Happy wrote in a comment:
Why not a daily checklist for medical patients. It works in the ICU. It works in the OR. It should work on my medical patients.
I envision a mostly IT data gathering process with some RN driven process. I wish to make it voluntary. But as a physician, I should WANT a daily checklist reminder of what I may be forgetting for my patients. I know of know initiative within SHM along this path. I’m starting from scratch at my hospital.
Now the question is what should I include on my cost and quality saving mission. I have some empiric ideas on what I believe can save money and reduce complications. I have not researched it. It is just based on experience.Urinary cathers: Present or absent
Telemetry: present or absent
Central line: How long has it been there
patient status: General care or progressive
IVFs: If present, what are they
Weights: Admit weight and what’s the current weight
IV medications: can they be converted to po?
VTE prophylaxis: present or absent
Happy has made a great start. If you read Gawande's book, the challenge of checklists is making them usable. I visualize 3 steps – develop an extensive list, edit the list, test the list. Here are some of my thoughts. We can all help here through comments.
First let me comment on the list. I would add to the first three elements on the list – are they still necessary if present? We sometimes forget to remove urinary catheters because they make hospital care easier.
I would omit patient status from a checklist. Since we are revisiting IV fluids, we should review them in the context of the basic metabolic panel. Generally patients receiving IV fluids need basic metabolic panels daily.
I love the idea of weights, and find them very difficult to obtain.
IV medications and whether the patient is ready to convert to oral raises an important associated problem. We should generally have a "game plan" for the patient. Discharge planning should begin on day 1. My mental checklist always includes an explicit understanding of why the patient was admitted, what needs to be done, and what the eventual discharge plans will be. Another comment suggested PT/OT and I agree. Trying to develop the proper checklist for this concept is challenging. I often ask my residents and students, "Where are we going". I would rather get social work and case managers involved a day too early than a day too late.
VTE prophylaxis is part of our checklist at admission.
Addendum:
We need an antibiotic checklist:
- How many days out of how many total days?
- Any evidence that we can move to more narrow coverage?
- Any reason to consider broadening antibiotics?
- If on IV antibiotics, will the patient need IV antibiotics at discharge?
I will think about this checklist carefully during my rounds this week. I may post more on this topic later this week. Hopefully Happy will have more thoughts in response to my screed.
{ 4 comments… read them below or add one }
I don ‘t understand what’s the big deal : first year residents should learn (and internalize) this during the first few months of residency. If they don’t, well … fire the chief of that residency program.
@amy: I think that’s the point — the checklist assumes the physician has the knowledge, yet still forgets some of the items in practice. With all the interruptions hospital physicians face, a checklist is a good way to ensure everything gets done.
Great comments. My thoughts are both a cost savings initiative and a quality initiative. If the patient is progressive status and could be general care status, changing them could reduce nurse staffing and save money.
I also envision my process as making the checklist initiative as a split orde sheet with the data on the left and an order section on the right so a physician can look at the data in one fell swoop AND write orders at the same time. I have other ideas from other physicians I’ve been surveying in my group.
They came up with things like do we still need accuchecks?, positive culture results, coumadin use and daily INR, on probiotics?, I’s and O’s, last BM, Current antibiotic start date,
I’m sure there are others as well, and I appreciate your comments. It’s a work in progress, but I can think of many situations where patients may not have gotten worse and delayed discharge if we had been diligent with following simply daily reminders for some aspects of their care.
The problem with check lists, and I am a fan of them, is that often times the natural thought process from A to B is shortchanged and the checker dismisses the significance of the item checked as soon as she checks it off. Additionally, it is much easier to make an mistake with a checklist, which is then perpetuated when others “check the checklist”