aTypical Joe: a gay New Yorker living in the rural South
Sunday, January 13, 2008
Battling hospital-acquired infections. With checklists
Two million patients get bacterial infections from health-care workers each year. Nearly 100,000 of them die as a result.
Dr. Richard Shannon, chairman of the Department of Medicine at the University of Pennsylvania Health System, believes these infections are preventable. He says medicine can learn from industry.
Shannon was interviewed on Fresh Air last week:
I spent time at Alcoa, where I learned the Alcoa business model as to how they went about identifying any unsafe condition that might pose a risk to a worker. And then Paul O’Neill exposed me to the Toyota production system model, where I went to Georgetown, Kentucky, and I watched them make automobiles. And Toyota is the world’s greatest manufacturer of automobiles because their processes are defect free. And I watched how they relentlessly pursued excellence by doing processes the same way every time. And that said to me, if we went back to hospitals and we took the same approach...we might be able to achieve similar sorts of very impressive results. [...]
I think that doctors and nurses are engaging in regular hand hygiene much more commonly. But are they doing it a hundred percent of the time? No. And what my point would be is they must do it a hundred percent of the time. In order to do that, we have to make that process simply a part of their work.
The interview with Shannon reminded me of a an outstanding New Yorker article from last December, THE CHECKLIST, If something so simple can transform intensive care, what else can it do? by Atul Gawande:
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 revolutionaryâ€¦ 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 zeroâ€¦ They calculated that, in this one hospital, the checklist had prevented forty-three infections and eight deaths, and saved two million dollars in costs. [...]
The checklists provided two main benefits, Pronovost observed. First, they helped with memory recall, especially with mundane matters that are easily overlooked in patients undergoing more drastic eventsâ€¦ A second effect was to make explicit the minimum, expected steps in complex processes. Pronovost was surprised to discover how often even experienced personnel failed to grasp the importance of certain precautionsâ€¦ Checklists established a higher standard of baseline performance.
So if checklists are so good, why haven’t we heard more about them?
Tom Wolfe’s “The Right Stuff” tells the story of our first astronauts, and charts the demise of the maverick, Chuck Yeager test-pilot culture of the nineteen-fifties. It was a culture defined by how unbelievably dangerous the job was. Test pilots strapped themselves into machines of barely controlled power and complexity, and a quarter of them were killed on the job. The pilots had to have focus, daring, wits, and an ability to improvise-the right stuff. But as knowledge of how to control the risks of flying accumulated-as checklists and flight simulators became more prevalent and sophisticated-the danger diminished, values of safety and conscientiousness prevailed, and the rock-star status of the test pilots was gone.
Something like this is going on in medicine. We have the means to make some of the most complex and dangerous work we do-in surgery, emergency care, and I.C.U. medicine-more effective than we ever thought possible. But the prospect pushes against the traditional culture of medicine, with its central belief that in situations of high risk and complexity what you want is a kind of expert audacity-the right stuff, again. Checklists and standard operating procedures feel like exactly the opposite, and that’s what rankles many people.
The still limited response to Pronovost’s work may be easy to explain, but it is hard to justify. 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 versionâ€¦ 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.