How a checklist saved lives at Ann Arbor area hospitals

The patient's central IV line had been inserted under less than perfect conditions, Juneja said. But in her opinion, it would be safer to put off replacing the line for a while longer in that patient, who was on a round of antibiotics already. 

Nurse Mary Bryce spoke up, saying she was concerned the patient, who suffers from coronary artery disease, was aspirating his food. She asked for suggestions about how to best handle the problem.

"And how's the skin?" asked Gayle Byker, the senior resident in the group.

Her question was prompted by a small white card at her station, which held a seven-point safety checklist used at the hospital for just under five years.

The little checklist doesn't look like much.

But it's a tool that experts at the University of Michigan and St. Joseph Mercy Hospital credit with saving hundreds of lives in Michigan after the state became a test case in a study for reducing infection rates of central IV lines.

Central IV lines have often been a point for bloodstream infections, with the U.S. Centers for Disease Control and Prevention estimating between 250,000 to 500,000 central line-associated blood stream infections in U.S. hospitals every year. The infections can lead to longer hospital stays, higher health care costs and increased risk of deaths, according to a report from the Michigan Health and Hospital Association.

U.S. hospital-associated infections are believed to occur in 4.5 out of every 100 hospital admissions and result in 99,000 associated deaths every year and an additional $6.7 billion per year in expenses.

So the Michigan hospitals joined in a study they say kicked off a culture change in local intensive care units by requiring doctors to use a short checklist to remind them of proper procedures for inserting central IVs — and giving nurses the authority to call them out if they didn't.

Infection rates for the procedure plummeted.

“The results were quite striking,” said Robert Hyzy, a U-M assistant professor of internal medicine. “The median blood stream infection rate went down to zero. Nobody knew the results were going to be as dramatic as they were."

With the ongoing quality improvement project, officials say, the culture of safety in hospitals continues to improve, and bloodstream infection rates in Michigan have remained below national averages five years later. Officials at Ann Arbor area hospitals say they're in the thick of expanding on their original work of reducing the IV-related infections by spreading the ideas to other procedures and other hospitals around the country.

The idea

"You don't have to be a rocket scientist to say, 'I, as a busy doctor, can't do 100 things. I'll be lucky if I can do five.' But they don't prioritize for us," Pronovost said earlier this year at a meeting of health care journalists in Chicago.

So from hundreds of Centers for Disease Control and Prevention recommendations for preventing infections, he picked out five steps evidence seemed to indicate were the most important to follow every time. Pronovost wanted to keep it simple and included requirements like washing hands or wearing sterile masks while inserting a central line into a patient.

Looking at doctors in Johns Hopkins, Pronovost found at least one of the recommendations wasn't being followed at least a third of the time. Often, the reason had to do with supplies not being readily available when they were needed for the central IV lines, so the hospital created a single cart stocked with all the supplies that might be needed.

Then Pronovost convinced administrators to require the checklists. And he went a step further to get nurses empowered to correct a doctor if he or she failed to perform the steps. Within months, infection rates had dropped from more than 10 percent to virtually zero in that hospital.

"Checklists aren't new," Pronovost said, referring to their widespread use in aviation as an example. "But we haven't yet applied them in medicine. I think most likely because we live this myth of perfection, and I can only get aids to help me if I'm humble enough to say 'I'm human. I'm going to forget. I need someone to help.' That mindset isn't widely spread in health care."

The Michigan Health and Hospital Association became interested in the findings. After government funding became available, the MHA courted Pronovost to see whether his idea would have the same impact on infection rates in the Michigan hospitals. The Keystone study kicked off in 2003.

Sam Watson, senior vice president for safety and quality for the MHA and executive director of the MHA Keystone Center - developed in the wake of the study's success - still remembers the overwhelming interest from hospitals around the state volunteering to participate in a study that promised a potential reduction in hospital-acquired infections.

“There was a clear commitment from hospital leadership saying, 'We need to do something'," he said.

The checklists went into intensive care units, and infection rates began to fall.

What's happening now

The center has received yet another Agency for Healthcare Research and Quality Grant to take its ICU findings to hospitals around the country. Local hospital leadership are assisting the Keystone Center and Johns Hopkins to spread the use of the checklist system for inserting central IV lines.

And Ann Arbor hospitals have joined the Michigan Health and Hospital Association Keystone Center at creating new safety standards for preventing ventilator-related pneumonia and sepsis in the hospital, among other projects.

This fall, the Keystone Center is launching a similar program in 10 states to reduce urinary tract infections, often characterized as common but preventable infections most often caused by catheter use in hospital settings.

"It's gone beyond the ICU," said Pat Posa, system performance improvement leader at St. Joseph Mercy Hospital, who sits on the technical expert panel to scale the checklist practice nationwide. "It gave us a form and strategy to get evidence-based research into play … so you can rely on getting a consistent outcome."

Expanding on the original idea is what makes the culture change stick the way it has in Michigan hospitals, Watson said. "We term that as ‘spread,’” Watson said. “I don’t know that you can change the culture of a hospital at large. We focus efforts on a single unit."

Why it worked

The morning rounds at St. Joseph Mercy clearly show a culture shift has occurred. The checklists have given a structure that was never seen before in rounds, Posa said. 

Also new was the back-and-forth discussion between the different disciplines like respiratory therapists and pharmacists during rounds.

"See, that's culture," Posa said. "If I'm a junior nurse and someone's been there a lot longer than me, I won't feel comfortable saying something to them. But this is about creating that environment where I feel comfortable saying, 'You didn't wash your hands. Can you do that before you touch the patient?'"

Registered nurse Pat Posa, a System Performance Improvement Leader at St. Jospeh Mercy Hospital, shows off one of the hospitals systems for communication between staff members in a patient's room.

Lon Horwedel | AnnArbor.com

At most hospitals, the change isn't as simple as it might sound.

“Unfortunately, that is the culture of health care," Watson said. "We are in this business because we want to make people better. Even among people with the highest skill levels and knowledge, at the end of the day errors still happen because they are still human."

And although the knowledge and experience that physicians bring to the bedside is typically respected, knowledge brought by other members of the care team traditionally hasn't enjoyed the same level of respect, Watson said.

"In health care, we’re good at technical fixes when something goes wrong. We’re not as good at looking in the mirror,” Watson said.

But it wasn't just the checklists that made the change. Rather, it was empowering an entire team around a goal of safety and speaking up when someone spotted a problem, Hyzy said.

“For nurses to be able to tell a doctor, ‘You’re no longer sterile, you shouldn’t insert that line … there has to be a cultural change," Hyzy said. "I had a good unit before. They’re a great unit now.”

Pronovost doesn't mince words when he talks about the initial reaction he got from doctors at U-M when he presented the idea. It wasn't an unusual reaction.

"It's funny. They came initially, super arrogant, and said 'What am I going to learn from Johns Hopkins?' And now, they're champions of it," Pronovost said.

The MHA data proves the culture change has had results.

“Underlying all that work is solid measurement - we use safety attitude questionnaire measuring attitudes about safety, teamwork, and look at changes over time," Watson said. "What’s really fascinating is we’ve been able to link results of answers to that survey with reductions in blood stream infections and there is a strong statistical correlation."

Between March 2004 and March 2009, the MHA estimates the Keystone ICU study saved more than 1,800 lives and avoided more than 140,700 excess hospital days. It's estimated to have saved more than $271 million health care dollars alone in Michigan and proved that quality can be quantified, improved upon and ultimately be sustained, Watson said.