-ScR). Databases to be searched will include MEDLINE, Embase, and Emcare (via Ovid), CINAHL (via EBSCOhost), and Scopus. Figures and tables, along with accompanying narrative synthesis, will be used to present the results in line with the review questions. Studies will be mapped in terms of common characteristics of care bundles and outcome measures used to evaluate their effects. OSF: osf.io/dqnsh.

Maintaining normothermia throughout the perioperative period prevents the occurrence of complications related to hypothermia. To determine the effect of a thermal care bundle with a short prewarming period on inadvertent perioperative hypothermia (IPH), surgical site infection (SSI), and unplanned readmission among osteosynthesis patients, and to identify associated variables. Open-label, randomised controlled trial. University hospital. One hundred and forty-eight patients who underwent osteosynthesis surgery. The intervention group received the thermal care bundle, which consisted in prewarming patients 10 min before anaesthesia delivery and maintaining body temperature with a forced air device during surgery and the immediate postoperative period; in addition, the operating room environmental temperature was kept at 21 °C, and fluids were warmed to 38 °C. For the primary objective, hypothermia was defined as core body temperature below 36 °C and measured using the 3M Spot On zero heat flux sensor. Core temperature was recorded upon admission to the preoperative holding area and subsequently every 30 min until postanaesthesia care unit (PACU) discharge. Secondary objectives were SSI and readmissions: a follow-up at 30 to 60 and 90 days was performed by the principal investigator. All 148 patients completed the study, and there were no significant differences between the groups at baseline. At the start of surgery, the incidence of hypothermia was significantly lower in the bundle group (1.3 vs. 9.9% among controls; odds ratio = 7.59, P = 0.021). A significantly lower incidence of hypothermia was also observed at admission to the PACU (14.3% in the bundle group vs. 29.6% among controls; odds ratio = 2.07; P = 0.024). Application of the bundle increased patients' core body temperature by 0.13 °C (95% confidence interval (CI), 0.003 to 0.254; P = 0.045). Patients in the bundle group had a slightly lower observed incidence of wound infections requiring readmission (odds ratio = 0.35; 95% CI, 0.04 to 2.92), although this difference was not statistically significant (P = 0.332). The bundle reduces perioperative hypothermia by up to 59%, but does not affect on SSI; factors like presurgery hospital stay, operating room and PACU occupancy were identified as risk factors for SSI. 21 July 2022: NCT05469958 (Clinical Trials.gov), first recruitment 15 August 2022.

Even though relapse rates for Clostridioides difficile infection (CDI) are high, vancomycin-a medication that targets C. difficile and works well during acute episodes-has gut microbiota-disrupting effects. The Chinese herbal formula Shengjiang Xiexin decoction (SXD) is helpful for microbial reversion, justifying the use of combination therapy. One often invoked tactic in such bundles of care is to minimize patients' antibiotic exposure. In this work, we challenged this paradigm in a murine CDI model. Divergently with regard to the dose deescalation (low-dose vs. short-course), we found that it significantly undermined the synergy between the drugs. Despite the resolution of acute symptoms by all combination regimens containing SXD, deescalation strategies (CDR2 and CDR3) resulted in significantly worse relapse, enhanced inflammation and sustained gut dysbiosis. Conversely, only the CDR1 regimen with SXD co-treatment resulted in a full recovery of gut microbiota alpha-diversity and long-term ecological stability, associated with a better shift of metabolic pathways. Accordingly, our key finding is that standard vancomycin dosing is necessary for this therapeutic synergy to be realized and that dose deescalation blunts it and raises the risk of relapse. Such evidence invites a more sophisticated antibiotic stewardship approach with concomitant treatments, favoring preservation of synergistic effect over simplistic dose reduction.

Acute kidney injury (AKI) affects up to 20% of hospitalised patients and is associated with significant morbidity, mortality, and healthcare burden. Despite national guidelines, variability in recognition and management persists. This review bridges the UK Kidney Association (UKKA) AKI Summit recommendations with real-world National Health Service (NHS) clinical practice, summarising 24 key recommendations into core principles and translating them into practical guidance for clinicians across emergency, ward-based, critical care, and geriatric settings. Emphasis is placed on early identification, fluid and medication management, escalation to specialist teams, and discharge planning. We highlight implementation tools, including e-alert systems, care bundles, and standardised referral pathways. Finally, the article discusses barriers to consistent AKI care and proposes system-wide strategies to support education, coordination, and long-term follow-up. This practical review offers a setting-specific roadmap to improve patient outcomes and promote consistent, proactive care across the AKI continuum.

Threatened abortion (abortus imminens) is a common early-pregnancy condition characterized by first-trimester vaginal bleeding with a closed cervix and an ongoing intrauterine pregnancy. Besides clinical risk, it frequently produces psychological distress and is influenced by socioeconomic barriers, health literacy, and the coordination of care across providers and families. Objective: This study aimed to describe and analyze midwifery care management for women with threatened abortion at approximately 8 weeks’ gestation at Medan Haji Hospital, using an SDG-oriented lens on access (SDG 1), education/health literacy (SDG 4), and partnerships (SDG 17). Methods: A qualitative descriptive approach was combined with a desk-based document review. Primary information was collected through semi-structured interviews with women receiving care for threatened abortion in the Jabal Uhud UPTD Room. Secondary information was obtained from peer-reviewed literature, midwifery textbooks, and official reports/guidelines. Data were analyzed through thematic categorization and integrated by triangulation to synthesize patterns across access, education, and partnership domains. Findings: Three major patterns emerged. First, economic and transportation/coverage constraints were consistently linked to delayed or fragmented antenatal care and follow-up, weakening early detection and safety-netting. Second, limited health literacy and inconsistent counseling contributed to delayed care-seeking and suboptimal adherence to follow-up recommendations. Third, stronger partnerships interprofessional coordination, facility-to-system linkages, and family (including husband) support were associated with clearer referral pathways, improved continuity of care, and better emotional support for women experiencing early pregnancy bleeding. Implications: A continuity-oriented midwifery care bundle is recommended, integrating standardized counseling and return precautions, structured follow-up planning, and partnership mechanisms involving interprofessional coordination and family engagement to improve early pregnancy care quality and maternal well-being. Originality/Value: This study offers an integrated, SDG-linked interpretation of threatened-abortion midwifery care management by connecting clinical processes with structural access barriers, maternal health literacy, and partnership mechanisms, providing a practical framework for service improvement.

Scalable approaches for collecting patient-reported outcome and experience measures (PROMs/PREMs) are essential to operationalize value-based healthcare (VBHC). This paper presents implementation insights from MomCare, a digital pregnancy care bundle in Kenya and Tanzania that scaled phone-based PROM/PREM collection to over 7000 women. It describes implications of its implementation approach on patient reach, data quality, and cost. It highlights how design choices, such as standardization, contextualization, and automation, contribute to enhancing feasibility and generating value. Transitioning from SMS surveys to computer-assisted telephone interviewing enabled increased patient reach and improved data quality, while costs lowered with scale. These findings indicate that phone-based PROM/PREM collection is scalable in resource-constrained health systems. Lessons from MomCare offer actionable insights for embedding patient voices into quality improvement and VBHC models, providing practical recommendations for strengthening patient-centered care in low- and middle-income countries.

Abstract Introduction Acute Kidney Injury (AKI) is a serious and preventable complication in older adults following orthopaedic surgery. At Lincoln County Hospital, inconsistent AKI recognition and response led to a Quality Improvement Project (QIP) aiming to embed the trust’s AKI bundle into routine postoperative care. Method A prospective, two-cycle audit was conducted on orthopaedic postoperative patients. Patient records and electronic data were reviewed for AKI recognition, management, and outcomes. Between cycles, interventions included targeted teaching sessions, visual reminders across wards, and the introduction of a structured AKI assessment proforma. Results Initial audit findings revealed only 20% adherence to the AKI care bundle. Following intervention, compliance rose to 100% in the second cycle. Clinician engagement with medication review and fluid assessments improved significantly, leading to earlier detection and fewer AKI cases. The project was presented at the hospital’s Clinical Governance Meeting, where it was well received and subsequently integrated into the junior doctors’ induction programme. It was also showcased at a regional quality improvement conference. Conclusion This QIP demonstrates that low-cost, high-impact interventions—driven by education, visibility, and practical tools—can dramatically improve AKI management in orthopaedic patients. By embedding these changes into routine practice and institutional teaching, we’ve established a sustainable, replicable model for improving postoperative outcomes in older adults.

As the management of intracerebral hemorrhage (ICH) shifts from historical inertia to more proactive, evidence-based care, ensuring sex-equitable access to best-practice stroke care is increasingly important. Data on sex differences in access to care for ICH remains limited and often conflicting. More robust evidence is required to understand where disparities may exist to inform targeted interventions. We aimed to determine sex differences in the clinical and surgical management of patients with acute ICH who participated in the third Intensive Blood Pressure Reduction in Acute Cerebral Haemorrhage Trial (INTERACT3). We performed a post hoc analysis of INTERACT3, an international stepped-wedge, cluster-randomised trial undertaken in 121 hospitals across 9 low- to middle-income countries and 1 high-income country. The trial aimed to evaluate a care bundle composed of intensive blood-pressure lowering, rapid correction of hyperglycemia, fever control, and reversal of anticoagulation; in adults presenting within 6 h of ICH onset. We used mixed-effects logistic regression to evaluate sex differences in access to surgical interventions, admission to an intensive care unit or acute stroke unit, assisted feeding, physiotherapy, occupational therapy, withdrawal of care, and use of pharmacological therapies (antiepileptic drugs, mannitol, dexamethasone, and statins). Patterns of care were further evaluated using latent class analysis, with sex differences analyzed using the same regression framework. Of 7036 patients with ICH, 2533 (36%) were female. Females were older and had more severe neurological deficits. Overall care provision was similar across sexes. However, females were more likely to receive assisted feeding (odds ratio [OR] 1.15, 95% CI = 1.02-1.31), and were less likely to withdraw from active care (OR 0.41, 95% CI = 0.19-0.87) than males. Surgical interventions were accessed at similar rates among sexes, a finding that persisted in analyses restricted to supratentorial ICH with hematoma volumes ⩾ 30 mL. Three distinct care classes were identified: high-intensity, high-rehabilitation, and low-intensity, with females and males having comparable distributions within the classes. Following acute ICH, females generally receive similar active acute care interventions as males, except for observed differences in access to assisted feeding and decision to withdraw from active care. These findings suggest that equal access to ICH interventions for females and males is feasible and exists in some settings. However, disparities in certain key interventions remain and present actionable opportunities for improvement. Further research is needed to explore not only access but also the timing and frequency of these interventions.Data access statement:Individual, de-identified participant data used in these analyses will be shared on request from any qualified investigator after the approval of a protocol and signed data access agreement via both the trial steering committee and the research office of The George Institute for Global Health (Sydney, NSW, Australia).