Hospital Checklists Can Save Patients' Lives

From the Concord Monitor

The more steps in a procedure and the more procedures that must be done, the more likely it is that one step will be forgotten. Sometimes no harm is done. But in flying a plane, defusing a bomb or performing a medical procedure, skipping one step can prove fatal. That step could be as simple as a harried physician forgetting to wash his hands.

Some 80,000 to 100,000 people die each year from infections acquired in a hospital, according to federal estimates. Many of those deaths result from "line infections" that occur when a pathogen is introduced into the bloodstream by a catheter inserted into a vein or artery. Line infections, which in one hospital led to an average of $61,000 in additional charges, add billions each year to the nation's health care bill.

In the current issue of The New Yorker, Atul Gawande, a surgeon and Harvard Medical School professor, explains how in 2001 a doctor developed a program that reduced the line infection rate to near zero in the hospitals that adopted it. The basic tool used by that doctor, Peter Pronovost of Johns Hopkins Hospital, was the checklist.

The steps on Pronovost's checklist are simple: wash hands with soap; clean the patient's skin with antiseptic; cover the patient with sterile drapes; wear a sterile mask, hat, gown and gloves; and place a sterile dressing over the catheter line.

Pronovost tested the effectiveness of his list in several facilities, including an inner-city Detroit hospital whose intensive care unit saw a steady influx of gunshot victims. That hospital had a whopping 11 percent line infection rate. Within a year, using the checklist, the rate fell to zero, thanks in good measure to empowering nurses to call a halt if doctors forgot a step. By eliminating line infections, the hospital calculated that it had prevented 43 infections and eight deaths and saved $2 million.

New Hampshire's intensive care units already have low line infections rates. The state's 26 hospitals had just 28 in the first six months of 2006. Though the hospitals aren't using Pronovost's list, they follow a similar protocol. But the right rate, state epidemiologist Jose Montero says, should be zero. Almost all such infections are preventable, though when they occur, it's not always easy to determine whether the intensive care unit rather than an ambulance crew or emergency room staff was to blame.

Next month, the state is launching a pilot program in six facilities, including Concord Hospital, to track not just line infections in ICUs, but also whether antibiotics are administered prior to surgery and how often knee replacement surgery results in an infection. Hospitals with the lowest rates will be studied to see what they do right. Then that information will be shared with other hospitals so they can change their procedures.

Checklists like the one that has practically eliminated line infections in the hospitals that use them have been developed for a number of medical procedures - like care of patients who need a ventilator to help them breathe, for example. More lists are being developed all the time.

Unfortunately, Gawande reports, though line infection checklists could be in use nationwide within two years, hospitals have been slow to adopt them. That shouldn't be the case in New Hampshire, and thanks to efforts already undertaken and others under way, it doesn't look like it will be. The faster medical science advances, the more valuable the humble checklist - the same tool shoppers use - becomes. When doctors can do so much, there's so much to remember.