Better Health: Smart Health Commentary Better Health (TM): smart health commentary

Article Comments

Nurse Prompts Are Key To Successful Implementation Of ICU Safety Measures

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*

You may also like these posts

    None Found

Read comments »

Comments are closed.

Return to article »

Latest Interviews

IDEA Labs: Medical Students Take The Lead In Healthcare Innovation

It’s no secret that doctors are disappointed with the way that the U.S. healthcare system is evolving. Most feel helpless about improving their work conditions or solving technical problems in patient care. Fortunately one young medical student was undeterred by the mountain of disappointment carried by his senior clinician mentors…

Read more »

How To Be A Successful Patient: Young Doctors Offer Some Advice

I am proud to be a part of the American Resident Project an initiative that promotes the writing of medical students residents and new physicians as they explore ideas for transforming American health care delivery. I recently had the opportunity to interview three of the writing fellows about how to…

Read more »

See all interviews »

Latest Cartoon

See all cartoons »

Latest Book Reviews

Book Review: Is Empathy Learned By Faking It Till It’s Real?

I m often asked to do book reviews on my blog and I rarely agree to them. This is because it takes me a long time to read a book and then if I don t enjoy it I figure the author would rather me remain silent than publish my…

Read more »

The Spirit Of The Place: Samuel Shem’s New Book May Depress You

When I was in medical school I read Samuel Shem s House Of God as a right of passage. At the time I found it to be a cynical yet eerily accurate portrayal of the underbelly of academic medicine. I gained comfort from its gallows humor and it made me…

Read more »

Eat To Save Your Life: Another Half-True Diet Book

I am hesitant to review diet books because they are so often a tangled mess of fact and fiction. Teasing out their truth from falsehood is about as exhausting as delousing a long-haired elementary school student. However after being approached by the authors’ PR agency with the promise of a…

Read more »

See all book reviews »

Commented - Most Popular Articles