Infection rates drop as Michigan hospitals turn to checklists

From the surgical suite to the ICU, checklists are protecting patients from harm, a study says. But some advocates say they are not a cure-all.

By — Posted March 1, 2010

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For years, catheter-related bloodstream infections seemed to be a sometimes unavoidable complication of caring for the sickest patients in intensive care units. The infections kill 17,000 patients annually, and the average cost of caring for an infected patient is $45,000, studies show.

But then a stunning thing happened: A group of Michigan hospitals implemented a relatively simple set of interventions, including a checklist of infection-control practices, and their average infection rate dropped 66% after one year. The median central-line infection rate fell to zero per 1,000 catheter days, compared with a national average of 5.2. The achievement was due to hand washing, using full-barrier precautions when inserting central venous catheters, cleaning the skin with chlorhexidine, avoiding the femoral site for insertion and removing unnecessary catheters.

Three years after the project began, 85 Michigan ICUs have improved their success. The average infection rate has dropped 86%, while the median rate remains at zero, according to a Feb. 4 study published in the British medical journal BMJ.

"Most of the time these things go a different way," said Peter J. Pronovost, MD, PhD, lead author of the study and a consultant on the Michigan project. "The history is that quality improvement is like an accordion. You push on it, it goes in, and then you stop pushing on it and it comes back out."

Atul Gawande, MD, MPH, hailed the Michigan project's continued effectiveness.

"It's remarkable," said Dr. Gawande, who has promoted the checklist concept as lead of the World Health Organization's Safe Surgery Saves Lives initiative. "We have few examples where we've been able to demonstrate sustained success in quality improvement, and what Peter Pronovost has really demonstrated there is that there are simple interventions that can make a big difference and be sustained if the culture of medicine embraces them."

With the WHO, Dr. Gawande helped implement a safe-surgery checklist covering items such as the risk of blood loss, antibiotic prophylaxis, and surgical-site marking. Testing the checklist in eight cities around the world in 2007 and 2008, the death rate was cut in half to 0.8% and complications were cut nearly 60%, according to a study Dr. Gawande and his colleagues published in the Jan. 29, 2009, New England Journal of Medicine.

The limits of checklists

Drs. Pronovost and Gawande are among the foremost proponents of using checklists. In December 2009, Dr. Gawande's book, The Checklist Manifesto: How to Get Things Right, was published and, as of Feb. 12, stood at No. 14 on the New York Times best-seller list for hardcover nonfiction. Dr. Pronovost's book, Safe Patients, Smart Hospitals: How One Doctor's Checklist Can Help Us Change Health Care from the Inside Out, was published in February.

While they are promoting the checklist as a way to help doctors and nurses perform the safety steps that protect patients from harm, Drs. Pronovost, Gawande and other physician boosters of the concept argue that checklists alone are not enough to correct the many safety problems that plague medicine and, according to the Institute of Medicine, kill as many as 98,000 patients annually.

"The checklist makes a great journalist story, but it's over-simplistic and risks underresourcing these [safety] efforts," said Dr. Pronovost, an intensivist and medical director of the Center for Innovation in Quality Patient Care at the Johns Hopkins University School of Medicine in Maryland. "How many people do you know who make a New Year's resolution and fail? Well, that's essentially a checklist. ... With quality what we've seen is that the piece of paper is nothing. You need to make it easy to comply, and you need to change the culture. But then, most important, you need to measure and be accountable for results."

Dr. Pronovost is part of a team at Johns Hopkins that in October 2008 received a $3 million Agency for Healthcare Research and Quality grant to implement nationwide the infection-control changes that were so successful in Michigan.

Dr. Gawande said checklists should not just be another hurdle for physicians and other health professionals to jump.

"If checklists are understood to be bureaucracy and mindless tick-box exercises, we will fail," said Dr. Gawande, a surgeon at Brigham and Women's Hospital and associate professor of surgery at Harvard Medical School, both in Boston. "This stuff is hard, and the biggest mistake we'll make is if we think checklists mean this is easy. Checklists make knowledge usable, but they can be done badly."

Another proponent of the power of checklists said they are only as effective as the culture of communication among doctors, nurses and other health professionals allows.

"Checklists play a role, but they're not a magic bullet," said James P. Bagian, MD, chief patient safety officer at the Veterans Health Administration, where he helped pioneer the use of checklists in medicine to avoid wrong-site surgeries. "We use them to drive a conversation, but that conversation needs the participation of the people involved in a meaningful way. If it's just going to be done pro forma, you might as well talk about who did what in snowboarding in the Olympics."

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A checklist for developing checklists

For all the promise that checklists have to help busy doctors and nurses protect patients from harm, it is tricky to create ones that are useful. A recent study offers some tips, advising that checklist developers:

  • Address health professionals' needs and the realities of their clinical work.
  • List the most critical items at the beginning of the checklist whenever possible.
  • Avoid long checklists; subdivide them into smaller, meaningful and time-sensitive sections.
  • Pay close attention to usability, including the time it takes to complete the checklist; avoid harm to health professionals or patient safety.
  • Pilot-test and validate the checklists before implementing them widely.
  • Include potential users, content experts and human factors engineers in the development process.
  • Re-evaluate and update checklists based on new medical evidence and experience.

Source: "Clinical review: Checklists -- translating evidence into practice," Critical Care, Dec. 31, 2009 (link)

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External links

"Sustaining reductions in catheter related bloodstream infections in Michigan intensive care units: observational study," abstract, BMJ, Feb. 4 (link)

"A Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global Population," abstract, New England Journal of Medicine, Jan. 29, 2009 (link)

"A Checklist for Checklists," Project Check (link)

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