Thread by @phlegmfighter

#ICUchecklist is to make sure the plane doesn’t crash, not to assure the stewardesses don’t run out of Diet Coke on the way to Los Angeles. If the checklist gets too long, it becomes pro forma, and is rattled off without attention. The picture shows a cumbersome #checklist

It seems to imply that the individual patient and their disease process does not matter, you simply have to check some boxes like you were starting a plane or baking some cookies. It seems also to imply that we will forget to monitor medications and labs and…everything

Much of what is there is based on flimsy, dated, or no evidence (GI PPX) and will hardly lead to a plane crash if ignored for a day - the NNH is huge. Few patients are harmed by a day or two “delay” in starting enteral nutrition - there is scant evidence of harm. So, why do we…

…mention it on the checklist day after day? It should be part of the presentation and if so we don’t need to repeat ourselves on the #checklist. Same with #codestatus - default is #fullcode for a reason & that’s what’s gonna happen if we fail to have the obvious discussion…

And the more dire the situation and the more urgent to “clarify” it, the more obvious it is and the less I need a checklist to remind me. I don’t want to hear “full code” as the last thing on an inane and mindless checklist as the capstone of every presentation

There are some things that are important enough - because the consequences of omission or delay are severe enough - that deserve to be on a checklist but they are few: SAT/SBT, DVT PPX, remove lines/tubes, a few others.

But there is no free lunch: every moment spent prattling about fatuous routines is a moment not spent on higher priorities; it reinforces a cookbook mentality; and encourages mindless rote rattling off of a list in a perfunctory way w/o earnestly engaging with the patients

“A foolish consistency is the hobgoblin of little minds, adored by little statesmen and philosophers and divines.” - Emerson

For context I spent 2 weeks in 2005 rounding with Pete Pronovost at the height of enthusiasm for checklists & later that year instituted a checklist at Ohio State MICU. I watched it become bloated with everybody’s pet topic (CAM-ICU was one that really rankled me cuz: so what?)…

I went around policing use of the “green sheets” as we called them (they were printed on green paper), so this thread is not some glib wayward stream of consciousness it is a reflection of 17 years experience using checklists in the ICU

I have seen a mindless repetition of items on the “checklist” cut and pasted from former notes that gets things wrong yet everybody stands there nodding their head ready to move on to the next patient - the unintended and unfortunate consequence of bloated mindless checklists