Prompting Physicians to Address a Daily Checklist and Process of Care and Clinical Outcomes

Abstract

Rationale: Checklists may reduce errors of omission for critically ill patients. Objectives: To determine whether prompting to use a checklist improves process of care and clinical outcomes. Methods: We conducted a cohort study in the medical intensive care unit (MICU) of a tertiary care university hospital. Patients admitted to either of two independent MICU teams were included. Intervention team physicians were prompted to address six parameters from a daily rounding checklist if overlooked during morning work rounds. The second team (control) used the identical checklist without prompting. Measurements and Main Results: One hundred and forty prompted group patients were compared with 125 control and 1,283 preintervention patients. Compared with control, prompting increased median ventilator-free duration, decreased empirical antibiotic and central venous catheter duration, and increased rates of deep vein thrombosis and stress ulcer prophylaxis. Prompted group patients had lower risk-adjusted ICU mortality compared with the control group (odds ratio, 0.36; 95% confidence interval, 0.13-0.96; P ¼ 0.041) and lower hospital mortality compared with the control group (10.0 vs. 20.8%; P ¼ 0.014), which remained significant after risk adjustment (odds ratio, 0.34; 95% confidence interval, 0.15-0.76; P ¼ 0.008). Observed-to-predicted ICU length of stay was lower in the prompted group compared with control (0.59 vs. 0.87; P ¼ 0.02). Checklist availability alone did not improve mortality or length of stay compared with preintervention patients. Conclusions: In this single-site, preliminary study, checklist-based prompting improved multiple processes of care, and may have improved mortality and length of stay, compared with a stand-alone checklist. The manner in which checklists are implemented is of great consequence in the care of critically ill patients.

The Power of Suggestion

“…Ultimately, the tool may have helped change human behavior in a positive fashion. This is similar to the effect of checklists on human behavior, 3,4 and it is why clinicians continue to create and use tools to support their decision making.…”

Using a Post-Intubation Checklist and Time Out to Expedite Mechanical Ventilation Monitoring: Observational Study of a Quality Improvement Intervention

“…[13][14][15][16] These methods take an unstructured process and apply a standardized protocol and deliberate pause to encourage communication and reduce variations in care. During this process, team members from all disciplines review the plan of care in an effort to better coordinate responsibilities, ensure timeliness of action, and reaffirm agreement upon the proposed plan.…”

“…15,26 We encourage our personnel to set mobile telephone alarms as deadline reminders during the time-out huddle. An alarm at 15 min prompts ABG collection, and a second alarm at 60 min prompts checklist completion.…”

Review article: Perioperative checklist methodologies

“…In an interesting study on the use of a checklist in an ICU, two medical ICU teams were evaluated for their compliance with six care standards using a checklist. 22 The intervention team included a ''prompter'' who alerted the team to the checklist if it was not actively used, while a control team used the same previously developed and implemented checklist as part of their daily rounds. The study included 140 patients in the prompted group, 125 control patients, and 1,283 patients in the preintervention group.…”