Protocols: help for improvement but beware of regression to the mean and mediocrity

Excerpt

It is now well recognized that organizational factors in the ICU are of great importance in improving the outcome of critically ill and injured patients [1]. These factors include “closed ICUs” staffed by intensivists who possess the knowledge, skills, and expertise to manage critically ill and injured patients on the basis of the best current scientific evidence while at the same time respecting the goals and values of the patients, ensuring adequate staffing by well-trained dedicated ICU nurses, pharmacists, and ancillary support staff, excellent teamwork, cooperation of all medical specialities involved in the management of the patient and administrators who place the interests of the patients’ as the overarching priority. Every ICU patient deserves to receive high-quality, compassionate, and time-sensitive care. All of these mentioned elements can be jeopardized by many factors, including poor human and financial resources, poor leadership, inadequate training, poor teamwork, and inconsistent, inappropriate, and conflicting treatments. The objective of clinical protocols is to enact the best up-to-date knowledge and ensure consistency in the treatment of patients. Indeed, several publications have reported on an improvement of outcomes in groups of patients in association with the introduction and implementation of clinical protocols [2‐4]. Whether a protocol actually improves outcome depends to a large extent on the baseline outcome of interest, i.e., before the introduction of the protocol. Checklists and protocols are therefore expected to be useful in the hands of inexperienced healthcare providers or those working in suboptimal environments. The findings from an “emerging country” as reported by Soares et al. in a recent article in Intensive Care Medicine [5], together with data that surgical checklists are associated with improved peri-operative outcomes in developing nations, support the concept that protocols and checklists per se improve outcome. The concept of checklists was popularized following the Keystone Quality ICU project where the risk of catheter-associated bloodstream infection was reduced using a checklist consisting of five items, namely handwashing, full barrier precautions during the insertion of central venous catheters, cleaning the skin with chlorhexidine, and avoiding the femoral site, although some of these checklist factors are either self-evident (handwashing) or have questionable benefit (avoiding the femoral site) [6, 7]. …