The Checklist Manifesto Page 4

  But we have had glimmers that it might, at least in some corners. What, for instance, are the vital signs that every hospital records if not a kind of checklist? Comprised of four physiological data points--body temperature, pulse, blood pressure, and respiratory rate--they give health professionals a basic picture of how sick a person is. Missing one of these measures can be dangerous, we've learned. Maybe three of them seem normal--the patient looks good, actually--and you're inclined to say, "Eh, she's fine, send her home." But perhaps the fourth reveals a fever or low blood pressure or a galloping heart rate, and skipping it could cost a person her life.

  Practitioners have had the means to measure vital signs since the early twentieth century, after the mercury thermometer became commonplace and the Russian physician Nicolai Korotkoff demonstrated how to use an inflatable sleeve and stethoscope to quantify blood pressure. But although using the four signs together as a group gauged the condition of patients more accurately than using any of them singly, clinicians did not reliably record them all.

  In a complex environment, experts are up against two main difficulties. The first is the fallibility of human memory and attention, especially when it comes to mundane, routine matters that are easily overlooked under the strain of more pressing events. (When you've got a patient throwing up and an upset family member asking you what's going on, it can be easy to forget that you have not checked her pulse.) Faulty memory and distraction are a particular danger in what engineers call all-or-none processes: whether running to the store to buy ingredients for a cake, preparing an airplane for takeoff, or evaluating a sick person in the hospital, if you miss just one key thing, you might as well not have made the effort at all.

  A further difficulty, just as insidious, is that people can lull themselves into skipping steps even when they remember them. In complex processes, after all, certain steps don't always matter. Perhaps the elevator controls on airplanes are usually unlocked and a check is pointless most of the time. Perhaps measuring all four vital signs uncovers a worrisome issue in only one out of fifty patients. "This has never been a problem before," people say. Until one day it is.

  Checklists seem to provide protection against such failures. They remind us of the minimum necessary steps and make them explicit. They not only offer the possibility of verification but also instill a kind of discipline of higher performance. Which is precisely what happened with vital signs--though it was not doctors who deserved the credit.

  The routine recording of the four vital signs did not become the norm in Western hospitals until the 1960s, when nurses embraced the idea. They designed their patient charts and forms to include the signs, essentially creating a checklist for themselves. With all the things nurses had to do for their patients over the course of a day or night--dispense their medications, dress their wounds, troubleshoot problems--the "vitals chart" provided a way of ensuring that every six hours, or more often when nurses judged necessary, they didn't forget to check their patient's pulse, blood pressure, temperature, and respiration and assess exactly how the patient was doing.

  In most hospitals, nurses have since added a fifth vital sign: pain, as rated by patients on a scale of one to ten. And nurses have developed yet further such bedside innovations--for example, medication timing charts and brief written care plans for every patient. No one calls these checklists but, really, that's what they are. They have been welcomed by nursing but haven't quite carried over into doctoring.

  Charts and checklists, that's nursing stuff--boring stuff. They are nothing that we doctors, with our extra years of training and specialization, would ever need or use.

  In 2001, though, a critical care specialist at Johns Hopkins Hospital named Peter Pronovost decided to give a doctor checklist a try. He didn't attempt to make the checklist encompass everything ICU teams might need to do in a day. He designed it to tackle just one of their hundreds of potential tasks, the one that nearly killed Anthony DeFilippo: central line infections.

  On a sheet of plain paper, he plotted out the steps to take in order to avoid infections when putting in a central line. 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 mask, hat, sterile gown, and gloves, and (5) put a sterile dressing over the insertion 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 for something so obvious. Still, Pronovost asked the nurses in his ICU to observe the doctors for a month as they put lines into patients and record how often they carried out each step. In more than a third of patients, they skipped at least one.

  The next month, he and his team persuaded the Johns Hopkins Hospital administration to authorize nurses to stop doctors if they saw them skipping a step on the checklist; nurses were also to ask the doctors 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 measure 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, the nurses would have backup from the administration to intervene.

  For a year afterward, Pronovost and his colleagues monitored what happened. The results were so dramatic that they weren't sure whether to believe them: the ten-day line-infection rate went from 11 percent 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.

  Pronovost recruited more colleagues, and they tested some more checklists in his Johns Hopkins ICU. One aimed to ensure that nurses observed patients for pain at least once every four hours and provided timely pain medication. This reduced from 41 percent to 3 percent the likelihood of a patient's enduring untreated pain. They tested a checklist for patients on mechanical ventilation, making sure, for instance, that doctors prescribed antacid medication to prevent stomach ulcers and that the head of each patient's bed was propped up at least thirty degrees to stop oral secretions from going into the windpipe. The proportion of patients not receiving the recommended care dropped from 70 percent to 4 percent, the occurrence of pneumonias fell by a quarter, and twenty-one fewer patients died than in the previous year. The researchers found that simply having the doctors and nurses in the ICU create their own checklists for what they thought should be done each day improved the consistency of care to the point that the average length of patient stay in intensive care dropped by half.

  These checklists accomplished what checklists elsewhere have done, Pronovost observed. They helped with memory recall and clearly set out the minimum necessary steps in a process. He was surprised to discover how often even experienced personnel failed to grasp the importance of certain precautions. In a survey of ICU staff taken before introducing the ventilator checklists, he found that half hadn't realized that evidence strongly supported giving ventilated patients antacid medication. Checklists, he found, established a higher standard of baseline performance.

  These seem, of course, ridiculously primitive insights. Pronovost is routinely described by colleagues as "brilliant," "inspiring," a "genius." He has an M.D. and a Ph.D. in public health from Johns Hopkins and is trained in emergency medicine, anesthesiology, and critical care medicine. But, really, does it take all that to figure out what anyone who has made a to-do list figured out ages ago? Well, maybe yes.

  Despite his initial checklist results, takers were slow to come. He traveled around
the country showing his checklists to doctors, nurses, insurers, employers--anyone who would listen. He spoke in an average of seven cities a month. But few adopted the idea.

  There were various reasons. Some physicians were offended by the suggestion that they needed checklists. Others had legitimate doubts about Pronovost's evidence. So far, he'd shown only that checklists worked in one hospital, Johns Hopkins, where the ICUs have money, plenty of staff, and Peter Pronovost walking the hallways to make sure that the idea was being properly implemented. How about in the real world--where ICU nurses and doctors are in short supply, pressed for time, overwhelmed with patients, and hardly receptive to the notion of filling out yet another piece of paper?

  In 2003, however, the Michigan Health and Hospital Association approached Pronovost about testing his central line checklist throughout the state's ICUs. It would be a huge undertaking. But Pronovost would have a chance to establish whether his checklists could really work in the wider world.

  I visited Sinai-Grace Hospital, in inner-city Detroit, a few years after the project was under way, and I saw what Pronovost was up against. Occupying a campus of red brick buildings amid abandoned houses, check-cashing stores, and wig shops on the city's West Side, just south of Eight Mile Road, Sinai-Grace is a classic urban hospital. It employed at the time eight hundred physicians, seven hundred nurses, and two thousand other medical personnel to care for a population with the lowest median income of any city in the country. More than a quarter of a million residents were uninsured; 300,000 were on state assistance. That meant chronic financial problems. Sinai-Grace is not the most cash-strapped hospital in the city--that would be Detroit Receiving Hospital, where more than a fifth of the patients have no means of payment. But between 2000 and 2003, Sinai-Grace and eight other Detroit hospitals were forced to cut a third of their staff, and the state had to come forward with a $50 million bailout to avert their bankruptcy.

  Sinai-Grace has five ICUs for adult patients and one for infants. Hassan Makki, the director of intensive care, told me what it was like there in 2004, when Pronovost and the hospital association started a series of mailings and conference calls with hospitals to introduce checklists for central lines and ventilator patients. "Morale was low," he said. "We had lost lots of staff, and the nurses who remained weren't sure if they were staying." Many doctors were thinking about leaving, too. Meanwhile, the teams faced an even heavier workload because of new rules limiting how long the residents could work at a stretch. Now Pronovost was telling them to find the time to fill out some daily checklists?

  Tom Piskorowski, one of the ICU physicians, told me his reaction: "Forget the paperwork. Take care of the patient."

  I accompanied a team on 7:00 a.m. rounds through one of the surgical ICUs. It had eleven patients. Four had gunshot wounds (one had been shot in the chest; one had been shot through the bowel, kidney, and liver; two had been shot through the neck and left quadriplegic). Five patients had cerebral hemorrhaging (three were seventy-nine years and older and had been injured falling down stairs; one was a middle-aged man whose skull and left temporal lobe had been damaged by an assault with a blunt weapon; and one was a worker who had become paralyzed from the neck down after falling twenty-five feet off a ladder onto his head). There was a cancer patient recovering from surgery to remove part of his lung, and a patient who had had surgery to repair a cerebral aneurysm.

  The doctors and nurses on rounds tried to proceed methodically from one room to the next but were constantly interrupted: a patient they thought they'd stabilized began hemorrhaging again; another who had been taken off the ventilator developed trouble breathing and had to be put back on the machine. It was hard to imagine that they could get their heads far enough above the daily tide of disasters to worry about the minutiae on some checklist.

  Yet there they were, I discovered, filling out those pages. Mostly, it was the nurses who kept things in order. Each morning, a senior nurse walked through the unit, clipboard in hand, making sure that every patient on a ventilator had the bed propped at the right angle and had been given the right medicines and the right tests. Whenever doctors put in a central line, a nurse made sure that the central line checklist had been filled out and placed in the patient's chart. Looking back through the hospital files, I found that they had been doing this faithfully for more than three years.

  Pronovost had been canny when he started. In his first conversations with hospital administrators, he hadn't ordered them to use the central line checklist. Instead, he asked them simply to gather data on their own line infection rates. In early 2004, they found, the infection rates for ICU patients in Michigan hospitals were higher than the national average, and in some hospitals dramatically so. Sinai-Grace experienced more central line infections than 75 percent of American hospitals. Meanwhile, Blue Cross Blue Shield of Michigan agreed to give hospitals small bonus payments for participating in Pronovost's program. A checklist suddenly seemed an easy and logical thing to try.

  In what became known as the Keystone Initiative, each hospital assigned a project manager to roll out the checklist and participate in twice-monthly conference calls with Pronovost for troubleshooting. Pronovost also insisted that the participating hospitals assign to each unit a senior hospital executive who would visit at least once a month, hear the staff 's complaints, and help them solve problems.

  The executives were reluctant. They normally lived in meetings, worrying about strategy and bud gets. They weren't used to venturing into patient territory and didn't feel they belonged there. In some places, they encountered hostility, but their involvement proved crucial. In the first month, the executives discovered that chlorhexidine soap, shown to reduce line infections, was available in less than a third of the ICUs. This was a problem only an executive could solve. Within weeks, every ICU in Michigan had a supply of the soap. Teams also complained to the hospital officials that, although the checklist required patients be fully covered with a sterile drape when lines were being put in, full-size drapes were often unavailable. So the officials made sure that drapes were stocked. Then they persuaded Arrow International, one of the largest manufacturers of central lines, to produce a new kit that had both the drape and chlorhexidine in it.

  In December 2006, the Keystone Initiative published its findings in a landmark article in the New England Journal of Medicine. Within the first three months of the project, the central line infection rate in Michigan's ICUs decreased by 66 percent. Most ICUs--including the ones at Sinai-Grace Hospital--cut their quarterly infection rate to zero. Michigan's infection rates fell so low that its average ICU outperformed 90 percent of ICUs nationwide. In the Keystone Initiative's first eighteen months, the hospitals saved an estimated $175 million in costs and more than fifteen hundred lives. The successes have been sustained for several years now--all because of a stupid little checklist.

  It is tempting to think this might be an isolated success. Perhaps there is something unusual about the strategy required to prevent central line infections. After all, the central line checklist did not prevent any of the other kinds of complications that can result from sticking these foot-long plastic catheters into people's chests--such as a collapsed lung if the needle goes in too deep or bleeding if a blood vessel gets torn. It just prevented infections. In this particular instance, yes, doctors had some trouble getting the basics right--making sure to wash their hands, put on their sterile gloves and gown, and so on--and a checklist proved dramatically valuable. But among the myriad tasks clinicians carry out for patients, maybe this is the peculiar case.

  I started to wonder, though.

  Around the time I learned of Pronovost's results, I spoke to Markus Thalmann, the cardiac surgeon who had been the lead author of the case report on the extraordinary rescue of the little girl from death by drowning. Among the many details that intrigued me about the save was the fact that it occurred not at a large cutting-edge academic medical center but at an ordinary community hospital. This one was in Klagenfurt, a s
mall provincial Austrian town in the Alps nearest to where the girl had fallen in the pond. I asked Thalmann how the hospital had managed such a complicated rescue.

  He told me he had been working in Klagenfurt for six years when the girl came in. She had not been the first person whom he and his colleagues had tried to revive from cardiac arrest after hypothermia and suffocation. His hospital received between three and five such patients a year, he estimated, mostly avalanche victims, some of them drowning victims, and a few of them people attempting suicide by taking a drug overdose and then wandering out into the snowy Alpine forests to fall unconscious. For a long time, he said, no matter how hard the hospital's medical staff tried, they had no survivors. Most of the victims had been without a pulse and oxygen for too long when they were found. But some, he was convinced, still had a flicker of viability in them, yet he and his colleagues had always failed to sustain it.

  He took a close look at the case records. Preparation, he determined, was the chief difficulty. Success required having an array of people and equipment at the ready--trauma surgeons, a cardiac anesthesiologist, a cardiothoracic surgeon, bioengineering support staff, a cardiac perfusionist, operating and critical care nurses, intensivists. Almost routinely, someone or something was missing.

  He tried the usual surgical approach to remedy this--yelling at everyone to get their act together. But still they had no saves. So he and a couple of colleagues decided to try something new. They made a checklist.

  They gave the checklist to the people with the least power in the whole process--the rescue squads and the hospital telephone operator--and walked them through the details. In cases like these, the checklist said, rescue teams were to tell the hospital to prepare for possible cardiac bypass and rewarming. They were to call, when possible, even before they arrived on the scene, as the preparation time could be significant. The telephone operator would then work down a list of people to notify them to have everything set up and standing by.