De-escalation of critical care and prevention of iatrogenicity through a self-tracking daily rounding checklist

TL;DR

A daily checklist for pediatric ICU rounds helped doctors make timely care adjustments and reduce unnecessary treatments.

Contribution

A feasible daily checklist was developed to promote de-escalation and prevent iatrogenic harm in pediatric ICU care.

Findings

The checklist prompted 198 documented care modifications over 300 days.

Common changes included bowel regimen initiation and medication route conversion.

Checklist compliance was 71%, with early adoption exceeding but later declining below 75%.

Abstract

As part of the Society of Critical Care Medicine's Pediatric ICU Liberation Campaign Collaborative, Mayo Clinic developed a daily physician-led rounding checklist to promote timely de-escalation of ICU support and proactive measures to prevent iatrogenic conditions. We hypothesized that implementing this checklist would be feasible and would reduce missed opportunities to optimize care through both de-escalation and initiation of key preventive tasks.

We conducted a prospective study in a 16-bed medical/surgical PICU at a quaternary academic center over a 300-day period from May 2017 to March 2018. A 15-task daily rounding checklist was integrated into standard patient-centered rounds for every admitted patient to prompt physicians to address common de-escalation and preventive care tasks. For each task, physicians documented whether it had already been addressed during rounds, was not applicable to the patient, or the checklist directly prompted a plan modification. Trends in checklist compliance and the frequency/type of plan modifications were assessed in 60-day intervals to evaluate sustainability over time.

1,710 rounding checklists were completed across 2,424 patient-days (71% compliance). The checklist prompted 198 documented plan modifications from 9% of all completed checklists. The most frequent modifications involved initiating a bowel regimen (n = 47), converting intravenous to enteral medications (n = 32), initiating gastrointestinal prophylaxis (n = 30), consulting rehabilitation services (n = 18), and restarting home medications (n = 18), which together accounted for 73% (145/198) of all modifications.

Implementation of a daily rounding checklist was feasible, achieved acceptable compliance, and identified 198 opportunities for timely de-escalation and proactive care in a complex PICU environment. Although overall compliance did not meet the a priori >75% target across the entire study period, early adoption exceeded this threshold and later decline highlighted sustainability challenges. This initiative demonstrates the potential of structured physician-led checklists to standardize care and reduce iatrogenic risk in pediatric critical care.

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