What pilots can teach doctors

Last month our board applauded the first-ever public release in Canada of standardized mortality rates for hospitals. "Publication of the hospital standardized mortality ratios (HSMRs)," we wrote, "will provoke change faster than any number of dreary meetings in doughnut-dusted boardrooms. Administrators working from the top down will find it easier to push front-line staff to get behind new evidence-based programs. And better yet, caregivers who already know where and why problems exist will have more power to command the attention of their superiors, their health ministers and the public." We added that the changes needed to reduce hospital mortality are often pretty simple. At this point in the history of medicine, it's easier to save lives by cutting back on medical errors and hospital infections than it is to discover the next big heroic intervention.

Just ask Johns Hopkins hospital specialist Dr. Peter Pronovost, who is the subject of a glowing profile in a recent New Yorker by the ever-compelling surgeon/journalist Atul Gawande. Dr. Pronovost (note the good solid Canadian surname!) has become an international crusader for the humblest of frontline care tools imaginable: the checklist. In 2001, he made an outrageously simple experiment--he wrote down the things a doctor is supposed to do before inserting an intravascular line into a patient.

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... 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 zero. So they followed patients for fifteen more months. Only two line infections occurred during the entire period. They calculated that, in this one hospital, the checklist had prevented forty-three infections and eight deaths, and saved two million dollars in costs.

This and a handful of other short intensive-care checklists have been shown to save lives by the dozens--or indeed thousands, if introduced to large regions or nations. Doctors in places where the technique has been tried initially grumble about "paperwork" and resist the idea that a checklist can be useful in a chaotic hospital environment, but eventually they come to realize that it's precisely the chaos that necessitates a checklist. The next great wave in medicine is likely to consist of purely functional measures like this that constitute an overdue retrenching--getting bureaucratized hospitals to implement, in evidence-based ways, what's already known about patient care. Gawande's piece is long but, as usual, rewards the attention.


Source:network.nationalpost.com