NORTHWESTERN (US) — Mortality rates in the intensive care unit dropped 50 percent when the attending physician was assisted by someone prompting him to address items on a checklist.
Using a checklist alone does not improve mortality rates.
“Attending physicians are good at thinking about big picture issues like respiratory failure or whatever diagnosis brought a patient to the intensive care unit,” says Curtis Weiss, fellow in pulmonary and critical care medicine at Northwestern University. “But some important details are overlooked because it’s impossible for one person to remember and deal with all those details.”
The ICU checklist, a fairly new concept in medicine, is a useful tool only if a physician gets continual reminders to use it to promote decision making, Weiss says.
“We showed the checklist itself is just a sheet of paper,” Weiss says. “It’s how doctors interact with it and best implement it that makes it most effective. That’s how we came up with prompting.”
Weiss developed a checklist to be used by physicians in the medical intensive care unit, focusing on important issues that are often overlooked by physicians during daily rounds, including testing whether a patient can be taken off a ventilator and the duration of empiric antibiotics (for suspected but not confirmed infections), and central venous catheters.
“We observed that physicians sometimes wrote information on the checklist but were not using it to improve their decision making,” Weiss says.
The study, published online in the American Journal of Respiratory and Critical Care Medicine, set out to determine whether prompting physicians to use the checklist would affect the decisions they made about managing their patients’ care.
One team of physicians had face-to-face, frequent prompting by a resident physician to address issues on the checklist, only if the issues were overlooked during daily rounds. The other team of physicians continued to use the checklist without such prompting. The prompted physician team oversaw the care of 140 patients; the unprompted team oversaw 125 patients.
The prompting by a physician not actively involved in the patients’ care reduced mortality by 50 percent over three months. The saved lives may have resulted in part from reducing the time patients were on ventilators (thus reducing cases of ventilator-associated pneumonia) as well as reducing the number of days patients were on empiric antibiotics and central catheters. Prompting also cut patients’ intensive care unit length of stay, on average, by more than a day.
Researchers also wanted to see if using a checklist alone (without prompting) made any difference. They compared a pre-study group of almost 1,300 patients to patients in the study whose physicians used the checklist alone. The results: a checklist alone did not improve mortality or reduce the length of stay.
Having a subtle approach with the physicians was key to the success of the prompting, Weiss says. “We didn’t mandate that they had to change their management. It was ‘do you plan to continue the antibiotics today?’ not ‘you should stop the antibiotics.'”
Hospitals are unlikely to hire physicians just to be prompters, Weiss says, but perhaps nurses or electronic versions of the verbal prompting could be equally effective.
“It should be fresh eyes or someone from the existing team who is assigned to concentrate on these issues. What matters is that someone is specifically thinking about these issues.”
The research was funded by the National Institutes of Health.
More news from Northwestern University: www.northwestern.edu/newscenter/index.html