Baylor University Medical Center Proceedings April 2014, Volume 27, Number 2 | Page 27

Medication list review
Is patient receiving medications as ordered
Deep vein thrombosis prophylaxis—subcutaneous heparin or pneumatic boots
if contraindicated (elevated INR unrelated to Coumadin is not a contraindication)
Beta-blocker for known varices or documented contraindications to
beta-blockers
Spontaneous bacterial peritonitis (SBP)
Prophylaxis with either Cipro 500 mg once a day or Bactrim DS once a day for
one of the following:
1. Previous episode of SBP
2. Ascitic fluid protein <1.5 g/dL and one of the following is present:
—serum creatinine >1.2 mg/dL
—blood urea nitrogen >25 mg/dL
—serum sodium <130 mEq/L
—Child-Pugh >9 points with bilirubin >3 mg/dL
Prophylaxis, gastrointestinal bleeding: 7 days of Ceftriaxone 1 g once a day,
Bactrim DS twice a day, or Cipro 500 mg twice a day
Treatment
Antibiotics (Ceftriaxone 1 g twice a day or 2 g once a day, unless allergic)
(Consider vancomycin if hospital acquired)
Albumin (1.5 g/kg on day 1 and 1 g/kg on day 3)
Hepatic encephalopathy
Patient carries a diagnosis: ensure lactulose and rifaximin ordered and received
Acute hepatic encephalopathy:
If low grade (stage 1 or 2)—lactulose 30–45 mL every 2 h orally or by nasogastric tube
If no improvement in 6 hours, convert to lactulose enemas every 2 h
If high grade (stage 3 and 4)—lactulose enemas every 2 h
If improvement in 6 hours, convert to every 2 h lactulose orally or by
nasogastric tube

Figure. The daily rounding checklist.

sent to the study coordinator’s office. These sheets were then
audited to determine the adherence rate (the number of completed adherence sheets divided by the total number of adherence sheets reviewed). The housestaff were surveyed on the day
after the end of their rotations.
Phase 2 was designed to evaluate whether modifying the
factors affecting adherence, discovered from the survey conducted during phase 1, would affect the adherence rate. Phase
2 lasted 5 weeks.
All data were entered into a password-protected Microsoft
Excel database. Data were analyzed using JMP SAS 8 (SAS
Institute Inc, Cary, NC). Statistical analysis included Fisher’s
exact test with a two-tailed P value.

RESULTS
During the 22-week study period, 232 patients were cared
for on the hepatology service, 190 patients in phase 1 and 42 patients in phase 2. Of the 232 patients, 59% were men, and their
mean age was 56 years. They had an average admission Model
for End-Stage Liver Disease score of 17 ± 8, an average length
of stay of 6 ± 7 days, and a 42% 30-day readmission rate.
During phase 1, adherence sheets were completed for 87
of the 190 patients. Accordingly, the overall checklist adherence rate during phase 1 was 46%. Twenty-three of 25 unique
residents who rotated during this phase (two graduated from
residency) responded to the written survey. The principal reasons
for nonadherence were that the attending did not prompt use
of the checklist (39%), the checklist adherence sheet was not
available (35%), and the housestaff forgot to do the checklist
(12%). Other reasons given included lack of time, unclear protocol, “too difficult,” and “didn’t pay attention.”
Based on the feedback, several steps were taken prior to
phase 2 (Table). First, adherence sheets were moved from the
chart used for the permanent record to the bedside chart (used
for the medication administration record). This allowed more
convenient medication reconciliation during bedside rounds.
Second, nurses were recruited to ensure that sheets were in the
chart. Third, the division chief reminded all hepatologists that
checklist completion was mandatory. The phrase “mandatory
checklist” was used during all correspondence. Fourth, the color
of the adherence sheet was changed from white to yellow to
make it more conspicuous. Fifth, data on patient outcome,
length of stay, and readmission rates were presented to housestaff, nurses, and attending physicians.
During phase 2, 42 patients were seen on the inpatient
hepatology, and adherence sheets were completed for 35 out of
the 42 patients. The difference in adherence rates between phase
1 (46%) and phase 2 (83%) was significant, P < 0.001.
DISCUSSION
Two major categories of factors affected guideline adherence: ease of task and physician commitment. Addressing these
factors significantly increased the adherence rate from 46%
to 83%. Workflow was critical to adherence. If the adherence
sheet was not available at the bedside during bedside rounds,
the chance that one would interrupt rounds to find it was low.

Table. Approaches to and solutions for barriers to adherence
Barrier to adherence

Approach
Galvanize institutional support

Physician commitment
• Attending did not prompt
checklist
• Low housestaff enthusiasm

Invigorate support from superiors, foster coownership Presentations on patient outcomes; reminder e-mails; strengthening
of attending involvement

Ease of task
• Adherence sheets hard to find
• Adherence sheets not in chart

April 2014

Solution
Reminders from division chief; reminder e-mails about “