Checklists in Healthcare
An example of an effective use of a medical checklist is the checklist developed in the intensive care unit (ICU) at Johns Hopkins University School of Medicine. The aim was to reduce bloodstream infections related to the insertion of central lines. The checklist focused on five evidence-based interventions recommended by the Centre for Disease Control that would have the greatest effect and have the lowest barriers to implementation. These interventions were: hand washing, using full-barrier precautions during the insertion of central lines, cleaning the skin with chlorhexidine, avoiding the femoral site if possible, and removing unnecessary catheters.
These items were not novel approaches in infection control, they did not involve the introduction of new devices or techniques, and they were known to have a strong evidence base. The initial study also included a control ICU, where there was an educational programme on how to reduce infections, but without the implementation of the checklist programme. The quality improvement team introduced the checklist programme in a stepwise manner, but focused on more than just using the checklist. The programme had institutional backing; it included staff education, routine surveillance, reporting and investigation of infections, supply of appropriate equipment (such as a dedicated i.v. access trolley), and a focus on teamwork, with encouragement for the nurses to speak up if the checklist was not followed.
The improved system helped to maintain adherence to the infection control guidelines and showed a sustained reduction in bloodstream infections from a baseline of 11.3 infections per 1000 catheter days to zero (no change in infection rate was noted in the control hospital). Interestingly, the nurses found the checklist useful to refer to if the doctors did not adhere to the required processes, and, far from leading to confrontation, the programme led to improved team working in the ICU. The same process was then adopted by the Michigan Health and Hospital Association (MHA) Keystone Center for Patient Safety and Quality Keystone ICU project as part of a state-wide safety initiative in hospitals in Michigan. The results again showed a sustained reduction in bloodstream infections that was maintained with time. The same methodology has been introduced to the UK as the NPSA 'Matching Michigan' campaign (http://www.nrls.npsa.nhs.uk/matchingmichigan/). This study highlights the importance of a checklist to ensure adherence to evidence-based interventions, the value of routine good practice in reducing morbidity and also the powerful gains when local teams work together to improve the care of their patients.
Checklists have been used successfully in other areas of ICU practice, for instance to identify daily goals, reduce ventilator acquired infections, and to structure information handover between teams. A structured checklist used after paediatric cardiac surgery improved the quality and safety of ICU handovers by reducing technical and communication errors while also improving teamwork and efficiency of the handover process. Other ICUs have found similar findings, and checklists have also been found to be useful during intra-hospital transfers and transfer from theatre to recovery.