The New York Times

January 22, 2008
Personal Health

A Basic Hospital To-Do List Saves Lives


This is a call to arms for everyone who may someday be hospitalized, or who has a relative who may someday be hospitalized — which is to say everyone.

These days, to spend time in the hospital is to be at risk of contracting a hospital-acquired infection. Some of these infections can be life-threatening. But there is a simple way to make that hospital stay safer, devised by Dr. Peter J. Pronovost, a physician-researcher at Johns Hopkins.

The method — a five-item checklist to assure that proper precautions are taken to prevent infection — has been thoroughly tested, first at Johns Hopkins and later in 108 intensive-care units in Michigan, where it succeeded beyond anyone’s wildest dreams in saving lives and reducing costs for patients who received the major fluid tube called a central venous catheter.

According to Dr. Pronovost, whose findings in Michigan were published in The New England Journal of Medicine on Dec. 28, 2006, about half of intensive-care patients receive these catheters; about 80,000 a year become infected and 28,000 die, with an economic cost of $2.3 billion.

Five Simple Steps

Using the checklist, in 18 months the average I.C.U. at these diverse hospitals reduced its catheter-related infection rate to zero, from 4 percent. All told, the checklist saved more than 1,500 lives and nearly $200 million. The program itself cost only $500,000.

Dr. Pronovost, a professor of anesthesiology and critical care medicine, said in an interview that he distilled the five steps from a 64-page federal document on controlling hospital-acquired infections. When inserting a central venous catheter, doctors should do the following:

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.

5. Put a sterile dressing over the catheter site.

To someone on the outside, this list may seem like a no-brainer. But in the crush of crisis medicine, one or more of these steps is often neglected, sometimes with disastrous results. What made the program work in Michigan was continuous — and anonymous — collection of data. The hospitals were monitored on their use of the list, their rates of infection and their feedback to medical personnel to show what was working and where gaps remained in quality care.

The task now is to expand the checklist concept to other procedures and to get hospitals throughout the country to adopt it. New Jersey and Rhode Island are already planning to use it. And following a report on the checklist in the Dec. 10, 2007, issue of The New Yorker by Dr. Atul Gawande, a surgeon at Brigham and Women’s Hospital in Boston, Dr. Pronovost said he had been approached by health care authorities in California, Washington and Tennessee seeking the program for their states. Spain is adopting the program nationwide, and the World Health Organization is hoping to take it global.

As Dr. Pronovost explained, medical research must go beyond understanding the biology of disease and devising effective therapies.

“We have to assure that we deliver those therapies safely and effectively, but research examining 300 quality measures showed that patients receive adequate therapy only about half the time,” he said.

“My approach was to figure out what it takes to change behavior,” Dr. Pronovost said. “This represents the biggest opportunity to improve health — making sure that what we know works is delivered safely, effectively and efficiently.”

Coincidentally, a report in the Jan. 15 issue of Clinical Infectious Diseases by Dr. Sanjay Saint and colleagues at the Veterans Affairs Ann Arbor Healthcare System and the University of Michigan stated that 1 percent of hospital patients fitted with a urinary catheter developed a urinary tract infection. Forty percent of all hospital-acquired infections are urinary.

Dr. Saint’s national study “found no strategy that appeared to be widely used to prevent hospital-acquired urinary tract infections.” Nearly half of hospitals had no system telling them which patients had a catheter, and three-fourths had no system to show how long the catheter was in place or whether it had been removed. Furthermore, fewer than 10 percent of hospitals used any system to remind doctors to check daily on whether a patient’s catheter was necessary; the longer one is in, the greater the likelihood of infection.

A nationally imposed checklist for safe urinary catheter insertion and removal could sharply reduce the risk to patients and the costs of hospital care.

But checklists need not be limited to reducing the risk of hospital-acquired infections. As Dr. Gawande and Dr. Pronovost explained, they could be used to enhance the safety of surgery and anesthesia, the treatment of patients with heart disease, diabetes, pulmonary diseases like asthma and a host of other conditions where certain approaches to care have been scientifically established as most effective but are still often neglected.

What You Can Do

The federal Office for Human Research Protections recently ruled that because this quality-control program constituted research on human subjects, every participating hospital must first get approval from its institutional review board. That ruling did not halt the use of checklists in the Michigan hospitals where they had become part of routine care. But it did stop the collection of data based on the lists, which Dr. Gawande described as “the driving force behind the effectiveness of the program,” until each hospital’s institutional review board approved it.

These boards meet monthly, bimonthly or quarterly. Sam Watson, executive director of the Michigan Hospital Association’s Keystone Center for Patient Safety and Quality, a sponsor of the Michigan checklist program, said the need for their approval could seriously delay the use of checklists for other aspects of medical care, like preventing hospital-acquired urinary infections — something his center has been working on with Dr. Saint.

Dr. Gawande suggested that consumers write to their members of Congress and the Department of Health and Human Services, asking that the ruling be reversed. Dr. Pronovost suggested that consumers let Congress know that checklist programs “could have a profound impact on their health,” ask local hospitals whether they are using checklists to reduce infections, and write to state hospital associations asking for a statewide effort to reduce infections.

In addition, Dr. Pronovost said, hospital patients should be their own advocates, armed with their own checklist and asking medical personnel whether they are using it “to help assure that I don’t get an infection” or asking, “Do I still need this catheter?”