Quality improvement in the ICU: treat first what kills first.

Professionals in the ICU, like nurses and doctors, are constantly working on quality improvement by developing protocols and monitoring the implementation with indicators. Protocols and quality indicators are usually based on evidence. Studies on quality improvement often measure the effect of protocols after implementation but frequently cannot replicate the results of the previously performed RCTs in clinical practice. Amongst other reasons, this is due to the selection of patients that are included in RCTs. Several quality improvement initiatives can be studied together in daily practice as a bundle with a multifaceted approach. A recent study is discussed that shows that this approach can only give significant results when the interventions are focussed on the main processes that are related to the chosen outcome measures. Several different reasons are apparently the cause that quality improvement studies often reveal negative results. Quality improvement studies need to have a rigorous design and well-chosen endpoints.