A decade ago, Israeli scientists published a study in which engineers
observed patient care in I.C.U.s for twenty-four-hour stretches. They
found that the average patient required a hundred and seventy-eight
individual actions per day, ranging from administering a drug to
suctioning the lungs, and every one of them posed risks. Remarkably,
the nurses and doctors were observed to make an error in just one per
cent of these actions—but that still amounted to an average of two
errors a day with every patient. Intensive care succeeds only when we
hold the odds of doing harm low enough for the odds of doing good to
prevail. This is hard. There are dangers simply in lying unconscious in
bed for a few days. Muscles atrophy. Bones lose mass. Pressure ulcers
form. Veins begin to clot off. You have to stretch and exercise
patients’ flaccid limbs daily to avoid contractures, give subcutaneous
injections of blood thinners at least twice a day, turn patients in bed
every few hours, bathe them and change their sheets without knocking
out a tube or a line, brush their teeth twice a day to avoid pneumonia
from bacterial buildup in their mouths. Add a ventilator, dialysis, and
open wounds to care for, and the difficulties only accumulate. . . .
Substantial parts of what hospitals do—most notably, intensive
care—are now too complex for clinicians to carry them out reliably from
memory alone. I.C.U. life support has become too much medicine for one
person to fly.
Yet it’s far from obvious that something as simple as a checklist
could be of much help in medical care. Sick people are phenomenally
more various than airplanes. A study of forty-one thousand trauma
patients—just trauma patients—found that they had 1,224 different
injury-related diagnoses in 32,261 unique combinations for teams to
attend to. That’s like having 32,261 kinds of airplane to land. Mapping
out the proper steps for each is not possible, and physicians have been
skeptical that a piece of paper with a bunch of little boxes would
improve matters much.
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 revolutionary. Nurses have always had
their ways of nudging a doctor into doing the right thing, ranging from
the gentle reminder (“Um, did you forget to put on your mask, doctor?”)
to more forceful methods (I’ve had a nurse bodycheck me when she
thought I hadn’t put enough drapes on a patient). But many nurses
aren’t sure whether this is their place, or whether a given step is
worth a confrontation. (Does it really matter whether a patient’s legs
are draped for a line going into the chest?) 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 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. . . .
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 events.
(When you’re worrying about what treatment to give a woman who won’t
stop seizing, it’s hard to remember to make sure that the head of her
bed is in the right position.) 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 precautions. In a survey of I.C.U. staff taken
before introducing the ventilator checklists, he found that half hadn’t
realized that there was evidence strongly supporting giving ventilated
patients antacid medication. Checklists established a higher standard
of baseline performance. . . .
I called Pronovost recently at Johns Hopkins, where he was on duty
in an I.C.U. I asked him how long it would be before the average doctor
or nurse is as apt to have a checklist in hand as a stethoscope (which,
unlike checklists, has never been proved to make a difference to
patient care).
“At the current rate, it will never happen,” he said, as monitors
beeped in the background. “The fundamental problem with the quality of
American medicine is that we’ve failed to view delivery of health care
as a science. The tasks of medical science fall into three buckets. One
is understanding disease biology. One is finding effective therapies.
And one is insuring those therapies are delivered effectively. That
third bucket has been almost totally ignored by research funders,
government, and academia. It’s viewed as the art of medicine. That’s a
mistake, a huge mistake. And from a taxpayer’s perspective it’s
outrageous.” We have a thirty-billion-dollar-a-year National Institutes
of Health, he pointed out, which has been a remarkable powerhouse of
discovery. But we have no billion-dollar National Institute of Health
Care Delivery studying how best to incorporate those discoveries into
daily practice.
