title: Testing the implementation of an electronic process-of-care checklist for use during morning medical rounds in a tertiary intensive care unit: a prospective before-after study.
abstract: BACKGROUND
  To improve the delivery of important care processes in the ICU, morning ward round checklists have been implemented in a number of intensive care units (ICUs) internationally. Good quality evidence supporting their use as clinical support tools is lacking. With increased use of technology in clinical settings, integration of such tools into current work practices can be a challenge and requires evaluation. Having completed preliminary work revealing variations in practice and evidence supporting the construct validity of a process-of-care checklist, the need to develop, test and further validate an e(lectronic)-checklist in an ICU was identified.
  
  
  METHODS
  A prospective, before-after study was conducted in a 19-bed general ICU within a tertiary hospital. Data collection occurred during baseline and intervention periods for 6 weeks each, with education and training conducted over a 4-week period prior to intervention. The e-checklist was used at baseline by ICU research nurses conducting post-ward round audits. During intervention, senior medical staff completed the e-checklist after patient assessments during the morning ward rounds, and research staff conducted post-ward round audits for validity testing (via concordance measurement). To examine changes in compliance over time, checklist-level data were analysed using generalised estimating equations that factored in confounding variables, and statistical process control charts were used to evaluate unit-level data. Established measures of concordance were used to evaluate e-checklist validity.
  
  
  RESULTS
  Compliance with each care component improved significantly over time; the largest improvement was for pain management (42% increase; adjusted odds ratio = 23, p < 0.001), followed by glucose management (22% increase, p < 0.001) and head-of-bed elevation (19% increase, p < 0.001), both with odds ratios greater than 10. Most detected omissions were corrected by the following day. Control charts illustrated reduced variability in care compliance over time. There was good concordance between physician and auditor e-checklist responses; seven out of nine cares had kappa values above 0.8.
  
  
  CONCLUSIONS
  Improvements in the delivery of essential daily care processes were evidenced after the introduction of an e-checklist to the morning ward rounds in an ICU. High levels of agreement between physician and independent audit responses lend support to the validity of the e-checklist.
authors.affiliation: NSW Intensive Care Co-ordination and Monitoring Unit, Agency for Clinical Innovation, Chatswood, Australia, karena.conroy@health.nsw.gov.au.
authors.forename: Karena M
authors.initials: KM
authors.lastname: Conroy
authors.forename: Doug
authors.initials: D
authors.lastname: Elliott
authors.forename: Anthony R
authors.initials: AR
authors.lastname: Burrell