The use of checklists and multidisciplinary

rounds: do they work? FLAVIA MACHADO

Wright Field, Dayton, Ohio,October 30, 1935

Why we need them?

✓ Error is inevitable

▪ Memory and attention subject to failure ( even among experts)

▪ Cognitive function is compromised under stress conditions and fadigue

▪ ICU is a complex environment

✓ Power distance is a key barrier to solve

▪ Cultural problem among HCP

▪ National cultural problem

✓ To bring evidence to bedside

Why we need them?

Crit Care Med 2012; 40:3189–3195

Only 24% of patients fullycompliant with applicableguidelines

The most famous one

Haynes NEJM 2009

And its first level of evidence

Low income: Jordan, India, Philippines, TanzaniaHigh income: USA, UK, Canada, New Zealand

And then, the negative studies…

Haynes et al. N Engl J Med 2009;360:491-9

Inconsistent results

BMC Health Services Research 2011, 11:211

✓ 9 before-after studies , low to moderate quality, high risk of bias.

✓ Improvements in patient safety

✓ Inconsistent results

✓ Benefits in terms of protocol adherence and patient safety

✓ More high quality studies are needed

✓ Only RCT - 9 studies - moderate quality of evidence

✓ Not restricted to ICU

✓ Improvement in process of care

✓ Reduction in postoperative complication, medications erros

✓ 3 studies showing reduction in mortality

✓ Urgent need for high-quality studies

So many checklists…

Different rates of adoption

Adjunctive tools: which are important?

Professional interventions

Distribution of education materials Educational meetings

Local consensus processes Education outreach visits

Local opinion leaders Audit and feedback

Reminders Tailored

Mass media Other; time out procedures

Patient interventions

Organizational interventions

Family education

Revision of professional roles

Clinical multidisciplinary teams

Skill mix change

Continuity of care

Satisfaction of providers

Structural interventions

Changes in medical record system.

Multidisciplinary rounds

Multidisciplinary careand 30-day mortality

OR=0.84, 95% CI: 0.76–0.93,p=0.001)

112 hospitals107,324 patients

Multidisciplinary rounds

Facilitators • rounds conducted by a multidisciplinary group• explicitly defined roles• standardized structure and goal-oriented approach (checklist)

Barriers • Poor information retrieval and documentation, • interruptions, • long rounding times• allied healthcare provider perceptions of not being valued by physicians.

The reminder of the reminder

✓To determine if a multifaceted quality improvement intervention

including a daily checklist with goal-setting during rounds, and

clinician prompting reduces mortality of critically ill patients.

Objective

Checklist ICU – Study design

Checklist ICU – Elegibility

ICUs

• Inclusion criteria: ICUs that primarily admit adult patients, conduct (or want to

conduct) multidisciplinary daily rounds with at least a physician and a nurse on

all working days.

• Exclusion criteria: ICUs that admit exclusively cardiac patients, step down units,

and ICUs that already systematically used checklists during daily rounds.

Patients:

• First 60 patients with >48 hours of ICU admission in each phase.

Checklist ICU – Checklist development

• What is the relevance of the outcome(s) affected by the checklist item?

• Is the recommendation strong?

• Is it applicable to most ICU patients?

• Are complications common, serious and costly?

• Is omission common? (at the individual level)

• Can we generate an objective question (recommendation) associated with a

clear intervention?

Daily Checklist

Main ICU characteristics

Intervention arm Control

(n=59) (n=59)

ICU beds – median (range) 11 (10 to 20) 14 (10 to 20)

Specialty

Surgical – % 3.4 5.0

Medical – % 6.8 13.6

Mixed (medical and surgical) – % 84.7 74.6

Specialized – % 5.1 6.8

Hospital regime

Public – % 49.2 45.8

Private nonprofit – % 23.7 30.5

Private for-profit – % 27.1 23.7

Academic hospital – % 22.0 44.1

Hospital beds – median (range) 157 (111 to 285) 239 (154 to 352)

In-hospital mortality (at baseline) 31.6 33.4

Main patients characteristics

Characteristic

Randomized phase

Intervention Control

n=3324 n=3434

Age – yr 59.1 ± 19.2 60.0 ± 18.8

Female sex – % 45.2 46.4

Type of admission

Medical – % 72.9 71.4

Elective surgery – % 16.2 14.6

Emergency surgery – % 10.9 14.0

Comorbidities

Cancer treatment, metastatic or hematological – % 6.6 10.4

Cirrhosis – % 2.6 2.5

Heart failure – % 6.9 6.8

AIDS – % 3.5 3.9

SAPS 3 score at admission 51.2 ± 17.9 54.2 ± 17.5

Care process

Safety climate

Outcome

Intervention arm Control armIntervention vs

controlP value

n=3151 n=3224Odds ratio

(95% CI)

Team work climate – % 53.8 45.8 1.30 (1.08 to 1.57) 0.01

Safety climate – % 36.5 31.9 1.27 (1.02 to 1.57) 0.03

Job satisfaction – % 75.2 70.1 1.10 (0.87 to 1.39) 0.41

Stress recognition – % 51.4 54.1 0.92 (0.75 to 1.12) 0.39

Perception of management – % 22.0 18.4 1.14 (0.9 to 1.45) 0.26

Working conditions – % 47.2 41.9 1.18 (0.96 to 1.45) 0.11

Clinical outcomes

• A multifaceted quality improvement (QI) intervention including a checklist and definition of daily care goals during daily rounds, and clinician prompting increased adoption of care processes and improved safety climate.

• However, the intervention did not improve mortality or other clinical outcomes.

Conclusions

• Our study?

• Checklists have no impact in clinical outcomes?

Why we were not able to showimprovement in clinical outcomes?

Study issues

• Our observational period was too short

• Our checklist items have negligible effect on mortality

• Modest effects in care process – absence of training?

• Different approaches to introduce them

“Checklists works, as long as it is implemented well” - Atul Gawande

• Discrepancies between middle and high-income countries?

Why?

Checklists in daily round don’t work

• Checklist can only improve process

• ICUs are complex environments, unpredictable. Checklist are of little help

• They encourage mindless checking and discourage conceptual thinking

• Team skips steps and shorter the discussion – checklist are burdensome

• Fatigue in daily rounds

Why?

Checklists in daily rounds do work

• Allows a structured visit, goals settings and prompting – improve process

• Flatters hierarchy - Improve team work and safety climate

Why not?

Thepilot

The co-pilot

Conclusions - do they work?

✓ Checklists are cool!

✓ They can improve process of care, safety climate and team work

✓ But it is not easy to use them properly

✓ They demand preparation and continuous assessment