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Checklist-styled Daily Sign-out Rounds Improve

Hospital Throughput in a Major Trauma Center


JOHN C. LEE, M.D., MICHAEL HORST, PH.D., AMELIA ROGERS, B.S., FREDERICK B. ROGERS, M.D., M.S.,
DANIEL WU, D.O., TRACY EVANS, M.D., MATHEW EDAVETTAL, M.D., PH.D.

From the Division of Trauma/Critical Care, Lancaster General Health, Lancaster, Pennsylvania

The checklist concept has received much attention as a result of its ability to improve patient care
by minimizing complications. We hypothesized daily sign-out rounds using a checklist, by im-
proving team communication and consistency of clinical care, could lead to expedited throughput
for patients at a major trauma center. A retrospective study examined patients admitted to a mature
trauma center. Two time periods, PRE (September 2008 to January 2009) and POST (September
2009 to January 2010), were selected to match for seasonal variation in admission diagnosis. An
organ system-based checklist was used during daily sign-out for all admitted trauma patients in
the POST period. We examined discharge status, complications and rates, and intensive care unit
(ICU) and overall hospital length of stay for differences. There were similar numbers of patients
(824 PRE vs 798 POST) admitted in these two cohorts. We found no statistical differences in the
incidence of complications or mortality rate. We did discover statistically significant differences in
the median ICU days (2 PRE vs 1 POST, P 5 0.007) as well as median hospital length of stay (2
days, interquartile differences Q1 to Q3 PRE [1 to 5] and POST [1 to 4] P 5 0.000). These trends
remained valid even among the severely injured (Injury Severity Score 16 or greater) with a hos-
pital length of stay of 5 (PRE) versus 3 days (POST; P 5 0.021). A simple, organ system-based
checklist can be successfully adopted for daily sign-out round on a busy, multiprovider trauma
service. We were able to expedite trauma patient throughput in both ICU and overall hospital stays
with a trend toward decreasing mortality. This improved throughput may potentially translate
into a cost saving for the hospital.

best known in the aviation We have recently shown that a trauma intensivist
C HECKLISTS ARE PERHAPS
industry as a means of assisting pilots in their
accurate and timely completion of complex tasks.
model as applied to a community hospital trauma pro-
gram, with the surgeon as the captain of the ship, could
Similar to these nonmedical fields, the practice of improve intensive care unit (ICU) throughput.4 With the
medicine has grown increasing complicated, both in further expansion of our trauma service at Lancaster
terms of the amount of knowledge as well as the skills General Hospital, from three to six full-time surgeons,
necessary to execute and deliver best care. It has only we felt that a more efficient and effective work flow
been recently that the concept of using a checklist in system must be instituted to maintain high standards.
medicine received much attention, even in the lay Surgeon communication lapses and ineffective in-
press.1 A large measure of the current interest can be formation transfers have been well described as reasons
attributed to seminal studies by Pronovost et al.2 at that attribute to adverse patient outcomes and provider
Johns Hopkins, who demonstrated that a simple inefficiencies.5, 6 With its proven track record as a tool
checklist can lead to improved outcome for specific for performance improvement and error prevention and
tasks. The goals of checklists used in health care are management, a checklist system could serve as a further
therefore primarily tools for error reduction and ad- refinement to our trauma care model. We hypothesized
herence to best practices in clinical care to improve the that daily sign-out rounds using a checklist, by improving
quality of patient care.3 team communication and consistency of clinical care,
could expedite patient throughput at our trauma center.

Presented as a poster presentation at the 69th Annual Meeting of Methods


the American Association for the Surgery of Trauma, Boston, MA,
September 22–25, 2010. Location and Trauma Service Composition
Address correspondence and reprint requests to John C. Lee,
M.D., Lancaster General Health, 555 N. Duke Street, Lancaster, Lancaster General Hospital has been a Pennsylvania
PA 17602. E-mail: jclee@lghealth.org. Trauma Systems Foundation (PTSF) state-verified

434
No. 5 CHECKLIST-STYLED SIGN-OUT IMPROVES PATIENT CARE ? Lee et al. 435

Level II trauma center since 1987. It is a community- initiated by the admitting trauma surgeon, and daily
based, not-for-profit hospital that does not have a free- additions were made by the rounding trauma surgeon.
standing surgery residency and is the only verified A list was maintained for each patient from admission
trauma center for Lancaster County. Since 1997, the until discharge; each was then properly disposed per
trauma program has provided 24/7 in-house surgeon hospital/HIPAA regulations. The checklists themselves
coverage for any trauma activation or consultation. were not part of the patient’s actual hospital medical
Care of all trauma patients after admission were records.
provided exclusively by critical care certified trauma
surgeons, of which there were three in the first study
Patient Population and Analysis
period (PRE, September 2008 to January 2009) and six
in the second period (POST, September 2009 to Jan- All patients admitted to the trauma service in the two
uary 2010). All were employed by the hospital on study periods were eligible for review. These two
a full-time basis and shared equally the core clinical 4-month study periods were divided into two phases:
responsibilities of daytime trauma response, most PRE (September 2008 to January 2009) and POST
overnight trauma calls, and 24/7 uninterrupted ICU (September 2009 to January 2010). The time periods
coverage. A core group of five community-based gen- were matched to account for potential seasonal varia-
eral surgeons without critical care training filled in the tions in mechanisms of trauma injuries match sea-
gaps in overnight trauma coverage. However, they sonally (September to January). After admission, all
relinquished all responsibilities, the next morning, for trauma service-specific and PTSF-required data were
all trauma patients, which they had admitted overnight, collected on a daily basis by trauma case managers.
to the trauma intensivists. Attendance was mandatory These included demographics, mechanism of injuries,
for all five community surgeons only for the purpose resuscitations, pre-existing medical conditions, and
of relaying name, diagnosis, and major issue. The occurrences. All data points were then maintained in
employed trauma intensivists (three in the PRE group Collector (Digital Innovation, Forrest Hill, MD), a
and six in the POST group) made any further care PTSF-mandated trauma database used by the Lancas-
decisions. The sign-out occurred within 15 hours of ter General Hospital trauma service. Information was
beginning their overnight call. All information passed extracted from the Collector database by our trauma
on was then independently reviewed and act on by the registrars. Variables such as length of stay days, age,
trauma intensivists. Injury Severity Score (ISS), occurrences, and mortality
In the PRE period (September 2008 to January for each group were extracted from the database. An
2009), the morning sign-out was an informal process occurrence is a PTSF term defined as an ‘‘unexpected
consisting of the following: the post call surgeon, the event affected patient care.’’ Hospital length of stay
on-call trauma surgeon, the distinct trauma intensivist was inclusive from time of admission to actual dis-
who is solely covering the ICU, physician assistants, and charge of the patient. ICU length of stay was calculated
trauma case managers. It typically occurred at 7:30 AM from time of admission to time of determination by the
on weekdays and 9 AM on weekends and holidays. attending surgeon for transfer out of ICU or discharge.
There was no organized structure to the sign-out Complication is defined as greater than one occurrence
itself. Sufficient time was spent to pass on the name, per standard PTSF definition, of which there were 45
pertinent diagnosis, and relevant clinical issues of in total.
each patient on the service. We also examined the compliance rate of our own
In the POST period (September 2009 to January internal trauma service management guidelines. These
2010), the morning sign-out was a required event of all guidelines were established in the preceding three years
available trauma surgeons, physician extenders, and as a way of standardizing the treatment of commonly
trauma case managers. There was no change to the encountered clinical scenario. Data from the entire
actual starting time of these sign-outs. Each patient on calendar years of 2008 and 2009 were examined for
the daily trauma census was discussed individually cases that were deemed to have been noncompliant
using the sign-out checklist as a template (Fig. 1) with with the established guidelines.
all relevant radiographic studies projected for group Basic descriptive statistics were calculated for the
viewing. Time for sign-out of all patients was kept to two groups. We used Kruskal-Wallis nonparametric
a 1-hour maximum. tests to asses for differences across continuous var-
Our sign-out checklist used an organ-based ap- iables and Fisher’s exact test for categorical vari-
proach to systematically address patient care issues ables of interest. A P value < 0.05 was considered
and is inclusive of tentative discharge plans. For ease statistically significant. All statistical analyses were
of use, the checklist was purposefully kept to one page. conducted using Minitab Version 15 (State College,
Data population on the checklist for each patient was PA).
436 THE AMERICAN SURGEON May 2014 Vol. 80

FIG. 1. Sign-out checklist.


No. 5 CHECKLIST-STYLED SIGN-OUT IMPROVES PATIENT CARE ? Lee et al. 437

Results during the formal training phase of their careers. The


During the 8-month study period, a total of 1622 few studies that have examined this singular activity
patients were admitted to the trauma service. The have all noted that sign-outs are rarely standardized
numbers in the PRE and POST groups were similar and often managed haphazardly.7, 8 These factors can
(824 PRE vs 798 POST). There was no statistical dif- easily lead to patient care errors with significant con-
ferences in the median age (45 years PRE vs 46 years sequences. By examining internal medicine house staff
POST; P 4 0.85), median ISS (8 PRE vs 8 POST; P 4 sign-outs from a quantitative and qualitative stand-
0.70), mechanism of injury of blunt (94.3% PRE vs point, Horwitz noted that, per patient, the typical sign-
93.5% POST; P 4 0.84) and penetrating (4.4% PRE vs out was short in duration (median of 35 seconds) and
4.9% POST; P 4 0.84), or the probability of ICU ad- that errors of omission or frank mischaracterization of
mission (36.9 vs 33.3%; P 4 0.12). These de- data occurred in upward of 22 per cent. She concluded
mographics are summarized in Table 1. that a standardization of key content onto a written
There was no significant difference between the template would lead to greater emphasis on patient
PRE and POST cohorts in complication rates (3.1% safety.9, 10
PRE vs 2.9% POST; P 4 0.86; Table 2) and mortality The checklist is a deceptively mundane instrument
rates (4.1% PRE vs 2.7% POST; P 4 0.12; Table 2); whose potential for affecting process improvements
however, there was a trend toward a decrease in both and minimizing errors belies its fundamental simplic-
complication rates and mortality in the POST group. ity. Although its use has been the norm in aviation and
These outcomes may have failed to reach statistical industry, the use of a checklist in medicine is still in the
significance as a result of a Type II error of the small infancy stage.11 It has been publicized as a tool for
patient population. As far as patient length of stay is error management by reducing costly mistakes and
concerned, we did find statistically significant differ- performance improvement.12 In recent years, several
ences in both the median ICU days (2 vs 1 day, P 4 examples of the effectiveness of the medical checklist
0.01; Table 2) and the overall hospital stay days (2 days have been published. Some notable outcomes included
PRE vs 2 days POST; interquartile differences Q1 to 1) reductions in incidences of catheter-related blood-
Q3, PRE [1 to 5] vs POST [1 to 4]; P < 0.001; Table 2). stream infections2; 2) reductions in surgical compli-
This hospital stay difference was even more pro- cations such as in-hospital death rate and surgical site
nounced for those with ISS 16 or greater (5 days PRE infections13; 3) reductions in ICU length of stay by
vs 3 days POST; P 4 0.02; Table 2). 50 per cent using a daily goal checklist14; and 4) re-
Table 3 summarizes the noncompliance rates with ductions in ICU mortality, length of stay, and the need
our own internal trauma management guidelines. for mechanical ventilation.15 In short, it is becoming
Events from the entire calendar years of 2008 and 2009 clear that in medicine, just like in other fields of human
were used for comparison. Of the 11 categories, eight endeavor, a simple checklist can be an effective way to
demonstrated a decreasing trend with the high-risk organize a vast amount of data, often presented in a
geriatric item reaching statistical significance (P 4 0.00). chaotic and disorganized fashion, and allows the cli-
nician to deliver care safely, correctly, and reliably.
With this background in mind, we undertook the
same checklist benefits could be realized on a busy
Discussion
trauma service. We applied the checklist concept to
Sign-out among healthcare practitioners in a group a necessary daily care event (the morning sign-out) and
setting is an integral part of their daily activity, and theorized that this simple and yet comprehensive sys-
most certainly have had experience with this technique tem, by improving team communication consistency

TABLE 1. Demographics
PRE (September 2008 POST (September 2009
to January 2009) to January 2010) P Value
Patients 824 798
Median age (years) 45 46 0.85
ISS 8 8 0.70
Mechanism of injury
Blunt 777 (94.3%) 746 (93.5%)
Penetrating 36 (4.4%) 39 (4.9%) 0.84
Rate of ICU admission 36.9% 33.3% 0.12
ISS, Injury Severity Score; ICU, intensive care unit.
438 THE AMERICAN SURGEON May 2014 Vol. 80

TABLE 2. Results
PRE (September 2008 POST (September 2009
to January 2009) to January 2010) P Value
Complications 3.1% 2.9% 0.86
Mortality 4.1% 2.7% 0.12
ICU LOS (median days) 2 1 0.01
Hospital LOS (all) 2 2 <0.001*
Hospital LOS (ISS $ 16) 5 3 0.02
* Interquartile differences Q1–Q3, Pre (1–5) vs Post (1–4).
ICU, intensive care unit; LOS, length of stay; ISS, Injury Severity Score.

of clinical care, would lead to expedited patient results assuaged some initial concerns and doubts per-
throughput. We had previously reported that a trauma taining to the possible dangers associated with im-
intensivist model improves ICU throughput at a busy proved overall patient throughput.
Level II community hospital trauma program by We feel that the appropriate delivery of patient care
streamlining the patients’ ICU stay.4 With the addition information is just as important as the quality and
of a sign-out checklist, we hoped to see further im- substance of the care itself. Certainly at a minimum,
provement in throughput of our trauma patients with- they are inextricably linked. The Joint Commission’s
out any concurrent increases in morbidity or mortality. annual report in 2006 emphasized the importance of
The time periods were matched to account for po- care provider communications as part of its effort to
tential seasonal variations in mechanisms of trauma reduce error. It reported communication failure as the
injuries. Statistically, our two cohorts of patients were primary root cause of 65 per cent of reported sentinel
similar in age (45 vs 46 years, P 4 0.85) and sustained events that year and likewise a similar fraction within
similar types of injury (blunt vs penetrating) of equal the preceding 11-year interval.16 Petersen et al.,17 who
severity (ISS of 8 vs 8, P 4 0.70). The likelihood of evaluated housestaff handoffs at an urban tertiary care
being admitted directly to the ICU did not differ in the setting, found that 44 per cent of 124 consecutive ad-
two groups (37 vs 33%, P 4 0.12). verse events were deemed preventable and correlated
We demonstrated improved trauma service through- statistically to presence of cross-coverage and directly
put, both in the ICU and in the overall hospital length of proportional with patients’ severity of illness. In-
stay. Our data were even more significant for the most tuitively, it makes sense that the sicker the patient, the
severely injured (ISS 16 or greater), who had a 40 per more complicated their care would be and therefore
cent decrease in their hospital duration of stay (5 vs 3 more prone to errors.
days, P 4 0.02). This system-wide efficiency occurred These facts point out the potential danger in a setting
in the absence of a noticeable increase in complication where multiple providers are responsible for the care
rates (3.1 vs 2.9%, P 4 0.86) or mortality rate (4.1 vs of the patient. Such a situation is inherent and neces-
2.7%, P 4 0.12). Despite the lack of significance sary on a busy, multiprovider trauma service. Our ex-
between the PRE and POST groups in regard to the perience and trauma coverage pattern are certainly not
complication and mortality rates, we are encouraged unique and, in fact, is likely the norm. Our own trauma
by the decreasing trends in the POST period. These management guideline compliance rate in the years

TABLE 3. Lancaster General Health Trauma Service Management Guideline Noncompliance


MGMNT Guidelines CY 2008 Events CY 2008 Percent CY 2009 Events CY 2009 Percent P Value
1 AC reversal 58/115 50.4% 40/109 36.7% 0.053
2 Airway 40/114 35.1% 32/103 31.1% 0.629
3 Blunt abdominal workup 27/928 2.9% 28/1014 2.8% 0.952
4 BCI 6/212 2.8% 3/266 1.1% 0.307
5 Cervical spine clearance 7/1197 0.6% 6/1141 0.5% 0.931
6 DVT prophylaxis 7/522 1.3% 2/511 0.4% 0.191
7 Epidural catheter 11/143 7.7% 18/153 11.8% 0.326
8 High Risk Geriatric 53/184 28.8% 26/202 12.9% 0.000
9 ICP monitor 11/59 18.6% 16/45 35.6% 0.085
10 Nutrition 39/195 20.0% 34/156 21.8% 0.780
11 Sedation/analgesia 26/159 16.4% 14/139 10.1% 0.157
MGMNT, management; CY, calendar year (January to December); AC, anticoagulation; BCI, blunt cardiac injury; DVT, deep
vein thrombosis; ICP, intracranial pressure.
No. 5 CHECKLIST-STYLED SIGN-OUT IMPROVES PATIENT CARE ? Lee et al. 439

before and after checklist implementation illustrates implementation of the checklist process, as we hoped
this point (Table 3). Although only the high-risk ge- to demonstrate the ease of implementation and the
riatric protocol reached statistical significance, eight of quick return possible with such a change. We are
the 11 measured categories showed a trend toward currently evaluating the validity of the checklist pro-
improved compliance. We feel that these improve- cess over longer periods.
ments are direct consequences of the application of a In conclusion, we have shown that a change to a
standardized checklist to the care of our patients. routine, daily event like the physician sign-out can
Important to every hospital that strives to provide significantly impact patient care and hospital length of
best care in an environment of ever diminishing re- stay. The reported advantages of using a checklist can
imbursements, the issue of patient length of stay has be effectively duplicated on a busy trauma service to
not been well characterized in the medical literature. improve overall patient throughput without adversely
It was only recently that Fakhry et al.18 reported the affecting morbidity or mortality.
correlation between trauma center profitability and
patient length of stay. Staffing pattern change has been Acknowledgments
reported to positively affect length of stay.4, 11, 19 We thank Lois Sakorafas, M.D., for her participation in
Protocol-driven care processes for diseases have also the development and use of the checklist.
been described.20 Lastly, formalized multidisciplinary
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