Checklist-styled Daily Sign-out Rounds Improve

Hospital Throughput in a Major Trauma Center

JOHN C. LEE, M.D., MICHAEL HORST, PH.D., AMELIA ROGERS, B.S., FREDERICK B. ROGERS, M.D., M.S.,
DANIEL WU, D.O., TRACY EVANS, M.D., MATHEW EDAVETTAL, M.D., PH.D.

From the Division of Trauma/Critical Care, Lancaster General Health, Lancaster, Pennsylvania

The checklist concept has received much attention as a result of its ability to improve patient care
by minimizing complications. We hypothesized daily sign-out rounds using a checklist, by im-
proving team communication and consistency of clinical care, could lead to expedited throughput
for patients at a major trauma center. A retrospective study examined patients admitted to a mature
trauma center. Two time periods, PRE (September 2008 to January 2009) and POST (September
2009 to January 2010), were selected to match for seasonal variation in admission diagnosis. An
organ system-based checklist was used during daily sign-out for all admitted trauma patients in
the POST period. We examined discharge status, complications and rates, and intensive care unit
(ICU) and overall hospital length of stay for differences. There were similar numbers of patients
(824 PRE vs 798 POST) admitted in these two cohorts. We found no statistical differences in the
incidence of complications or mortality rate. We did discover statistically significant differences in
the median ICU days (2 PRE vs 1 POST, P 5 0.007) as well as median hospital length of stay (2
days, interquartile differences Q1 to Q3 PRE [1 to 5] and POST [1 to 4] P 5 0.000). These trends
remained valid even among the severely injured (Injury Severity Score 16 or greater) with a hos-
pital length of stay of 5 (PRE) versus 3 days (POST; P 5 0.021). A simple, organ system-based
checklist can be successfully adopted for daily sign-out round on a busy, multiprovider trauma
service. We were able to expedite trauma patient throughput in both ICU and overall hospital stays
with a trend toward decreasing mortality. This improved throughput may potentially translate
into a cost saving for the hospital.

best known in the aviation
C HECKLISTS ARE PERHAPS
industry as a means of assisting pilots in their
accurate and timely completion of complex tasks.
Similar to these nonmedical fields, the practice of
medicine has grown increasing complicated, both in
terms of the amount of knowledge as well as the skills
necessary to execute and deliver best care. It has only
been recently that the concept of using a checklist in
medicine received much attention, even in the lay
press.1 A large measure of the current interest can be
attributed to seminal studies by Pronovost et al.2 at
Johns Hopkins, who demonstrated that a simple
checklist can lead to improved outcome for specific
tasks. The goals of checklists used in health care are
therefore primarily tools for error reduction and ad-
herence to best practices in clinical care to improve the
quality of patient care.3
We have recently shown that a trauma intensivist
model as applied to a community hospital trauma pro-
gram, with the surgeon as the captain of the ship, could
improve intensive care unit (ICU) throughput.4 With the
further expansion of our trauma service at Lancaster
General Hospital, from three to six full-time surgeons,
we felt that a more efficient and effective work flow
system must be instituted to maintain high standards.
Surgeon communication lapses and ineffective in-
formation transfers have been well described as reasons
that attribute to adverse patient outcomes and provider
inefficiencies.5, 6 With its proven track record as a tool
for performance improvement and error prevention and
management, a checklist system could serve as a further
refinement to our trauma care model. We hypothesized
that daily sign-out rounds using a checklist, by improving
team communication and consistency of clinical care,
could expedite patient throughput at our trauma center.

Presented as a poster presentation at the 69th Annual Meeting of Methods

the American Association for the Surgery of Trauma, Boston, MA,
September 22–25, 2010.
Address correspondence and reprint requests to John C. Lee,
M.D., Lancaster General Health, 555 N. Duke Street, Lancaster,
PA 17602. E-mail: jclee@lghealth.org.
Location and Trauma Service Composition
Lancaster General Hospital has been a Pennsylvania
Trauma Systems Foundation (PTSF) state-verified

434
No. 5 CHECKLIST-STYLED SIGN-OUT IMPROVES PATIENT CARE
Level II trauma center since 1987. It is a community-
based, not-for-profit hospital that does not have a free-
standing surgery residency and is the only verified
trauma center for Lancaster County. Since 1997, the
trauma program has provided 24/7 in-house surgeon
coverage for any trauma activation or consultation.
Care of all trauma patients after admission were
provided exclusively by critical care certified trauma
surgeons, of which there were three in the first study
period (PRE, September 2008 to January 2009) and six
in the second period (POST, September 2009 to Jan-
uary 2010). All were employed by the hospital on
a full-time basis and shared equally the core clinical
responsibilities of daytime trauma response, most
overnight trauma calls, and 24/7 uninterrupted ICU
coverage. A core group of five community-based gen-
eral surgeons without critical care training filled in the
gaps in overnight trauma coverage. However, they
relinquished all responsibilities, the next morning, for
all trauma patients, which they had admitted overnight,
to the trauma intensivists. Attendance was mandatory
for all five community surgeons only for the purpose
of relaying name, diagnosis, and major issue. The
employed trauma intensivists (three in the PRE group
and six in the POST group) made any further care
decisions. The sign-out occurred within 15 hours of
beginning their overnight call. All information passed
on was then independently reviewed and act on by the
trauma intensivists.
In the PRE period (September 2008 to January
2009), the morning sign-out was an informal process
consisting of the following: the post call surgeon, the
on-call trauma surgeon, the distinct trauma intensivist
who is solely covering the ICU, physician assistants, and
trauma case managers. It typically occurred at 7:30 AM
on weekdays and 9 AM on weekends and holidays.
There was no organized structure to the sign-out
itself. Sufficient time was spent to pass on the name,
pertinent diagnosis, and relevant clinical issues of
each patient on the service.
In the POST period (September 2009 to January
2010), the morning sign-out was a required event of all
available trauma surgeons, physician extenders, and
trauma case managers. There was no change to the
actual starting time of these sign-outs. Each patient on
the daily trauma census was discussed individually
using the sign-out checklist as a template (Fig. 1) with
all relevant radiographic studies projected for group
viewing. Time for sign-out of all patients was kept to
a 1-hour maximum.
Our sign-out checklist used an organ-based ap-
proach to systematically address patient care issues
and is inclusive of tentative discharge plans. For ease
of use, the checklist was purposefully kept to one page.
Data population on the checklist for each patient was
? Lee et al. 435
initiated by the admitting trauma surgeon, and daily
additions were made by the rounding trauma surgeon.
A list was maintained for each patient from admission
until discharge; each was then properly disposed per
hospital/HIPAA regulations. The checklists themselves
were not part of the patient’s actual hospital medical
records.
Patient Population and Analysis
All patients admitted to the trauma service in the two
study periods were eligible for review. These two
4-month study periods were divided into two phases:
PRE (September 2008 to January 2009) and POST
(September 2009 to January 2010). The time periods
were matched to account for potential seasonal varia-
tions in mechanisms of trauma injuries match sea-
sonally (September to January). After admission, all
trauma service-specific and PTSF-required data were
collected on a daily basis by trauma case managers.
These included demographics, mechanism of injuries,
resuscitations, pre-existing medical conditions, and
occurrences. All data points were then maintained in
Collector (Digital Innovation, Forrest Hill, MD), a
PTSF-mandated trauma database used by the Lancas-
ter General Hospital trauma service. Information was
extracted from the Collector database by our trauma
registrars. Variables such as length of stay days, age,
Injury Severity Score (ISS), occurrences, and mortality
for each group were extracted from the database. An
occurrence is a PTSF term defined as an ‘‘unexpected
event affected patient care.’’ Hospital length of stay
was inclusive from time of admission to actual dis-
charge of the patient. ICU length of stay was calculated
from time of admission to time of determination by the
attending surgeon for transfer out of ICU or discharge.
Complication is defined as greater than one occurrence
per standard PTSF definition, of which there were 45
in total.
We also examined the compliance rate of our own
internal trauma service management guidelines. These
guidelines were established in the preceding three years
as a way of standardizing the treatment of commonly
encountered clinical scenario. Data from the entire
calendar years of 2008 and 2009 were examined for
cases that were deemed to have been noncompliant
with the established guidelines.
Basic descriptive statistics were calculated for the
two groups. We used Kruskal-Wallis nonparametric
tests to asses for differences across continuous var-
iables and Fisher’s exact test for categorical vari-
ables of interest. A P value < 0.05 was considered
statistically significant. All statistical analyses were
conducted using Minitab Version 15 (State College,
PA).
436 THE AMERICAN SURGEON May 2014 Vol. 80

FIG. 1. Sign-out checklist.

No. 5 CHECKLIST-STYLED SIGN-OUT IMPROVES PATIENT CARE
Results
During the 8-month study period, a total of 1622
patients were admitted to the trauma service. The
numbers in the PRE and POST groups were similar
(824 PRE vs 798 POST). There was no statistical dif-
ferences in the median age (45 years PRE vs 46 years
POST; P 4 0.85), median ISS (8 PRE vs 8 POST; P 4
0.70), mechanism of injury of blunt (94.3% PRE vs
93.5% POST; P 4 0.84) and penetrating (4.4% PRE vs
4.9% POST; P 4 0.84), or the probability of ICU ad-
mission (36.9 vs 33.3%; P 4 0.12). These de-
mographics are summarized in Table 1.
There was no significant difference between the
PRE and POST cohorts in complication rates (3.1%
PRE vs 2.9% POST; P 4 0.86; Table 2) and mortality
rates (4.1% PRE vs 2.7% POST; P 4 0.12; Table 2);
however, there was a trend toward a decrease in both
complication rates and mortality in the POST group.
These outcomes may have failed to reach statistical
significance as a result of a Type II error of the small
patient population. As far as patient length of stay is
concerned, we did find statistically significant differ-
ences in both the median ICU days (2 vs 1 day, P 4
0.01; Table 2) and the overall hospital stay days (2 days
PRE vs 2 days POST; interquartile differences Q1 to
Q3, PRE [1 to 5] vs POST [1 to 4]; P < 0.001; Table 2).
This hospital stay difference was even more pro-
nounced for those with ISS 16 or greater (5 days PRE
vs 3 days POST; P 4 0.02; Table 2).
Table 3 summarizes the noncompliance rates with
our own internal trauma management guidelines.
Events from the entire calendar years of 2008 and 2009
were used for comparison. Of the 11 categories, eight
demonstrated a decreasing trend with the high-risk
geriatric item reaching statistical significance (P 4 0.00).
Discussion
Sign-out among healthcare practitioners in a group
setting is an integral part of their daily activity, and
most certainly have had experience with this technique
TABLE 1. Demographics
PRE (September 2008
to January 2009)
Patients 824
Median age (years) 45
ISS 8 8
Mechanism of injury
Blunt 777 (94.3%)
Penetrating 36 (4.4%)
Rate of ICU admission 36.9%
ISS, Injury Severity Score; ICU, intensive care unit.
? Lee et al. 437
during the formal training phase of their careers. The
few studies that have examined this singular activity
have all noted that sign-outs are rarely standardized
and often managed haphazardly.7, 8 These factors can
easily lead to patient care errors with significant con-
sequences. By examining internal medicine house staff
sign-outs from a quantitative and qualitative stand-
point, Horwitz noted that, per patient, the typical sign-
out was short in duration (median of 35 seconds) and
that errors of omission or frank mischaracterization of
data occurred in upward of 22 per cent. She concluded
that a standardization of key content onto a written
template would lead to greater emphasis on patient
safety.9, 10
The checklist is a deceptively mundane instrument
whose potential for affecting process improvements
and minimizing errors belies its fundamental simplic-
ity. Although its use has been the norm in aviation and
industry, the use of a checklist in medicine is still in the
infancy stage.11 It has been publicized as a tool for
error management by reducing costly mistakes and
performance improvement.12 In recent years, several
examples of the effectiveness of the medical checklist
have been published. Some notable outcomes included
1) reductions in incidences of catheter-related blood-
stream infections2; 2) reductions in surgical compli-
cations such as in-hospital death rate and surgical site
infections13; 3) reductions in ICU length of stay by
50 per cent using a daily goal checklist14; and 4) re-
ductions in ICU mortality, length of stay, and the need
for mechanical ventilation.15 In short, it is becoming
clear that in medicine, just like in other fields of human
endeavor, a simple checklist can be an effective way to
organize a vast amount of data, often presented in a
chaotic and disorganized fashion, and allows the cli-
nician to deliver care safely, correctly, and reliably.
With this background in mind, we undertook the
same checklist benefits could be realized on a busy
trauma service. We applied the checklist concept to
a necessary daily care event (the morning sign-out) and
theorized that this simple and yet comprehensive sys-
tem, by improving team communication consistency
POST (September 2009
to January 2010) P Value
798
46 0.85
0.70
746 (93.5%)
39 (4.9%) 0.84
33.3% 0.12
438 THE AMERICAN SURGEON May 2014 Vol. 80

TABLE 2. Results
PRE (September 2008 POST (September 2009
to January 2009) to January 2010) P Value
Complications 3.1% 2.9% 0.86
Mortality 4.1% 2.7% 0.12
ICU LOS (median days) 2 1 0.01
Hospital LOS (all) 2 2 <0.001*
Hospital LOS (ISS $ 16) 5 3 0.02
* Interquartile differences Q1–Q3, Pre (1–5) vs Post (1–4).
ICU, intensive care unit; LOS, length of stay; ISS, Injury Severity Score.

of clinical care, would lead to expedited patient
throughput. We had previously reported that a trauma
intensivist model improves ICU throughput at a busy
Level II community hospital trauma program by
streamlining the patients’ ICU stay.4 With the addition
of a sign-out checklist, we hoped to see further im-
provement in throughput of our trauma patients with-
out any concurrent increases in morbidity or mortality.
The time periods were matched to account for po-
tential seasonal variations in mechanisms of trauma
injuries. Statistically, our two cohorts of patients were
similar in age (45 vs 46 years, P 4 0.85) and sustained
similar types of injury (blunt vs penetrating) of equal
severity (ISS of 8 vs 8, P 4 0.70). The likelihood of
being admitted directly to the ICU did not differ in the
two groups (37 vs 33%, P 4 0.12).
We demonstrated improved trauma service through-
put, both in the ICU and in the overall hospital length of
stay. Our data were even more significant for the most
severely injured (ISS 16 or greater), who had a 40 per
cent decrease in their hospital duration of stay (5 vs 3
days, P 4 0.02). This system-wide efficiency occurred
in the absence of a noticeable increase in complication
rates (3.1 vs 2.9%, P 4 0.86) or mortality rate (4.1 vs
2.7%, P 4 0.12). Despite the lack of significance
between the PRE and POST groups in regard to the
complication and mortality rates, we are encouraged
by the decreasing trends in the POST period. These
results assuaged some initial concerns and doubts per-
taining to the possible dangers associated with im-
proved overall patient throughput.
We feel that the appropriate delivery of patient care
information is just as important as the quality and
substance of the care itself. Certainly at a minimum,
they are inextricably linked. The Joint Commission’s
annual report in 2006 emphasized the importance of
care provider communications as part of its effort to
reduce error. It reported communication failure as the
primary root cause of 65 per cent of reported sentinel
events that year and likewise a similar fraction within
the preceding 11-year interval.16 Petersen et al.,17 who
evaluated housestaff handoffs at an urban tertiary care
setting, found that 44 per cent of 124 consecutive ad-
verse events were deemed preventable and correlated
statistically to presence of cross-coverage and directly
proportional with patients’ severity of illness. In-
tuitively, it makes sense that the sicker the patient, the
more complicated their care would be and therefore
more prone to errors.
These facts point out the potential danger in a setting
where multiple providers are responsible for the care
of the patient. Such a situation is inherent and neces-
sary on a busy, multiprovider trauma service. Our ex-
perience and trauma coverage pattern are certainly not
unique and, in fact, is likely the norm. Our own trauma
management guideline compliance rate in the years

TABLE 3. Lancaster General Health Trauma Service Management Guideline Noncompliance

MGMNT Guidelines CY 2008 Events CY 2008 Percent CY 2009 Events CY 2009 Percent P Value
1 AC reversal 58/115 50.4% 40/109 36.7% 0.053
2 Airway 40/114 35.1% 32/103 31.1% 0.629
3 Blunt abdominal workup 27/928 2.9% 28/1014 2.8% 0.952
4 BCI 6/212 2.8% 3/266 1.1% 0.307
5 Cervical spine clearance 7/1197 0.6% 6/1141 0.5% 0.931
6 DVT prophylaxis 7/522 1.3% 2/511 0.4% 0.191
7 Epidural catheter 11/143 7.7% 18/153 11.8% 0.326
8 High Risk Geriatric 53/184 28.8% 26/202 12.9% 0.000
9 ICP monitor 11/59 18.6% 16/45 35.6% 0.085
10 Nutrition 39/195 20.0% 34/156 21.8% 0.780
11 Sedation/analgesia 26/159 16.4% 14/139 10.1% 0.157
MGMNT, management; CY, calendar year (January to December); AC, anticoagulation; BCI, blunt cardiac injury; DVT, deep
vein thrombosis; ICP, intracranial pressure.
No. 5 CHECKLIST-STYLED SIGN-OUT IMPROVES PATIENT CARE
before and after checklist implementation illustrates
this point (Table 3). Although only the high-risk ge-
riatric protocol reached statistical significance, eight of
the 11 measured categories showed a trend toward
improved compliance. We feel that these improve-
ments are direct consequences of the application of a
standardized checklist to the care of our patients.
Important to every hospital that strives to provide
best care in an environment of ever diminishing re-
imbursements, the issue of patient length of stay has
not been well characterized in the medical literature.
It was only recently that Fakhry et al.18 reported the
correlation between trauma center profitability and
patient length of stay. Staffing pattern change has been
reported to positively affect length of stay.4, 11, 19
Protocol-driven care processes for diseases have also
been described.20 Lastly, formalized multidisciplinary
meetings that bring together the trauma service, major
surgical consultants, and other ancillary support ser-
vices have been shown to improve patient through-
put.21, 22 A decreased patient hospital length of stay for
any given disease process is a marker of overall effi-
ciency. We described a novel method of efficiency
improvement that required little to no change in staffing
pattern nor does it require any noticeable upfront cost; it
is merely a modification of an existing process.
This retrospective study has several limitations. First
and foremost, our checklist-styled morning sign-out is
a rigorous process of daily medical discussion and, as
much as possible, consensus-building. As such, it did
require the attendance of all available trauma surgeons
to maximize its effectiveness. It may not be easily
duplicated at other institutions. Second, in the interest
of providing the highest quality care, we chose to ad-
dress difficult clinical issues early and, with the aid of
the checklist, maintained continuity of care by the
proper execution of the plans of care. Difficult clinical
issues, which used to produce significant practitioner
variations, required that a consensus in treatment plan
be achieved very early in the course of patient stay; the
timing and method of venous thromboembolism pro-
phylaxis in those with relative contraindications would
be an example of such. To some, this may be perceived
as cookbook medicine or, worse, the removal of indi-
vidual decision-making and judgment. Third, our
checklist, by design, must be a fluid and dynamic pro-
cess improvement instrument that keeps up with the
latest innovations in health care. An effective sign-out
checklist in 2009 may be less useful in 2015 or 2020 as
new advancements are made and treatment strategies
discovered. Fourth, even as we attribute the efficiency
improvement to the successful implementation of our
checklist-styled daily morning sign-out, we may have
missed other contributing factors. Lastly, the POST
period represented the beginning phase of the
? Lee et al. 439
implementation of the checklist process, as we hoped
to demonstrate the ease of implementation and the
quick return possible with such a change. We are
currently evaluating the validity of the checklist pro-
cess over longer periods.
In conclusion, we have shown that a change to a
routine, daily event like the physician sign-out can
significantly impact patient care and hospital length of
stay. The reported advantages of using a checklist can
be effectively duplicated on a busy trauma service to
improve overall patient throughput without adversely
affecting morbidity or mortality.
Acknowledgments
We thank Lois Sakorafas, M.D., for her participation in
the development and use of the checklist.
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