What if a hall monitor-type “prompter” person followed you around the ICU on rounds with a checklist and a red pen, pointing out all the oversights and omissions you were committing on an almost-daily basis? Sounds annoying, right?
Weiss et al show fairly convincingly that that might be exactly what we all need to be most effective — and more importantly, what might best help our patients. It’s a tale of two teams at Northwestern’s MICU; each admits patients on alternate days. One team was tailed by a prompter (resident) who asked scripted questions to draw attention to all the usual checklisted care processes (DVT prophylaxis, central line removal, empiric antibiotic duration, etc.). The other team was left to its own devices (free to use checklists at will) and acted as controls. They did this for 82 days, so they got multiple personnel cohorts rotating through.
140 patients were in the prompted group and 125 in the controls. Prompting was required on almost all days the prompter was there (65% of total days; the prompter was only there 68% of the days). Patients in the prompted group had (all stat.significant):
- 6 more ventilator-free days
- 1 fewer day of antibiotics
- 96% pharmacologic DVT prophylaxis, vs. 76%
- Reduced mortality in the ICU (6.4% vs. 13.6%…p=0.050) and hospital (10% vs. 21%, p=0.01).
- Odds ratio for death, adjusted for APACHE score, of 0.34
Pre-intervention, mortality was equal between teams in the MICU. Both groups of patients included in the study had equal predicted mortality by APACHE scores.
Authors are quick to point out that this since this is single-center and non-randomized, let’s not get over-excited. Nevertheless, don’t these findings grab you? And almost make you admit we might be fallible and need extra help being perfect? Of course, Atul Gawande, Peter Provonost and other have been saying and doing this for years — and achieving improvement in outcomes that make the biggest blockbuster drugs and devices look like billion-dollar snake oil.
Weiss CH et al. Prompting Physicians to Address a Daily Checklist and Process of Care and Clinical Outcomes. Am J Resp Crit Care Med 2011;184:680-686.