As I mentioned last week, I am an Atul Gawande “groupie.” His book, The Checklist Manifesto, convinced me that checklists are key to how we improve the quality of care.
A Scenario
You have a 3yr old male cat named Phil. Phil develops a urinary tract obstruction and is yowling when you get home from work at 7pm. You take him to the emergency clinic for care. At the hospital, the doctor recommends a minimum database, urinalysis, radiograph, urine culture, unblocking and hospitalization for 24-48 hours. The estimated cost is $1400-1800. At the end of 36 hours, you are able to take him home with a set of written discharges and a single prescription of pain medication.
The Second Cat
Because it is not your month (and maybe because of the stressful remodel in your apartment), your other 3yr old male cat, Jay, also develops a urinary tract obstruction. You take him to the same ER expecting a similar cost and plan. However, this time the estimated cost is $2000-2500. When you ask, Jay is no sicker than Phil, and doesn’t have an infection or stone. This time the vet on duty recommends a full blood panel, antibiotics just in case, 48-72 hours of care, and 4 medications to go home. When you come to pick up Jay, there are no written discharges despite the 4 medications and a technician is not available to discuss at home care.
How would you feel if this happened? Would you have confidence in the hospital?
Scenarios like these happen all the time in veterinary emergency rooms. The mantra is that doctors should be allowed to practice medicine their way. We don’t question how treatment variations are perceived by clients. We leave it up to doctor discretion how discharges are communicated to clients.
When reliability is an expectation
In other areas of our lives, we would not accept this type of inconsistent service. Would you go back to a restaurant if the same meal varied in price by 30% in a month? Would you go back if you had a great meal one time and then a mediocre meal or poor service the second? If you had another choice of where to eat out that was consistently good in the way you expected, you are likely to choose it instead.
Quality care means reliable care
My definition of quality veterinary care is safe, reliable, effective healthcare that puts pets and their families first. Assuring that the care received in your hospital by different doctors, different technicians and at different times of day is always safe and effective is part of creating reliable healthcare. Understanding the perceptions of clients when care recommendations differ is how we put pet families first.
How do you create reliable care?
When your hospital is staffed by doctors who have trained and worked in different hospitals in the past, care recommendations will tend to differ. Because we have a paucity of high quality large studies, many treatment recommendations are based on opinion or experience. For new graduate veterinarians, it is easy to miss a diagnostic step or a differential due to inexperience. For more experienced veterinarians, it is hard to keep track of new publications and adapt care to new recommendations.
On the human side, it is recognized that written care bundles, pathways, and checklists provide “guardrails” for care for new doctors and provide “at your fingertips” newest evidence-based recommendations for more experienced doctors. In addition, checklists and care bundles help assure consistent care for patients whenever they are seen.
Evidence supports that care is better with checklists and algorithms
Several studies in both human healthcare and veterinary healthcare have demonstrated more reliable care and improved outcomes with checklists and care bundles.
Written resuscitation algorithms save lives
In 2001, Rivers, et al, published a report in the New England Journal of Medicine showing that early goal directed therapy of septic shock led to increased hospital discharge and also decreased mortality at 28 days. In the study, randomized patients received either standard resuscitation or were resuscitated according to a written algorithm with set resuscitation goals. By setting a time by which patients should reach certain cardiovascular parameters, patients received care more quickly.
Care bundles are now widely accepted for sepsis. This means that “standard” care is now also based on written guidelines and algorithms. More recent studies have not shown the same result as the Rivers study because the treatment arms are less different. A meta-analysis of 50 studies confirmed that compliance with 6-hour and 24-hour sepsis care bundles led to a significant decrease in mortality from sepsis. . The first hour pocket card algorithm can be found here http://www.survivingsepsis.org/SiteCollectionDocuments/Surviving-Sepsis-Campaign-Hour-1-Bundle-2018-Print-Card.pdf
Surgery checklists save lives
In 2009, Hayes, et al reported in the New England Journal of Medicine that complications and per-operative mortality were both decreased with use of a surgical checklist. In this study, surgical complications and mortality were tracked for 3 months in 8 hospitals in 8 different countries throughout the world. After 3 months, a collaboratively developed surgical checklist was implemented in all the hospitals. At the end of the next 3 months, the rate of complications and death were compared to prior. The study involved almost 8000 patients. The use of a checklist, taking less than 10 minutes total time, decreased 30 day mortality from 1.5% to 0.8% and decreased complications from 11% to 7%.
Evidence from Veterinary Medicine
A written care bundle improves time to administration of antibiotics in septic patients
Studies in human medicine have demonstrated that time to antibiotic administration is directly related to outcome in septic patients. In fact, survival drops with each hour delay. In an interesting study from Tufts University, time to administration of antibiotics was measured in 20 dogs presenting with septic peritonitis. After establishing a baseline, a written protocol was implemented in septic peritonitis patients. Time to antibiotic administration was then measured in the next 40 dogs. Time to appropriate antibiotic administration dropped from 6 hours to 1 hour with the implementation of the protocol.
Mortality and complications also decrease with veterinary surgical checklists
In a prospective case study, 300 dogs and cats were followed after surgery prior to implementation of a checklist. A checklist, modified from the human surgery checklist, was implemented and the next 220 dogs and cats were followed. This study, like the study in human medicine, confirmed that a simple checklist significantly reduced complications and wound infections.
Here is the surgical checklist we developed for our hospitals:
What about Blocked Cats?
At my previous hospital, the emergency team agreed to standardize our approach to blocked cats. In a multiyear study, we demonstrated that by making protocol changes over time, we were able to decrease the incidence of re-occurance. This standard approach also meant that clients had a similar estimate and treatment plan no matter which doctor they saw. Email me at bdavidow@vetidealist.com for a copy of our protocol.
PS The real reason for my blog title today – this is blog number 42.