Simple Reminders Reduce Deadly Infections

New York Times
by Anemona Hartocollis

Loose strands of sweaty dark hair fell across the woman’s face, but she was too sick to push them back. She was in respiratory failure, and nurses were rushing her to intensive care. They grabbed a sheet under her body and heaved her from the gurney onto a bed as if she were a fish in a net, then attached her to a beeping monitor, hand-pumped oxygen into her lungs and got ready to administer an intravenous sedative.

“Timeout!” a first-year resident called, as the medical team at Woodhull Medical and Mental Health Center in Brooklyn was about to insert a catheter into the woman’s jugular vein.

Then he reminded everyone to wash their hands.

Timeouts to wash hands and put on hairnets, a simple checklist to ensure that such seemingly obvious precautions are done, and advertising campaigns directed at everyone from the most senior doctors to the poorest of patients have been credited with drastically reducing the number of serious infections at New York City’s public hospitals.

Since 2005, central-line bloodstream infections, which stem from bacteria invading a catheter leading to the heart and can often be fatal, have fallen 55 percent in adult intensive care units at the city’s 11 public hospitals, according to statistics released last week. Ventilator-associated pneumonia, caused by bacteria in breathing tubes and which also can be fatal, declined by 78 percent.

Before the hospital system began cracking down on them in late 2005, preventable infections were considered part of the collateral damage of advanced lifesaving techniques, such a routine occurrence that few people questioned their prevalence, or the deaths that resulted from them. In fact, there had been a perverse financial upside to hospital-based infections, since they filled beds that might otherwise be empty. But changes in government reimbursements have driven New York’s public hospitals, which serve the city’s poorest patients, to tackle the problem.

As part of a pay-for-performance plan, the federal government and many private insurers are planning to stop reimbursing hospitals for harm caused to patients by certain preventable errors.

In October, Medicare, the federal insurance program for the elderly, will no longer cover the additional cost of eight preventable complications, including central-line bloodstream infections. Some hospital administrators expect Medicaid, which covers health care for the poor, to follow suit. The government may also stop covering ventilator-associated pneumonia in 2009.

The turning point in the campaign to stop hospital infections in New York had all the glamour of compiling a grocery list.

In late 2005, the city’s Health and Hospitals Corporation adopted a series of simple, standardized protocols based on those developed by Dr. Peter J. Pronovost, a crusader against preventable hospital deaths and a professor of anesthesiology and critical care medicine at Johns Hopkins University. Dr. Pronovost calls his protocols a checklist, and that is pretty much what they are.

A red binder at the nursing station at Woodhull contains dozens of forms, labeled “Central Venous Catheter Insertion Checklist,” which instruct doctors to, first of all, make sure that they have the right patient and are planning the right procedure. The 14-item list goes on to include washing hands; putting on caps, masks, sterile gowns and gloves; draping the patient from head to toe; preparing the patient’s skin with chlorhexidine antiseptic; maintaining a sterile field; and applying a sterile dressing.

One person, usually a nurse, acts as the referee by calling, “Timeout!” and checking off the “completed” or “not completed” columns on the list as each step is called out and performed.

Dr. Pronovost, who developed his checklist at Johns Hopkins in 2001 and tested it in more than 100 intensive care units in Michigan in 2003, found that the simple hygiene it takes to avoid many infections can seem like a low priority in the frenzied atmosphere of high-tech medical care.

At Woodhull last week, when the resident called timeout for hand-washing, he was interrupting a team focused on serious and complex issues like the woman’s respiratory rate and ratio of body weight to medication.

“What’s going on in the critical care units is so complicated that the simple things get overlooked,” said Alan Aviles, president of the city’s Health and Hospitals Corporation, which administers the 11 municipal hospitals.

Dr. Pronovost, testifying before Congress last month, estimated that infections acquired during treatment affect 1 in 10 patients nationally and kill about 90,000 people a year, costing the health care system $5 billion to $11 billion.

City officials said that because patient deaths are often attributed to the primary illness rather than complications like hospital-acquired infections that may have pushed the patient over the brink, they could not provide parallel local statistics.

As an answer to a seemingly intractable problem, Dr. Pronovost’s checklist epiphany recalls the classic medical school story of Ignaz Semmelweis, the 19th-century Hungarian physician who found that deaths from puerperal fever in obstetrical clinics could be sharply reduced when doctors washed their hands. He noticed that the death rate was much lower at a clinic staffed by midwives, and traced the difference to medical students who failed to wash their hands after autopsies.

Because the checklist is so simple, its potency is easy to underestimate, Dr. Pronovost said, joking that, “If the checklist were a drug, I’d be rich.”

The secret of the checklist, he said, is focus, and the theory behind it has broad applications. He likes to illustrate his point by telling how in the Netherlands, “they paint flies on the urinals because they found that men were four times more accurate if aiming at a fly than if they weren’t.”

“It’s a simple intervention to help you focus and execute,” he said.

In an article last week in the Journal of the American Medical Association, Dr. Pronovost wrote that the new federal policy of refusing payment for some mistakes in treatment could be flawed because some errors were more preventable than others.

In principle, he said in an interview, “I actually think that’s wise policy. People suffer preventable harm in this health care system, regulators and the public get outraged by it, but we haven’t been really disciplined in trying to improve it.”

At Woodhull, the focus begins in the lobby, which can be almost as crowded as a subway platform during the evening rush.

Other than a giant Keith Haring mural, the most prominent décor is a banner that proclaims: “Clean Hands Save Lives.”

Outside of every room in the intensive care unit, there is a squirt bottle of hand sanitizer attached to the wall. “What are the top 10 carriers of infectious agents?” asks the caption of a poster on the wall, a picture of 10 fingers.

Patients have been enlisted to spread the anti-infection gospel, urged to watch whether their doctors wash their hands and to remind them if they do not. Doctors have been told to receive such reminders with a polite thank you, said Iris Jimenez-Hernandez, Woodhull’s chief executive.

“It has been a culture change,” said Dr. Jose O. Mejia, chairman of Woodhull’s department of medicine and critical care division.

But the checklist can be cumbersome and time-consuming. The team treating the woman in respiratory failure last week fidgeted nervously as they waited for their referee to tick off the items.

The attending physician, Dr. Rose Marie Flores, said doctors in the emergency room do not always have time to follow the list to the letter. But once the patients are stabilized, she said, they go back and do it all over again.