{"id":10183,"date":"2022-03-22T15:31:52","date_gmt":"2022-03-22T15:31:52","guid":{"rendered":"https:\/\/tvn.tv-multi-theme.com.216-70-96-51.jvv2-rfnp.accessdomain.com\/?p=10183"},"modified":"2022-06-20T18:07:54","modified_gmt":"2022-06-20T18:07:54","slug":"the-evidence-for-checklists-and-patient-care-bundles-in-veterinary-nursing","status":"publish","type":"post","link":"https:\/\/navc.sitepreview.app\/todaysveterinarynurse.com\/emergency-medicine-critical-care\/the-evidence-for-checklists-and-patient-care-bundles-in-veterinary-nursing\/","title":{"rendered":"The Evidence for Checklists and Patient Care Bundles in Veterinary Nursing"},"content":{"rendered":"<p class=\"p1\"><span class=\"s1\">I<\/span>n human medicine, checklists and patient care bundles have been widely researched for their effectiveness at preventing medical errors and ultimately reducing morbidity and mortality in the emergency and critical care setting. In the veterinary intensive care unit (ICU), implementation of checklists and patient care bundles allows the veterinary team to elevate the standard of patient care, create a standardized approach, and improve patient outcomes. This article reviews the evidence for checklists and patient care bundles used in human medicine as well as the measures applicable to veterinary patients.<\/p>\n<h2 class=\"p1\">Factors in Medical Errors<\/h2>\n<p class=\"p2\"><span class=\"s1\">The potential for medical errors in the hospital setting is of significant concern. In human health care, patient safety research has found that up to 98<\/span><span class=\"s2\">\u2009<\/span><span class=\"s1\">000 patients die annually in the United States as the result of medical errors.<sup>1<\/sup> The most common contributor to these errors is human error resulting from cognitive limitations, deficiencies in nontechnical skills, or system or environmental limitations that influence decisions.<sup>1<\/sup> Cognitive limitations include mistakes, lapses, slips, distractions, stress, and bias. Nontechnical deficiencies include ineffective communication skills and leadership. System limitations include management, workflow, organization, and staffing deficiencies.<sup>1<\/sup><\/span><\/p>\n<p class=\"p1\"><div class=\"su-box su-box-style-default\" id=\"\" style=\"border-color:#333333;border-radius:0px;\"><div class=\"su-box-title\" style=\"background-color:#666666;color:#ffffff;border-top-left-radius:0px;border-top-right-radius:0px\">BOX 1 Causes of Errors in Veterinary Practice<sup>1<\/sup><\/div><div class=\"su-box-content su-u-clearfix su-u-trim\" style=\"border-bottom-left-radius:0px;border-bottom-right-radius:0px\"><strong>Active failures <\/strong><\/p>\n<ul>\n<li class=\"p1\">Cognitive limitations (e.g., mistakes, lapses, slips, distractions, stress, bias)<\/li>\n<li class=\"p1\">Individual factors<\/li>\n<li class=\"p1\">Lack of technical ability<\/li>\n<li class=\"p1\">Inadequate care<\/li>\n<\/ul>\n<p><strong>System failures<\/strong><\/p>\n<ul>\n<li class=\"p1\">Communication<\/li>\n<li class=\"p1\">Leadership<\/li>\n<li class=\"p1\">Design of product or equipment<\/li>\n<li class=\"p1\">Productivity<\/li>\n<li class=\"p1\">Organizational failure (e.g., management, workflow, staffing)<\/li>\n<li class=\"p1\">Clients<\/div><\/div><\/li>\n<\/ul>\n<p class=\"p2\"><span class=\"s1\">Although veterinary research investigating overall morbidity and mortality statistics is limited, medical errors also occur in the veterinary profession. A survey published in 2004 found that 78% of recent veterinary graduates admitted to making medical errors.<sup>1<\/sup> The most common causes of these errors included lack of experience, time management, and communication breakdowns.<sup>1<\/sup> A survey published in 2015 sought to determine the causes and types of errors in veterinary practice.<sup>2<\/sup> <\/span><strong><span class=\"s3\">BOX 1<\/span><\/strong><span class=\"s1\"> lists the causes of errors it identified and <\/span><strong><span class=\"s3\">FIGURE 1<\/span><\/strong><span class=\"s1\"> summarizes the incidence area of each error type.<sup>2<\/sup> Although more research is needed, the findings from this survey closely correlate to the types and causes of errors in human health care.<sup>1,2<\/sup><\/span><\/p>\n<div id=\"attachment_6141\" style=\"width: 510px\" class=\"wp-caption aligncenter\"><a href=\"http:\/\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2022\/03\/Waxman_ICUChecklistsBundles_TVNSpring22_Fig1.png\" target=\"_blank\" rel=\"noopener\"><img fetchpriority=\"high\" decoding=\"async\" aria-describedby=\"caption-attachment-6141\" class=\"wp-image-6141\" src=\"http:\/\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2022\/03\/Waxman_ICUChecklistsBundles_TVNSpring22_Fig1-300x279.png\" alt=\"\" width=\"500\" height=\"465\" \/><\/a><p id=\"caption-attachment-6141\" class=\"wp-caption-text\"><strong>Figure 1.<\/strong> Incidence of types of errors in veterinary practice.1 Surgical=49%, medical=35%, diagnosis=9%, advice=5%, and anesthesia=2%.<\/p><\/div>\n<h2 class=\"p1\">Patient Care Checklists<\/h2>\n<p class=\"p2\"><span class=\"s1\">A checklist can be described as a step-by-step process of evidence-based interventions that help prevent medical oversights during ICU patient care.<sup>3,4<\/sup> A checklist is typically specific to a given procedure or treatment and does not encompass all aspects of patient care.<sup>4<\/sup><\/span><\/p>\n<p class=\"p2\"><span class=\"s1\">Checklists have been implemented as patient safety systems in several other fields, including aviation, engineering, construction, and human health care.<sup>2,5<\/sup> In his book <i>The Checklist Manifesto<\/i>, Atul Gawande says in regard to patient care, \u201cthis is the reality of intensive care; at any point, we are as apt to harm as we are to heal.\u201d<sup>5<\/sup> Gawande\u2019s book focuses on the use of checklists in relation to several elements of daily and professional life and examines how checklists can be used for greater efficiency, consistency, and safety.<sup>5<\/sup><\/span><\/p>\n<p class=\"p2\"><span class=\"s1\"><div class=\"su-box su-box-style-default\" id=\"\" style=\"border-color:#333333;border-radius:0px;\"><div class=\"su-box-title\" style=\"background-color:#666666;color:#ffffff;border-top-left-radius:0px;border-top-right-radius:0px\">BOX 2 Benefits of Checklists and Patient Care Bundles<\/div><div class=\"su-box-content su-u-clearfix su-u-trim\" style=\"border-bottom-left-radius:0px;border-bottom-right-radius:0px\"><strong>Checklists<sup>2,3<\/sup><\/strong> <\/span><\/p>\n<ul>\n<li class=\"p2\"><span class=\"s1\">Create memory recall (e.g., users are less likely to overlook simple steps) <\/span><\/li>\n<li class=\"p2\"><span class=\"s1\">Create a culture of accountability <\/span><\/li>\n<li class=\"p2\"><span class=\"s1\">Standardize care <\/span><\/li>\n<li class=\"p2\"><span class=\"s1\">Reduce patient harm <\/span><\/li>\n<li class=\"p2\"><span class=\"s1\">I<\/span><span class=\"s1\">mprove consistency of care <\/span><\/li>\n<li class=\"p2\"><span class=\"s1\">Help avoid medical errors <\/span><\/li>\n<\/ul>\n<p><strong><span class=\"s1\">Patient care bundles<sup>4<\/sup> <\/span><\/strong><\/p>\n<ul>\n<li class=\"p2\"><span class=\"s1\">Maintain consistency in patient care <\/span><\/li>\n<li class=\"p2\"><span class=\"s1\">Set patient care standards <\/span><\/li>\n<li class=\"p2\"><span class=\"s1\">Improve overall quality of the nursing care provided <\/span><\/li>\n<li class=\"p2\"><span class=\"s1\">Establish best clinical practices <\/span><\/li>\n<li class=\"p2\"><span class=\"s1\">Improve clinical effectiveness <\/span><\/li>\n<li class=\"p2\"><span class=\"s1\">Reduce morbidity and mortality by promoting a more all-inclusive approach to patient care<\/div><\/div><\/span><\/li>\n<\/ul>\n<p class=\"p2\"><span class=\"s1\">Checklists can be used by the veterinary healthcare team as tools to minimize errors and instill a culture of quality improvement when it comes to patient care.<sup>2<\/sup> <\/span><strong><span class=\"s3\">BOX 2<\/span><\/strong><span class=\"s1\"> lists some identified benefits of using checklists in patient care, many of which address causes of error listed in <strong><span class=\"s3\">BOX 1<\/span><\/strong><\/span><span class=\"s1\">. <strong><span class=\"s3\">BOX 3<\/span><\/strong><\/span><span class=\"s1\">\u00a0provides links to specific published protocols.<span class=\"Apple-converted-space\">\u00a0<\/span><\/span><\/p>\n<p class=\"p2\"><span class=\"s1\"><span class=\"Apple-converted-space\"><div class=\"su-box su-box-style-default\" id=\"\" style=\"border-color:#333333;border-radius:0px;\"><div class=\"su-box-title\" style=\"background-color:#666666;color:#ffffff;border-top-left-radius:0px;border-top-right-radius:0px\">BOX 3 Published Checklists and Patient Care Bundles<\/div><div class=\"su-box-content su-u-clearfix su-u-trim\" style=\"border-bottom-left-radius:0px;border-bottom-right-radius:0px\"><\/span><\/span><\/p>\n<ul>\n<li class=\"p2\"><span class=\"s1\"><span class=\"Apple-converted-space\">The World Health Organization Surgical Safety Checklist (2009): <a href=\"http:\/\/bit.ly\/3Bsn3Ll\">bit.ly\/3Bsn3Ll<\/a> <\/span><\/span><\/li>\n<li class=\"p2\"><span class=\"s1\"><span class=\"Apple-converted-space\">RECOVER Initiative CPR algorithm, drugs and dosages chart, and post-cardiac arrest care algorithm (2012): <a href=\"http:\/\/bit.ly\/3JBVW36\">bit.ly\/3JBVW36<\/a> <\/div><\/div><\/span><\/span><\/li>\n<\/ul>\n<h3 class=\"p3\">Human Medical Literature<\/h3>\n<p class=\"p2\"><span class=\"s1\">Checklists have been widely researched in the human emergency and critical care setting.<sup>3<\/sup> The most commonly used checklists include those intended to prevent ventilator-associated pneumonia (VAP), to prevent catheter-related bloodstream infections (CRBSIs), and to ensure surgical safety.<span class=\"Apple-converted-space\">\u00a0<\/span><\/span><\/p>\n<h3 class=\"p4\">Ventilator-Associated Pneumonia<\/h3>\n<p class=\"p2\"><span class=\"s1\">In the human ICU setting, VAP affects 15% of patients who receive ventilation therapy.<sup>6<\/sup> Because infection from any source contributes to higher morbidity and mortality rates, a study was conducted in trauma patients to determine if implementation of a VAP prevention checklist would decrease the incidence of VAP.<sup>6<\/sup> The elements of the VAP checklist are (1) elevation of the head to 30\u00b0 to 45\u00b0, (2) twice-daily oral cleansing with dilute chlorhexidine, (3) daily assessment of readiness to wean, (4) nasogastric tube placement for peptic ulcer prophylaxis at the earliest possible time, and (5) deep thrombosis prophylaxis. The study results showed a 45% reduction in the incidence of VAP after implementation of the checklist.<span class=\"Apple-converted-space\">\u00a0<\/span><\/span><\/p>\n<h3 class=\"p4\">Catheter-Related Bloodstream Infections<\/h3>\n<p class=\"p2\"><span class=\"s1\">Similar to VAP, CRBSIs are associated with high morbidity and mortality in human ICU patients, an estimated 48% of whom have indwelling central venous catheters.<sup>7<\/sup> In an effort to eliminate CRBSIs in the ICU setting, a study was conducted to examine if implementation of a checklist based on previously developed clinical guidelines would decrease the incidence of CRBSIs. The elements of the CRBSI checklist were (1) appropriate hand hygiene, (2) skin preparation using dilute chlorhexidine, (3) full barrier precautions during central venous catheter placement (<\/span><strong><span class=\"s3\">FIGURE 2<\/span><\/strong><span class=\"s1\">), (4) optimal catheter site selection, (5) sterile field maintenance during central venous catheter placement, and (6) daily assessment of central line necessity.<sup>8<\/sup> The study results showed a 66% reduction in the incidence of CRBSIs that was sustained over a 15-month period after implementation of the checklist.<sup>7,8<\/sup><\/span><\/p>\n<div id=\"attachment_10145\" style=\"width: 360px\" class=\"wp-caption aligncenter\"><a href=\"https:\/\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2022\/03\/Waxman_ICUChecklistsBundles_TVNSpring22_Fig2.png\"><img decoding=\"async\" aria-describedby=\"caption-attachment-10145\" class=\" wp-image-10145\" src=\"https:\/\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2022\/03\/Waxman_ICUChecklistsBundles_TVNSpring22_Fig2.png\" alt=\"\" width=\"350\" height=\"234\" srcset=\"https:\/\/navc.sitepreview.app\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2022\/03\/Waxman_ICUChecklistsBundles_TVNSpring22_Fig2.png 864w, https:\/\/navc.sitepreview.app\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2022\/03\/Waxman_ICUChecklistsBundles_TVNSpring22_Fig2-300x200.png 300w, https:\/\/navc.sitepreview.app\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2022\/03\/Waxman_ICUChecklistsBundles_TVNSpring22_Fig2-768x513.png 768w\" sizes=\"(max-width: 350px) 100vw, 350px\" \/><\/a><p id=\"caption-attachment-10145\" class=\"wp-caption-text\">Figure 2. Veterinary nurse wearing full barrier precautions. David Herraez Calzada\/shutterstock.com<\/p><\/div>\n<h3 class=\"p4\">Surgical Safety<span class=\"Apple-converted-space\">\u00a0<\/span><\/h3>\n<p class=\"p2\"><span class=\"s1\">Surgical errors account for 49% of errors in human ICUs.<sup>9<\/sup> In 2008, the World Health Organization (WHO) created a surgical safety checklist in an effort to improve patient safety during surgical procedures and reduce adverse events associated with surgical procedures.<sup>10<\/sup> The WHO looked at the major checkpoints associated with surgical procedures: before anesthesia induction (sign in), before surgical incision (time out), and before recovery (sign out). The authors of a study published in 2009 hypothesized that implementing a surgical safety checklist would improve team communication, reduce surgical complications, and reduce postsurgical infections.<sup>9<\/sup> They aimed to evaluate the effect of implementation of the WHO surgical safety checklist. The study results showed that there was a 35% reduction in postoperative morbidity and a 48% reduction in mortality after implementation. As a result of the data, the WHO surgical safety checklist is now routinely used in hospitals around the world.<sup>9<\/sup><\/span><\/p>\n<h3 class=\"p3\">Veterinary Literature<\/h3>\n<p class=\"p2\"><span class=\"s1\">As veterinary medicine is continuously evolving, so are client expectations for the level of patient care. In the emergency and critical care setting, patient care checklists can be used to optimize patient care quality and standards. The most common checklists used in veterinary medicine include Kirby\u2019s Rule of 20, the RECOVER CPR algorithm, and the surgical safety checklist.<span class=\"Apple-converted-space\">\u00a0<\/span><\/span><\/p>\n<h3 class=\"p4\">Kirby\u2019s Rule of 20<span class=\"Apple-converted-space\">\u00a0<\/span><\/h3>\n<p class=\"p2\"><span class=\"s1\">Kirby\u2019s Rule of 20 is a checklist created by Rebecca Kirby, DVM, DACVIM, DACVECC. It consists of 20\u00a0patient parameters that should be evaluated daily in critically ill patients to ensure quality patient care (<\/span><strong><span class=\"s3\">BOX 4<\/span><\/strong><span class=\"s1\">).<sup>11<\/sup> Following the Kirby\u2019s Rule of 20 checklist allows veterinary nurses to assess the overall clinical picture of a patient, implement critical thinking skills, elevate the quality of patient care, set standards for patient care, and decrease morbidity and mortality, resulting in improved patient outcomes.<span class=\"Apple-converted-space\">\u00a0<\/span><\/span><\/p>\n<p class=\"p2\"><span class=\"s1\"><span class=\"Apple-converted-space\"><div class=\"su-box su-box-style-default\" id=\"\" style=\"border-color:#333333;border-radius:0px;\"><div class=\"su-box-title\" style=\"background-color:#666666;color:#ffffff;border-top-left-radius:0px;border-top-right-radius:0px\">BOX 4 Kirby\u2019s Rule of 20<sup>11<\/sup><\/div><div class=\"su-box-content su-u-clearfix su-u-trim\" style=\"border-bottom-left-radius:0px;border-bottom-right-radius:0px\"> <\/span><\/span><\/p>\n<ul>\n<li class=\"p2\"><span class=\"s1\"><span class=\"Apple-converted-space\">Fluid balance, colloidal osmotic pressure <\/span><\/span><\/li>\n<li class=\"p2\"><span class=\"s1\"><span class=\"Apple-converted-space\">Oxygenation and ventilation <\/span><\/span><\/li>\n<li class=\"p2\"><span class=\"s1\"><span class=\"Apple-converted-space\">Blood pressure <\/span><\/span><\/li>\n<li class=\"p2\"><span class=\"s1\"><span class=\"Apple-converted-space\">Heart rate, contractility, rhythm <\/span><\/span><\/li>\n<li class=\"p2\"><span class=\"s1\"><span class=\"Apple-converted-space\">Glucose <\/span><\/span><\/li>\n<li class=\"p2\"><span class=\"s1\"><span class=\"Apple-converted-space\">Body temperature <\/span><\/span><\/li>\n<li class=\"p2\"><span class=\"s1\"><span class=\"Apple-converted-space\">Albumin <\/span><\/span><\/li>\n<li class=\"p2\"><span class=\"s1\"><span class=\"Apple-converted-space\">Electrolytes <\/span><\/span><\/li>\n<li class=\"p2\"><span class=\"s1\"><span class=\"Apple-converted-space\">Mentation <\/span><\/span><\/li>\n<li class=\"p2\"><span class=\"s1\"><span class=\"Apple-converted-space\">Red blood cells and hemoglobin <\/span><\/span><\/li>\n<li class=\"p2\"><span class=\"s1\"><span class=\"Apple-converted-space\">Gastrointestinal motility and int<\/span><\/span><span class=\"s1\"><span class=\"Apple-converted-space\">egrity <\/span><\/span><\/li>\n<li class=\"p2\"><span class=\"s1\"><span class=\"Apple-converted-space\">Nutrition <\/span><\/span><\/li>\n<li class=\"p2\"><span class=\"s1\"><span class=\"Apple-converted-space\">Renal function <\/span><\/span><\/li>\n<li class=\"p2\"><span class=\"s1\"><span class=\"Apple-converted-space\">Coagulation <\/span><\/span><\/li>\n<li class=\"p2\"><span class=\"s1\"><span class=\"Apple-converted-space\">Immune status, antibiotics <\/span><\/span><\/li>\n<li class=\"p2\"><span class=\"s1\"><span class=\"Apple-converted-space\">Drug dosage and metabolism <\/span><\/span><\/li>\n<li class=\"p2\"><span class=\"s1\"><span class=\"Apple-converted-space\">Wound care and bandages <\/span><\/span><\/li>\n<li class=\"p2\"><span class=\"s1\"><span class=\"Apple-converted-space\">Pain control <\/span><\/span><\/li>\n<li class=\"p2\"><span class=\"s1\"><span class=\"Apple-converted-space\">Nursing care <\/span><\/span><\/li>\n<li class=\"p2\"><span class=\"s1\"><span class=\"Apple-converted-space\">Tender loving care<\/div><\/div><\/span><\/span><\/li>\n<\/ul>\n<h3 class=\"p4\">RECOVER CPR Algorithm<\/h3>\n<p class=\"p2\"><span class=\"s1\">The Reassessment Campaign on Veterinary Resuscitation (RECOVER) Initiative was designed to systematically evaluate the scientific literature regarding the clinical practice of cardiopulmonary resuscitation (CPR) in veterinary medicine.<sup>12<\/sup> The initiative had 2\u00a0goals: (1) create clinical consensus guidelines on how best to address cardiopulmonary arrest in dogs and cats and (2) identify important knowledge gaps within veterinary CPR to improve the consensus recommendations and overall quality of patient care.<sup>12<\/sup><\/span><\/p>\n<p class=\"p2\"><span class=\"s1\">The initiative found that cognitive aids used in ICU\/CPR settings help with memory recall and rescuer compliance, as well as provide a point of reference for the team about what CPR care is needed.<sup>13<\/sup> It therefore <\/span>created a CPR algorithm as a cognitive aid to summarize<span class=\"s1\"> the clinical guidelines most relevant for performing CPR.<sup>13<\/sup> The algorithm provides step-by-step prompts to the veterinary rescuers involved in CPR efforts.<sup>13<\/sup><span class=\"Apple-converted-space\">\u00a0<\/span><\/span><\/p>\n<h3 class=\"p4\">Surgical Safety Checklist<\/h3>\n<p class=\"p2\"><span class=\"s1\">Since the significant results supporting use of the WHO surgical safety checklist were published in the human medical literature, with subsequent widespread adoption of the checklist across human health care, 2\u00a0studies using the WHO checklist have been published in veterinary literature.<span class=\"Apple-converted-space\">\u00a0<\/span><\/span><\/p>\n<p class=\"p2\"><span class=\"s1\">In 2014, the University of Georgia Veterinary Teaching Hospital created a study to determine the incidence of specific anesthesia patient safety incidents (closed adjustable pressure limiting valve, esophageal intubation, medication error), develop interventions to address common incidents reported, and evaluate the effectiveness of the developed interventions. In the first period of the study, the rate of anesthesia patient safety incidents was 3.6% (74 incidents in 2028 patients); in the second period, the rate was 1.4% (30 incidents in 2112 patients). Between the study periods, the hospital implemented 2 protocol changes as well as 2\u00a0checkboxes in anesthesia records that documented <\/span>confirmation of intubation both before the operation and in the operating room.<sup>14<\/sup><span class=\"Apple-converted-space\">\u00a0<\/span><\/p>\n<p class=\"p2\"><span class=\"s1\">In 2016, a veterinary teaching hospital in Sweden adapted the WHO surgical safety checklist to examine its effectiveness in the hospital\u2019s patient population. The researchers specifically wanted to evaluate whether the checklist could reduce the incidence of complications after small animal surgery, so they mirrored their study after those published in the human literature. The study results showed a 10% reduction in the frequency of postoperative complications following implementation of the surgical safety checklist (52\/300\u00a0patients before implementation versus 15\/220\u00a0patients after).<sup>15<\/sup><\/span><\/p>\n<h2 class=\"p1\">Patient Care Bundles<\/h2>\n<p class=\"p2\"><span class=\"s1\">The concept of patient care bundles was first developed at Johns Hopkins University in 2002. Patient care bundles can be described as a grouping of care elements based on evidence-based interventions used in hospital ICUs. The idea is that by combining several practices, healthcare providers will have a greater effect on patient care, leading to more positive patient outcomes.<sup>4<\/sup> Similar to checklists, patient care bundles have the <\/span>overall goal of helping to reduce and\/or prevent medical <span class=\"s1\">errors and patient care oversights. Unlike checklists, patient care bundles encompass more aspects of patient care and are generally created on a particular <\/span>clinical sign, treatment, or procedure as part of a general<span class=\"s1\"> disease process. <\/span><span class=\"s3\">Box 2<\/span><span class=\"s1\"> lists some identified benefits of using patient care bundles; again, many correlate to active and system failures that can be causes of error.<span class=\"Apple-converted-space\">\u00a0<\/span><\/span><\/p>\n<h3 class=\"p3\">Human Medical Literature<span class=\"Apple-converted-space\">\u00a0<\/span><\/h3>\n<p class=\"p2\"><span class=\"s1\">In the human medical literature, patient care bundles have a longstanding record of success in reducing patient morbidity and mortality. Care bundles came about from an expectation of following evidence-based practice in human health care and an interest in developing tools to improve the quality of patient care.<sup>4<\/sup> Although patient care bundles have not been as thoroughly researched or implemented in veterinary medicine, similar concepts can be applied and adapted for use in the veterinary ICU setting.<\/span><\/p>\n<p class=\"p2\"><span class=\"s1\">The most common care bundles used in human medicine that are relevant in the veterinary ICU setting include the patient handoff program, the CRBSI care bundle, and the Surviving Sepsis Campaign (SSC) hour-1 bundle.<\/span><\/p>\n<h3 class=\"p4\">Patient Handoff Program<\/h3>\n<p class=\"p2\"><span class=\"s1\">A key aspect of patient care is the ability to effectively perform patient rounding. Patient rounds involve the exchange of patient information between care providers. This is most routinely performed at shift changes between off-going and oncoming veterinary nurses but is also indicated during departmental transfers. The patient rounding process should be relatively quick (1 to 3 minutes per patient) and include only the most pertinent patient information (fine details can be found in the medical record). It is also ideal to have any member of the veterinary healthcare team who will be caring for ICU patients participate in patient rounds.<\/span><\/p>\n<p class=\"p2\"><span class=\"s1\">Effective team communication is essential to providing exceptional patient care, and the most effective way to communicate with the entire veterinary team is through a structured, systematic patient handoff program. A 2014 study conducted in 9 human hospitals identified miscommunication as a leading cause of medical errors and aimed to evaluate if implementation of a patient handoff program would reduce medical errors, prevent adverse events, and improve overall workflow.<sup>16<\/sup> The study found that implementation of a patient handoff form was associated with a 23% reduction in medical errors and a 30% reduction in preventable adverse events. The study results showed that implementation of a patient handoff program was associated with decreases in medical errors and adverse events, development of a standardized rounding routine, and improved communication (e.g., increased rate at which patient information is transferred and retained rather than overlooked or omitted) without negatively affecting workflow.<sup>16<\/sup> A sample handoff form for use in veterinary hospitals is provided (<\/span><strong><span class=\"s3\">FIGURE 3<\/span><\/strong><span class=\"s1\">).<\/span><\/p>\n<div id=\"attachment_6143\" style=\"width: 710px\" class=\"wp-caption aligncenter\"><a href=\"http:\/\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2022\/03\/Waxman_ICUChecklistsBundles_TVNSpring22_Fig3.png\" target=\"_blank\" rel=\"noopener\"><img decoding=\"async\" aria-describedby=\"caption-attachment-6143\" class=\"wp-image-6143\" src=\"http:\/\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2022\/03\/Waxman_ICUChecklistsBundles_TVNSpring22_Fig3.png\" alt=\"\" width=\"700\" height=\"603\" \/><\/a><p id=\"caption-attachment-6143\" class=\"wp-caption-text\"><strong>Figure 3.<\/strong> Example of a veterinary patient handoff form. CPR=cardiopulmonary resuscitation, DVM=doctor of veterinary medicine.<\/p><\/div>\n<h3 class=\"p4\">Catheter-Related Bloodstream Infections<\/h3>\n<p class=\"p2\"><span class=\"s1\">In addition to the previously discussed CRBSI checklist, the same study team looked at a patient care improvement bundle to eliminate the incidence of CRBSIs. The elements of the CRBSI bundle were (1)\u00a0implementing an educational intervention program to increase provider awareness of evidence-based infection control practices, (2) creating a central catheter insertion cart with all the necessary supplies, (3) asking providers daily if central venous catheters could be removed, (4) adhering to the checklist, and (5) empowering nurses to stop the procedure if the bundle guidelines were not followed. The incidence of CRBSIs in the ICU setting was nearly eliminated after implementation of the patient improvement bundle, with the rate decreasing from 11.3 CRBSIs\/1000 catheter-days to 0 CRBSIs\/1000 catheter-days over a 4-year period.<sup>7<\/sup><\/span><\/p>\n<h3 class=\"p4\">Surviving Sepsis Campaign<\/h3>\n<p class=\"p2\"><span class=\"s1\">The Surviving Sepsis Campaign (SSC) is a global commitment to reducing morbidity and mortality from sepsis in human and veterinary patients. Consensus guidelines are published every 4 years, with the most recent full guidelines published in 2021.<sup>17<\/sup> Previous guidelines provided 3-hour and 6-hour care bundles; however, in the 2018 update, these bundles were combined into a single hour-1 bundle.<sup>18<\/sup> The elements of this revision are summarized in <\/span><strong><span class=\"s3\">TABLE 1<\/span><\/strong><span class=\"s1\">. An international multicenter study conducted to evaluate the effect of SSC bundle implementation on morbidity and mortality, conducted before the creation of the hour-1 bundle, showed a 40% reduction in the likelihood of a patient dying in hospital with use of the 3-hour care bundle and a 36% reduction with use of the 6-hour care bundle.<sup>19<\/sup><span class=\"Apple-converted-space\">\u00a0<\/span><\/span><\/p>\n<p class=\"p2\"><span class=\"s1\"><span class=\"Apple-converted-space\"><a href=\"http:\/\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2022\/03\/Waxman_ICUChecklistsBundles_TVNSpring22_Table1.png\"><img loading=\"lazy\" decoding=\"async\" class=\"aligncenter wp-image-6144\" src=\"http:\/\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2022\/03\/Waxman_ICUChecklistsBundles_TVNSpring22_Table1.png\" alt=\"\" width=\"800\" height=\"233\" \/><\/a><\/span><\/span><\/p>\n<h2 class=\"p3\">RECOVER Initiative<span class=\"Apple-converted-space\">\u00a0<\/span><\/h2>\n<p class=\"p2\"><span class=\"s1\">To supplement its CPR algorithm, the RECOVER initiative created 2 additional cognitive aids: the CPR Emergency Drugs and Doses chart and the Post-Cardiac Arrest Care algorithm. The CPR Emergency Drugs and Doses chart contains only the drugs most commonly used during a cardiopulmonary arrest event and CPR attempt. It provides the volume of each drug based on an estimated patient body weight (in kilograms) to aid in reduction of drug calculation errors. The Post-Cardiac Arrest Care algorithm was designed as a summary of the key interventions the veterinary team should implement for patients that achieve return of spontaneous circulation (<\/span><strong><span class=\"s3\">BOX 3<\/span><\/strong><span class=\"s1\">).<span class=\"Apple-converted-space\">\u00a0<\/span><\/span><\/p>\n<p class=\"p2\"><span class=\"s1\">The full evidence-based review also provides consensus guidelines over 5 domains: preparedness and prevention, basic life support, advanced life support, monitoring, and post-resuscitative care.<sup>13<\/sup><\/span><\/p>\n<p class=\"p2\"><span class=\"s1\">The RECOVER evidence review showed that cognitive aids (e.g., checklists, charts, algorithms) improved compliance with CPR guidelines; therefore, these aids should be readily available and visible in areas where cardiopulmonary arrest may occur (e.g., surgical suite, procedure rooms, treatment area). Using these resources in addition to the evidence-based clinical guidelines constitutes a patient care bundle for small animal patients.<sup>13<\/sup><\/span><\/p>\n<h2 class=\"p1\">Checklist and Care Bundle Implementation<\/h2>\n<p class=\"p2\"><span class=\"s1\">Going through the process of identification, creation, and implementation of checklists and patient care bundles ultimately leads to quality improvement of patient care. Quality improvement is the process of combined, continuous efforts by members of the veterinary healthcare team to make changes that contribute to better patient outcomes and better system performance.<sup>2<\/sup><\/span><\/p>\n<p class=\"p7\"><span class=\"s1\">The human medical literature has identified 7 steps to identifying, creating, and implementing patient checklists and care bundles in practice:<sup>4<\/sup><\/span><\/p>\n<ol>\n<li class=\"p8\"><span class=\"s1\">Identify a patient, staff, or hospital need. An area in which errors and\/or oversights are common is an area to focus on. Some options are suggested in <\/span><strong><span class=\"s3\">BOX 5<\/span><\/strong><span class=\"s1\">.<\/span><\/li>\n<li class=\"p8\"><span class=\"s1\">Identify interventions\/practices that would meet the need.<\/span><\/li>\n<li class=\"p8\"><span class=\"s1\">Perform literature research to find published, current, evidence-based practices and recommendations regarding the interventions or practices identified in step 2.<\/span><\/li>\n<li class=\"p8\"><span class=\"s1\">Review the evidence-based research to strengthen the integrity of the identified interventions or practices.<\/span><\/li>\n<li class=\"p8\"><span class=\"s1\">Establish a clinical protocol (checklist or patient care bundle) based on the literature search and evidence-based review to address the need identified in step 1.<span class=\"Apple-converted-space\">\u00a0<\/span><\/span><\/li>\n<li class=\"p8\"><span class=\"s1\">Provide team training and education about the protocol (e.g., why it was developed, why certain elements are included based on evidence-based medicine, how the protocol will be used).<\/span><\/li>\n<li class=\"p9\"><span class=\"s1\">Audit compliance with the protocol.<\/span><\/li>\n<\/ol>\n<p><span class=\"s1\"><div class=\"su-box su-box-style-default\" id=\"\" style=\"border-color:#333333;border-radius:0px;\"><div class=\"su-box-title\" style=\"background-color:#666666;color:#ffffff;border-top-left-radius:0px;border-top-right-radius:0px\">BOX 5 Processes That Might Benefit From Checklists or Care Bundles<\/div><div class=\"su-box-content su-u-clearfix su-u-trim\" style=\"border-bottom-left-radius:0px;border-bottom-right-radius:0px\"><strong>Patient checklists<\/strong> <\/span><\/p>\n<ul>\n<li><span class=\"s1\">Feeding tube placement <\/span><\/li>\n<li><span class=\"s1\">Urinary catheterization <\/span><\/li>\n<li><span class=\"s1\">Central line placement <\/span><\/li>\n<li><span class=\"s1\">Nasal oxygen cannula placement <\/span><\/li>\n<li><span class=\"s1\">Blood transfusion administration <\/span><\/li>\n<li><span class=\"s1\">Anesthetic machine setup <\/span><\/li>\n<li><span class=\"s1\">Operating room setup <\/span><\/li>\n<\/ul>\n<p><strong><span class=\"s1\">Patient care bundles <\/span><\/strong><\/p>\n<ul>\n<li><span class=\"s1\">Critical assessment plan <\/span><\/li>\n<li><span class=\"s1\">Urinary catheter care <\/span><\/li>\n<li><span class=\"s1\">R<\/span><span class=\"s1\">ecumbent patient care <\/span><\/li>\n<li><span class=\"s1\">Respiratory tube care (e.g., long-term intubation, thoracostomy tubes, tracheostomy tubes) <\/span><\/li>\n<li><span class=\"s1\">Long-term ventilator care<\/div><\/div><\/span><\/li>\n<\/ul>\n<p><span class=\"s1\">In the author\u2019s experience, a hospital created and implemented a feeding tube checklist for nasoesophageal and nasogastric feeding tube placement following a medical error that resulted in a patient\u2019s death (<\/span><strong><span class=\"s3\">FIGURE 4<\/span><\/strong><span class=\"s1\">). The negative patient outcome became a learning opportunity for the veterinary healthcare team, as they were able to identify a critical need, implement an intervention, and establish the checklist as a hospital protocol.<span class=\"Apple-converted-space\">\u00a0<\/span><\/span><\/p>\n<div id=\"attachment_6145\" style=\"width: 760px\" class=\"wp-caption aligncenter\"><a href=\"http:\/\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2022\/03\/Waxman_ICUChecklistsBundles_TVNSpring22_Fig4.png\" target=\"_blank\" rel=\"noopener\"><img loading=\"lazy\" decoding=\"async\" aria-describedby=\"caption-attachment-6145\" class=\"wp-image-6145\" src=\"http:\/\/todaysveterinarynurse.com\/wp-content\/uploads\/sites\/3\/2022\/03\/Waxman_ICUChecklistsBundles_TVNSpring22_Fig4.png\" alt=\"\" width=\"750\" height=\"1031\" \/><\/a><p id=\"caption-attachment-6145\" class=\"wp-caption-text\"><strong>Figure 4.<\/strong> Example of a nasal feeding tube placement checklist. DACVECC=diplomate of the American College of Veterinary Emergency Critical Care, DVM=doctor of veterinary medicine.<\/p><\/div>\n<h2 class=\"p1\">Conclusion<\/h2>\n<p class=\"p2\"><span class=\"s1\">As veterinary medicine is continuously evolving, so are owner expectations for the level of care their pets receive. Research into use of patient checklists and care bundles in veterinary medicine has only just begun; however, the results published so far suggest that checklists and patient care bundles can improve overall patient outcomes and reduce morbidity and mortality. Areas of opportunity exist for creation and use of checklists and patient care bundles in the veterinary ICU to improve the quality of care for critical patients.<span class=\"Apple-converted-space\">\u00a0<\/span><\/span><\/p>\n","protected":false},"excerpt":{"rendered":"<p>Areas of opportunity exist for the creation and use of checklists and patient care bundles in the veterinary ICU to improve the quality of care for critical patients.<\/p>\n","protected":false},"author":236,"featured_media":10148,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_acf_changed":false,"iawp_total_views":0,"footnotes":""},"categories":[228],"tags":[145],"class_list":["post-10183","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-spring-2022","tag-peer-reviewed","column-features","clinical_topics-emergency-medicine-critical-care"],"acf":{"hide_sidebar":false,"hide_sidebar_ad":false,"hide_all_ads":false},"yoast_head":"<!-- This site is optimized with the Yoast SEO Premium plugin v24.7 (Yoast SEO v27.4) - https:\/\/yoast.com\/product\/yoast-seo-premium-wordpress\/ -->\n<title>The Evidence for Checklists and Patient Care Bundles in Veterinary Nursing | Today&#039;s Veterinary Nurse<\/title>\n<meta name=\"description\" content=\"Areas of opportunity exist for the creation and use of checklists and patient care bundles in the veterinary 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