163 Effects of de-implementation strategies aimed at reducing low-value nursing procedures 6 nursing procedures. Therefore, the aim of this systematic review is to summarize the evidence of effective de-implementation strategies aiming to reduce or eliminate lowvalue nursing procedures. Methods This systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) [19]. The review protocol was registered in the PROSPERO database of systematic reviews (registration number: CRD42018105100). Search strategy To identify all eligible studies reporting on effective de-implementation strategies aiming to reduce low-value nursing procedures, a systematic literature search was performed in PubMed, Embase, Emcare, CINAHL, PsycINFO, Cochrane Central Register of Controlled Trials, Web of Science and Google Scholar. The full search strategy is included in Appendix A. The search was limited to the literature published till January 2020. Search terms were based on 43 unique terms for de-implementation that were used for the process of reducing low value care found by Niven et al. [20], and there were no language or other search filter limits. After the initial search, the reference lists and citations of all included studies were explored to find more relevant studies. An expert health librarian at the Leiden University Medical Center guided the search. Selection of studies Two researchers (TR, AB or LvB) first independently reviewed title and abstract of the studies, followed by full texts review. If there was no consensus between the two reviewers and differences could not be solved by discussion, a third reviewer was consulted. Studies were eligible for inclusion in the systematic review if they fulfilled the following inclusion criteria: • Focus of the study: reduction of low-value nursing procedures. Low-value nursing procedures were in this review defined as actual treatments and actions that are unlikely to benefit the patient given the harms, costs, available alternatives, or preferences of patients, and are initiated independently by a nurse and/ or nurse specialist (i.e. without an order of another healthcare provider). • Type of study: all studies that use a reference group (including pre-post comparisons), i.e. randomized controlled trials, cluster randomized trials, quasirandomized controlled trials, non-randomized controlled trials, controlled beforeafter studies, interrupted time series studies or uncontrolled before-after studies.
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