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Tilting at Windmills

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February 13, 2008
By: Kevin Drum

THE CHECKLIST....If you've ever been treated in an ICU, there's a good chance you've been fitted at some point with a "central line," a catheter sewn into a large vein and used to deliver medications and monitor cardiovascular status. Central lines are a critical part of modern intensive care, but unfortunately, as Atul Gawande wrote in the New Yorker a few weeks ago, they can also be killers:

Line infections are so common that they are considered a routine complication. I.C.U.s put five million lines into patients each year, and national statistics show that, after ten days, four per cent of those lines become infected. Line infections occur in eighty thousand people a year in the United States, and are fatal between five and twenty-eight per cent of the time, depending on how sick one is at the start. Those who survive line infections spend on average a week longer in intensive care. And this is just one of many risks.

In 2001, a critical-care specialist at Johns Hopkins Hospital named Peter Pronovost decided to create a simple checklist designed to reduce line infections. The result was astonishing: line infection rates dropped to zero percent. A couple of years later, Pronovost tried out his checklist in a more demanding environment: public hospitals throughout the state of Michigan. Here's the good news — and the bad:

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.

....If someone found a new drug that could wipe out infections with anything remotely like the effectiveness of Pronovost's lists, there would be television ads with Robert Jarvik extolling its virtues, detail men offering free lunches to get doctors to make it part of their practice, government programs to research it, and competitors jumping in to make a newer, better version. That's what happened when manufacturers marketed central-line catheters coated with silver or other antimicrobials; they cost a third more, and reduced infections only slightly — and hospitals have spent tens of millions of dollars on them. But, with the checklist, what we have is Peter Pronovost trying to see if maybe, in the next year or two, hospitals in Rhode Island and New Jersey will give his idea a try.

....I asked [Pronovost] how much it would cost for him to do for the whole country what he did for Michigan. About two million dollars, he said, maybe three, mostly for the technical work of signing up hospitals to participate state by state and coordinating a database to track the results. He's already devised a plan to do it in all of Spain for less.

"We could get I.C.U. checklists in use throughout the United States within two years, if the country wanted it," he said.

So far, it seems, we don't. The United States could have been the first to adopt medical checklists nationwide, but, instead, Spain will beat us. "I at least hope we're not the last," Pronovost said.

If you extrapolate what happened in Michigan to the entire country, a $2 million investment in Pronovost's checklists would save perhaps $2 billion and 10-20,000 lives each year. And yet, we're not doing it. After all, who's got both the incentive and the clout to make it happen? Insurance companies basically earn a percentage of the cost of the medical care they cover, so they don't really care if costs go down. Corporations would certainly like lower costs, but they're too diffuse to put up a united front to demand change. The federal government doesn't have the authority to mandate the checklists. Doctors don't want to be pestered about them. And patients don't know enough to even realize there's a problem.

The American healthcare system is a grand thing, isn't it? Nobody wants to be bothered with stuff like this, and in the end it will probably only get adopted thanks to another beloved American institution: fear of medical malpractice lawsuits. After a few whopping awards in cases where doctors are forced to admit on the stand that, no, they didn't use Pronovost's simple and proven line infection checklist, eventually they'll get the message.

But wait. What am I thinking? I guess they could get the message. Or it could become just another excuse for the AMA to start screaming about how the legal system is driving doctors out of business. That's an American institution too.

Kevin Drum 8:47 PM Permalink | Trackbacks | Comments (62)

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Comments

"Doctors don't want to be pestered about them."

I'm unfamiliar with this particular checklist, but there are multiple studies looking at various ways of reducing line infections, and as a resident in Hawaii I have been subjected to multiple lectures on the topic. We are routinely and repeatedly told to use excellent hand hygiene, maximum barrier precautions, sterile technique, and daily insertion site checks to reduce infections. The moment we no longer need the line, it comes out.

The vast majority of ICU-trained physicians are already using evidence-based methods of reducing line infections. It's simply unfair to imply that doctors don't care about this stuff.

Posted by: Jonathan Dworkin on February 13, 2008 at 9:03 PM | PERMALINK

Insurance companies make a percentage off of health care expenditures? No, they don't.

I read an article about this, and in answer to the first post, it's not that doctors don't care, it's just that "in the moment" it's easy to forget or justify not doing certain things. This isn't a rap on doctors, it's human nature. If the airline industry worked like this, no one would fly. Some medical specialties, like anesthesiology, were forced to adopt a checklist or rote model or else they were uninsurable. Eventually, the future belongs to checklists, because hospitals that won't use them will be paying so much in liability payments they won't be able to survive.

Posted by: Barbara on February 13, 2008 at 9:07 PM | PERMALINK

Dr. Dworkin, I'm sure that you care and are personally very careful, and of course doctors care about this stuff, but would you want airline pilots to get rid of their pre-flight checklists because they are insulting to pilots, who are after all trained professionals who care about this stuff?

If there's data indicating that a formal checklist decreases infections, let's do it.

Posted by: Joe Buck on February 13, 2008 at 9:07 PM | PERMALINK

Beee-atch! The Market is working! Don't go having fucking interference, you Commie!

Posted by: Gore/Edwards 08 on February 13, 2008 at 9:10 PM | PERMALINK

It's even worse than what you've written here, Kevin. The study was actually shut down by the Office for Human Research Protections because imposing the checklist was changing the standard of care for the patients, and the hospitals would thus be forced to get informed consent from each and every patient before they used the checklist on them. No checklist = standard care, no consent required. Checklist = consent required. This shut down the study.
Your government at work.
Read the gory details here.

Posted by: LLamura on February 13, 2008 at 9:13 PM | PERMALINK

I'm all for checklists, provided they are practical, evidence-based, and can be done in a rush on someone who is crashing (i.e. I wouldn't want the pilot going through his checklists while the plane enters a nosedive).

My only point is that doctors have no financial, professional, or ethical interest in providing lousy care. So why create a false dichotomy in which doctors and patients are enemies? It's not helpful.

Posted by: Jonathan Dworkin on February 13, 2008 at 9:14 PM | PERMALINK

Apologies, that link should have been this one.

Posted by: LLamura on February 13, 2008 at 9:15 PM | PERMALINK

As a constitutional matter, the federal government undoubted has the authority to pass a law or authorize a regulation to mandate use of a checklist like the one you describe. That's not even a close or controversial call.

Perhaps you meant that the federal government doesn't currently have such a law. I don't know about that. But if the federal government hasn't acted, why hasn't it?

Posted by: Mark on February 13, 2008 at 9:17 PM | PERMALINK

Jonathan Dworkin: The vast majority of ICU-trained physicians are already using evidence-based methods of reducing line infections.

Then how do you explain the dramatic results of the Michigan program?

It's simply unfair to imply that doctors don't care about this stuff.

You're right - it would have been unfair. Fortunately, he made no such implication - he didn't blame any particular party.

Your defensive "not my fault" attitude is precisely what has to be avoided in operations research and its application. This has been understood by people in other fields since at least WWII. I hope that medicine catches up.

My only point is that doctors have no financial, professional, or ethical interest in providing lousy care.

Who said that they did?

So why create a false dichotomy in which doctors and patients are enemies?

Who's trying to do that, and what makes you think that doctors are the only important element in patient care?

Posted by: alex on February 13, 2008 at 9:20 PM | PERMALINK

Sounds like 19th century medicine. I cringe when I go in a hospital, even when healthy. They can't even get the fundamentals right; too busy salivating about their latest big buck, hi-tech acquisitions.

Posted by: Michael7843853 G-O/F in 08! on February 13, 2008 at 9:23 PM | PERMALINK

Are you sure Big Pharma haven't paid off their pals in the White House:

But the veteran Johns Hopkins safety researcher also drew critical scrutiny from government regulators. In a decision last month that upset his colleagues nationwide, the federal Office of Human Research Protections said using a safety checklist - and studying its effects - amounted to conducting an experiment without a patient's consent.

So the agency directed the 70 Michigan hospitals that participated in Pronovost's study to stop sending him data on future infection rates.

Both Pronovost and federal officials play down the dispute. But elsewhere, researchers say the government's heavy-handed treatment of a simple, commonsense project that has saved more than 1,500 lives - at almost no cost - could delay similar safety initiatives nationwide.

"I think it's ludicrous. It probably will kill people if they don't fix this soon," said Dr. Robert Wachter, a national expert on patient safety at the University of California, San Francisco. "This is regulation run amok."

Posted by: blowback on February 13, 2008 at 9:24 PM | PERMALINK

And surely, airline pilots have even less interest in crashing their plane -- they still use the pre-flight checklist.

And sadly, while doctors have no incentive to give poor care, they don't necessarily have compelling incentives to provide "better" or "best" care.

The refusal to acknowledge the ubiquity of innocent failure of even highly skilled humans engaged in potentially high risk activities is a large part of what holds medicine back from doing what it takes to avoid mistakes and overcome errors.

Posted by: Barbara on February 13, 2008 at 9:25 PM | PERMALINK

Dworkin needs to get off his high horse of "but it ain`t me" as alex suggests.

The evidence seems to be solid and the next step (in a sane world which admittedly ours isn`t) would be to implement the check list.

There are no reasons not to, just excuses.

“Once you start a project, amazing people start to join” - Major Nate Allen

Posted by: daCascadian on February 13, 2008 at 9:25 PM | PERMALINK

There are ways around this, as asinine as the situation is. Essentially, by using checklists against institution-identifed standards (which can be identical to the criteria in question), one can adopt them as in-house measures of compliance with hospital policy and procedure, and thus, these do not need IRB approval. The Institute for Healthcare Improvement (IHI.org)website has done yeoman's work in identifying groups of behaviors (referred to as bundles) which favorably affect patient outcomes, and it provides many tools for measurement, many best practice exemplars and many fora for sharing operational tips.

The key is to move these checklists from medical practice/research oversight venues and move them into the performance improvement aspects of nursing practice operations, where both oversight and IRB interference impact differently.

Posted by: Annie on February 13, 2008 at 9:41 PM | PERMALINK

Wow, a couple quick points to the mob:

1) Blame & High Horses - To quote Kevin, "in the end it will probably only get adopted thanks to another beloved American institution: fear of medical malpractice lawsuits. After a few whopping awards in cases where doctors are forced to admit on the stand that, no, they didn't use Pronovost's simple and proven line infection checklist, eventually they'll get the message.

But wait. What am I thinking? I guess they could get the message. Or it could become just another excuse for the AMA to start screaming about how the legal system is driving doctors out of business."

Now let's see here, doctors won't do something proven to work unless forced to do so by lawsuits. Except they're so slimy, they might not even do that. That sure sounds like blame. In fact, by pointing out that doctors and patients both care about this issue, I'm the only one on this thread who is not involved in blame. So I think I'll stay on my high horse, thank you very much.

2) The Real Scandal - It's ultrasound. There are studies showing fewer mechanical complications (e.g. pneumothorax) when ultrasound is used. And yet when I moved from New York to Hawaii, I realized it's far from standard practice everywhere. That ought to be a scandal, but isn't, and I'm not sure why.

3) Checklists - Again, I'm all for a checklist that works and is usable in an emergency. So please don't lump me in the anti-checklist, anti-progress category.


Posted by: Jonathan Dworkin on February 13, 2008 at 9:46 PM | PERMALINK

BGRS,

You are a saint and, at least in my experience, absolutely correct about ICU staffing.

Posted by: Jonathan Dworkin on February 13, 2008 at 9:52 PM | PERMALINK

i.e. I wouldn't want the pilot going through his checklists while the plane enters a nosedive.

Yes you would. That's what they do ya know, whenever any emergency takes place. They stabilize as best they can, and then they get out the manuals for the aircraft and work the checklists.

What do you think they have in those big black bags of theirs, stethoscopes?

(It's not clear anyone is saying that there needs to be a big checklist for an ICU for someone that is crashing...)

Posted by: Bob who watches too much History Channel on February 13, 2008 at 9:53 PM | PERMALINK

Doctor Napoleon can't be bothered with a friggin' checklist.

Most of all the specialty doctors I've known and worked with for the last 30 years are grossly overpaid, pompous, would be corporate suits, that for the most part, don't give a shit about anything other than maintaining the status quo, i.e, their lavish livelihoods. Please, just regulate them and their precious license to steal from the unfortunate. They make me sick.

Posted by: SId's Id on February 13, 2008 at 9:55 PM | PERMALINK

Holy cow - let's try this again - there is a chunk of my comment that is missing...

Thank god - a topic that a) isn't about the horserace and b) I actually know something about.

I'm going to address this from the vantage point of a 25 year veteran of critical care and laboratory medicine (people like me set up, incubate and read the blood cultures to identify the critter when an infection happens. IOW: We take the guesswork out of Dr. Dworkin's job. :)

Understaffing is a huge factor here. Understaffing leads to infections. Harried nurses are less likely to engage in proper hand hygiene, and housekeeping - er - excuse me - "environmental services" - will eventually take shortcuts of necessity.

I was the lab shift lead one weekend afternoon at a large for-profit chain's flagship hospital when the cultures came over from a sister facility to confirm MRSA in three critical care newborns. I have been the infection control officer at a couple of facilities. I know that that happens one of two ways: Either the nurses aren't handwashing properly, or housekeeping isn't properly cleaning the isolettes.

This was a for-profit chain that had cut staff to the point that one night the agency RN's refused to clock in because they were not willing to risk their licenses. Yes. They were accusing the administration at that facility of criminal conduct. Adequate staff was called in, but for a little over an hour, one of the busiest trauma centers in the entire state was closed and helicopters and ambulances diverted.

When ICU's are adequately staffed, new protocols don't meet a lot of resistance. That would be a good place to start. If that requires state legislatures, so be it.

Posted by: Blue Girl, Red State on February 13, 2008 at 9:57 PM | PERMALINK

I was in an ICU for a week, and an IV the majority of the time, was never in danger of crashing, so would probably have been a good candidate for a checklist.

Posted by: jerry on February 13, 2008 at 9:59 PM | PERMALINK

I'll jump into the swamp here to comment that 1.)I'm one of those slimy doctors, 2.)I've worked quite a bit in ICUs, and 3.)It has nothing to do with the indifference of individual physicians to providing the best care they can, and everything to do with institutional inertia. It takes a lot more than one ICU doc saying "Hey man, we gotta get one of them checklists" to get a hospital-wide, advertised, enforced initiative underway. In fact, it takes the coordination and effort of a lot of people who aren't even doctors. Of course, it's much cooler to ascribe the lack of universal acceptance to the idea that we MDs "don't want to be pestered."

Posted by: jb on February 13, 2008 at 10:00 PM | PERMALINK

Llamura actually is right about the cause for all this, and Kevin would have looked into this a little more he would have found that out himself. But no, go ahead and yell at doctors.

Scienceblogger Orac had a good rundown of the issues involved, if you're interested.

Posted by: Cain on February 13, 2008 at 10:00 PM | PERMALINK

http://www.atchistory.org/History/checklst.htm

How the Pilot's Checklist Came About

History written by John Schamel

This page contains a brief history about the development of aviation checklists used in aircraft today.

October 30, 1935
Wright Field, Dayton, Ohio

The final phase of aircraft evaluations under U.S. Army specification 98-201 (July 18, 1934) was to begin. Three manufactures had submitted aircraft for testing. Martin submitted their Model 146; Douglas submitted the DB-1; and Boeing submitted their Model 299. Boeing, a producer of fighters for U.S. Navy aircraft carriers, had little success in commercial airliners or bombers for the U.S. Army Air Corps.

Boeing’s entry had swept all the evaluations, figuratively flying circles around the competition. Many considered these final evaluations mere formalities - talk was of an order for between 185 and 220 aircraft. Boeing executives were excited - a major sale would save the company.

At the controls of the Model 299 this day were two Army pilots. Major Ployer P. Hill (his first time flying the 299) sat in the left seat with Lieutenant Donald Putt (the primary Army pilot for the previous evaluation flights) as the co-pilot. With them was Leslie Tower (the Boeing Chief Test Pilot), C.W. Benton (a Boeing mechanic), and Henry Igo (a representative of Pratt and Whitney, the engine manufacturer).

The aircraft made a normal taxi and takeoff. It began a smooth climb, but then suddenly stalled. The aircraft turned on one wing and fell, bursting into flames upon impact.

Putt, Benton, and Igo - although seriously burned - were able to stagger out of the wreckage to the arriving safety crews. Hill and Tower were trapped in the wreckage but were rescued by First Lieutenant Robert Giovannoli, who made two trips into the burning aircraft to rescue both men

Both men later died of their injuries. Lt. Giovannoli was awarded the Cheney Medal for his heroism that day, but he died in an aircraft accident before receiving it..

The investigation found "Pilot Error" as the cause. Hill, unfamiliar with the aircraft, had neglected to release the elevator lock prior to take off. Once airborne, Tower evidently realized what was happening and tried to reach the lock handle, but it was too late.

It appeared that the Model 299 was dead. Some newspapers had dubbed it as ‘too much plane for one man to fly.’ Most of the aircraft contracts went to the runner-up, the Douglas DB-1. Some serious pleading and politicking by Air Corps officers gave Boeing a chance to keep the Model 299 project alive - 13 aircraft were ordered for ‘further testing’. Douglas, however, received contracts for 133 aircraft for active squadron service. The DB-1 became the B-18.

Twelve of those Boeing aircraft were delivered to the 2nd Bombardment Group at Langley Field, Virginia, by August, 1937. The 2nd Group’s operations were closely watched by Boeing, Congress, and the War Department. Any further accidents or incidents with the Model 299 would end its career. Commanders made this quite clear to all the crews.

The pilots sat down and put their heads together. What was needed was some way of making sure that everything was done; that nothing was overlooked. What resulted was a pilot’s checklist. Actually, four checklists were developed - takeoff, flight, before landing, and after landing. The Model 299 was not ‘too much airplane for one man to fly’, it was simply too complex for any one man’s memory. These checklists for the pilot and co-pilot made sure that nothing was forgotten.

With the checklists, careful planning, and rigorous training, the twelve aircraft managed to fly 1.8 million miles without a serious accident. The U.S. Army accepted the Model 299, and eventually ordered 12,731 of the aircraft they numbered the B-17.

The idea of the pilot’s checklist caught on. Other checklists were developed for other crew members. Checklists were developed for other aircraft in the Air Corps inventory.

End of article.

References:
Gilbert, James "The Great Planes", 1970
Jablonski, Edward "Flying Fortress", 1965
Jones, Lloyd "U.S. Fighters", 1975
Above article written by John Schamel

Posted by: Bob who watches too much History Channel on February 13, 2008 at 10:05 PM | PERMALINK

jb: I'm one of those slimy doctors

At least you're honest enough to admit it.

It has nothing to do with the indifference of individual physicians to providing the best care they can, and everything to do with institutional inertia. It takes a lot more than one ICU doc saying "Hey man, we gotta get one of them checklists" to get a hospital-wide, advertised, enforced initiative underway. In fact, it takes the coordination and effort of a lot of people who aren't even doctors.

Thank you, that was exactly my point.

As a corollary, good doctors freely admit that it takes more than just doctors to effectively care for patients, particularly in a place like an ICU. As a corollary to the corollary, those non-doctors can screw things up too.

That's why effective implementation of systems research avoids the blame game and concentrates on fixing the problem.

Posted by: alex on February 13, 2008 at 10:07 PM | PERMALINK

I'm all for checklists, provided they are practical, evidence-based, and can be done in a rush on someone who is crashing (i.e. I wouldn't want the pilot going through his checklists while the plane enters a nosedive).
Posted by: Jonathan Dworkin

Just wanted to be precise here. In a nosedive a pilot would indeed use a checklist. He would execute what are known as the bold face steps, which are the ones he has to have memorized. Once things are stable, he must then execute the remaining steps explicitly using the checklist. If something goes wrong later and they found out he did not open the checklist and verify the bold face was followed and the other steps worked through...he's in trouble.

Posted by: sjrsm on February 13, 2008 at 10:08 PM | PERMALINK

To add, (hit enter too quick) PIC infections are near and dear to my heart. FIL has been battling leukemia for a year now, and has had line infections. Bad news those.

Posted by: sjrsm on February 13, 2008 at 10:09 PM | PERMALINK

Alex,

I'm glad we agree. One of the distressing things to me, as a young surgeon, is the distressingly vitriolic rhetoric than many of my fellow progressive Democrats use when they speak about physicians. I can't tell you how many otherwise left-leaning people in the healthcare industry are utterly turned off and pushed in the wrong direction from the type of ad hominem crap that's spewed on message boards like this one. In an election year, when the centerpiece of our agenda should be providing universal healthcare, it seems like a good idea to stop alienating docs and start trying to get them in the tent. I'm not calling for a love-fest here (we as a profession have a lot to answer for), but we could at least keep the attacks to a professional level, not on SId's Id's.

Posted by: jb on February 13, 2008 at 10:17 PM | PERMALINK

As a corollary, good doctors freely admit that it takes more than just doctors to effectively care for patients, particularly in a place like an ICU. As a corollary to the corollary, those non-doctors can screw things up too.

Oh all kinds of shit happens that shouldn't in an ICU. For instance, I have seen stressed RN's tell a phlebotomists to draw from lines because they don't have the time. And are you aware that phlebotomists, the only employees who, every single shift move all over the hospital, performing invasive procedures have minimal training? In some states there is no registration or licensing required, and training is on the job.

Posted by: Blue Girl, Red State on February 13, 2008 at 10:18 PM | PERMALINK

One more on the nose dive checklist:

In the navy, a watchstander is expected to know by heart his/her actions to take immediately in the event of a casualty. Once the actions are complete, the watchstander is then expected to grab a checklist, and verify that all the actions have indeed been accomplished. (and then use written procedures to perform the follow-on recovery actions)

So I could imagine a similar thing for medicine. You have to know the "CBC, Chem 6, intubate stat" stuff and issue orders of the cuff, but then you verify with written guidance at the appropriate time.

And the first thing I thought of when I read this was that it was shut-down due to a violation of human factors ethics rules (not due to funding or anything like that), but I see it was mentioned above

Posted by: Kolohe on February 13, 2008 at 10:19 PM | PERMALINK

Jonathan Dworkin posted "I'm unfamiliar with this particular checklist.....The vast majority of ICU-trained physicians are already using evidence-based methods of reducing line infections." and "I'm all for checklists..."

Now that you ARE aware of this checklist and its evidence-based success at Johns Hopkins as well as Michigan public hospitals, will you be using it? If not, why not?

Posted by: jeri on February 13, 2008 at 10:24 PM | PERMALINK

I never go near an ICU anymore, so I haven't got a dog in the fight, but I imagine that if checklists have been shown to be useful, they'll be adopted. It may take some months to a year or two to become widespread. It would be great if every new medical breakthrough became instantly accepted (at least all the good ones...), but there are a lot of people involved and a pretty steady torrent of information to be disseminated, absorbed, filtered and adopted or discarded.

Kevin, I love you, but whenever I see someone blame anything on "the AMA", I instantly assume they don't know what they are talking about. The AMA is a lobbying organization to which about a third of U.S. physicians belong and the rest of us ignore.

Posted by: J Bean on February 13, 2008 at 11:08 PM | PERMALINK

Lesson here is to not get sick, and if you get sick, don't go to a hospital.

Posted by: Jim on February 13, 2008 at 11:50 PM | PERMALINK

A straightforward checklist involving a few moments of commonsenese thinking resulting in huge benefits versus expensive medical equipment with limited benefits: It's a no-brainer: expensive medical equipment it is!

Let's treat all the interns to an expensively catered lunch of croissant sandwiches packed in paper boxes--including pickles!!!

They'll want to show up for this lunch and sign up for these swell freebies!!! It's expensive coating time!!

Do the manufacturers also make that brain-dead software for that fraudulent company run by George W. Bush's brother Neil Bush?? Freebies for the school!! Everyone sign up!!

Posted by: Anon on February 13, 2008 at 11:52 PM | PERMALINK

It occurred to me that I might wish to see what was on the checklist, in case I was conscious when I suffered a line to be put in, or was around when a procedure was attempted on a loved one.

But nothing in Kevin's post or the comments. The linked New Yorker article has it:

(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.

If your ICU isn't following the checklist, complain.

And that saves thousands of lives? Amazing.
On tomorrow's personal checklist: subscribe to the New Yorker.

Posted by: Barry on February 14, 2008 at 12:42 AM | PERMALINK

As a medicine resident at Hopkins about to do a fellowship in Pulm Critical Care, I am very familiar with the checklist. Basically, the big changes involve completely draping the patient head-to-toe, gowning and gloving in a sterile fashion after handwashing much like what is done with surgery (note that for non-central lines, sterile draping and gloving is not needed), cleaning the patient, selecting a right site (femoral access is last choice due to its high rate of infection), using an experienced operator, and dressing (and redressing) it correctly. Also nurses do qshift assessments of the line entry site.

I'd agree with the above that we the physicians have no reason not to implement these changes. The big problem is with education. At Hopkins, we have the entire treatment team on the checklist -- the nurse sits outside the ICU room while we are doing the procedure running down the checklist, and thus, as such, in a training hospital, it becomes second nature. That's how to improve care, especially in a setting where things have to happen fast because we are often dealing with code or near-code situations. If I am wasting twenty minutes organizing and carrying out an unfamiliar checklist, that is fine for outpatient medicine or even non-sick people on the floor. But in the ICU, if I need a line in, it is often right here, right now. And so it needs to be second nature. It's hard to get to that level in a non-training hospital situation.

Little changes do make big differences, and I fully acknowledge it. Unfortunately, this little change doesn't save much money around here -- Maryland (and many other states) have capitated care. By the time a patient gets to the ICU, they usually are at or near their cap. When their ICU stay is shortened from 3 weeks to 2.5 weeks, that extra money is only saving the hospital money as they are the ones eating the cost for anything over the capitation. Believe me, the Johns Hopkins ICU is not a money making venture...

Posted by: Ed on February 14, 2008 at 1:13 AM | PERMALINK

Just to broaden it out, Blue Girl, 9:57 PM, points out why market driven medical care has exactly the same shortfalls as underfinanced universal health care (understaffing, too few spare beds) except this incentive is inherent to the system and in direct tension with the patient, and it's suits that make the decisions. At least with "social" health care the politicos can be made to feel the heat and nobody's walking away with millions.

Medicine is not market driven. Or, more precisely, the patient is not the customer.

Second, hasn't the Mayo been working on best practices for some time, trying to reduce unnecessary tests, etc., essentially looking for best outcomes at lower cost.

Perhaps someone here knows something about their work?

Posted by: notthere on February 14, 2008 at 2:16 AM | PERMALINK

Nobody wants a simple solution? Dr. Semmelweis discovered that washing hands was a good idea if you were delivering babies, particularly if you were delivering many in one day. Do you think that idea spread like an (I was going to write infection)? Hell no - women were dying in droves, giving birth, and that was nature's way. Washing your hands had nothing to do with whether they didn't - except in Semmelweis' tests - where the incidence of fatal puerperal fever fell from 1/5 women dying to 1/100.
Yeah - but the medical establishment wasn't convinced, and Pasteur hadn't found microbes yet. Semmelweis was committed to an insane asylum, by the way, so Pronovost should probably watch out.

http://en.wikipedia.org/wiki/Ignaz_Semmelweis

Posted by: SteinL on February 14, 2008 at 2:43 AM | PERMALINK

Kevin, I really appreciate you focusing on health care as such a huge issue.

I am a deeply cynical and depraved individual, as my name suggests, but I do have some ideals floating around, and one of them is that we can actually make very profound changes in people's lives if we only focus on health care.

You know? All the telecom immunity stuff enrages me, as well as the senseless slaughter in Iraq, and it's all important, but if we could just get health care right ... I would feel like this country has a chance, ya know? If maybe we could increase Mississippi's infant mortality rate so that it is even just a little better than a third world country, that would be real progress, for real.

So as a really grumpy and cynical person who is sometimes driven mad by some of your opinions, I really appreciate you focusing on this very important issue that means so much to so many people.

Posted by: BombIranForChrist on February 14, 2008 at 2:43 AM | PERMALINK

I see the aviation folks have beat me to the punch, checklists have been a part of military aviation since before World War II. In commercial aviation, pilots (and flight attendants) are required to carry around the appropriate checklists on every flight. They are randomly stopped by FAA inspectors and asked to produce their manuals. If they can't, they and their airline are in big trouble.

How hard would it be for federal (or state) health inspector to randomly check ICU's to determine if checklists are handy and are being used? If government health inspectors have the authority to inspect the kitchen of a pizza joint, I'd suggest they have the authority to inspect a hospital.

To put Kevin's extrapolated numbers (10-20,000 lives saved each year) in perspective; imagine if the FBI had a plan to reduce the annual murder rate (17,000) to zero, or the CDC had a new AIDS treatment that reduced HIV/AIDS fatalities (13,000) to zero.

Does anyone think Uncle Sam would balk at paying $2 billion and using government regulators to ensure compliance?

Posted by: beowulf on February 14, 2008 at 2:52 AM | PERMALINK

I'm glad to see some other docs jumped into this discussion. Out here in Hawaii we haven't adopted the checklist as a formal policy (I asked one of our pulmonary ICU docs today). But we're already doing everything on the checklist as part of our own protocols.

So there's no controversy over this issue, at least not in Maryland or Hawaii.

JB makes a good point about the tone of the debate, and I think ultimately that's what I was getting at earlier. Doctors ought to be in support of universal standards and universal coverage, and I think most of us are. Likewise patients ought to realize that lawsuits, and the constant threat of litigation, create a poisonous atmosphere for the practice of healthcare. A case in point is obstetrics - my wife is pregnant and the OBs in Honolulu are so surgically minded that it was a real struggle to find someone who would work with us for a natural birth. I would argue that this is one cost of defensive medicine and a litiginous/paranoid medical culture.

They have perfectly good healthcare in Europe without all of our vitriol and mutual distrust. The tone, and the way we carry out our debate, is important if you want to build a real civic coalition for medical reform in this country.

Posted by: Jonathan Dworkin on February 14, 2008 at 2:55 AM | PERMALINK

This is a wonderful example of a medical innovation's happening *without* any profit motive on the part of the innovator.

The guy was just interested in saving lives. Imagine that.

This kind of thing was routine in the past, before $$ became the all-and-only of American life.

Posted by: Nancy Irving on February 14, 2008 at 4:45 AM | PERMALINK

As to the question of resistance to change, especially where there is money to be made, take the odd case of Heliobacter. I'm working from deep memory here so please forgive or correct at will.

For ages stomach ulcers were thought to be stress induced, other factors too, but definitely not bacteria. The thought was that no bacteria could live in the stomach because of the acids.

Then some guy down in Australia discovered that the ulcers were indeed caused by a bacteria, heliobacter, and could be cured with a two week run of antibiotics. He gave himself the bacteria and then cured himself as no one else would believe him. There was much resistance to what he had found. Why? Because the industry and money relying on ulcers being treated and not cured was huge.

He presented at conferences and symposiums for quite a while and was at first laughed off the stage for redefining the conventional wisdom. But in the end he, and his cure, was vindicated and is now used.

All groups have inertia. Why did the Beatles never get a Grammy while they were in their prime even though at one time they had the five top slots in the top 100?

It is unfortunate, but part of human nature to resist change to the group dynamic. You'd hope scientists. like MDs would be different, and perhaps they are to a degree, but overall, not.

And why don't Docs just start using this checklist? Why does the change have to come from the top down? If there is enough publicity and it works, which it seems to do, why don't they demand it's adoption? They are by and large wealthy, articulate and organized - just do it guys. And if you are told to stop, publicize that you are being instructed to stop saving lives. Call up the networks.

Ed

Posted by: Ed D. on February 14, 2008 at 6:39 AM | PERMALINK

someone should go back and learn how the Apgar Score was first brought into widespread use. it too is just a simple list of things to look for, and came from a doctor who saw a pattern.

Posted by: cleek on February 14, 2008 at 8:44 AM | PERMALINK

Kevin, you sound bitter and angry. Bipartisanship requires that you go along to get along, especially if you are a healthcare provider.

Posted by: Where's Sally? on February 14, 2008 at 8:56 AM | PERMALINK
My only point is that doctors have no financial, professional, or ethical interest in providing lousy care.

Who said that they did?

It is my understanding that doctors do have a financial interest in providing lousy care. I don't know why Kevin said that Insurance companies are paid for a percentage of procedures --- don't they pay out for procedures? But doctors are paid for procedures and hospital visits. It is more profitable to sell a pound of cure than an ounce of prevention.

I know a cardiac surgeon who quit practice because the existing evidence called into question the effectiveness of most angioplasty procedures. Yet, angioplasty has become a billion dollar a year industry, and his colleagues are definitely not stepping away.

Then there are the speaking fees and other goodies from drug companies. Those are surely not financial incentives for evidence-based medicine.

The doctors I know are as ethical as anyone else, and I generally trust them. But I will say: there are financial incentives for doctors to provide lousy and unnecessary care, though I doubt that is a factor here.

Posted by: Dagome on February 14, 2008 at 8:59 AM | PERMALINK

I disagree that the insurance industry has no reason to support this. For one thing they are the ones who pay for malpractice insurance. It would be nothing for them to come up with a couple of million dollars to finance the check list implementation and they could use it as a PR talking point. I think there is inertia there, too.
Another thing that is missing here is our idiotic media. This kind of thing should be front page news and all over television. That alone would put pressure on hospitals to change their procedures.
For profit medicine has been a disaster for our system. My father was a doctor and he hated what he saw happening in the last years he was in practice. He said that even though the focus on money making had increased his income significantly it had completely changed the culture in his group. He complained that when the doctors were together during breaks, eating lunch, etc. they talked a lot less about medicine, patient care, problems they were encountering with diagnoses and spent much more time talking about financial issues. He hated it.

Posted by: BernieO on February 14, 2008 at 9:12 AM | PERMALINK

LLamura,

there is nothing in the research regulations that would keep the hospitals from using the checklist. They just would not be able to collect the data for publication. They can use the quality data in house but not for scholarly publication.

Posted by: superdestroyer on February 14, 2008 at 9:13 AM | PERMALINK

The other big thing aviation brings to the picture but medicine doesn't is crew resource management (CRM). Aviation is much bigger on the decision-making team, while when I watch doctors and nurses interact, it is much more of a master-subject relationship. I've learned to watch the nurse in the background when talking to the doctor. They can't help but express with their body language and such what they're thinking. While doctors are smart as all and training to the highest quality, the nurses have the quantity of eyes-on time with the patient. And as the Chinese say, "Quantity has a quality of its own."

And continuity of care across multiple doctors sucks. One goes on a trip for a week, and the next changes the protocol based on his favorite approach. There is only one true patient advocate. That's the patient and their family. Caveat emptor.

Posted by: sjrsm on February 14, 2008 at 9:35 AM | PERMALINK

Umm, this may be a stupid question, but why isn't the Federal government doing this? He comments in the article that it will take $2-3 million to implement this nationwide. We have a Surgeon General, a Department of Health. Why isn't this happening?

Kevin seems to be on a bit of a rant about how lousy our healthcare system is. Fair enough, but you'll forgive me for being at least a bit skeptical that having the federal government take it over will solve these problems.

If you think the current system is resistant to change, just wait....

Posted by: rhinoman on February 14, 2008 at 10:10 AM | PERMALINK

Hmmm... Gee whiz. Medical mistakes cost billions and kill thousands?

If mistakes are a problem, will someone explain why internists are routinely required to work 24 to 30 hour shifts?

While you're at it, also explain why having a 'professional organization' (really a craft guild) monopolizing the supply of medical care in the United States is a good idea.

Posted by: Buford on February 14, 2008 at 10:17 AM | PERMALINK

Maybe someone more familiar with the process could answer this: Why doesn't JAHCO demand checklist use in order to certify hospitals? Is that kind of specific procedure enforcement to far down in the weeds for what they do?

Posted by: Captured Shadow on February 14, 2008 at 10:22 AM | PERMALINK

There is only one true patient advocate. That's the patient and their family.

Which is why it is absolutely critical to have a family member in with the patient at all times during a hospital stay. I'd go so far as to say that a patient representative of some sort should be present in the operating room, and that second opinions should be fucking mandatory.

It may annoy the hospitals, doctors, and nurses, but screw'em, and I'm talking from repeated personal experiences and much bitterness.

Posted by: jerry on February 14, 2008 at 10:23 AM | PERMALINK

The American healthcare system is a lot like a Chrysler factory.

Posted by: Brojo on February 14, 2008 at 11:27 AM | PERMALINK

Perhaps someone already mentioned this, but if you are interested in a good read that addresses many of the core issues in the current American healthcare system, try Michael Porter's "Redefining Healthcare." The book gets to the heart of what's wrong and makes an interesting suggestion for solving the problems. At the heart, the healthcare system must be driven as all other industries are. Players must compete to provide value for the customer. The way the current system is structured, in most cases the customer (payer) and patient are not the same. Porter argues that we must change that, so that hospitals, insurance companies, and physicians work to provide quality care for the patient. If that is done, it can be a win-win-win situation. Quality hospital, physicians, and insurers get more business (and profit) AND patients get better care. Innovation, like the checklist at the heart of this discussion, is encouraged and rewarded if it proves to increase the quality of care. I don't agree with everything Porter suggests, but he presents many interesting and sensible ideas.

Posted by: CMP on February 14, 2008 at 11:33 AM | PERMALINK

J Bean,

Kevin, I love you, but whenever I see someone blame anything on "the AMA", I instantly assume they don't know what they are talking about. The AMA is a lobbying organization to which about a third of U.S. physicians belong and the rest of us ignore.

Since you are claiming special knowledge about the AMA then I wonder what your experience is.

Do you belong to the AMA or do you ignore them? If you ignore them then where do you get your special knowledge? You can't have it both ways you know. If you are ignorant then who are you to claim the rest of us are ignorant?

Posted by: Tripp on February 14, 2008 at 11:47 AM | PERMALINK

Barbara, in the second comment above, is right. Insurers would love to reduce hospital costs so they could keep those extra premium dollars those reduced costs would produce. So insurers could very well be one of the forces pushing the checklist. And establishing the checklists in hospitals would not have to depend on doctors' willingness to implement them. If the hospital administration sees a way to reduce its costs and liabilities, those lists will show up rapidimento. They would be monitored by the ICU nurses, hospital employees, and doctors would have no choice but to follow the checklist recommendations. Doctors would like to have fewer complications and poor outcomes for their patients. They just don't want to have to add another layer of administrative work to their schedule. Fine. It wouldn't have to depend on them. Shorter version: there won't be resistance from doctors on this.

Posted by: digitusmedius on February 14, 2008 at 11:57 AM | PERMALINK

PS Someone needs to investigate this Office of Human Research Protections right away. That is a bizarre interpretation of "experimental therapy." If this is allowed to stand, every time a doctor goes through a differential diagnosis process, including ordering lab work or xrays to rule in/out those diagnoses, she could be said to be doing "experimental procedures." In general, the consent for doing all that is covered on the admission document in any case. This OHRP ruling is horribly off base.

Posted by: digitusmedius on February 14, 2008 at 12:09 PM | PERMALINK

Insurance companies have incentives to support this kind of thing, as has been argued, but no individual insurance company has enough reason to care to spend resources to make it happen. It's a classic collective action problem.

Medicare should be big enough to push this kind of thing, though, if it were run properly. It would obviously earn a return on its investment if it spent a few million and only earned a fraction of the total savings.

But here's what I can't figure out: Shouldn't a vertically integrated HMO like Kaiser have strong incentives to do this? Any thoughts on why they haven't (or have they)?

Posted by: Oaktown on February 14, 2008 at 12:29 PM | PERMALINK

As a former aviator I can confirm that pilots use checklists in emergencies. It is required.

We have two kinds of checklists: normal procedures and emergencies. The normal procedures checklists are pulled out followed from top to bottom every time.

Emergency checklists start with a few items in bold print. Those have to be memorized and followed in order. They are intended to stabilize the situation so more deliberate actions can be taken.

Once in a great while the bold items may not help much in an emergency. An investigation may then cause them to be changed. In contrast, failure to follow the bold items almost always fails to help the situation.

Crew Resource Management is another tool from the aviation world that, ISTM, could be appropriately adapted to be useful in ER's and ICU's, but that is another subject.

My experience with hospitals, especially ICU's and ER's, has been limited. Until know I always thought there were standardized checklists appropriate to each patient's situation being used.

I suspect teams of medical professionals could develop a number of useful checklists that would prove as beneficial as the central line chedlist.

Posted by: Paul E. Tickle on February 14, 2008 at 12:47 PM | PERMALINK

Jonathan Dworkin: Out here in Hawaii we haven't adopted the checklist as a formal policy (I asked one of our pulmonary ICU docs today). But we're already doing everything on the checklist as part of our own protocols.

RTFA. Everything on the checklist was pretty much standard practice already. The secret was to have a formal checklist, and to change policy, regulations and culture such that the checklist was always used, and both doctors and nurses were formally required to verify the use of the checklist and take corrective action when necessary.

This isn't the Semmelweis story - people already knew how to minimize infection risk - it's the B-17 story - pilots knew to release the locking mechanism on the elevator and rudder controls, but sometimes forgot.

Ergo, if your hospital hasn't "adopted the checklist as a formal policy", then it hasn't done what the article is talking about.

Posted by: alex on February 14, 2008 at 1:11 PM | PERMALINK

It would be great if every new medical breakthrough became instantly accepted (at least all the good ones...), but there are a lot of people involved and a pretty steady torrent of information to be disseminated, absorbed, filtered and adopted or discarded. J Bean at 11:08 pm

Maybe a solution would be to have a non-profit organization (not a medical supplier) create a virtual hospital on the internet, where the best practices, like checklists, could be posted as determined by awards given, money saved, lives saved, etc. All anyone would have to do is click on a room in the hospital, like the ICU, and see a list of the latest best practices with links to the journal articles, etc., explaining the procedures.

This virtual hospital could be constantly updated as better solutions were discovered.

Posted by: emmarose on February 14, 2008 at 1:57 PM | PERMALINK

Clearly, Dr. Provonost has shown checklists are helpful in "project managing" complicated procedures. I'm curious if treatment algorithms (someone comes in with symptoms, practitioners works through a written algorithm for diagnosis and treatment) are equally as effective.

IIRC, Nurse Practitioners are allowed to, in effect, practice medicine because they use algorithms. I wonder if there've been clinical trials comparing a nurse practitioner (or for that matter a physician) using an algorithm versus a physician treating similar cases without using one.

Its certainly cheaper to use nurse practitioners as primary care providers instead of physicians, but if their use of algorithms make them as (or perhaps more) effective than physicians, then perhaps future physicians should all be trained as specialists and leave the gatekeeping to nurse practitioners or physician assistants.

In some ways its similar to the use of Direct Instruction in schools.
DI is scalable. Its success isn't contingent on the personality of some uber-teacher....You don't need to be a genius to be an effective DI teacher. DI can be implemented in dozens upon dozens of classrooms with just ordinary teachers. You just need to be able to follow the script.
http://www.marginalrevolution.com/marginalrevolution/2007/09/heroes-are-not-.html

Whether you call it a checklist, algorithm or script, prepared materials allow less experienced or trained professionals do the work that only more experienced professionals could do previously.

Posted by: beowulf on February 14, 2008 at 2:45 PM | PERMALINK




 

 

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