Care bundles: implementing evidence or common sense?

In things necessary, unity; in things doubtful, liberty.St. AugustineIn the previous issue of Critical Care, Ni？l-Weise and colleagues [1] investigate the effectiveness of the semiupright position (and elements of the 'ventilator bundle') in preventing ventilator-associated pneumonia (VAP).The effective and consistent implementation of beneficial treatments can improve patient outcome. However, while physicians try to reconcile the art with the science of medicine by attempting to apply at the bedside the results of clinical trials, intensive care patients receive, on average, only about one half of the recommended core clinical interventions.This inconsistency in clinical decision-making and care provision is not due exclusively to variation in case mix and facilities but is the result of the intrinsic complexity of critical care, on one hand, and the physician's heuristics (that is, intuitive judgments) on the other [2]. Errors of omission, such as failure to perform routine tasks or an intended plan, or the loss of key information at handover [3] are particularly relevant today, when the management of critically ill patients is more complex, the working shift pattern of health-care professionals requires multiple daily handovers, and patients and physicians experience discontinuity in care. These considerations highlight the fact that idiosyncratic practices are unsustainable and dangerous. The standardization of the process of care, therefore, requires structuring the task environment and compensating for heuristics to facilitate consistent and reliable delivery of best evidence based practice. This is the aim of care bundles [4], defined by the Institute of Healthcare Improvement as a 'a group of interventions related to a disease process that, when executed together, result in better outcomes than when implemented individually' [5]. The definition implies that its elements should function as a package and that its effectiveness comes from the excellence of the