Prospective application of the interdisciplinary bedside rounding checklist 'TEMP' is associated with reduced infections and length of hospital stay

Abstract

Protocols that enhance communication between nurses, physicians and patients have had a variable impact on the quality and safety of patient care. We combined standardised nursing and physician interdisciplinary bedside rounds with a mnemonic checklist to assure all key nursing care components were modified daily. The mnemonic TEMP allowed the rapid review of 11 elements. T stands for tubes assuring proper management of intravenous lines and foleys; E stands for eating, exercise, excretion and sleep encouraging a review of orders for diet, exercise, laxatives to assure regular bowel movements, and inquiry about sleep; M stands for monitoring reminding the team to review the need for telemetry and the frequency of vital sign monitoring as well as the need for daily blood tests; and P stands for pain and plans reminding the team to discuss pain medications and to review the management plan for the day with the patient and family. Faithful implementation eliminated central line-associated bloodstream infections and catheter-associated urinary tract infections and resulted in a statistically significant reduction in average hospital length of stay of 13.3 hours, one unit achieving a 23-hour reduction. Trends towards reduced 30-day readmissions (20% down to 10%-11%) were observed. One unit improved the percentage of patients who reported nurses and doctors always worked together as a team from a 56% baseline to 75%. However, the combining of both units failed to demonstrate statistically significant improvement. Psychologists well versed in implementing behavioural change were recruiting to improve adherence to our protocols. Following training physicians and nurses achieved adherence levels of over 70%. A high correlation (r²=0.69) between adherence and reductions in length of stay was observed emphasising the importance of rigorous training and monitoring of performance to bring about meaningful and reliable improvements in the efficiency and quality of patient care.

Keywords: Checklists; Communication; Continuous quality improvement; Healthcare quality improvement; Implementation science.

Figure 1

Drawings illustrating the elements of TEMP created by the nursing staff. TEMP card posted on the floors. TEMP card posted on each workstation on wheels.

Figure 2

(A) Hospital Length of stay (LOS) over time. Each individual LO) in hours was plotted as a line with a filled circle near the top on the day of discharge. The median length of stay is plotted as a horizontal solid line and was determined for each experimental period separated by a vertical dashed line: baseline, intervention 1 and intervention 2. Unit 1 change in LOS over time. There is a significant decrease in median LOS after intervention 2 shown by the arrow and labelled shift. Unit 2 change in LOS over time. There is a significant decrease in the median LOS following both intervention 1 and 2, shown by the arrows and called shifts. Note the reduction in variability of LOS over time. (B) Correlation between LOS and adherence. LOS in hours was plotted in the y-axis and adherence % on the x-axis. Correlation coefficient = 0.69. (C) 30-day readmission percentages over time. Unit 1 readmission percentage each month before (pre), after Intervention 1 (first dashed line on the left), and after intervention 2 (third dashed line). Unit 2 readmission percentage each month before (pre, after intervention 1 (second dashed line) and after intervention 2 (fourth dashed line). (D) Patient perceptions of teamwork before, after intervention 1, intervention 2 and 2 months after intervention 2. Asterisk marks the only statistically significant difference by χ² p=0.0352. Respondents varied from N=16 to 51.