IBCD: development and testing of a checklist to improve quality of care for hospitalized general medical patients

Abstract

Background: Several studies have demonstrated the usefulness of medical checklists to improve quality of care in surgery and the ICU. The feasibility, effectiveness, and sustainability of a checklist was explored.

Methods: Literature on checklists and adherence to quality indicators in general medicine was reviewed to develop evidence-based measures for the IBCD checklist: (I) pneumococcal immunization, (B) pressure ulcers (bedsores), (C) catheter-associated urinary tract infections (CAUTIs), and (D) deep venous thrombosis (DVT) were considered conditions highly relevant to the quality of care in general medicine inpatients. The checklist was used by attending physicians during rounds to remind residents to perform four actions related to these measures. Charts were audited to document actions prompted by the checklist.

Results: The IBCD checklist was associated with significantly increased documentation of and adherence to care processes associated with these four quality indicators. Seventy percent (46/66) of general medicine teams during the intervention period of July 2010-March 2011 voluntarily used the IBCD checklist for 1,168 (54%) of 2,161 patients. During the intervention period, average adherence for all four checklist items increased from 68% on admission to 82% after checklist use (p < .001). Average adherence after checklist use was also higher when compared to a historical control group from one year before implementation (82% versus 50%, p < .0001). In the six weeks after the checklist was transitioned to the electronic medical record, IBCD was noted in documentation of 133 (59%) of 226 patients admitted to general medicine.

Conclusion: A checklist is a useful and sustainable tool to improve adherence to, and documentation of, care processes specific to quality indicators in general medicine.

Figure 1

The paper checklist was designed to mimic billing logs (with multiple patients on one page), and attending physicians were instructed to verbalize and record checklist items with the rest of the team during postcall rounds. Pneumovax is referred to as a pneumococcal polysaccharide in the text. MRN, medical record number; EOL, end of life; DVT, deep venous thrombosis; SCD, sickle cell disease; COPD, chronic obstructive pulmonary disease.

Figure 2

The IBCD checklist was printed on laminated pocket cards and distributed to general medicine residents as a reference tool. In addition to the checklist, the pocket card contains information regarding deep venous thrombosis (DVT) prophylaxis and pressure ulcer staging, as well as references to additional resources. COPD, chronic obstructive pulmonary disease; SCD, sickle cell disease; SQ, subcutaneous.

Figure 3

Adherence, as calculated from data entered on the checklist, was determined by measuring evidenced-based care processes specific for each quality indicator: 1. Pneumococcal vaccination for eligible patients; 2. Heel and sacrum skin exams for patients at high risk for pressure ulcers; 3. Documentation of indication for urinary catheter and prompt removal of urinary catheters from patients without an indication; and 4. Administering pharmacologic DVT prophylaxis to any patient without a contraindication. Actions prompted by the checklist were confirmed by chart review and added to the initial responses entered on the checklist to derive a total quality score.

Figure 4

As the intervention progressed, a greater percentage of patients began receiving the recommended care on admission and before use of the checklist. On admission, more patients received skin examinations if at high risk for pressure ulcers (p = .034) and had their Foley catheter discontinued if the catheter was not indicated (p = .01) than when the intervention started.

Figure 5

Adherence was determined by measuring evidenced-based care processes specific for each quality indicator: 1. Pneumococcal vaccination for eligible patients; 2. Heel and sacrum skin exams for patients at high risk for pressure ulcers; 3. Documentation of indication for urinary catheter and prompt removal of urinary catheters from patients without an indication; and 4. Administering pharmacologic DVT prophylaxis to any patient without a contraindication. DVT, deep venous thrombosis.