Over the last few years, you may have heard a lot about the value of checklists in ICU medicine and their ability to reduce mortality, reduce cost and reduce length of stay. But a recent study took the concept one step further and suggested that checklists by themselves may not be effective unless physicians are prompted to act on the checklist.
As reported in the American Journal of Respiratory and Critical Care Journal, a single site cohort study performed at Northwestern University Feinberg School of Medicine’s medical intensive care unit compared two rounding groups of physicians. One group was prompted to use the checklist. The other group of physicians had access to the checklist but were not prompted to use it.
What they found was shocking. Both groups had access to the checklist. However, patients followed by physicians who were prompted to use the checklist had
- Increased ventilator free duration
- Decreased empirical antibiotic use
- Decreased central venous catheter duration
- Increased rates of DVT prophylaxis
- Increased rates of stress ulcer prophylaxis
- Lower risk adjusted ICU mortality
- Lower risk adjusted hospital mortality
- Lower observed-to-predicted ICU length of stay
Interesting indeed. What they found was that using the checklist without prompting did not reduce mortality or length of stay. It’s not the checklist that’s important. It’s addressing the checklist that matters. This makes sense, completely. In fact, here’s what happens in a patient’s chart when standard orders are placed and meant to be reviewed and addressed by the physicians. Nobody pays attention. Nobody claims ownership of the process. Everyone assumes someone else is going to address it or they simply aren’t paying attention. Or even more likely, additional orders get written and placed in front of the checklists and these blank checklist order sheets work their way farther and farther into no man’s land in the chart. I see it every day.
One of my goals as a hospitalist at my institution is to eventually get a system wide checklist order set implemented for all patients in the hospital. There are many things I know, intuitively, that we do to patients every day that increase cost and length of stay and probably increase mortality as well but nobody has defined a process to make addressing them a daily priority. Things like
- Daily assessment of telemetry need
- Foley catheter removal criteria
- Central line removal
- Easily accessible start time for antibiotics with defined stop dates
- Daily weights
- Changing IV to po medications
- VTE prophylaxis reminders
This study is important. What it tells me is that having a checklist available is not enough. It needs to have daily reminders and communication between the physician and the RN.
This is further vindication for physician-RN rounds to occur every day. I ask to speak to the patient’s nurse on every patient, every day, because I know that they know stuff that isn’t written anywhere and is not easily available anywhere. I don’t read nursing documentation prose because I talk to the nurse.
Perhaps, someday, every day, patient’s on all floors will have daily reminders addressed in one easy to access centralized process that nurses, respiratory therapists, pharmacists and all other hospital team members can communicate their recommendations at the bedside and physicians are prompted to act.
Now, if I can just get the hospital decision-makers to stop viewing this as another in a long series of worthless, time consuming required nursing duties and get them to understand they need to own the process in the interest of patient safety. Nurses are the patient’s greatest asset and this process could help their patients shine in their recovery. What they forget, and I know this to be true, is that if we can communicate daily, face-to-face, between physician and RN, then that is time well spent reducing all the other complications and time wasting activity that eventually creates chaos in the hospital when complications ensue. It’s like the 5Ps of hourly rounding by nurses. We need to add a sixth P: Prompt the physician.
I think every hospital in this country should strive to have a daily checklist on medical rounds and every patient should have the right to have physician-nurse reminder prompting as a matter of patient safety. Now that’s a concept worth fighting for. And I wonder where the Joint Commission is. Oh yeah, they’re busy shutting down hospitals because a physician didn’t sign off a verbal order that was carried out 23 hours and 59 minutes after the fact.
*This blog post was originally published at The Happy Hospitalist*