I saw The Checklist Manifesto: How to Get Things Right on a “what I’m reading” spot on Amit Maini’s EDTCC Blog recently, and thought it looked interesting, so bought myself the Kindle version, and read it a couple of days on my iphone.
The author (Atul Gawande), an American surgeon, delves into the story behind his recruitment into a project to develop surgical checklists. He was directly involved in the development of a checklist, which was distributed internationally by WHO and was shown to drastically improve patient safety and reduce morbidity and mortality.
His research covered areas as diverse as business, skyscraper building, fast-food, disaster management, aviation and of course, medicine. The book contains a fascinating plethora of anecdotes showing how checklists are used in all of these industries (and many more) to improve outcomes.
The underlying theme is about simplifying processes that we as modern professionals, in industries where the volume and complexity of information we are expected to know has outstripped our ability to retain and execute all of the tasks and procedures we’re expected to deal with.
How does this apply to Emergency Medicine? Firstly, in exam preparation: I used checklists (2 years before I read this book) to keep track of topics I was studying for the Fellowship exam. I didn’t just use the syllabus as the checklist (a sure fire path to insanity), instead I looked through the syllabus and picked out the expert level knowledge topics, and made one checklist of those, as they were the “must know” topics. I also used them to plan my study for the week, putting short lists of topics I had to get through for each day up on post it notes. Once I got better at writing checklists, I started writing some topic summaries as checklists. The most obvious topics these could be used for are the resuscitation topics, as these require factual knowledge and procedural skills to be combined, and are often done incorrectly or out of sequence. Checklists are different to most lists you learn for the exam, and from protocols (which are voluminous and tiresome to follow). They are succinct, practical lists of things to check & do in defined situations, and by definition should improve your practice, not hinder you by being an obstruction to proceding with whatever task you’re applying it to.
I also think that given the complexity of what Emergency Medicine entails, there are numerous potential applications for checklists that could be formally used in our day to day work. While experienced ED docs subconsciously use them, they would be great teaching aids, and would surely improve the performance of just about everything we do, from resuscitation, to procedures, to referrals, admissions and patient discharge.
Here’s a couple of examples:
Pre Intubation Checklist:
Check BSL – don’t intubate hypoglycemia
Check K+ on VBG – no sux if K+ high – femoral stab if no IV access
Check Laryngoscope handle/light
Check backup handle/light
Check & size ETT/cuff
Check & size LMA
Check BVM/O2 supply
Check patient position – ear to sternal notch
Check Vital signs – normalise as able
Check drugs & doses
Check & allocate staff roles before commencing
Check difficult airway trolley – cric kit at bedside
Communicate failed intubation plan to team
You can see how having a nurse standing next to you reading these items out while holding a red pen and a clipboard would minimise the chance of a bad intubation attmept!
Pre Lumbar Puncture:
Check for raised ICP – Clinically
CT If indicated
Check Platelets +/- coags – reconsider need if Plts < 50
Check for petechial rash (contra-indication in some jurisdictions)
Check for local skin infection
Check for previous back surgery
Check ability to maintain patient position
Check nurse assistant available for whole procedure
Check that lab able to process samples (BEFORE procedure commences)
Explanation & Consent verbal/written
I just made these up off the top of my head, but you can see, in our job, with the constant interruption to our thought processes, where it’s quite easy to forget or be distracted from one or two items on a checklist, how these sorts of lists could help avoid complications, and even potential disasters.
While the information you need to know to write these lists is all in the books, combining this with practical experience and sequencing of tasks is what helps create checklists, and like all dynamic tools, they need to be frequently revised before the optimal checklist is created. The practical application of this knowledge is also what turns it from a “list” (that you need to know for an exam) to a “checklist” that you can actually use in your day-to-day work.
I’d thoroughly recommend The Checklist Manifesto: How to Get Things Right to anyone studying for ACEM Primary or Fellowship Exams, and any experienced Emergency Physicians who want to improve their practice and teaching.