Process-of-care in the ICU : a multi-method exploration of an electronic checklist to support medical morning rounds

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The need for comprehensive and effective methods to ensure the delivery of required processes of care to intensive care unit (ICU) patients is acknowledged globally. In response various tools have been implemented, although many have not yet been empirically tested or rigourously evaluated in ICUs. Early evidence suggests that using a checklist is one way of ensuring evidence-based or accepted processes of care are performed routinely and systematically. The aim of this program of study was to identify areas of need, then develop, validate, test and evaluate an electronic process-of-care checklist (e-checklist) for use by intensive care physicians during morning ward rounds in a tertiary-level adult ICU. Need for improvements in the delivery of ICU processes of care were identified via a comprehensive literature search, a point prevalence study of 50 Australian and New Zealand ICUs, and baseline data collected at the local ICU level. Evidence on checklist validity was obtained via multiple methods at different research stages: comparison of checklist responses and documentation of care recorded in patients’ medical records demonstrated high correlations for each care component, providing support for its concurrent validity; local clinician interviews and a modified-Delphi technique using an expert clinician panel confirmed the relevance and adequacy of content and produced a list of clear, concise and descriptive checklist statements; high levels of concordance between clinician and auditor responses during the intervention phase contributed evidence to the e- checklist’s construct validity based on response processes; and user feedback obtained before and after the intervention demonstrated the e-checklist had face validity with ICU physicians. Importantly, the prospective before-after intervention study demonstrated improved compliance with processes of care over time (odds ratios ranged from 1.9 for mechanical ventilation weaning to 22.9 for pain management) and user-satisfaction was achieved. Implications for practice include implementing this versatile tool at the point-of-care to collect real-time, process-of-care data that can be completed by clinicians delivering and auditing care. Recommendations for further research include: testing for reliability; investigating the reasons for practice variability and impact on outcomes; conducting observations of e-checklist utility in clinical practice and in larger multi-centre studies adequately powered to detect significant differences in patient outcomes over time; and comparing the e-checklist with other clinical support tools or across different delivery platforms such as tablet PCs. Overall, this research demonstrated the utility of an e-checklist in measuring and improving the delivery of ICU processes of care and provided a substantial amount of evidence in support of its’ construct validity.
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