Use of Care Process Checklists May Not Result in Quality Improvement in ICUs

The use of checklists and other interventions had no significant effect on quality improvement among critically ill patients in intensive care units (ICUs), according to a study published April 12 in the Journal of the American Medical Association.

The study’s researchers, led by Alexandre B. Cavalcanti, MD, PhD, conducted a cluster randomized trial between April and November 2014 in 118 ICUs in Brazil. After an assessment of baseline data, 3,327 patients were assigned to the intervention group and 3,434 were assigned to the routine care group.

Intervention care entailed daily rounds modified to include the use of a checklist, discussion of goals of care, and clinician prompting to ensure follow-through with checklist adherence and goals of care for all patients during their ICU stay. The checklist targeted 11 care processes aimed at preventing complications, improving nutrition, reduction in sedation, assessment of readiness for extubation, detection of severe sepsis and acute respiratory distress syndrome, optimization of antibiotics and reduction of tidal volume.

In-hospital deaths, the primary outcome, occurred in 32.9 percent of patients in the intervention group and 34.8 percent of patients in the routine care group. Secondary exploratory clinical outcomes, including ICU mortality, central line-associated bloodstream infection, ventilator-associated pneumonia, and urinary tract infections were not affected by the intervention measures.

“Low income countries such as Brazil sustain 85 percent of the global burden of critical illness,” the study’s authors stated. “Adherence with guidelines is lower, and severity-adjusted outcomes are higher than in high-income countries.”

Because the use of checklists has shown to improve work climate and process adherence in such settings, the authors “hypothesized that such an approach would improve work climate, care processes, and mortality in Brazilian ICUs.” After analyzing the study’s findings, the authors suggested several potential explanations for the lack of quality improvement, including a limited observation period, possible negligible effects of the actual checklist items, and the presence of multiple unadjusted comparisons.

Kim A. Eagle, MD, MACC, editor-in-chief of, adds that “the airline industry proved 50 years ago that checklists improved the safety of air travel; multiple studies have shown that checklists improve outcomes for surgery. ICU care, by virtue of the heterogeneity of the patients, may be a bit different. Checklists work when there is evidence that a particular care strategy is effective and there is practice variation around that care. In this case, the nature of the patients may be such that it is hard to identify strategies that pertain to all of the patients.” 

Clinical Topics: Diabetes and Cardiometabolic Disease

Keywords: Airway Extubation, American Medical Association, Anti-Bacterial Agents, Bacteremia, Brazil, Checklist, Critical Illness, Developed Countries, Intensive Care Units, Patient Care Planning, Pneumonia, Ventilator-Associated, Quality Improvement, Respiratory Distress Syndrome, Adult, Sepsis, Tidal Volume, Urinary Tract Infections

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