Checklists in Infection Control

By Noel Brandon Kelsch, RDHAP

My life would be a lot more frustrating if I did not have checklists. I have a checklist for packing my suitcase when I go to a speaking engagement, one for the things I need each time I go to our cabin that is two hours away from any stores, and one that covers all aspects of infection control in my dental hygiene practice. Each of these lists helps avoid frustration, simplifies my life, and keeps people safe.

Checklists are important tools to help ensure a consistent standard of care in the medical field. They can condense large quantities of knowledge in a concise fashion, reduce the frequency of omission errors, create reliable and reproducible evaluations, and improve quality standards and use of best practices.1

In medicine, lists can help reduce risk and ultimately save lives. The Centers for Disease Control and Prevention (CDC) wanted tools to decrease the morbidity and mortality rates with infections. Impacting the outcome of exposure to infectious organisms has been a major goal of the CDC. Checklists have proven to be a great part of the positive outcomes.

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Other articles by Kelsch:

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On any given day, about one in every 20 hospitalized patients has an infection that was brought on when they received medical care. A staggering 2 million people a year will acquire an infection as a result of exposure in the healthcare setting, and of those, 23,000 will die.2

One of the major health accomplishments in 2013 was a decrease in healthcare-associated infections (HAI) by the CDC. This accomplishment was aided by the use of a checklist.

The Agency for Healthcare Research and Quality (AHRQ) definition of a checklist helps us understand how vital this list can be. "A checklist is an algorithmic listing of actions to be performed in a given clinical setting, the goal being to ensure that no step will be forgotten. Although a seemingly simple intervention, checklists have a sound theoretical basis in principles of human factors engineering, and have played a major role in some of the most significant successes achieved in the patient safety movement."

AHRQ breaks down the reasons errors happen into two categories that are identified in the field of cognitive psychology. Number one is tasks involving schematic behavior, i.e., tasks performed reflexively or "on autopilot." Failures in this area are called slips and occur due to lapses in concentration, distraction, or fatigue. Number two is attentional behavior, which requires active planning and problem-solving. Failures in this area are called mistakes and are often caused by lack of experience or insufficient training.

Slips are the most common form of errors and are greatly impacted by the use of checklists. The use of these checklists and memory aids in clinical pathways has been shown to improve the quality of medical care.1

An example of a slip occurs in central line infections. These infections cost the U.S. healthcare system billions of dollars, and can have devastating emotional, financial, and medical consequences for patients. A study of checklist use in evidence-based infection control interventions on reduction of the risk of central line-associated bloodstream infections in intensive-care patients proved how valuable this tool can be. The lists helped achieve a stunning reduction in line infections, with many ICUs completely eliminating line infections for months at a time. With this system, bloodstream infections in patients with central lines have decreased by 44% overall.3,4,5

In the dental setting, most errors are caused by slips rather than mistakes. The checklist is the ultimate way of avoiding slips. Putting together a standardized list of steps in the form of a checklist and requiring their use in the office will help reduce errors.

When disseminating the information to staff, it is vital to make sure they are trained and proficient in all the areas on the checklist before asking them to take on a task and use the list.

Developing your own checklist

In some areas of your office you may find it necessary to develop your own checklist. There are many formats. These suggestions from "Development of Medical Checklists for Improved Quality of Patient Care" are adapted to the dental setting and can be a great tool for getting started.

Context -- Location of the checklist should be determined prior to development. Some checklists will be kept in the patient's chart and some in the appropriate area, such as sterilization.

Content -- When possible, synthesis of published peer-reviewed guidelines and evidence-based best practices should be considered to form the body of the checklist.

Criteria points should be from a broad range of peer-reviewed, reliable sources and include perspectives of all types and disciplines that represent the continuum of intended users.

Checklists should also reflect local, state, and federal policies and procedures and should be updated as they change.

Structure -- Checkpoints should be presented in a logical and functional order that reflect the sequence or flow of real-time clinician activities and regular patient care routines.

If the checklist is to be part of standard patient care, it might be important to include a checkpoint at the end where two users can sign off that it was completed.

Images -- Clear, equally spaced, bold fonts are suggested for letter differentiation and reading comprehension.

If colors are to be used, ensure that they are consistent with those commonly used in the intended environment, e.g., if red is commonly associated with emergency situations, it should not be used to highlight text unless it is urgent information.

Checklists should include appropriate institutional logos or letterheads (e.g., if it is to be included in the medical record, it will need to match the format of other forms/orders).

Usability -- Checklists should not be so burdensome or time consuming as to notably interfere with patient care. Overall checklists should encompass checkpoints of major importance, while still providing clinicians with the freedom to use their own judgment.

Members of each responsibility (assistants, dentists, hygienists, office managers, office staff) in an office should pilot the checklist, particularly if the checklist is to be used by all personnel. Validation of the checklist should occur, where possible, within the appropriate simulated clinical environment.1

My life is easier with the use of checklists. Checklists are important tools in ensuring a consistent standard of care in the dentistry. 

References:

1. Hales B, Terblanche M. Development of medical checklists for improved quality of patient care, Sunnybrook Health Sciences Centre, Toronto, Canada, and Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom, International Journal for Quality in Health Care 2008; Volume 20, Number 1: pp. 22–30 10.1093/intqhc/mzm062 Advance Access Publication: 11 December 2007.
2. http://www.cdc.gov/HAI/pdfs/guidelines/ambulatory-care-checklist-07-2011.pdf
3. http://blogs.cdc.gov/cdcworksforyou24-7/2013/12/cdc's-top-ten-5-health-achievements-in-2013-and-5-health-threats-in-2014/
4. http://www.cdc.gov/media/dpk/2013/dpk-2013-review.html
5. http://psnet.ahrq.gov/primer.aspx?primerID=14

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There are many checklists available that can be adapted to your clinical setting. Here are my top three!

OSAP

The Organization for Safety, Asepsis and Prevention (OSAP) is a unique group of dental educators, consultants, researchers, clinicians, industry representatives, and other interested persons with a collective mission to be the world's leading advocate for the safe and infection-free delivery of oral healthcare.
http://www.osap.org/?page=ChartsChecklists

These checklists include incorporating the CDC Guidelines into your dental practice, Clinical Contact Surface Disinfectant Chart, Guidance on Infection Control Considerations for Dental Services in Sites Using Portable Equipment or Mobile Vans, Healthcare Personnel Vaccination Recommendations, and immunization. One of my favorite documents in the group helps the healthcare provider in a mobile setting: www.nappr.org/files/dental-resource-guide/QA%20Tools/OSAP.checklist.portabledenta.pdf

The Centers for Disease Control and Prevention (CDC)

The CDC was developed to help keep the community safe. The Infection Prevention checklist for outpatient settings, "Minimum Expectations for Safe Care," was prepared to ensure that facilities have appropriate infection prevention policies and procedures in place, as well as appropriate supplies, to allow healthcare personnel to provide safe care, and to systematically assess personnel adherence to correct infection prevention practices. (Assessment of adherence should be conducted by direct observation of healthcare personnel during the performance of their duties.)
www.cdc.gov/HAI/pdfs/guidelines/ambulatory-care-checklist-07-2011.pdf

Occupational Safety and Health Administration

This booklet was developed for the small business. It takes you from A to Z in what needs to be in a program. Did you know OSHA will come out and help you with this for free? All you have to do is ask. Also, if you request a visit, you cannot be fined or issued a citation during their visit.
www.osha.gov/Publications/smallbusiness/small-business.pdf

NOEL BRANDON KELSCH, RDHAP, is a syndicated columnist, writer, speaker, and cartoonist. She serves on the editorial review committee for the Organization for Safety, Asepsis and Prevention newsletter and has received many national awards. Kelsch owns her dental hygiene practice that focuses on access to care for all and helps facilitate the Simi Valley Free Dental Clinic. She has devoted much of her 35 years in dentistry to educating people about the devastating effects of methamphetamines and drug use. She is a past president of the California Dental Hygienists' Association.

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