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Posted on Sun, Jul 18, 2010 : 6:02 a.m.

How a checklist saved lives at Ann Arbor area hospitals

By Tina Reed

071310_ST._JOE'S_KEYSTONE_S.JPG.jpeg

Registered nurse Mary Bryce, second from right, voices her concerns about one of her patients to Dr. William Patton, right, on the sixth floor at St. Jospeh Mercy Hospital last week. All team members - from doctors, to residents, to nurses, to pharmacists - are encouraged to participate in the daily discussions to help with patient care. The guidelines also include a checklist instituted to help reduce hospital-acquired infections.

Lon Horwedel | AnnArbor.com

In one of the long corridors of St. Joseph Mercy Hospital's intensive care units, a group of medical staff huddled outside a patient's room for morning rounds.

They were meeting, the way they do every day, to discuss the progress of their patients and plan for the day ahead. And this morning, resident Nadia Juneja was presenting the case.

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

Before Michigan became a test case for the checklist, the original idea started with a critical-care physician named Peter Pronovost at Johns Hopkins Hospital in Baltimore.

Pronovost was frustrated with a particular case where an infection of a central IV line caused the death of a little girl. He was also frustrated with how common infections in U.S. hospitals were, and Pronovost didn't agree with the prevailing idea that infections were unavoidable complications of using IV lines.

To him, it seemed, the key to reducing infection rates was in the hands of medical staff and what he called a "ruthlessly simple" tool: the checklist.

"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?'"

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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.

“If you don’t measure culture, you’re not going to change culture," Watson said.

Tina Reed covers health and the environment for AnnArbor.com. You can reach her at tinareed@annarbor.com, call her at 734-623-2535 or find her on Twitter @TreedinAA.

Comments

Tina Reed

Mon, Jul 19, 2010 : 7:46 p.m.

Thanks for pointing out those links. Gawande also wrote an interesting piece about this subject in The New Yorker a few years back. Here's the link: http://www.newyorker.com/reporting/2007/12/10/071210fa_fact_gawande

Michael Cohen

Mon, Jul 19, 2010 : 5:40 p.m.

Two readers asked what was on the checklist. Here is a version of it (from http://info.navilystmedical.com/Blog/?Tag=central%20line%20catheter ): "According to [Pronovost's] checklist doctors should: 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" There is more on hand-washing, and other efforts to improve medical practice in Atul Gawande's book, Better. He also has a more recent book on this exact issue, The Checklist Manifesto.

StartupGeek

Sun, Jul 18, 2010 : 8:31 p.m.

@scole. I agree doctors have overwhelming jobs with too much information to remember and to process in addition to an excessive, unhealthy and sometimes dangerous workload (to their customers). Extending my earlier 747 analogy, pilots have checklists for the same reason that doctors/other healthcare professionals could sometimes benefit from them. Also, the "Nobody has bothered to say what is more effective." strikes me as an excuse. I assume there is a known best practice for inserting a IV line and the issue is this best practice is not followed (eg the nurse can say you missed a step). Similarly, a major source of hospital infections is hospital/doctors not washing their hands before touching patients. Compliance and following best practices is the issue. Knowing, sharing and following best practices vs. "I know what is best for my patient". Tracking everything. Providing transparency of the data and outcomes to everyone. The larger question for me is that this 5 point checklist is somehow an innovation in the healthcare industry. Why has it taken so long to recognize the problem of preventable hospital infections and implement solutions (central IV lines being one source)? Can anyone name another major industry (auto, computer, oil drilling) where it is acceptable to have 4.5 defects/errors (4.5 out of every 100 hospital admissions and result in 99,000 associated deaths). Or a major industry that did not implement and embrace continuous quality improvement decades ago? Or an industry that produces errors resulting in hundreds of death per day that is not covered in the media (kudos to your industry PR for whoever came up with the line "unavoidable complications")? Why has it been acceptable NOT to question "prevailing idea that infections were unavoidable complications of using IV lines." How many other "prevailing ideas" are out there? The good news there is room for improvement in health care. The question is - when will it happen in a widespread way?

AlphaAlpha

Sun, Jul 18, 2010 : 6:40 p.m.

Get real, scole. There is most certainly not one 747 crash each day, even in the Pretend General Hospital fantasy land you describe. You say, : "He [the doc] works hard, and is exhausted all the time, but holds it together pretty well." Major major problem here : "[he] is exhausted all the time". Why exhausted? Too much working. Why? For the $$. Nothing wrong with making a profit; lots wrong with working when overtired. We can't regulate reasonable hours for docs; but we do sue for errors. The job isn't that hard; common sense can be in short supply, however. Do you know why doctors make some of the worst pilots of all? They fly into trouble, thinking 'they can handle it'. They believe they are more skilled than most. It's a shame, really. 100,000 preventable dead per year. Worse than the wars. By far...

Rasputin

Sun, Jul 18, 2010 : 5:47 p.m.

Fascinating nevertheless

michiganpoorboy

Sun, Jul 18, 2010 : 5:43 p.m.

I have been involved with three tests preformed at st joe and am 3 for 3 as none were correct? They ether forgot something or read the data wrong? How would a check list help incompetence? No st joe for me they run the worst health care system I have found. I live in Ann Arbor and go to Boumant on Woodward imagine that, my life is worth more than having a Boondoggle that is handy.

Hactin

Sun, Jul 18, 2010 : 5:35 p.m.

We all have had to deal with the frustration caused by people who are "super arrogant", but it is frightening when they control your health care. My little story happened in the U of M ER, where I was waiting for a consultation for swelling in my forearm three days after the surgery to repair the laceration. I was waiting and I watched the resident eat a slice of pizza and then he came over and started to touch the stitches. When I asked him to wash, he said "You can wait." A person is pretty helpless in such a situation. Why is quality in private practice an individual or institutional matter and not a public matter? I've been told that half of the $$ spent on health care in the US is from Medicare. Do we not deserve an assurance that behavior and performance is improving when it costs us so much? The "super arrogant" don't really have to answer that question, do they?

Hactin

Sun, Jul 18, 2010 : 5:09 p.m.

We all have had to deal with the frustration caused by people who are "super arrogant", but it is frightening when they control your health care. My little story happened in the U of M ER, where I was waiting for a consultation for swelling in my forearm three days after the surgery to repair the laceration. I was waiting and I watched the resident eat a slice of pizza and then he came over and started to touch the stitches. When I asked him to wash, he said "You can wait." A person is pretty helpless in such a situation. Why is quality in private practice an individual or institutional matter and not a public matter? I've been told that half of the $$ spent on health care in the US is from Medicare. Do we not deserve an assurance that behavior and performance is improving when it costs us so much? The "super arrogant" don't really have to answer that question, do they?

scole

Sun, Jul 18, 2010 : 4:29 p.m.

So let's take the 747 analogy from a different angle. Let's say the pilot is already flying the plane the way he's been doing it for years, and is doing a fine job. There are many airlplane crashes (one a day!!) and it really bothers him, so he does the best that he can to avoid them with what he knows. He works hard, and is exhausted all the time, but hold it together pretty well. Then the FAA says that they have a list of things that you might think about doing to prevent crashes, but it's a big list, and flying the plane is already really taxing. Nobody has bothered to say what is more effective, and he already does many of the things on the list, and trying to remember an extra 100 things or so just doesn't work. He knows adding more things to his routine will make him forget other important things, like lowering the landing gear. Somebody making a list of the 5 most important things, and making it mandatory (and encouraging other team members to help him, rather than stay silent and watch him crash) seems like a pretty good idea. It is probably also good to remind him that listening to team members is beneficial to him too.

AlphaAlpha

Sun, Jul 18, 2010 : 2:17 p.m.

"Even among people with the highest skill levels and knowledge, at the end of the day errors still happen because they are still human."" Wrong. Errors happen because "they are not careful", not because "they are human". Think about the above comment: the equivalent of one 747 every day. Every day. All completely preventable. Incredible. Customers acquiring these infections should, at the very least, demand free infection treatment, and, generally, should sue for damages. Medicine is a business; when the bottom line is affected, administrators will demand improvements in customer care.

StartupGeek

Sun, Jul 18, 2010 : 12:33 p.m.

A quote from the doc who developed the checklist is telling:."I, as a busy doctor, can't do 100 things. I'll be lucky if I can do five." Indeed, like most professionals, doctors are very busy. According to the article, 99K deaths each year result from U.S. hospital-associated infections- many which presumably could be prevented from better procedures. This is just one example of preventable medical errors. Now, could you imagine a 747 pilot saying the above quote to cut down on his pre-flight checklist - especially if the equivalent of one 747 crashed every day as a result of not using better procedures? My conclusion, doctors are the best marketers in the world and should be recognized as such.

glottic

Sun, Jul 18, 2010 : 10:59 a.m.

The professional chap standing directly left of Mary Bryce, R.N. might want to take his finger out of his mouth; to help reduce hospital-acquired infections!! C'mon dude, wash your hands before you touch your patients!

SonnyDog09

Sun, Jul 18, 2010 : 10:24 a.m.

I would also like to see the checklist. There is more information on Healthcare Associated Infection from the CDC at http://www.cdc.gov/ncidod/dhqp/healthDis.html

krc

Sun, Jul 18, 2010 : 9:07 a.m.

It would have been interesting to see the actual list.