The Checklist

THE CHECKLIST....If you've ever been treated in an ICU, there's a good chance you've been fitted at some point with a "central line," a catheter sewn into a large vein and used to deliver medications and monitor cardiovascular status. Central lines are a critical part of modern intensive care, but unfortunately, as Atul Gawande wrote in the New Yorker a few weeks ago, they can also be killers:
Line infections are so common that they are considered a routine complication. I.C.U.s put five million lines into patients each year, and national statistics show that, after ten days, four per cent of those lines become infected. Line infections occur in eighty thousand people a year in the United States, and are fatal between five and twenty-eight per cent of the time, depending on how sick one is at the start. Those who survive line infections spend on average a week longer in intensive care. And this is just one of many risks.
In 2001, a critical-care specialist at Johns Hopkins Hospital named Peter Pronovost decided to create a simple checklist designed to reduce line infections. The result was astonishing: line infection rates dropped to zero percent. A couple of years later, Pronovost tried out his checklist in a more demanding environment: public hospitals throughout the state of Michigan. Here's the good news — and the bad:
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 infection rate in Michigan's I.C.U.s decreased by sixty-six per cent. The typical I.C.U. — including the ones at Sinai-Grace Hospital — cut its quarterly infection rate to zero. Michigan's infection rates fell so low that its average I.C.U. outperformed ninety per cent of I.C.U.s nationwide. In the Keystone Initiative's first eighteen months, the hospitals saved an estimated hundred and seventy-five million dollars in costs and more than fifteen hundred lives. The successes have been sustained for almost four years — all because of a stupid little checklist.

....If someone found a new drug that could wipe out infections with anything remotely like the effectiveness of Pronovost's lists, there would be television ads with Robert Jarvik extolling its virtues, detail men offering free lunches to get doctors to make it part of their practice, government programs to research it, and competitors jumping in to make a newer, better version. That's what happened when manufacturers marketed central-line catheters coated with silver or other antimicrobials; they cost a third more, and reduced infections only slightly — and hospitals have spent tens of millions of dollars on them. But, with the checklist, what we have is Peter Pronovost trying to see if maybe, in the next year or two, hospitals in Rhode Island and New Jersey will give his idea a try.

....I asked [Pronovost] how much it would cost for him to do for the whole country what he did for Michigan. About two million dollars, he said, maybe three, mostly for the technical work of signing up hospitals to participate state by state and coordinating a database to track the results. He's already devised a plan to do it in all of Spain for less.

"We could get I.C.U. checklists in use throughout the United States within two years, if the country wanted it," he said.

So far, it seems, we don't. The United States could have been the first to adopt medical checklists nationwide, but, instead, Spain will beat us. "I at least hope we're not the last," Pronovost said.
If you extrapolate what happened in Michigan to the entire country, a $2 million investment in Pronovost's checklists would save perhaps $2 billion and 10-20,000 lives each year. And yet, we're not doing it. After all, who's got both the incentive and the clout to make it happen? Insurance companies basically earn a percentage of the cost of the medical care they cover, so they don't really care if costs go down. Corporations would certainly like lower costs, but they're too diffuse to put up a united front to demand change. The federal government doesn't have the authority to mandate the checklists. Doctors don't want to be pestered about them. And patients don't know enough to even realize there's a problem.

The American healthcare system is a grand thing, isn't it? Nobody wants to be bothered with stuff like this, and in the end it will probably only get adopted thanks to another beloved American institution: fear of medical malpractice lawsuits. After a few whopping awards in cases where doctors are forced to admit on the stand that, no, they didn't use Pronovost's simple and proven line infection checklist, eventually they'll get the message.

But wait. What am I thinking? I guess they could get the message. Or it could become just another excuse for the AMA to start screaming about how the legal system is driving doctors out of business. That's an American institution too.

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