Daily Prompting on ICU Checklist Use Improves Patient Outcomes as Well as Processes of Care

Abstract & Commentary

By David J. Pierson, MD, Professor Emeritus, Pulmonary and Critical Care Medicine, University of Washington, Seattle.

This article originally appeared in the November 2011 issue of Critical Care Alert. It was peer reviewed by William Thompson, MD. Dr. Thompson is Associate Professor of Medicine, University of Washington, Seattle. Drs. Pierson and Thompson report no financial relationships relevant to this field of study.

Synopsis: In this study from a single medical ICU, prompting physicians to discuss all six items on a daily rounding checklist, as compared with the use of the same checklist without prompting, significantly improved several processes of care and appeared to decrease length of stay and mortality as well.

Source: Weiss CH, et al. Prompting physicians to address a daily checklist and process of care and clinical outcomes: A single-site study. Am J Respir Crit Care Med 2011;184:680-686

Previous studies have shown that the use of a multi-part daily rounding checklist reduces errors of omission in the ICU — such as failure to discontinue empirically started antibiotics, to perform spontaneous breathing trials to see whether ventilated patients can be weaned and extubated, or to provide prophylaxis against deep venous thrombosis (DVT). This study sought to determine whether daily prompting of physicians to deal with the items in such a checklist during ICU rounds would improve processes of care and patient outcomes in comparison to simply introducing the same checklist into the ICU.

The study was carried out in the medical ICU of a major academic medical center. After introduction of the ICU rounding checklist to the unit, patients cared for by the two unit teams (each with an attending physician, ICU fellow, several residents, and a clinical pharmacist) comprised a control group and an intervention group. In the intervention group, a resident working on the study came on rounds (but had no involvement with managing the patients) and prompted the attending or fellow to discuss any of the six target items omitted from the checklist while the team was still rounding on each patient. The control team had the checklist available but no explicit efforts were directed at its implementation on rounds. Data from 1283 patients admitted to the unit before the checklist was introduced were compared to prospective data collected from intervention and control patients during the 82-day study period.

The checklist contained color-coded items to be filled out by nurses (e.g., lines and tubes), pharmacists (e.g., antibiotics and DVT prophylaxis), and physicians (e.g., sedative use and appropriateness of daily weaning trial), and entries were to be made each day the patient remained in the ICU. There were 140 patients in the intervention (prompted) group and 125 in the control group. Patient demographics, admitting diagnoses, time and day of admission, illness severity (APACHE IV), and proportion requiring mechanical ventilation (29%) were the same in the two groups.

The prompter was present on 68% of study days in the intervention group, although all days and patients in that group were included. Overall, prompting on at least one omitted checklist item occurred on 65% of patient days — i.e., the great majority of days on which the prompter attended rounds. Of the six items targeted for prompting, discussion of continued need for a Foley catheter was most frequently omitted (41% of patient days), followed by empirical antibiotics (36%), a central venous catheter (26%), mechanical ventilation (14%), DVT prophylaxis (1.5%), and stress ulcer prophylaxis (1%).

Compared with the control group, the prompted group had more median ventilator-free days (22 vs 16, P = 0.028), fewer days of empirical antibiotics (2 vs 3, P = 0.012), shorter duration of central venous catheter (3 vs 5 days, P = 0.007), and significantly more administration of DVT and stress-ulcer prophylaxis. Although hospital mortality was not different between the retrospectively examined preintervention patients and the control group, both ICU and hospital mortalities were lower in the prompted group (9% vs 17%, P = 0.05). APACHE IV-predicted ICU lengths of stay were the same in the control and prompted groups, but prompted patients had shorter ICU stays when calculated according to observed/predicted length of stay ratio (0.59 vs 0.87, P = 0.02). The authors conclude that daily prompting on checklist use improved multiple processes of care and may also have reduced mortality and length of stay, compared with the presence of the checklist without such prompting.

Commentary

In this study, preintervention process-of-care data from the same unit (no checklist) were not different from results in the control group after the checklist was added. Little information is provided about just how the checklist was introduced in the unit. However, studies showing improved outcomes with checklists have also implemented substantial cultural change in the institution at the same time. In this study the cultural change was the prompting, and the control group results suggest that simply having a checklist available in the unit is not sufficient to change practice.

Patients managed by the team in which daily physician prompting occurred had improved processes of care and better outcomes. But several questions are raised as to how this finding might persist with different prompting scenarios. The prompter here was a physician (a resident), obviously an unrealistic situation for broader implementation. Would attending physicians and fellows (or community practitioners) be as receptive to real-time, face-to-face prompting by a nurse, or a clinical pharmacist — or a non-clinical hospital employee — during ICU rounds? Would some sort of automated, computerized prompting, perhaps tied to electronic order entry, work as well?

As pointed out by the authors, small pilot studies from single sites may have more impressive results than larger-scale multicenter studies of the same intervention. However, if the findings of this study hold up in broader contexts and with larger investigations, just how prompting is to be done may become an important issue. The decreased antibiotic use, shorter duration of mechanical ventilation, and reduced ICU length of stay found in this study have substantial potential economic implications that might be of interest to system administrators, third-party payers, and regulators. Some form of checklist-based, real-time prompting might well become part of daily practice in the ICU, making this matter one of considerable interest to the clinicians who work there. .