Image by Getty Images
Image by Getty Images

Do you need a checklist?

There's limited evidence but apparent potential for these tools in hospital medicine.

A checklist, even for COVID-19, is unlikely to tell hospitalists anything they don't already know.

“We've been taking care of patients for decades with the same problems that COVID-19 causes, so we have plenty of evidence on how to do it correctly,” said David Janz, MD, MSc, director of medical critical care services at University Medical Center New Orleans.

Yet patients with COVID-19 in New Orleans were more likely to survive and to spend time off the ventilator if they were treated in ICUs that followed a protocol instead of those that didn't, according to a study by Dr. Janz and colleagues, published Sept. 13, 2020, by CHEST. The protocol was based on existing research and guidelines for treatment of respiratory failure and acute respiratory syndrome, but protocolizing care helped the ICUs deal with surges without sacrificing quality.

“In this case, we needed to take what we already knew about critical illness and make it workable on a large scale—to manage influxes of 60, 70, or 80 patients a day versus about 20, on average, prior to the surge,” Dr. Janz said.

Dr. Janz's experience could be seen as an example of the need to apply checklists strategically, in the situations where they seem most likely to be effective, and to study their outcomes. A 2017 review in the Journal of Hospital Medicine found only nine randomized controlled trials reporting patient safety outcomes of checklist interventions across multiple segments of care, such as surgery, medication prescribing, infection control, and physician behavior, leading the authors to conclude that high-quality studies of checklists are needed to substantiate their perceived benefits.

“Checklists make good conceptual sense because they help us standardize parts of care,” said Henry Thomas Stelfox, MD, PhD, an author of the review and professor and head of the department of critical care medicine at the University of Calgary and Alberta Health Services in Canada. “However, we need more large randomized trials to help us identify the characteristics that make up effective checklists, how best to implement them, and what kind of impact they have.”

Both clinicians and researchers are working hard on this challenge, trying to find the optimal applications for checklists, which may eventually cover a range of hospital medicine, from diagnostics to procedures to discharge planning.

A diagnostic aid

Checklists have not been widely used for diagnosis thus far, but they hold potential to improve this difficult aspect of medicine, according to a commentary published in the Annals for Hospitalists section of the April 16, 2019, Annals of Internal Medicine.

They can prompt physicians to consider a wider range of possibilities, actively coming up with a differential diagnosis based on evidence rather than drawing the most obvious conclusions based on past experiences, said commentary author and ACP Member Ashwin Gupta, MD, assistant professor and hospitalist at the University of Michigan and the VA Ann Arbor Healthcare System.

“Checklists may offer an opportunity to shift away from reflexive type 1 thinking—such as assuming a patient has myocardial infarction based on a common pattern of symptoms—toward a more deliberate type 2 thought process,” he said. “Checklists could potentially provide a check against falling into the former. So instead of assuming this is [a myocardial infarction], the physician takes a step back and considers some of the alternatives, like a blood clot or pulmonary embolism, or any number of other possibilities.”

Unfortunately, there are considerable barriers to developing and implementing such checklists, he conceded. Unlike surgical errors, where mistakes carry immediate consequences, diagnostic errors may not become apparent for days, months, or years following an incorrect diagnosis.

“With diagnostic errors, we don't get the kind of immediate recall and feedback that triggers people to take action outside of their standard workflow, such as implementing a checklist,” said Dr. Gupta. “The other big challenge is understanding what should be on these checklists as it's hard to know what elements are really going to provide effective checks and balances to type 1 thinking.” Cognitive processes don't easily lend themselves to study in randomized controlled trials, he noted.

Procedures and protocols

Checklists have been more used and studied in procedures such as intubation, but even there, the evidence is mixed. A review published by JAMA on July 2, 2020, found no effect of an intubation checklist on mortality or most secondary outcomes, including hypotension and cardiac arrest.

However, the authors noted that only one study among 11 included in the review was a randomized controlled trial. Additionally, subgroup analyses found a trend toward benefit from checklists in the ED, even if they didn't work in the ICU.

The findings point to the potentially differential impact of checklists across diverse circumstances and patient populations, said primary author Joseph S. Turner, MD, associate professor of clinical emergency medicine at Indiana University School of Medicine in Indianapolis.

“The ED and the OR [operating room] are very different places,” Dr. Turner said. “The OR is much more controlled with more time to prepare versus the ED where clinicians are constantly dealing with emergent conditions.”

The results may also reflect less room for improvement in settings where clinicians have constant practice performing the items that would be on a checklist. “My suspicion is that a lot of the items on checklists are already being done by teams that do [the procedure in question] well, and that's why it's hard to show a big benefit,” said Dr. Turner. “A checklist could potentially show more benefit in places with less experience and lower success rates compared with hospitals that perform it regularly.”

Hospitals dealing with COVID-19 surges may be a perfect example. The pandemic put heavy demands on staffing and prompted hospitals to tap clinicians who do not normally work in the ICU to help with care, noted Dr. Janz. “You could hand the checklist to someone who's never been in this setting before and they can still do a good job of taking care of these patients.”

The New Orleans study results suggested as much. “Using this protocol, we kept patients flowing in and out of the hospital even when levels reached 180 or 190 patients a day in our hospitals,” he said. “A protocol like this has potential to be an easily accessible tool that can help lower-volume hospitals ramp up quickly during surges and apply evidence-based practices.”

The Louisiana Department of Health has since adopted the COVID-19 protocol described in the study and made it available to hospitals throughout the state. It's a model that could work on a state or national scale during health care emergencies, said Dr. Janz.

Rewriting routine

The results may not be as dramatic, but checklists are also well suited to routine tasks, such as rounding in the ICU, said Craig Coopersmith, MD, director of the Critical Care Center at Emory University School of Medicine in Atlanta. Those should be made up of items that are both tremendously important and easy to forget because they've become enmeshed in the everyday workflow, such as prophylaxis for deep venous thrombosis to prevent blood clots.

“It's not the most interesting or exciting thing we do, and if we forgot one day on one patient it probably won't make a difference,” said Dr. Coopersmith. “But if we forgot in half of patients on a consistent basis, we know, based on evidence, that there will be an increase in the number of preventable blood clots and associated deaths.”

Similarly, checklists can push clinicians to check on tracheal tubes, central and arterial lines, and Foley catheters. “The checklist forces us to ask every day whether there's a clear indication to continue these or remove them,” he said.

They can also be a valuable tool for organizing processes that involve multiple specialties and settings throughout the hospital, such as discharge, said Michelle Mourad, MD, a hospitalist at the University of California, San Francisco (UCSF). For example, a checklist might include a reminder to ask about a patient's functional status and order physical therapy—not life-or-death issues but ones that could delay discharge if it's later discovered that the patient can't climb stairs at home.

“You can discharge someone without a checklist and it will work,” said Dr. Mourad. “But what we hope a checklist will accomplish for hospitalists is decrease extra work on the back end. Checklists can greatly improve efficiency and ultimately patient satisfaction by allowing patients to leave the hospital sooner.”

Implementing a checklist

The implementation of a checklist is a key determinant of whether it will improve care.

“A good checklist is well validated and reliable and fits into workflow,” said Dr. Stelfox. “Clinicians will use it if they think it will make their lives simpler and free them up to use their cognitive abilities on things that require more detailed thought. If it doesn't fit into workflow, they will view it as a burden.”

To get buy-in, start by presenting clinicians with the evidence supporting use of the checklist, said Dr. Janz. Then focus on integrating the new checklist into the culture and workflow of your institution.

“The process may be slow at first because adding something new can feel clunky and unfamiliar to people,” he said. “But eventually it gets smoother and people buy into it because they see how it's actually making care better and more efficient.”

That initial stage is a good argument for making checklists mandatory, said Dr. Coopersmith. “If a checklist has utility, it should be mandatory,” he said. “If it's optional, it's as if you're saying it's OK if we only remember most of the time in most patients, because no one is perfect.”

For multifaceted processes like discharge, it often makes sense to divide the checklist into manageable chunks, recommended Dr. Mourad. “One way to shorten a checklist is to ask who is ultimately responsible for each step and make it a separate list,” she said. “Everyone on the team has access to the master checklist, but they're not overwhelmed by it because they know the parts they're responsible for.”

A discharge checklist that's integrated into the electronic record can be managed by multiple members of the team, she said. For example, at UCSF, physicians can't discharge a patient without acknowledgment of flu vaccination status, but everyone on the team can see when that box has been checked.

In general, no individual checklist should take more than a few minutes, said Dr. Coopersmith. The length should make sense based on the complexity of the process or procedure and should not include items with a low risk-benefit ratio—for example, something that may prevent an extremely rare yet nonfatal complication.

“A good checklist adds a very small amount of time and will prevent errors of commission and omission that will in turn reduce morbidity and mortality,” he said. “They're often not exciting or fascinating, but they can literally be lifesaving.”