The Checklist: If something so simple can transform intensive care...

  1. annals of medicine

    the checklist

    if something so simple can transform intensive care, what else can it do?

    by atul gawande

    if a new drug were as effective at saving lives as peter pronovost’s checklist, there would be a nationwide marketing campaign urging doctors to use it.

    full article: http://www.newyorker.com/reporting/2...?currentpage=1

    i found this very interesting! based on the logic behind military airplanes using checklists, general surgeon peter pronovost implemented checklists in icu at johns hopkins. the results were phenomenal - his first checklist for line infections (described below) resulted in this: "the ten-day line-infection rate went from eleven per cent to zero. so they followed patients for fifteen more months. only two line infections occurred during the entire period. they calculated that, in this one hospital, the checklist had prevented forty-three infections and eight deaths, and saved two million dollars in costs." (p. 4) such a simple idea - who would have ever thought?!

    an excerpt:

    "in 2001, though, a critical-care specialist at johns hopkins hospital named peter pronovost decided to give it a try. he didn’t attempt to make the checklist cover everything; he designed it to tackle just one problem, the one that nearly killed anthony defilippo: line infections. on a sheet of plain paper, he plotted out the steps to take in order to avoid infections when putting a line in. doctors are supposed to (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, and (5) put a sterile dressing over the catheter site once the line is in. check, check, check, check, check. these steps are no-brainers; they have been known and taught for years. so it seemed silly to make a checklist just for them. still, pronovost asked the nurses in his i.c.u. to observe the doctors for a month as they put lines into patients, and record how often they completed each step. in more than a third of patients, they skipped at least one.
    the next month, he and his team persuaded the hospital administration to authorize nurses to stop doctors if they saw them skipping a step on the checklist; nurses were also to ask them each day whether any lines ought to be removed, so as not to leave them in longer than necessary. this was revolutionary. nurses have always had their ways of nudging a doctor into doing the right thing, ranging from the gentle reminder (“um, did you forget to put on your mask, doctor?”) to more forceful methods (i’ve had a nurse bodycheck me when she thought i hadn’t put enough drapes on a patient). but many nurses aren’t sure whether this is their place, or whether a given step is worth a confrontation. (does it really matter whether a patient’s legs are draped for a line going into the chest?) the new rule made it clear: if doctors didn’t follow every step on the checklist, the nurses would have backup from the administration to intervene." (p. 4)
    Last edit by TXstudentRN on Dec 10, '07
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  2. 19 Comments

  3. by   oramar
    "the nurses would have backup from the administration to intervene" I am impressed.
  4. by   CraigB-RN
    Quote from oramar
    "the nurses would have backup from the administration to intervene" I am impressed.
    I've worked with Dr Pronovost. He's an impressive guy.
  5. by   birdgardner
    Great article - very worth reading. And no reason why nurses couldn't come up with life-saving checklists - it doesn't take physician training - just physician buying in.
  6. by   S.T.A.C.E.Y
    I think its a GREAT idea. But would just flop without the support of the higher ups.
  7. by   cardiacRN2006
    This is how we place lines in our ICU....and if a Dr doesn't wear the mask and hat and sterile gown then they get it from us! I say, "sorry, you can't place a line in my room without the proper gear!" It always works...

    We have to wear all that stuff too. And we have a very low line infection rate.
  8. by   LiverpoolJane
    In my clinical area (Renal / acute dialysis) we devised a CVC pathway that was started before line insertion and continuing until line removal. It is a checlklist and we audit the pathways to see areas we can improve on. Our ICU was having problems with MRSA bacteraemia and have now emplyed our pathway and have seen the bacteraemia rates fall significantly.
  9. by   EmmaG
    The next month, he and his team persuaded the hospital administration to authorize nurses to stop doctors if they saw them skipping a step on the checklist; nurses were also to ask them each day whether any lines ought to be removed, so as not to leave them in longer than necessary. This was revolutionary. Nurses have always had their ways of nudging a doctor into doing the right thing, ranging from the gentle reminder ("Um, did you forget to put on your mask, doctor?") to more forceful methods (I've had a nurse bodycheck me when she thought I hadn't put enough drapes on a patient). But many nurses aren't sure whether this is their place, or whether a given step is worth a confrontation.
    This just aggravates the crap outta me. We should NOT need special permission from administration to do our jobs. 'Authorize' my butt.
  10. by   S.T.A.C.E.Y
    We should not NEED authorization to stop them, but if a doctor challenges you, it sure helps to know you have the backup from above when someone is chewing your ass out about challenging his medical practices.
  11. by   HM2VikingRN
    Checklists save lives in aviation. It only makes sense to use them in medicine. We have had it drummed into our head through nursing school that if we carry through on an erroneous order from a doc that it would be our (potential) license on the line. I am going to measure twice and cut once!
  12. by   leslie :-D
    Quote from Emmanuel Goldstein
    This just aggravates the crap outta me. We should NOT need special permission from administration to do our jobs. 'Authorize' my butt.
    i think that's their way of saying, "we have your back.....this time.....only".

    until some other md comes along and realizes that aseptic technique really does prevent infections and death.

    maybe these checklists should be on their exams in med school.
    save us all a lot of headaches.
    esp our pts.

    leslie
  13. by   Diary/Dairy
    This was a GREAT article - Thanks for posting it!
  14. by   FireStarterRN
    This is a very well written article. Thanks!

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