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

Weiss CH, Moazed F, McEvoy CA, Singer BD, Szleifer I, Amaral LAN, Kwasny M, Watts CM, Persell SD, Baker DW, Sznajder JI, Wunderink RG
American Journal of Respiratory and Critical Care Medicine 184,  680-686 (2011)
Times cited: 58
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Abstract

Rationale: Checklists may reduce errors of omission for critically ill patients. Objective: 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: 140 prompted group patients were compared to 125 control and 1,283 pre-intervention patients. Compared to control, prompting increased median ventilator-free duration, decreased empirical antibiotic and central venous catheter duration, and increased rates of DVT and stress ulcer prophylaxis. Prompted group patients had lower risk-adjusted ICU mortality compared to the control group (OR 0.36, 95% CI 0.13-0.96, P=0.041), and lower hospital mortality compared to the control group (10.0% vs. 20.8, P=0.014), which remained significant after risk adjustment (odds ratio 0.34, 95 CI, 0.15-0.76, P=0.008). Observed-to-predicted ICU length of stay was lower in the prompted group compared to control (0.59 vs. 0.87, P=0.02). Checklist availability alone did not improve mortality or LOS compared to pre- intervention 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 to a stand-alone checklist. The manner in which checklists are implemented is of great consequence in the care of critically ill patients.