Checklist & prompting in intensive care unit: quality of care is improved but long way to go for better outcome

Crude mortality rate in intensive care unit varies according to the primary diagnosis of the patients, demographic characteristics of the patients and geographical location of the intensive care units (ICUs) (1-3). Though a decline in the mortality in ICU is evident over the last few decades (4,5), there is still significant gap between the knowledge and practice of the intensive care physicians even in the developed world (6). ICU checklists are expected to increase adherence to the guidelines, reduces medical errors and consequently improves patients’ outcome. A number of studies have evaluated utility of checklist in a particular area such as weaning from mechanical ventilation, catheter related blood stream infection etc. and most of the such studies are of before-after design. Results of the studies on checklist and prompting by the physicians are contradictory. Use of a surgical safety checklist was associated with a reduction in morbidity and mortality in patients with older than 16 years’ age and undergoing non-cardiac surgery (7). Implementation of checklist during ICU round has been associated with improved patients care and implementation of best evidence based practice (8,9). Weiss et al. (10) in 2011 reported a significant reduction in ICU mortality and in-hospital mortality even after baseline risk adjustment from checklist based prompting by a resident physician. In that study, during ICU round, following six areas were considered for prompting if it is missed: weaning from mechanical ventilation, empirical antibiotic therapy, central venous catheters, Foley urinary catheters, and deep vein thrombosis and stress ulcer prophylaxis and prompting continued from first round after ICU admission to ICU discharge.

Recently, a large randomized controlled trial from Brazil reported that implementation of a multifaceted quality improvement intervention with daily checklists, goal setting, and clinician prompting did not reduce in-hospital mortality (11). The study is uniquely designed as in the initial observational phase of the trial, the authors have assessed baseline data on work climate, care processes, and clinical outcomes in the participating ICU and in the later phase, the same ICUs were randomized to a quality improvement intervention, including a daily checklist and goal setting during multidisciplinary rounds with follow-up clinician prompting for 11 care processes, or to routine care. The 11 care processes included in the checklist were developed according to the Practice Guidelines Development Cycle (12). The authors reported no difference in the in-hospital mortality among both the groups in the second phase of the study. However, there was an improvement in terms of use of low tidal volume ventilation, use of light sedation and calm & alert mechanically ventilated patient, less use of central venous catheter and urinary catheter. Interestingly, all four parameters where an improvement was found had a low baseline compliance and no benefit was obtained on the parameters with better baseline compliance. There was also an improvement in team work climate and safety climate in the ICU from the intervention.

The strength of this study is that it is a large, well designed trial and baseline characteristics of the patients were comparable after randomization. However, though the authors included practice parameters in the checklist according to guidelines, effects of these practices on mortality is controversial. Such as a recent Cochrane review also failed to find in mortality benefit from head elevated position in mechanically ventilated patients (13). Similarly, benefit of a protocol driven ICU sedation is also not evident in another Cochrane review (14). Another important issue is that, this study aimed to delineate effects of checklist in short term period, a larger effect size may be found when these practices are implemented for longer term.

Encouraging input from this trial is that checklist and prompting improves adherence to practice standards particularly where baseline adherence is low but disappointing part is that at this time point there is no evidence that it improves clinical outcome.

Acknowledgements

None.

Footnote

Conflicts of Interest: The author has no conflicts of interest to declare.

References

1. Mukhopadhyay A, Tai BC, See KC, et al. Risk factors for hospital and long-term mortality of critically ill elderly patients admitted to an intensive care unit. Biomed Res Int 2014;2014:960575.
2. Siddiqui S. Mortality profile across our Intensive Care Units: A 5-year database report from a Singapore restructured hospital. Indian J Crit Care Med 2015;19:726-7. [Crossref] [PubMed]
3. Zimmerman JE, Kramer AA, Knaus WA. Changes in hospital mortality for United States intensive care unit admissions from 1988 to 2012. Crit Care 2013;17:R81. [Crossref] [PubMed]
4. Andrews RM, Russo CA, Pancholi M. Trends in Hospital Risk-Adjusted Mortality for Select Diagnoses and Procedures, 1994–2004: Statistical Brief #38. Healthcare Cost and Utilization Project (HCUP) Statistical Briefs [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US); 2006-.2007 Oct.
5. Hines A, Stranges E, Andrews RM. Trends in Hospital Risk-Adjusted Mortality for Select Diagnoses by Patient Subgroups, 2000–2007: Statistical Brief #98. Healthcare Cost and Utilization Project (HCUP) Statistical Briefs [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US); 2006-.2010 Oct.
6. Hewson-Conroy KM, Burrell AR, Elliott D, et al. Compliance with processes of care in intensive care units in Australia and New Zealand--a point prevalence study. Anaesth Intensive Care 2011;39:926-35. [PubMed]
7. Haynes AB, Weiser TG, Berry WR, et al. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med 2009;360:491-9. [Crossref] [PubMed]
8. Byrnes MC, Schuerer DJ, Schallom ME, et al. Implementation of a mandatory checklist of protocols and objectives improves compliance with a wide range of evidence-based intensive care unit practices. Crit Care Med 2009;37:2775-81. [Crossref] [PubMed]
9. Conroy KM, Elliott D, Burrell AR. Testing the implementation of an electronic process-of-care checklist for use during morning medical rounds in a tertiary intensive care unit: a prospective before-after study. Ann Intensive Care 2015;5:60. [Crossref] [PubMed]
10. Weiss CH, Moazed F, McEvoy CA, 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;184:680-6. [Crossref] [PubMed]
11. Writing Group for the CHECKLIST-ICU Investigators and the Brazilian Research in Intensive Care Network (BRICNet). Effect of a Quality Improvement Intervention With Daily Round Checklists, Goal Setting, and Clinician Prompting on Mortality of Critically Ill Patients: A Randomized Clinical Trial. JAMA 2016;315:1480-90. [Crossref] [PubMed]
12. Browman GP, Levine MN, Mohide EA, et al. The practice guidelines development cycle: a conceptual tool for practice guidelines development and implementation. J Clin Oncol 1995;13:502-12. [Crossref] [PubMed]
13. Wang L, Li X, Yang Z, et al. Semi-recumbent position versus supine position for the prevention of ventilator-associated pneumonia in adults requiring mechanical ventilation. Cochrane Database Syst Rev 2016.CD009946. [PubMed]
14. Aitken LM, Bucknall T, Kent B, et al. Protocol-directed sedation versus non-protocol-directed sedation to reduce duration of mechanical ventilation in mechanically ventilated intensive care patients. Cochrane Database Syst Rev 2015;1:CD009771. [PubMed]