Question special
Expert

The study clearly shows (like others) that implementing bundled care and adherence to the bundles effects mortality. This could be related to the effect on other elements of care, influenced by the implementation process, that mainly effect outcome where the elements of the bundle, have hardly any effect in and of itself. An interesting element of this is the Central Venous Pressure recommendation in the fluid resuscitation part of the Surviving Sepsis Guidelines that may even results in increased morbidity. If you then look at figure 4 in the publication, there seems to be a very significant effect of the organization (the hospital) where the completion of the 3h bundle varied largely. So, the question arises as to what is the effect of the organization itself? It might even be that implementing a 3h bundle in some hospitals is very unlikely to have any significant effect, while in others it could have huge effects. So, would it make sense to first assess the organizational aspects of the hospital before mandating to implement bundles of care? And, what organizational characteristics mark a more likely effect of implementing bundles of sepsis?