Standardized Care is Better Than Individualized Care for the Majority of Critically Ill Patients.

Critically ill patients are cared for by groups of clinicians and professionals with differing training, experiences, and skillsets who work in diverse clinical settings. It is therefore not surprising that the type of care delivered to critically ill patients varies widely between these settings and sometimes even within a single institution. In part, this variability may be explained by the lack of strong evidence supporting many common critical care interventions, and in the absence of compelling data, bedside clinicians may defer to previous training and experience to guide delivery of care. Even foundational critical care therapies, such as prescribing IV fluids (type and amount), the blood pressure titration target for vasopressor support, and the setting of individual parameters for mechanical ventilation have demonstrated substantial variation in practice (1, 2). In this viewpoint, we will make the case that, for the majority of critically ill patients, providing similar and reproducible care is superior to delivering individualized and variable care that substantially changes between institutions or different clinicians. Many patients, unfortunately, do not receive optimal or evidence-based care during their ICU stay. Even interventions which have demonstrable benefits such as early antibiotics in sepsis, lung protective mechanical ventilation in acute respiratory distress syndrome (ARDS), early mobility, and avoidance of high dose sedative infusions in mechanically ventilated patients are not consistently delivered in the ICU. While there are likely many reasons patients do not receive desired care, the competing demands of time and the lack of sufficient resources are likely at least partly responsible. Heterogeneous training and experience may also be a contributor. In addition, even for interventions with established benefits, some clinicians may not agree with specific facets of bundled clinical care pathways. Protocolized care and explicit clinical pathways provide a clear mechanism by which institutions can ensure desirable treatments are systematically considered, and, when appropriate, implemented in a timely manner (3). Protocols have demonstrated efficacy in ensuring desired care is delivered to patients with sepsis, ARDS, and shock among others (4–6). We will use the terms protocols and pathways interchangeably to refer to explicit mechanisms aimed at providing standard and desired care for a patient with a specific disease or syndrome.