title: Using a Post-Intubation Checklist and Time Out to Expedite Mechanical Ventilation Monitoring: Observational Study of a Quality Improvement Intervention.
abstract: BACKGROUND
  Delayed mechanical ventilation monitoring may impede recognition of life-threatening acidemia. Coordination of multidisciplinary processes can be improved by using a checklist and time-out procedure. The study objective was to evaluate process-related outcomes after implementation of a post-intubation checklist and time out.
  
  
  METHODS
  An observational study of a 24-bed medical ICU in Philadelphia, Pennsylvania, was conducted from January to December 2011. A random sample of mechanically ventilated adults was selected from the pre-intervention (n = 80) and post-intervention (n = 144) periods. The primary outcome was the proportion of subjects with an arterial blood gas (ABG) result within 60 min of mechanical ventilation initiation. Secondary outcomes included rates of respiratory acidosis, moderate-severe acidemia (pH <7.25), checklist initiation, and project sustainability. Chi-square analysis was used to evaluate differences in outcomes between time periods.
  
  
  RESULTS
  After the intervention, the proportion of subjects with an ABG result within 60 min increased (56% vs 37%, P = .01), and time to ABG result improved (58 min vs 79 min, P = .004). Adjusting for illness severity, the proportion with an ABG result within 60 min remained significantly higher in the post-intervention period (odds ratio 2.42, 95% CI 1.25-4.68, P = .009). Checklist adherence was higher with ICU intubations than for intubations performed outside the ICU (71% vs 27% checklist initiation rate, P < .001). Transfer from referring institutions (23% checklist initiation rate, P = .006) negatively impacted checklist use. Implementation challenges included frequent stakeholder turnover, undefined process ownership, and lack of real-time performance feedback.
  
  
  CONCLUSIONS
  A post-intubation checklist and time out improved the timeliness of mechanical ventilation monitoring through more rapid assessment of arterial blood gases. Implementing this peri-intubation procedure may reduce the risks associated with transitioning to full mechanical ventilatory support. Optimal implementation necessitates strategies to surmount organizational and behavioral barriers to change.
authors.affiliation: Division of Gastroenterology, Department of Medicine, University of California, San Francisco, San Francisco, California. ryan.mcconnell@ucsf.edu.
authors.forename: Ryan A
authors.initials: RA
authors.lastname: McConnell
authors.affiliation: Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.
authors.forename: Meeta Prasad
authors.initials: MP
authors.lastname: Kerlin
authors.affiliation: Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.
authors.forename: William D
authors.initials: WD
authors.lastname: Schweickert
authors.affiliation: Division of Cardiology, Department of Medicine, Northwestern University, Chicago, Illinois.
authors.forename: Faraz
authors.initials: F
authors.lastname: Ahmad
authors.affiliation: Department of Medicine, University of Pennsylvania, and Philadelphia Veterans Affairs Medical Center, Philadelphia, Pennsylvania.
authors.forename: Mitesh S
authors.initials: MS
authors.lastname: Patel
authors.affiliation: Division of Pulmonary, Allergy, and Critical Care, Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania.
authors.forename: Barry D
authors.initials: BD
authors.lastname: Fuchs
mesh_terms: D000368:Aged; D001784:Blood Gas Analysis; D057189:Checklist / Q000379:methods*; D003422:Critical Care / Q000379:methods / Q000592:standards*; D005260:Female; D006801:Humans; D007362:Intensive Care Units; D007440:Intubation / Q000009:adverse effects / Q000379:methods / Q000592:standards*; D008297:Male; D008875:Middle Aged; D008991:Monitoring, Physiologic / Q000379:methods / Q000592:standards; D010043:Outcome and Process Assessment, Health Care; D015143:Philadelphia; D058996:Quality Improvement; D012121:Respiration, Artificial / Q000009:adverse effects / Q000379:methods / Q000592:standards*; D013997:Time Factors; D055397:Ventilator-Induced Lung Injury / Q000209:etiology / Q000517:prevention & control
keywords: acidosis; artificial respiration; blood gas analysis; checklist; mechanical ventilators; quality improvement