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American Journal of Critical Care. 2008;17: 577-580
Copyright © 2008 by the American Association of Critical-Care Nurses.
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A regular feature of the American Journal of Critical Care, Clinical Evidence Review unveils available scientific evidence to answer questions faced in contemporary clinical practice. It is intended to support, refute, or shed light on health care practices where little evidence exists. To send an eLetter or to contribute to an online discussion about this article, visit www.ajcconline.org and click "Respond to This Article" on either the full-text or PDF view of the article. We welcome letters regarding this feature and encourage the submission of questions for future review.

Daily Goals Worksheets and Other Checklists: Are Our Critical Care Units Safer?

By Margo A. Halm, RN, PhD, CNS-BC. Margo A. Halm is a clinical nurse specialist and director of nursing research and quality at United Hospital in St Paul, Minnesota, where she leads and mentors staff in principles of clinical research and evidence-based practice.

Corresponding author: Margo A. Halm, RN, PhD, CNS-BC, United Hospital - Mailstop 60231, 333 N. Smith Ave, St Paul, MN 55102 (e-mail: margo.a.halm{at}allina.com).

In To Err Is Human,1 the Institute of Medicine (IOM) reported that system failures are responsible for 44 000 to 98 000 deaths of patients each year. Communication issues have been cited as a top safety incident that causes harm in medical and surgical intensive care units (ICUs), with training and team factors as major contributors.2 Health care professionals are confronted with multiple communications (pagers, phone calls, wireless phones), interruptions and distractions, escalating noise, and limits to human performance in short-term memory from multitasking and stress/fatigue. Although it may seem that safe communication does not stand a chance against these odds, researchers in a recent ICU study3 found that nurses interrupted 42% of serious errors.

In their 2001 publication, Crossing the Quality Chasm,4 the IOM called for radical redesign of the health care system to make it easier for clinicians to keep patients free from harm. The Joint Commission’s National Patient Safety goals5 have unquestionably brought acute focus to patient safety as every patient’s right and everyone’s responsibility. AACN’s Standards for a Healthy Work Environment also advocate that "nurses must be as proficient in communication skills as they are in clinical skills."6(p16) As a result of these forces, a culture of safety has become a strong ethic in health care organizations. Human factor science addresses interpersonal interactions implicated in adverse outcomes. The family of human factors skills—communication, briefings, cross-checking/verifying, addressing red flags with constructive assertion—is about detecting threats to patient safety as well as avoiding and managing errors in a team-based environment. As one approach, daily goals worksheets and checklists may reduce error by avoiding reliance on memory and transforming complex diagnostic and therapeutic decisions into a series of simple yes/no tasks.7–11 This clinical review discusses the evidence behind these tools for increasing reliability in the delivery of care.


   Methods
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The search strategy included searching MEDLINE, CINAHL, and Cochrane data bases. Key words included daily goals, checklists, structured communication, and ICUs. Recent primary research and quality improvement reports were included if focused on critical care.


   Results
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 Methods
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Recommendations
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As summarized in the TableGo, 14 reports describe evaluations of whether human factor tools eliminated communication gaps in the plan of care and promoted adherence with evidence-based practice guidelines. Daily goals worksheets and checklists were associated with improvements in all of the following: knowledge of the plan of care among clinicians; a culture of teamwork and safety; bundle adherence; and clinical (catheter-related bloodstream infection, ventilator-associated pneumonia, weaning, delirium screening, pain assessment/treatment, end-of-life care, mortality), financial (reduced length of stay), and service (patient/employee satisfaction) outcomes.


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  		Table Summary of studies

 

   Recommendations
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According to the evidence available, use of daily goals worksheets and checklists resulted in standardized delivery of care through higher adherence with evidence-based practice guidelines and promotion of teamwork cultures that enhanced effective communication. According to Pronovost et al,21 the leading national experts in the use of safety checklists, the single most important aspect of successful change in health care settings is engaging the culture. "Safety first" is the hallmark of high-reliability units, where communications are structured and rewarded, team contributions valued, and protocols founded on evidence-based practice are used. Staff respectfully speak up when encountering red flags—for instance, when a colleague lacks required skills or deviates from established protocol—honoring Florence Nightingale’s27 maxim "do the sick no harm." Memory aids are recognized not as signs of incompetence, but as useful tools to preserve safety in environments where complexity reigns—environments like our high-tech ICUs, where invasive diagnostic tests and treatments are the name of the game.

Critical care professionals are continually challenged to deliver care safely and effectively. With the hundreds of activities that ICU patients endure, daily goals and checklists could undoubtedly address complexities to reduce types of harm: physiological changes, discomfort, physical injury, family dissatisfaction, psychological distress, anticipated/prolonged length of stay, or even death.2 Although clinicians must attend to the intricacies of physiology, the aviation field’s track record with using human factors checklists28 provides important examples for health care because both industries are keenly responsible for the lives of millions of people.

Problems common to critical care populations—skin breakdown, delirium, hypoxia, altered hemodynamics, pain/anxiety, infection potential—might be preventable or have their severity at least reduced, if they were proactively assessed for on admission and if appropriate interventions were incorporated into the plan of care. Further, if caregivers indicated whether goals had been met for common problems by a simple yes/no check on a daily goals worksheet each shift, additional interventions could be addressed in multidisciplinary rounds. By creating redundancies that ensure each task occurs and is done correctly, complexities prone to error can be eliminated.10

Given that clinical reminders at the point of care are the most effective strategy for affecting practice,20 developing checklists for "mission critical" nursing interventions that, if not performed correctly, could lead to adverse events and substantial harm tightens the safety net. Checklists may also have value for situations where several tasks must be completed at one time. Titrating infusions; administering sedatives or analgesics; tightly controlling glycemic levels; preventing skin breakdown and delirium; turning patients prone or mobilizing patients receiving mechanical ventilation; weaning trials; caring for the insertion site for hemodynamic catheters; removing femoral sheaths; inserting small-bowel feeding tubes; relaying critical values or status changes to physicians and other departments, not to mention family members; and verbal hand-offs during crises or supporting families at the bedside during resuscitation—these are just a few critical priorities that come to mind.

As Dobkin14 contends, checklists are simple and cost-effective tools, but the greatest challenge rests with the commitment of the team to use them. With round-the-clock presence at the bedside, nurses must continue to seize their pivotal role in monitoring for situations of risk and skillfully executing not only clinical but also communication interventions that preserve a safety net. Patients are counting on us.

To purchase electronic or print reprints, contact The InnoVision Group, 101 Columbia, Aliso Viejo, CA 92656. Phone, (800) 809-2273 or (949) 362-2050 (ext 532); fax, (949) 362-2049; e-mail, reprints{at}aacn.org.


   REFERENCES
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  1. To Err Is Human: Building a Safer Health System. Washington, DC: Institute of Medicine; 1999.
  2. Spinoli D, Needham D, Thompson D, et al. Intensive care unit safety incidents for medical versus surgical patients: a prospective multicenter study. J Crit Care. 2007;22:177–183.[Medline]
  3. Rothschild J, Landrigan C, Cronin J, et al. The critical care safety study: the incidence and nature of adverse events and serious medical errors in intensive care. Crit Care Med. 2005;33(8):1694–1700.[Medline]
  4. Crossing the Quality Chasm. Washington, DC: Institute of Medicine; 2001.
  5. Joint Commission National Patient Safety Goals. The Joint Commission Web page. http://www.jointcommission.org/PatientSafety/NationalPatientSafetyGoals/. Accessed September 3, 2008.
  6. American Association of Critical Care Nurses. AACN Standards for Establishing and Sustaining Healthy Work Environments. Aliso Viejo, CA: AACN; 2005.
  7. Leape L. Error in medicine. JAMA. 1994;272(23):1851–1857.[Abstract/Free Full Text]
  8. Pronovost R, Thompson D. Reducing defects in the use of interventions. Intensive Care Med. 2004;30:1505–1507.[Medline]
  9. Hales B, Pronovost P. The checklist: a tool for error management and performance improvement. J Crit Care. 2006;21:231–235.[Medline]
  10. Pronovost P, Holzmueller C. Partnering for quality. J Crit Care. 2004;19(3):121–129.[Medline]
  11. Gawande A. The checklist: reporting and essays. New Yorker. December 10, 2007:86–101.
  12. Uhlig P, Brown J, Nason A, Camelio A, Kendall E. System innovation: Concord Hospital. Jt Comm J Qual Improv. 2002;28(12):666–672.[Medline]
  13. Pronovost P, Berenholtz S, Dorman T, Lipsett P, Simmonds T, Haraden C. Improving communication in the ICU using daily goals. J Crit Care. 2003;18(2):71–75.[Medline]
  14. Dobkin E. Checkoffs play key role in SICU improvement. Healthcare Benchmarks Qual Improv. October 2003:113–115.
  15. Narasimhan M, Eisen L, Mahoney C, Acerra F, Rosen M. Improving nurse-physician communication and satisfaction in the intensive care unit with a daily goals worksheet. Am J Crit Care. 2006;15(2):217–222.[Abstract/Free Full Text]
  16. Wolff A, Taylor S, McCabe J. Using checklist and reminders in clinical pathways to improve hospital inpatient care. Med J Aust. 2004;181(8):428–431.[Medline]
  17. Berenholtz S, Milanovich S, Faircloth A, et al. Improving care for the ventilated patient. Jt Comm J Qual Saf. 2004;30(4):195–204.[Medline]
  18. Walsh T, Dodds S, McArdle F. Evaluation of simple criteria to predict successful weaning from mechanical ventilation in intensive care patients. Br J Anaesth. 2004;92(6);793–799.[Abstract/Free Full Text]
  19. Berenholtz S, Pronovost P, Lipsett P, et al. Eliminating catheter-related bloodstream infections in the intensive care unit. Crit Care Med. 2004;32(10):2014–2020.[Medline]
  20. Wall R, Ely E, Elasy T, et al. Using real time process measurements to reduce catheter related bloodstream infections in the intensive care unit. Qual Saf Health Care. 2005;14(4):295–302.[Abstract/Free Full Text]
  21. Pronovost P, Berenholtz S, Goeschel C, et al. Creating high reliability in health care organizations. Health Serv Res. 2006;41(4 Pt 2):1599–1617.[Medline]
  22. Goeschel C, Bourgault A, Palleschi M, et al. Nursing lessons from the MHA Keystone ICU project: developing and implementing an innovative approach to patient safety. Crit Care Nurs Clin North Am. 2006;18(4):481–492.[Medline]
  23. Bergeron N, Dubois M, Dumont M, Dial S, Skrobik Y. Intensive care delirium screening checklist: evaluation of a new screening tool. Intensive Care Med. 2001;27(5):859–564.[Medline]
  24. Erdek M, Pronovost P. Improving assessment and treatment of pain in the critically ill. Int J Qual Health Care. 2004;16(1):59–64.[Abstract/Free Full Text]
  25. Hall R, Rocker G, Murray D. Simple changes can improve conduct of end-of-life care in the intensive care unit. Can J Anesth. 2004;51(6):631–636.[Medline]
  26. Clarke EB, Luce JM, Curtis JR, et al. A content analysis of forms, guidelines, and other materials documenting end-of-life care in intensive care units. J Crit Care. 2004;19 (2):108–117.[Medline]
  27. Nightingale F. Notes on Hospitals. London, England: John W. Parker and Sons; 1863.
  28. Helmreich R. Managing human error in aviation. Sci Am. 1997;276(5):62–67.[Medline]




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