Measurable Outcomes of Quality Improvement in the Trauma Intensive Care Unit: The Impact of a Daily Quality Rounding Checklist Joseph J. DuBose, MD, Kenji Inaba, MD, Anthony Shiflett, DO, Christine Trankiem, MD, Pedro G. R. Teixeira, MD, Ali Salim, MD, Peter Rhee, MD, MPH, Demetrios Demetriades, MD, PhD, and Howard Belzberg, MD Objective: The use of “care bundles” in the prevention of ventilator-associated pneumonia (VAP) and other intensive care unit (ICU) complications have been increasingly used in critical care practice. However, the effective implementation of these strategies represents a challenge in a busy Level I trauma ICU. We devised a daily “Quality Rounds Checklist” (QRC) tool for use in the ICU to increase compli- ance with these prophylactic measures and identify areas for improvement in quality of care. Methods: A prospective before-after design was used to examine the effective- ness of the QRC tool in promoting com- pliance with 16 prophylactic measures for VAP, deep venous thrombosis or pulmo- nary embolism, central line infection and other ICU complications. Compliance was assessed for 1 month before institution of the QRC. On daily analysis, the QRC was then applied by the ICU fellow to assess compliance. Any deficiencies were actively corrected in real time. Compliance was assessed by a multidisciplinary team for the next 3 months and compared with the pre-QRC compliance rates. Results: Implementation of the QRC tool facilitated improvement of all mea- sures not already at >95% compliance. Compliance with VAP prevention mea- sures of head of bed elevation >30 degrees (35.2% vs. 84.5%), sedation holiday (78.0% vs. 86.0%), and prophylaxis for both peptic ulcer disease (76.2% vs. 92.3%) and deep venous thrombosis (91.4% vs. 92.8%) were all increased. A decrease in central line duration >72 hours (62.4% vs. 52.8%) and ventilator duration >72 hours (74.0% vs. 61.7%) was also noted. Additionally, a decrease in mean monthly rates per 1,000 device days of VAP (16.3 vs. 8.9), central line infection (11.3 vs. 5.8) and self-extubation (7.8 vs. 2.2) was demonstrated. Conclusion: Introducing a daily QRC tool facilitated improved compliance rates for 16 clinically significant prophy- lactic measures in a busy Level I trauma ICU. The daily use of this tool, requiring just a few minutes per patient to complete, results in a sustainable improvement in patient outcomes. Key Words: Injury, Wounds and in- juries, Trauma, Outcome assessment, Quality assessment. J Trauma. 2008;64:22–29. T he Institute for Healthcare Improvement (IHI) issued a challenge to the medical industry in 2004: save 100,000 lives by June 2006 through the implementation of evidence-based interventions in six specific clinical areas. 1 The areas proposed for inclusion in the IHI “100,000 Lives Campaign” included deployment of rapid response teams, delivery of reliable evidence-based care for acute myocar- dial infarction, prevention of adverse drug events by im- plementing medical reconciliation, and implementation of scientifically grounded steps to prevent central line infec- tions, surgical site infections and ventilator-associated pneu- monia (VAP). Several groups, including the Centers for Disease Control (CDC) 2 and the American Thoracic Society, 3 have joined the IHI in emphasizing the importance of pre- ventative measures in improving patient outcomes. Particu- larly in the intensive care unit (ICU) setting, where the complexity of care is commonly the most pronounced, these groups have produced evidence-based consensus statements designed to provide guidelines for the maintenance of these preventative efforts. A major hurdle, however, remains the effective imple- mentation of these evidence-based best practices. 4,5 This challenge is magnified in a busy high-volume trauma center. The objective of this study was to assess the effectiveness of the implementation of a cost-effective and efficient “Quality Rounds Checklist” (QRC) tool to improve compliance with the VAP bundle recommendations and 12 other beneficial prophylactic measures at a high-volume Level I trauma center. METHODS A QRC tool (Fig. 1) was developed to quantify com- pliance with 16 recommended prevention measures. The preventative measures to be quantified were chosen after a comprehensive review of best-practices data by a multidis- ciplinary team of care providers that included intensivists, Submitted for publication September 10, 2007. Accepted for publication November 9, 2007. Copyright © 2008 by Lippincott Williams & Wilkins From the Division of Trauma Surgery and Surgical Critical Care, Department of Surgery, University of Southern California, Los Angeles, California. Presented at the 66th Annual Meeting of the American Association for the Surgery of Trauma, September 27–29, 2007, Las Vegas, Nevada. Address for reprints: Joe DuBose, MD, Trauma A, Division of Trauma Surgery and Surgical Critical Care, University of Southern California, USC + LAC Medical Center, 1200 North State Street, Room 10-750, Los Angeles, CA 90033; email: jjd3c@yahoo.com. DOI: 10.1097/TA.0b013e318161b0c8 The Journal of TRAUMA  Injury, Infection, and Critical Care 22 January 2008