Rationale: Checklists may reduce errors of omission for critically ill patients. Objectives: To determine whether prompting to use a checklist improves process of care and clinical outcomes. Methods: We conducted a cohort study in the medical intensive care unit (MICU) of a tertiary care university hospital. Patients admitted to either of two independent MICU teams were included. Intervention team physicians were prompted to address six parameters from a daily rounding checklist if overlooked during morning work rounds. The second team (control) used the identical checklist without prompting. Measurements and Main Results: One hundred and forty prompted group patients were compared with 125 control and 1,283 preintervention patients. Compared with control, prompting increased median ventilator-free duration, decreased empirical antibiotic and central venous catheter duration, and increased rates of deep vein thrombosis and stress ulcer prophylaxis. Prompted group patients had lower risk-adjusted ICU mortality compared with the control group (odds ratio, 0.36; 95% confidence interval, 0.13-0.96; P ¼ 0.041) and lower hospital mortality compared with the control group (10.0 vs. 20.8%; P ¼ 0.014), which remained significant after risk adjustment (odds ratio, 0.34; 95% confidence interval, 0.15-0.76; P ¼ 0.008). Observed-to-predicted ICU length of stay was lower in the prompted group compared with control (0.59 vs. 0.87; P ¼ 0.02). Checklist availability alone did not improve mortality or length of stay compared with preintervention patients. Conclusions: In this single-site, preliminary study, checklist-based prompting improved multiple processes of care, and may have improved mortality and length of stay, compared with a stand-alone checklist. The manner in which checklists are implemented is of great consequence in the care of critically ill patients.

Objective Low tidal volume ventilation (LTVV) lowers mortality in the acute respiratory distress syndrome (ARDS). Previous studies reported poor LTVV implementation. We sought to determine the rate, quality, and predictors of LTVV use. Design Retrospective cross-sectional study. Setting One academic, three community hospitals in the Chicago region. Patients 362 adults meeting the Berlin Definition of ARDS consecutively admitted between June-December, 2013. Measurements and Main Results Seventy patients (19.3%) were treated with LTVV (tidal volume <6.5mL/kg predicted body weight [PBW]) at some time during mechanical ventilation. 22.2% of patients requiring a fraction of inspired oxygen (FIO2) >40% and 37.3% of patients with FIO2>40% and plateau pressure >30cm H2O received LTVV. The entire cohort received LTVV 11.4% of the time patients had ARDS. Among patients who received LTVV, the mean (SD) percentage of ARDS time it was used was 59.1% (38.2%), and 34% waited more than 72 hours prior to LTVV initiation. Women were less likely to receive LTVV, whereas sepsis and FIO2>40% were associated with increased odds of LTVV use. Four attending physicians (6.2%) initiated LTVV within one day of ARDS onset for ≥50% of their patients, whereas 34 physicians (52.3%) never initiated LTVV within one day of ARDS onset. 54.4% of patients received a tidal volume <8ml/kg PBW, and the mean tidal volume during the first 72 hours after ARDS onset was never less than 8mL/kg PBW. Conclusions More than 12 years after publication of the landmark LTVV study, use remains poor. Interventions that improve adoption of LTVV are needed.

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Elevated bronchoalveolar lavage amylase is associated with risk factors for aspiration and may predict bacterial pneumonia. Bronchoalveolar lavage amylase may be useful as an early screening tool to guide management of patients suspected of aspiration.