A simple procedure is saving thousands of lives. Although it has been known for many years it has not been not widely used. This approach shows how sometimes simple ideas which respond to real needs can have a dramatic impact on people’s lives and health.
The rationale behind the development of this procedure was based on the several steps doctors have to follow when treating people in intensive care units, also known as “critical care”. It is estimated that, on a given day, some ninety thousand people are in intensive care, almost five million a year.
During a typical stay in an intensive care unit, patients undergo several procedures, most of them critical for its survival. Under these circumstances it is most important that some basic and necessary procedures are properly carried out. Failure to do so could result in the death of the patient.
In 2001, Dr. Peter Pronovost, a Professor at the Johns Hopkins University School of Medicine in the Department of Anesthesiology and Critical Care Medicine, began studying hospital-acquired infections. These infections affect 1 in 10 patients, killing 90,000 of them and costing as much as $11 billion each year.
Pronovost began investigating this alarming situation at Johns Hopkins Hospital focusing on bloodstream infections from central venous catheters used in intensive care units (ICUs). He concluded that providing physicians with a chart reminding them of each step in some routine procedures could drastically reduce the number of errors leading to such infections.
Pronovost shortened lengthy guidelines into a simple checklist of five precautionary steps. According to Pronovost doctors should wash their hands with soap; clean the patient’s skin with chlorhexidine antiseptic; put sterile drapes over the entire patient; wear a sterile mask, hat, gown and gloves, and put a sterile dressing over the catheter site.
Although it can be argued that these are very simple procedures, neglecting one or more can lead to disastrous results.
Pronovost initial findings were confirmed two years later in a Michigan study called the Keystone Initiative. The results of this study, published in 2006 in the New England Journal of Medicine, showed that in the first three months of the project the infection rate in Michigan’s ICUs decreased by sixty-six percent. Within the Initiative’s first eighteen months, the authors estimated that 1500 lives and $100 million were saved.
Based on his initial success, Pronovost and his colleagues later developed checklists for other situations in the ICU such as mechanical ventilation. Although he is not the first one to use a checklist to guide procedures, he is the first to be aware of its advantages and exploit its possibilities.
Dr. Atul Gawande, a surgeon at Brigham and Women’s Hospital in Boston and a professor of surgery at Harvard Medical School enthusiastically promoted this approach. Writing in The New Yorker, Gawande stated that Pronovost work had saved more lives than any other laboratory scientist in the last decade.
Working for the World Health Organization, Dr. Gawande brought the checklist idea to several hospitals around the world, with equally startling results. In eight hospitals ranging from a rural hospital in Tanzania to a high-tech university facility in Seattle Dr. Gawande and a team of public health experts applied a version of the checklist to assess if it improved surgical care.
Without adding a piece of equipment or any extra spending, the rate of major post surgical complications dropped by 36 percent in the six months after the checklist was used and deaths fell by 47 percent in all of the eight hospitals studied.
Despite some drawbacks, such as what to do when a patient has several disorders at the same time and its lack of flexibility, as pointed out by Dr. Sandeep Jauhar, author of “Intern: A Doctor’s Initiation,” it is clear that using checklists for some situations can save lives and money in health care. Pronovost’s approach is now being tried in California and in Spain. If the results are equally positive, it will create new standards of health care performance both in the U.S. and at the international level.
Cesar Chelala, MD, PhD, is an international public health consultant.