Background
Failure to detect and treat clinical deterioration, either from a medical condition or due to a complication of surgical treatment is a common life threatening problem [
1]. Hospitals have introduced Rapid Response Systems (RRS), which use an increasingly standardized evaluation and escalation treatment paradigm to manage patients with physiological derangements [
2,
3]. In contrast, the efferent limb clinical response is much more variable and ranges from the patient’s primary care team, to lone nurse practitioners, to dedicated Rapid Response Teams (RRTs) with intensive care, medical, nursing and allied care providers. The first responders of the efferent limb on general medical and surgical wards will nearly always be an ad hoc assembly of available providers with limited experience in managing common emergency situations .
The publication of ‘To Err is Human’ in 2000 [
4] has prompted a systems-approach towards safe care including applying human factors tools from safety-critical industries, such as aviation and nuclear power, that can be used to mitigate propagation of process failure to systems failures and adverse patient events [
5]. Checklists have been used effectively as part of routine safety procedures [
6]. The introduction of the Safer Surgery Checklist [
7] required operating theatre teams in 2009 to change their behaviour in team readiness and has been credited with the reduction of post-operative complications and mortality [
8]. Studies describing the use of checklists beyond the highly controlled environments of the Intensive Care Unit (ICU) and the operating theatre are rare: the SURPASS trial in the Netherlands demonstrated a slight reduction in mortality associated with the use of multiple checklists during the surgical patient pathway [
9]. Implementation of a ‘sepsis six’ care bundle in general ward areas using a checklist format has also demonstrated only a small reduction in mortality [
10]. However, Urbach et al., found that surgical checklists had little impact when clinicians were not involved in checklist design or implementation [
11].
Aviation distinguishes between ‘normal’, ‘non-normal’ and ‘emergency’ checklists [
6]. ‘Normal’ checklists are used as part of standard operating procedures. They include lists used for preparation of a flight or technical checks by maintenance staff. The World Health Organisation’s surgical checklist can be seen as a ‘normal’ checklist. Similar checklists have been used to effectively implement central venous catheter insertion [
12] and ventilator associated pneumonia prevention ‘care bundles’ in many ICUs. [
13] In these highly controlled settings, checklists seem to have reduced mortality and adverse events and helped to sustain improvements once embedded in clinical practice [
8,
12]. ‘Emergency’ checklists deal with uncommon, and unexpected crisis situations likely to have catastrophic outcomes. There are guidelines for the format and content of ‘emergency’ checklists that specify the recommended colours and typefaces to use [
14]. In intensive care and surgery the checklists are intended to be used by several people working together in close partnership [
15].
While Medical Emergency Team call-out criteria and Early Warning Scores have helped to standardize the recognition of deterioration it is not clear how response could be standardized. We aimed to provide clinicians with rapidly accessible standardized checklists to assist structuring standardized responses to patient deterioration using a checklist format. These exoplored how checklists could be designed to be used by the patient’s ‘home’ teams and help to structure emergency management and team response to common emergencies during escalation to Rapid Response teams.
Discussion
The aim of this study was to develop consensus recommendations to provide clinicians about the safe use of emergency checklists to assist in the emergency management of deteriorating patients on general medical wards. Hospitalized patient deterioration continues to challenge healthcare providers with variable outcomes and ongoing preventable harm(ref?). Utilizing previous evidence, simulation testing and expert opinion, the learning collaborative group achieved consensus on the best templates to use for RRT teams to assist in structuring patient management when faced with treating deteriorating patients on general medical wards.
This project used an established learning collaborative methodology to gain consensus on developing custom designed and rapidly accessible checklists for ward patients using standard procedures and clinical simulation technology to improve patient management. We found that general wards are qualitatively different from other clinical areas because the first responders must use resources that are available and therefore cannot rely on guidance by specialists. Our experience using a simulated environment suggests that while traditional checklist templates are not appropriate for general ward use, an innovative and flexible template we developed may be of value for the management of the common deteriorating patient by producing rapidly accessible and more reliable responses with improved measures of teamwork.
The systematic assessment of patient physiology at the bedside has led to dramatic reductions in rates of cardiopulmonary arrests [
23‐
25]. Despite this success many instances of abnormal patient physiology do not lead to early activation of a RRT [
26‐
29]. Moreover, even when a RRT team is called key interventions may be missed [
29], possibly as a result of errors in mental modelling and/or an incomplete understanding on how to respond to patterns of abnormal patient physiology [
30]. Consequently a significant proportion of patients that trigger a RRT response subsequently generate recurrent “call-outs” [
31]. A potential solution for these challenges would be the greater standardisation of RRT activation by routinely using standardized checklists to assist in structuring emergency care management.
While members of the nursing team are usually caring for patients for the duration of their shift most other staff involved may have just transiently entered the ward, and may not have the required competencies. It is incumbent on the first responder to achieve initial stabilisation, best accomplished by using the established airway, breathing and circulation management protocols (i.e. ABCDE).. Therefore, checklists requiring advanced diagnostic and therapeutic skills cannot be activated when a crisis is recognized. More advanced diagnostic and therapeutic interventions can only be provided when more members of the impromptu team arrive. The team’s leadership may then need to be re-defined and a reassessment performed using a secondary checklist.
Simulation for testing and training for RRTs and Cardiac Arrest Teams is well established [
32‐
35]. We found testing of checklists in high-fidelity simulation highlighted important differences between patient crises experienced on general wards as compared to templates used elsewhere (i.e. in operating theatres or non-medical settings) due to variable expertise, resources and limited organiztaional support.
Checklists for emergency management have been used for years by individual clinicians as personal aides de memoire, and health care administrators have encouraged the adoption of checklists in the hope that they will minimize the risk, increase patient safety and cost of litigation [
36]. However, as experience with the WHO surgical checklist has demonstrated, the benefits of checklists are only realised when the clinical staff are engaged and they are used to change the dynamics of a team’s culture [
37]. Medical checklists are more likely to follow a predictable course if they make clinical sense to providers, have clearly defined endpoints [
38] and actively engage the teams using them [
39].
Checklists should thus not be regarded as ‘magic bullets’. However they can help minimize variation and standardize care, maintain consistency and ensure quality of care resulting in reduced complication rates and lower mortality [
12,
13]. Many clinicians, however, worry that checklists may limit their clinical judgment, autonomy, and disrupt professional relationships [
40]. These concerns will require significant changes in organisational culture and take time to appreciate and overcome [
41‐
43]. Additionally investment in training will be required to embed the new checklist tools into clinical operations [
44]. A vital factor in their successful use is the creation of egalitarian and flattened hierarchical team structures, so that junior team members have ‘permission to challenge’ and feel psychological safety when raising challenging issues about improving the care processes [
45].
Acknowledgements
* The Crisis Checklists Collaborative members are:
Paul Barach, Anaethetist, Wayne State University School of Medicine, Michigan, USA; Helene Beaugrand, Monitoring Specialist, Philips Healthcare, France; Dorothy Breen, Intensivist, University Hospital, Cork, Ireland; Declan Byrne, Physician, St James Hospital, Dublin, UK; Catriona Chalmers, Intensivist, Ysbyty Gwynedd, Bangor, UK; Hayley Cleaver, Medical Student, Cardiff University, Cardiff, UK; Tim Cooksley, Physician, University Hospital South Manchester, Manchester, UK; Eilish Croke, Program Manager, Health Executive Irland, Dublin, Ireland; Elinor Davis, Medical Student, Cardiff University, Cardiff, UK; Ashley De Bie, Doctor in training, Catharina Ziekenhuis, Eindhoven, Netherlands; Peter Donnelly, Monitoring Specialist, Dundalk Institute of Technology, Dundalk, Ireland; Eímhín Dunne, Doctor in training, Health Executive Irland, Dublin, Ireland; Lesley Durham, Program Manager, North Tyneside General Hospital, UK; Bryn Ellis, Doctor in training, Ysbyty Gwynedd, Bangor, UK; Rohan Goel, Doctor in training, Ysbyty Gwynedd, Bangor, UK; Chris Hancock, Program Manager, 1000 Lives, Cardiff, UK; Jillian Hartin, Rapid Response Practitioner, University College Hospitals London, UK; Denise Hinge, Rapid Response Practitioner, Brighton, UK; Mark Holland, Physician, University Hospital South Manchester, Manchester, UK; Dirk Hueske-Kraus, Monitoring Specialist, Philips Medizin Systeme, Böblingen, Germany; John Kellett, Physician, Nenagh Hospital, Nenagh, Ireland; Sean Kennelly, Geriatrician, St James Hospital, Dublin, UK; Erik Korsten, Intensivist, Catharina Ziekenhuis, Eindhoven, Netherlands; Geoffrey Lighthall, Intensivist, Stanford University School of Medicine, Standford, USA; Rebecca Lunn, Registered Nurse, Ysbyty Gwynedd, Bangor, UK; Michael Müller, Anaethetist, St Josephskrankenhaus, Freiburg i. B., Germany; Clodagh O’Dwyer, Geriatrician, Trinity College Dublin, Dublin, Ireland; Kerian O’Mahony, Doctor in training, Ysbyty Gwynedd, Bangor, UK; Nigel Paice, Squadron Leader, Human Factors expert, Royal Air Force, UK; Lisa Roberts, Doctor in training, Ysbyty Gwynedd, Bangor, UK; Tracy Savijn, Rapid Response Practitioner, Ysbyty Gwynedd, Bangor, UK; Christian P Subbe, Physician, Ysbyty Gwynedd, Bangor, UK; Dafydd Thomas, Patient Representative, Ysbyty Gwynedd, Bangor, UK; Richard Walsh, Program Manager, Health Executive Irland, Dublin, Ireland; Frank Weber, Monitoring Specialist, Philips Medizin Systeme, Böblingen, Germany; John Welch, Rapid Response Practitioner, University College London Partners, London, UK; Simon Woodworth, Health Information Researcher, University College, Cork, Ireland.
We are grateful to St James’ Hospital, Dublin and Declan Byrne in particular for organising and hosting the first workshop. We would like to thank staff at Bangor University and the Simulation-laboratory Team Einir Mowll and Leon Hughes at the Ysbyty Gwynedd in Bangor for facilitating the second workshop, Christies’ Hospital, Manchester and Tim Cooksley for hosting the third workshop, the Information Librarian of the Ysbyty Gwynedd, Bangor, Nia Jenkins for undertaking the literature search and Sqn Ldr NJ Paice from The Royal Air Force for his input on human factors training, transport of unstable patients and checklist design. We are indebted for Prof Atul Gawande for inspiration and the permission to use templates from ‘projectcheck’ and to Prof Geoff Lighthall from Stanford or discussions around usage and format of peri-operative checklists.