Protocols and checklists in the modern ICU

Dr Brian Garibaldi is an associate professor in the Division of Pulmonary and Critical Care Medicine and director of the Biocontainment Unit at Johns Hopkins Medicine (USA).

Should we use protocols and checklists in the modern intensive care unit (ICU)? Why?

Brian Garibaldi, MD: I guess it depends on the specific context.

We know, for example, that protocols to drive low tidal volume ventilation in patients who have acute respiratory distress syndrome (ARDS) can make it much more likely that you achieve the goal of low tidal volume ventilation and minimize the risk of barotrauma. We know that protocols that screen patients for when they might be able to be liberated from the ventilator decrease the time of mechanical ventilation and [increase] the likelihood that you are going to achieve successful extubation. So in those cases protocols can be absolutely very, very helpful.

We know for sure that protocols can be very helpful for procedures. For example, bundling things for central line placement can reduce the risk of infection or other complications. The same is probably true for bundling interventions to reduce ventilator-associated pneumonia. So, there is absolutely a place for protocols in the ICU.

What I think is less clear but likely to be true is that if you had a protocol or a checklist driving the things that you want to accomplish on your bedside rounds in the ICU every day, I would imagine that it would help you identify common things that are missed in the ICU because we may not be spending as much time as we should doing a physical examination at the bedside.