Managing (Medical) Complexity

Another terrific medical article by Atul Gawande in the New Yorker. This one is about doctors using checklists to decrease the amount of infections in the Intensive Care Unit (ICU). I read it when it came out in December and didn't plan on blogging it ... but the article has stayed with me, so I thought I'd blog it. a) because maybe it'll interest you, Dear Reader, and b) so I could re-read the article and cement its ideas even more firmly in my memory.

The Checklist describes the work of Paul Pronovost, MD, PhD (public health) who developed a checklist to routinize the roughly 178 daily tasks ICU patients need. Gawande states that the average stay of an ICU patient is 4 days, and the survival rate is 86%. Pronovost's checklist, designed specifically to lower the rate of line infections in ICU patients, was implemented at Johns Hopkins in 2001. A year later, their 10-day line infection rate had dropped from 11% of all patients to 0%. Yes, zero percent! They reran the numbers and followed patients for another year. Over the 27 months of using the checklist, they had only 2 line infections. Astonishing!

Pronovost observed two main benefits of these checklists: a) they help with memory recall. As Gawande notes, "When you’re worrying about what treatment to give a woman who won’t stop seizing, it’s hard to remember to make sure that the head of her bed is in the right position." And b) the checklist itemizes "the minimum, expected steps in complex processes." Gawande notes that nurses were empowered to enforce the doctors' adherence to the checklist, thus improving their use.

Sadly, because a checklist for physicians is not sexy, Pronovost's ideas have not been widely adopted in this country. One exception is the 2003 implementation in the inner-city Detroit hospital Sinai-Grace, where line infection rates dropped by 66%. This was estimated to have saved over 1,500 lives and $75 million dollars over three years. Pronovost and the Keystone Initiative published these results in a 2006 New England Journal of Medicine article.

Gawande personalizes the case studies with his usual flair; the article discusses the near-drowning of a 3-year old in Austria who by age 5 had "recovered her faculties completely," (her doctors had used a checklist) and a Massachusetts limo driver who suffered a serious line infection in the hospital and fortunately recovered (his doctors had not used a checklist). He also talks about the process by which the US Army Air Corps implemented flight checklists as they rolled out the B-17 in the mid-1930s, commenting that "[m]edicine has entered its B-17 phase."

I hope that more hospitals will take this checklist approach, as it certainly seems to be a sound idea.

For More Information

• Berenholtz, S. M., Pronovost, P. J., Lipsett, P. A., Hobson, D., Earsing, K., Parley, J. E., et al. (2004). Eliminating catheter-related bloodstream infections in the intensive care unit. Critical Care Medicine, 32(10), 2014-2020.(abstract in PubMed)
• Gawande, Atul. Annals of Medicine: The Checklist. The New Yorker, Dec. 10, 2007.
  
• Hales, B. M., & Pronovost, P. J. (2006). The checklist-a tool for error management and performance improvement. Journal of Critical Care, 21(3), 231-235. (abstract in PubMed)
  
• Pronovost, P., Needham, D., Berenholtz, S., Sinopoli, D., Chu, H., Cosgrove, S., et al. (2006). An intervention to decrease catheter-related bloodstream infections in the ICU. New England Journal of Medicine, 355(26), 2725-2732. (See also Erratum: An intervention to decrease catheter-related bloodstream infections in the ICU. (2007). New England Journal of Medicine, 356(25), 2660.)
• Walker, Tim. Make a list of "crucial basics" and check it twice. Hoover’s Business Insight Zone, Feb. 11, 2008.
  In researching this post, I found a Hoover's blog post by Tim Walker commenting on the checklist idea and wondering how it could be applied to business and career.