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Home » General » Saving Lives, Old-School Style

What if there was a simple, old-school style procedure that could save tens of thousands of lives every year?

Better yet, what if it could be implemented at minuscule costs (about $3 million to rollout nationwide), and would require very little change in anyone’s procedure or daily lives?

What if that procedure was something as simple as going down a checklist before running any procedure on a patient?

The New Yorker has the scoop on how implementing simple checklists in intensive care units (ICUs) across the country could save perhaps as many as 28,000 lives a year. How so? Such lists quickly remind professionals of steps that are easily overlooked in patients undergoing more drastic events, and makes explicit the minimum, expected steps in complex processes. A simple checklist can reduce the number of preventable medical errors:

A decade ago, Israeli scientists published a study in which engineers observed patient care in I.C.U.s for twenty-four-hour stretches. They found that the average patient required a hundred and seventy-eight individual actions per day, ranging from administering a drug to suctioning the lungs, and every one of them posed risks. Remarkably, the nurses and doctors were observed to make an error in just one per cent of these actions—but that still amounted to an average of two errors a day with every patient. Intensive care succeeds only when we hold the odds of doing harm low enough for the odds of doing good to prevail.[…]

ICUs are difficult places to practice medicine. Patients require extraordinary care and are usually seen by lots of different professionals throughout the day running routine procedures. But what’s routine to an ICU nurse can also quickly turn into something mundane. When procedures become mundane, the chances of a preventable medical error increases, because the professional isn’t paying as much attention to what they’re doing. And this is where a checklist comes in:

In 2001, though, a critical-care specialist at Johns Hopkins Hospital named Peter Pronovost decided to give it a try. He didn’t attempt to make the checklist cover everything; he designed it to tackle just one problem, the one that nearly killed Anthony DeFilippo: line infections. On a sheet of plain paper, he plotted out the steps to take in order to avoid infections when putting a line in. Doctors are supposed to (1) wash their hands with soap, (2) clean the patient’s skin with chlorhexidine antiseptic, (3) put sterile drapes over the entire patient, (4) wear a sterile mask, hat, gown, and gloves, and (5) put a sterile dressing over the catheter site once the line is in. Check, check, check, check, check. These steps are no-brainers; they have been known and taught for years. So it seemed silly to make a checklist just for them. Still, Pronovost asked the nurses in his I.C.U. to observe the doctors for a month as they put lines into patients, and record how often they completed each step. In more than a third of patients, they skipped at least one.

The next month, he and his team persuaded the hospital administration to authorize nurses to stop doctors if they saw them skipping a step on the checklist; nurses were also to ask them each day whether any lines ought to be removed, so as not to leave them in longer than necessary. This was revolutionary. Nurses have always had their ways of nudging a doctor into doing the right thing, ranging from the gentle reminder (“Um, did you forget to put on your mask, doctor?”) to more forceful methods (I’ve had a nurse bodycheck me when she thought I hadn’t put enough drapes on a patient). But many nurses aren’t sure whether this is their place, or whether a given step is worth a confrontation. (Does it really matter whether a patient’s legs are draped for a line going into the chest?) The new rule made it clear: if doctors didn’t follow every step on the checklist, the nurses would have backup from the administration to intervene.

Pronovost and his colleagues monitored what happened for a year afterward. The results were so dramatic that they weren’t sure whether to believe them: the ten-day line-infection rate went from eleven per cent to zero. So they followed patients for fifteen more months. Only two line infections occurred during the entire period. They calculated that, in this one hospital, the checklist had prevented forty-three infections and eight deaths, and saved two million dollars in costs.[…]

But does it work when you try and roll it out on a state-wide scale? Just ask Michigan:

In December, 2006, the Keystone Initiative published its findings in a landmark article in The New England Journal of Medicine. Within the first three months of the project, the infection rate in Michigan’s I.C.U.s decreased by sixty-six per cent. The typical I.C.U.—including the ones at Sinai-Grace Hospital—cut its quarterly infection rate to zero. Michigan’s infection rates fell so low that its average I.C.U. outperformed ninety per cent of I.C.U.s nationwide. In the Keystone Initiative’s first eighteen months, the hospitals saved an estimated hundred and seventy-five million dollars in costs and more than fifteen hundred lives. The successes have been sustained for almost four years—all because of a stupid little checklist.

While hospital CIOs continue to push EHRs and EMRs in these tough economic times (at a cost of hundreds of millions dollars per state to implement), perhaps they should instead be examining something as simple and as old-school as a piece of paper with some steps printed on it as an equally effective method for saving lives.

Granted, paper isn’t as sexy as some fancy, expensive electronic health record (nor are the two mutually exclusive). But checklists are easier and quicker to implement, have solid research backing, and could begin saving lives tomorrow in any hospital that chooses to implement them.

The New Yorker makes the argument that because a checklist wasn’t invented by some company with a 30-year patent on it, the checklist garners little interest amongst management and boards that are always looking to impress with their race to keep up with the marketing technology and trends:

I called Pronovost recently at Johns Hopkins, where he was on duty in an I.C.U. I asked him how long it would be before the average doctor or nurse is as apt to have a checklist in hand as a stethoscope (which, unlike checklists, has never been proved to make a difference to patient care).

“At the current rate, it will never happen,” he said, as monitors beeped in the background. “The fundamental problem with the quality of American medicine is that we’ve failed to view delivery of health care as a science. The tasks of medical science fall into three buckets. One is understanding disease biology. One is finding effective therapies. And one is insuring those therapies are delivered effectively. That third bucket has been almost totally ignored by research funders, government, and academia. It’s viewed as the art of medicine. That’s a mistake, a huge mistake. And from a taxpayer’s perspective it’s outrageous.” We have a thirty-billion-dollar-a-year National Institutes of Health, he pointed out, which has been a remarkable powerhouse of discovery. But we have no billion-dollar National Institute of Health Care Delivery studying how best to incorporate those discoveries into daily practice.

Sad, but true.