Prompting physicians to address a daily checklist and process of care and clinical outcomes: a single-site study

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 = 0.041) and lower hospital mortality compared with the control group (10.0 vs. 20.8%; P = 0.014), which remained significant after risk adjustment (odds ratio, 0.34; 95% confidence interval, 0.15-0.76; P = 0.008). Observed-to-predicted ICU length of stay was lower in the prompted group compared with control (0.59 vs. 0.87; P = 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.

Figure 1.

Daily rounding checklist. The medical intensive care unit (MICU) checklist was introduced in March 2009. Faculty, fellows, pharmacists, and nurses were trained in its use. Multiple parameters are included along the left side. Nurses are responsible for filling out the yellow section, pharmacists the orange section, and physicians the green section. The checklist was designed to be able to follow parameters over time, with each column of boxes representing each ICU day. The attending or fellow is required to initial the checklist on each day. ARDS = acute respiratory distress syndrome; DVT = deep vein thrombosis; GI = gastrointestinal; HOB = head of bed; SCD = sequential compression device; VAP = ventilator-associated pneumonia.

Figure 2.

Hospital mortality. (A) Observed (light blue and red columns) and Acute Physiology and Chronic Health Evaluation (APACHE) IV–predicted (dark blue and red columns) hospital mortality in the prompted and control groups, and observed preintervention hospital mortality (gray column). Mortality rates (%) and standardized mortality ratios (SMRs) are shown. (B) Observed hospital mortality in the control group (blue columns) and prompted group (red columns) according to patient quartile of predicted risk. Prompted and control patients were pooled and divided into equal quartiles of predicted risk. The range of predicted mortality for patients in each quartile is shown underneath each quartile number.

Figure 3.

Kaplan-Meier analysis of intensive care unit (ICU) length of stay. Among ICU survivors, the proportion of patients remaining in the ICU is shown according to their ICU length of stay; tick marks represent ICU deaths. The Acute Physiology and Chronic Health Evaluation (APACHE) IV–adjusted hazard ratio (95% confidence interval) determined by Cox proportional hazards model was 0.67 (0.52–0.88; P = 0.003).