Implementation of systematic safety checklists in a neurocritical care unit: a quality improvement study

Abstract

Background and objectives: Structured and systematised checklists have been shown to prevent complications and improve patient care. We evaluated the implementation of systematic safety checklists in our neurocritical care unit (NCCU) and assessed its effect on patient outcomes.

Design/methods: This quality improvement project followed a Plan-Do-Study-Act (PDSA) methodology. A checklist for medication reconciliation, thromboembolic prophylaxis, glycaemic control, daily spontaneous awakening, breathing trial, diet, catheter/lines duration monitoring and antibiotics de-escalation was implemented during daily patient rounds. Main outcomes included the rate of new infections, mortality and NCCU-length of stay (LOS). Intervened patients were compared with historical controls after propensity score and Euclidean distance matching to balance baseline covariates.

Results: After several PDSA iterations, we applied checklists to 411 patients; the overall average age was 61.34 (17.39). The main reason for admission included tumour resection (31.39%), ischaemic stroke (26.76%) and intracerebral haemorrhage (10.95%); the mean Sequential Organ Failure Assessment (SOFA) score was 2.58 (2.68). At the end of the study, the checklist compliance rate throughout the full NCCU stays reached 97.11%. After controlling for SOFA score, age, sex and primary admitting diagnosis, the implementation of systematic checklists significantly correlated with a reduced LOS (ß=-0.15, 95% CI -0.24 to -0.06), reduced rate of any new infections (OR 0.59, 95% CI 0.40 to 0.87) and reduced urinary tract infections (UTIs) (OR 0.23, 95% CI 0.09 to 0.55). Propensity score and Euclidean distance matching yielded 382 and 338 pairs with excellent covariate balance. After matching, outcomes remained significant.

Discussion: The implementation of safety checklists in the NCCU proved feasible, easy to incorporate into the NCCU workflow, and a helpful tool to improve adherence to practice guidelines and quality of care measurements. Furthermore, our intervention resulted in a reduced NCCU-LOS, rate of new infections and rate of UTIs compared with propensity score and Euclidean distance matched historical controls.

Keywords: checklists; critical care; health services research; quality improvement.

Figure 1

Summary of secondary outcomes before matching cases with controls. Significant differences were observed between groups when comparing NCCU LOS (5.12 (4.65) vs 4.23 (3.93), p=0.001) and the eduction in the overall new infection rate (19.66% vs 12.65%, p=0.003) and UTI rate (5.28% vs 1.46%, p=0.001). ARD, absolute risk difference; CAUTI, catheter-associated urinary tract infection; CLABSI, central line-associated bloodstream infections; LOS, length of stay; NNT, number needed to treat; NS, non-significant; RR, relative risk; RRR, relative risk reduction; UTI, urinary tract infection.

Figure 2

Summary of baseline characteristics after matching with nearest neighbor propensity score, without replacement and caliper of 0.25. Significant differences were observed within the tumour resection category after matching. ICH, intracerebral haemorrhage; SAH, subarachnoid haemorrhage; SDH, subdural haemorrhage; SE, status epilepticus; SOFA, Sequential OrganFailure Assessment.

Figure 3

Summary of secondary outcomes after propensity score and Euclidean distance matching. After matching, the reduction of NCCU-LOS and the rate of overall new infections and UTIs remained significant for both matching methods. ARD, absolute risk difference; CAUTI, catheter-associated urinary tract infection; CLABSI, central line-associated bloodstream infections; LOS, length of stay; NNT, number needed to treat; NS, non-significant; RR, relative risk; RRR, relative risk reduction; UTI, urinary tract infection.

Figure 4

Summary of baseline characteristics after matching with the Euclidean distance LSAP algorithm. All covariates showed excellent balance. ICH, intracerebral haemorrhage; SAH, subarachnoid haemorrhage; SDH, subdural haemorrhage; SE, status epilepticus; SOFA, Sequential Organ Failure Assessment.