Co-Cure: A Basic Hospital To-Do List Saves Lives - New York Times

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Date:??? Thu, 24 Jan 2008 22:03:36 -0500

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A Basic Hospital To-Do List Saves Lives - New York Times

 

January 22, 2008

Personal Health

A Basic Hospital To-Do List Saves Lives

 

By JANE E. BRODY

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=92s 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=20=20

Diseases by Dr. Sanjay Saint and colleagues at the Veterans Affairs=20=20

Ann Arbor Healthcare System and the University of Michigan stated=20=20

that 1 percent of hospital patients fitted with a urinary catheter=20=20

developed a urinary tract infection. Forty percent of all hospital-=20

acquired infections are urinary.

 

Dr. Saint=92s national study =93found no strategy that appeared to be=20=20

widely used to prevent hospital-acquired urinary tract infections.=94=20=20

Nearly half of hospitals had no system telling them which patients=20=20

had a catheter, and three-fourths had no system to show how long the=20=20

catheter was in place or whether it had been removed. Furthermore,=20=20

fewer than 10 percent of hospitals used any system to remind doctors=20=20

to check daily on whether a patient=92s catheter was necessary; the=20=20

longer one is in, the greater the likelihood of infection.

 

A nationally imposed checklist for safe urinary catheter insertion=20=20

and removal could sharply reduce the risk to patients and the costs=20=20

of hospital care.

 

But checklists need not be limited to reducing the risk of hospital-=20

acquired infections. As Dr. Gawande and Dr. Pronovost explained, they=20=20

could be used to enhance the safety of surgery and anesthesia, the=20=20

treatment of patients with heart disease, diabetes, pulmonary=20=20

diseases like asthma and a host of other conditions where certain=20=20

approaches to care have been scientifically established as most=20=20

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=92s 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=20=20

own advocates, armed with their own checklist and asking medical=20=20

personnel whether they are using it =93to help assure that I don*t get

an infection or asking, Do I still need this catheter?

 

 

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[Guest guest]

It sounds like the last place we ought to go if we do get sick.