Testing the effects of checklists on team behaviour during emergencies on general wards: An observational study using high-fidelity simulation

Abstract

Introduction

Clinical teams struggle on general wards with acute management of deteriorating patients. We hypothesized that the Crisis Checklist App, a mobile application containing checklists tailored to crisis-management, can improve teamwork and acute care management.

Methods

A before-and-after study was undertaken in high-fidelity simulation centres in the Netherlands, Denmark and United Kingdom. Clinical teams completed three scenarios with a deteriorating patient without checklists followed by three scenarios using the Crisis Checklist App. Teamwork performance as the primary outcome was assessed by the Mayo High Performance Teamwork scale. The secondary outcomes were the time required to complete all predefined safety-critical steps, percentage of omitted safety-critical steps, effects on other non-technical skills, and users’ self-assessments. Linear mixed models and a non-parametric survival test were conducted to assess these outcomes.

Results

32 teams completed 188 scenarios. The Mayo High Performance Teamwork scale mean scores improved to 23.4 out of 32 (95% CI: 22.4–24.3) with the Crisis Checklist App compared to 21.4 (20.4–22.3) with local standard of care. The mean difference was 1.97 (1.34–2.6; p < 0.001). Teams that used the checklists were able to complete all safety-critical steps of a scenario in more simulations (40/95 vs 21/93 scenarios) and these steps were completed faster (stratified log-rank test χ² = 8.0; p = 0.005). The self-assessments of the observers and users showed favourable effects after checklist usage for other non-technical skills including situational awareness, decision making, task management and communication.

Conclusions

Implementation of a novel mobile crisis checklist application among clinical teams was associated in a simulated general ward setting with improved teamwork performance, and a higher and faster completion rate of predetermined safety-critical steps.

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.