Improving the Quality of Care of the Critically Ill Patient: Implementing the Care Bundle Approach in the Icu (Intensive Care Units‪)‬

Providing health care to the critically ill patient is generally associated with compassion, competence and excellent care. Excellent care is dependent on the quality of care delivery. 'The term "quality", traditionally regarded as related to products, should also be applied to the care given in an intensive care unit.... Intensive care standards can only be maintained by quality control of ICU facilities, activities and results. Unit directors should therefore be aware of developments in quality control of intensive care standards and should become involved in outcome analysis in the interests of their patients, their units and their hospital finances.' (1) These words were penned by Linton and Frutiger in the SAMJ of May 1996. Not much has changed in the intervening 11 years with regard to the concept, but in 2007 the capacity to do so has become a real challenge. Linton and Frutiger (1) go on to say that 'The introduction of quality management principles into the field of medical care was advanced by the work of Donabedian [reference 2], who identified that overall quality in medicine should include three aspects: Structures, Processes and Results (outcomes). For each of these aspects, distinct instruments to assess and maintain quality are suggested. The appropriate instrument for Structural quality is a standard. Process quality is ensured by formulating and implementing guidelines and protocols. Outcome quality is assessed by the use of specific indicators such as mortality prediction models, incidence of readmission, post-admission morbidity, etc. Medical (and nursing) audits are used to continuously improve the processes and outcome.' Health care improvement requires a collaborative effort by both managerial and clinical staff to implement and sustain initiatives to achieve quality patient care. The development of evidence-based clinical practice since the early 1990s has initiated a paradigm shift with the realisation that 'health care interventions, no matter how commonsense or physiologically sound, often lack benefit and sometimes can even cause harm'. (3) Evidence-based practice requires the integration of individual clinical expertise and the best external evidence. (4) Pronovost et al. stated in 2004 that 'the greatest opportunity to improve outcomes for patients over the next quarter century will probably come not from discovering new treatments but from learning how to deliver existing effective therapies'. (5) This article explores the potential of doing exactly that by using the care bundle approach to improve the quality of care of the critically ill patient.