Guidelines, pathways, bundles, and protocols: clinical recipes for success.

The development and implementation of clinical practice guidelines have been shown to improve patient care and outcomes and have been well described for over 2 decades. Although there are a myriad of terms such as pathways, protocols, care maps, and bundles, the fundamental aim is the same: evidence from clinical trials and associated research informs clinicians of best approaches for the delivery of care, prescription of medications, and application of technology.1 The development of clinical practice guidelines is a tremendous undertaking and typically entails the convening of a multidisciplinary group, usually composed of subject matter experts who agree to collaborate to achieve a common goal while concentrating on improved quality, safety, and outcomes for a particular patient population and increasingly with economic consideration.1 The development of a national approach to surveillance for ventilator-associated events, sponsored by the Centers for Disease Control and Prevention, serves as a good example.2 In their summary of a previously published Cochrane review, Rotter et al3 described the merits of clinical pathways, the effects on professional practice and patient outcomes, and economic impact. Data from studies had to meet four criteria to be considered in the final analysis, which included 27 studies from over 3,000 that were evaluated. Characteristics of the selected studies included primarily randomized controlled trials in 8 countries, with the majority comparing stand-alone clinical pathways with traditional practice. Their findings support the creation of clinical pathways, as the results demonstrated improved patient safety, cost-effective resource allocation, and efficiency of care and indicated that costs and stay could be reduced. The authors suggested that a more universal approach to clinical pathway definition and design needs to be established for improved comparisons. In this issue of RESPIRATORY CARE, Mola et al4 present their work with the use of a respiratory care bundle aimed at improving the quality of care in very low birthweight infants and reducing the incidence of bronchopulmonary dysplasia (BPD). They sought to evaluate the sustainability of this quality improvement initiative across four 2-y time periods spanning 2002 to 2010. The bundle is a compilation of evidence-based practices, including early surfactant replacement therapy, postextubation CPAP, and