Are my bedside rounds in critical care unit complete? – The undeniable power of a checklist

Abstract

“Checklists are a memory aid, they remind you of what you already know and prompt you to think about what you don’t.” -Atul Gawande In medicine and especially in the realm of intensive care units (ICUs), it is often the little things that make the maximum impact on the patient outcomes. One such tool, often underestimated in its simplicity yet profound in its impact, is the checklist. As we navigate the complex and high-stakes environment of the pediatric ICU (PICU), the implementation of checklists emerges as a crucial element in ensuring not only optimal patient outcomes but also a smoother workflow and enhanced communication. The concept of using checklists in health care is not a novel one. Aviation and other high-reliability organizations have demonstrated the life-saving potential of standardized procedures and task lists[1,2] In the context of the PICU, where a multitude of health-care professionals collaborate to deliver intricate and often urgent care, checklists provide a structured approach that can mitigate errors, foster teamwork, and promote a culture of accountability. At the heart of this approach lies the principle of “cognitive offloading,” where routine and critical tasks are documented and systematically checked off. This reduces the burden on health-care professionals’ working memory, enabling them to focus more on clinical decision-making and patient interactions.[3] Rounding is one part of the medicine that remains diverse. The direction, duration, and discussion on rounds may vary immensely depending on who is leading them. Holodinsky et al. surveyed adult ICUs in Canada and found considerable variation in rounding practices within and between institutions.[4] In this edition of the Journal of Pediatric Critical Care, Abbas et al. have published their quality improvement study, in which they have assessed the impact of introduction of a rounding checklist in a PICU.[5] In their before–after study, they assessed the impact of a 35-point rounding checklist on the coverage of patient care components, length of PICU stay, and health-care-associated infections. They demonstrated that, with the introduction of this checklist, the discussion on most components improved and overall compliance improved from 70% to 99%, which was in line with existing data.[6] They even demonstrated a reduction in length of PICU stay, health-care-associated infections, and mortality, with the introduction of this checklist. This significant impact on hard outcomes seems to have stemmed from increased compliance with the interventions of proven benefit such as infection control bundles, antibiotic stewardship, and nutrition optimization. The authors did a commendable job in preparing a nearly comprehensive checklist which included the various components of patient care in the PICU, including all organ systems, reminders for health-care-associated infections, nursing care, nutrition, and pharmacotherapy. They also included a reminder for resident teaching, but inexplicably, this decreased with the introduction of this checklist. The authors have tried to explain this with an increase in the size of the ICU and resulting increased workload. This explanation, however, brings into discussion, the impact of increasing number of residents, equipment, and overall growth of the unit on the measured outcomes. With time, the PICU team would have become more efficient and a positive impact on outcomes would bias the actual impact of a checklist introduced at the same time. Another important aspect of this study is the involvement and resulting empowerment of the nurses, in the implementation of the checklist. Empowerment of nurses is known to have a positive outcome on patient care, especially in similar PICUs in low- and middle-income countries.[7] Without a checklist, the risk of omitting a crucial step increases, especially when time is of the essence. By employing a well-structured checklist, the authors demonstrated that components such as pupillary reaction, sedation plan, endotracheal tube cuff pressure, gut dysfunction, glycemic control, and creatinine clearance were more often discussed. Furthermore, checklists foster interdisciplinary collaboration and communication. The dynamic nature of a PICU demands seamless interaction among doctors, nurses, respiratory therapists, pharmacists, and others. Checklists provide a shared framework, ensuring that everyone is on the same page and working toward a common goal. Regular check-ins to review the checklist also encourage open discussions, allowing team members to voice concerns, ask questions, and share insights. This collaborative atmosphere not only enhances patient care but also contributes to a culture of mutual respect and continuous learning. While the benefits of checklists are undeniable, their implementation requires careful consideration. A checklist should not be a rigid tool, but rather a dynamic aid that evolves based on the evidence-based practices, input from frontline health-care providers, and ongoing feedback loops. Critics may argue that the use of checklists could undermine the clinical judgment and foster a mechanistic approach to patient care. However, it is important to emphasize that checklists are not meant to replace critical thinking but to support it. They serve as a safety net, catching potential errors that can occur due to the inherent complexity of pediatric critical care. It is also important to recognize that checklists may not always improve hard outcomes, especially when implemented to procedures that are performed frequently.[8] On the other hand, it is important to understand that such low failure rates in these procedures may have been achieved by the help of the same checklists. They are essential aids in maintaining these numbers so that we do not falter from the targets already attained. In conclusion, the incorporation of checklists into the PICU represents a valuable addition to patient care. As we continue to explore innovative ways to improve outcomes and streamline processes, the power of this simple yet profound tool cannot be overlooked. By embracing the principles of cognitive offloading, interdisciplinary collaboration, and continuous improvement, we can harness the potential of checklists to create a safer, more efficient, and ultimately more compassionate environment.