Rapid response systemsTesting the effects of checklists on team behaviour during emergencies on general wards: An observational study using high-fidelity simulation
Introduction
Hospital medicine is dealing with increasingly complex patients who often present with multi-morbidity and a combination of conditions that seemingly require conflicting therapeutic strategies.1, 2, 3 At the same time a large proportion of acute and emergency care in hospital medicine is delivered by junior clinicians in the first years of their training.4, 5 In this setting simple systems using a structured Airway-Breathing-Circulation-Disability-Exposure (ABCDE) approach have become dominant to guide treatment during cardio-pulmonary arrests and peri-arrest situations.6, 7 They might however be applicable to only a fraction of deteriorating patients and of limited use in solving complex medical problems and interactions between professional groups and disciplines. Very few new approaches to the management of deteriorating patients outside sepsis and cardiac arrests have been developed to support clinicians at the bedside since the first publication of Advanced Life Support courses.8 The Crisis Checklist Learning Collaborative successfully developed a computerized application with crisis checklists (Crisis Checklist App) using an expert and consensus model to support physicians and nurses in managing acutely deteriorating hospitalized patients on general wards.9, 10, 11
The objective of this study was to determine the effect of a computerized application with crisis checklists on the acute care management and the teamwork of physicians and nurses who encounter a deteriorating patient. We hypothesized that the Crisis Checklist Application improves the teamwork performance and acute care patient management of clinicians.
Section snippets
Study design and setting
We conducted a multicentre simulation study from 1 September, 2017 until 1 December, 2018 in three European hospitals: The Catharina Hospital in Eindhoven in the Netherlands, the Ysbyty Gwynedd in Bangor, Wales, United Kingdom, and Odense University Hospital in Odense, Denmark. This study was undertaken in high fidelity simulation centres representing a typical room on the general ward with interactive mannequins possessing comparable functionalities (i.e., HALL 3201 by Gaumard in Bangor and
Participants and scenarios
We enrolled 101 volunteers for the study. The participants were assigned to 32 teams: 18 teams were randomized to schedule A and 14 teams to schedule B. There were no significant differences in the participants’ characteristics between the schedules (Table 2). Two scenarios could not be analyzed due to video recording malfunctions and one team was unable to complete two scenarios due to an unexpected clinical duty that intervened. Of the 188 reviewed scenarios, 93 scenarios were completed
Discussion
This study provides important insights into the conceptual development and testing of clinical decision support tools for teams that respond to deteriorating patients with complex problems on general wards. Introducing the Crisis Checklist App in a multicentre simulation study of medical emergencies was associated with marked improvements in measured and self-reported teamwork. In addition, both the percentage of omitted predefined safety-critical steps and the time to complete these steps were
Conclusions
Our findings suggest that a novel mobile crisis checklist application might be a valuable clinical decision support tool. We demonstrated improved teamwork performance and clinical decision making in a simulation-based study using an easily accessible checklist-based application for mobile devices to assist clinicians at the bedside. Further research is needed to determine the precise mechanisms, the role as an educational tool, and durability of these effects in clinical practice.
Conflicts of interest
A.J.R. De Bie Dekker – ADBD received a travel fee for two Crisis Checklist Collaborative meetings in Bangor and Manchester: approximately 700 euro. ADBD's PhD research is funded by the IMPULS-2 project: a collaboration of Catharina Hospital Eindhoven, Eindhoven University of Technology and Philips Research.
J.J. Dijkmans – JD has nothing to disclose.
N. Todorovac – NT has nothing to disclose.
R. Hibbs – RH has nothing to disclose
K. Boe Krarup – KBK has nothing to disclose.
A.R. Bouwman – ARB
Authors’ contribution
A.J.R. De Bie Dekker and C.P. Subbe – conceptualization; data curation; formal analysis; investigation; methodology; project administration; resources; supervision; validation; visualization; writing – original draft; writing – review & editing.
J.J. Dijkmans – data curation; formal analysis; investigation; methodology; project administration; resources; validation; visualization; writing – original draft; writing – review & editing.
N. Todorovac – formal analysis; investigation; project
Acknowledgements
We are indebted to all multidisciplinary team members in the study centre for their enthusiastic support and following the study interventions for this investigator-initiated research. We therefore want to thank the following persons particularly:
Sioned Davies, Niamh Liley, Jonathan Pugh, David Penney, Joanne Wylie, and Charles Hayes; all of the department of Acute Medicine; Ysbyty Gwynedd and Bangor University, Bangor, United Kingdom: all were members of the local research group and helped
References (33)
- et al.
The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies
Lancet
(2007) - et al.
Intelligent dynamic clinical checklists improved checklist compliance in the intensive care unit
Br J Anaesth
(2017) - et al.
Simulation based medical education in graduate medical education training and assessment programs
Prog Pediatr Cardiol
(2017) Vision document: medical specialist 2025
(2017)- et al.
Trends in inpatient admission comorbidity and electronic health data: implications for resident workload intensity
J Hosp Med
(2018) - et al.
Emergency hospital admissions in England: which may be avoidable and how?
(2018) - et al.
What factors influence ward nurses’ recognition of and response to patient deterioration? An integrative review of the literature
Nurs Open
(2017) - et al.
How nurses and physicians judge their own quality of care for deteriorating patients on medical wards: self-assessment of quality of care is suboptimal
Crit Care Med
(2012) - et al.
Initial assessment and treatment with the Airway, Breathing, Circulation, Disability, Exposure (ABCDE) approach
Int J Gen Med
(2012) - et al.
Using the ABCDE approach to assess the deteriorating patient
Nurs Stand
(2017)
The efficacy of advanced life support: a review of the literature
Prehospital Disaster Med
Crisis checklists for in-hospital emergencies: expert consensus, simulation testing and recommendations for a template determined by a multi-institutional and multi-disciplinary learning collaborative
BMC Health Serv Res
Efficient organisation of intensive care units with a focus on quality: the non-physician provider
Crit Care
Recognizing and responding to the deteriorating patient
Handb ICU Ther
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These authors contributed equally to this work.