A little over a year ago Dr Peter
Pronovost, a critical-care specialist at Johns Hopkins
Hospital, published some remarkable, life-saving results
in the New England Journal of Medicine. The doctor
hadn't discovered an innovative new treatment or invented
a high-tech device. He just wrote a checklist and convinced
his fellow ICU docs to use it.
Dr Pronovost's checklist runs through
basic hygiene practices like hand washing and sterilization
precautions like draping and wearing a mask and gloves.
Basic, but revolutionary. The humble document slashed
Michigan's central intravenous line infection rate by
66% and quarterly infection rate to zero. Just three
months after they started using it, Michigan's infection
rates fell so low that its average ICU outperformed
90% of others in the country. After 18 months, it had
saved 1,500 lives and roughly $175 million in care costs.
Some Canadian doctors took notice.
Dr Roy Ilan, a clinical fellow at Toronto's Sunnybrook
in 2006, adapted Dr Pronovost's checklist for Sunnybrook's
ICU, where it's still in use today after similar success.
Yet, despite the demonstrable affect of checklists like
this, their use is, at best, a patchwork throughout
Canadian healthcare.
MAKING
A LIST
Since 2001, Dr Pronovost has created a variety of checklists
for Johns Hopkins Hospital aimed at reducing central
line infection, increasing timely response to patient
pain, and improving care for those on mechanical ventilators.
His checklists focus on simple
but important tasks that are often overlooked by physicians
when dealing with complex patients. Before the introduction
of the central line insertion list, nurses at Johns
Hopkins' ICU observed doctors for over a month and reported
that they skipped one of the steps of insertion more
than a third of the time.
When he tested a checklist to ensure
patients on ventilators had their beds propped 30 degrees
and were given antacid medication, the occurrence of
pneumonia fell 15% and 21 fewer patients died than the
year before.
GET
OVER IT
"I'm ashamed to say I'm not using checklists right now,"
says Dr Ilan, who joined Queen's University's faculty
at Kingston General last July after completing his fellowship
at Sunnybrook. He admits he doesn't want to rock the
boat with his new employer — not yet at least.
"There's a long way to go before checklists will be
routinely used," says Dr Ilan. "Much of that has to
do with medical culture."
Anecdotally, doctors are notoriously
scornful of checklists. In a December post on his medical
blog Saskatoon urologist Dr Kishore Visvanathan recounts
overhearing a surgeon criticizing a nurse who read out
a checklist the Saskatoon Health Region requires to
be reviewed before every OR procedure. "C'mon," complained
the surgeon. "Like I don't know what procedure I'm going
to do on this patient?" The list ensures doctors operate
on the correct patient, the correct side of the body,
review patient allergies and whether perioperative antibiotics
are required. Dr Visvanathan fumes that surgeons are
a very "conservative bunch" who shy away from new ideas,
especially when they perceive it as extra work for not
much gain.
Proving the efficacy of checklists
in Canada is another hurdle. The reason Dr Ilan's central
line checklist never matured into a study is the difficultly
of collecting statistics, he says. Dr Pronovost was
barred from collecting further data last December when
the federal Office for Human Research Protections said
introducing a checklist and tracking the results without
written, informed consent from each patient and healthcare
provider violated US scientific ethics regulations.
Similar requirements in Canada also proved an obstacle
to Dr Ilan's plans for data collection.
BRING
IN THE LIST
The arduous process of setting up data collection hasn't
stopped some Canadian organizations from rallying to
get checklists into every hospital. The Safer Healthcare
Now! (SHN) program went public in 2006 and has succeeded
in attracting commitments to use central line checklists
from 81 hospitals across Canada. It's also attracted
106 commitments to mechanical ventilator checklists
and 152 to surgical site infection lists as well.
Building on Dr Pronovost's work
and the success of his study, SHN created guideline
kits, which can adapt checklists to the needs of various
hospital settings. Each starter kit is put together
with consultation from department heads, professors,
and quality improvement leaders throughout Canada, and
is available for download on SHN's website.
The adaptability of the program's
lists is one reason hospital's are now starting to catch
on, says Cynthia Majewski, an administrator for the
SHN program's Ontario arm. "What we know is that the
evidence supporting checklists exists, but it hasn't
been consistently applied," she says. "The checklists
need to fit the environment they are being used in.
For physicians it hasn't been a well adapted tool so
far."
CUTTING
COSTS
Dr Ilan believes that in the end checklists are easy
ways to save millions of much needed healthcare dollars.
Adverse events are expensive, he says. If checklists
act as a safety net to prevent adverse events it could
easily save costs.
For now though, Canada has some
catching up to do. Dr Pronovost's study has inspired
Spain to adopt checklists nation-wide and the World
Health Organization is taking it global.
|
