Surgeons should adopt “cockpit” checklists

A 'pre-flight' checklist can reduce deadly infections in hospitals

Today's Boston Globe reports that "deaths and complications dropped by an astounding one-third" when doctors and nurses began using a "safety checklist" before surgery, according to a Harvard study. This shouldn't be surprising, as checklists have long been mandatory in another high-pressure profession: flying planes.

Cockpit

In the next issue of CommonWealth magazine (available on January 20), Douglas Brown, a former pilot who is also senior vice president of UMass Memorial Health Care, spells out the parallels:

I learned in flight school [that] relying on individual human variation or individual memory was inimical to safety. Only through the rigorous and systematic use of standardized protocols could a pilot or hospital achieve transformative results in safety.

After the jump, read Brown's complete essay, in which he notes that as many as 100,000 people die each year from hospital-related infections, many of which are "entirely preventable" though "pre-flight checklists."

Photo by Tailspin T

A 'pre-flight' checklist can reduce deadly infections in hospitals

On a hazy August day in 1983, with about seven miles of visibility, I took my first solo flight in a Piper Cherokee single engine aircraft. I was 20 years old, and it was a moment I will never forget. I had less than 20 hours of flight instruction under my belt. I had just finished practicing with my instructor, and I thought we were calling it a day. But as we taxied in, he turned to me and said, “OK, Doug. Now, it’s your turn.” And then he stepped out of the plane. I had a flash of momentary panic and thought there was no way I was ready. But somehow, I was able to overcome my fears and fly.

Flying is relatively easy. It is 99 percent boredom interspersed with 1 percent sheer terror. That 1 percent — which can result in catastrophic consequences — is the hard part. The first thing I learned in flight school was the critical importance of performing a pre-flight safety check. This took the form of a laminated checklist, which I would use as I walked around the airplane to check the wings, flaps, tires, fuel, and other aspects of the plane.

The habitual use of this list is instilled in young pilots with an evangelical zeal. My original flight training manual (circa 1980) says it best: “[E]ven the most experienced professional pilots never attempt to fly without an appropriate checklist. The habit of using a written checklist … should be so instilled in pilots that they will follow this practice throughout their flying activities.”

The field of aviation learned long ago that relying on memory alone could have dire consequences. Pilot error is the primary cause of almost 80 percent of all general aviation accidents in our country. One missed step in the pre-flight process could cost a life. So the regular use of a written checklist is now as routine to most pilots as brushing their teeth.

The medical community is now discovering the benefits of a checklist in reducing hospital-acquired infections. As many as 100,000 people die each year from these infections. They are now one of the top 10 leading causes of death in the United States. We used to think that such infections were an unfortunate, but unavoidable, complication of hospital life. We were wrong. Many of these infections are entirely preventable. And some hospitals are now using checklists to do something about it.

Recently I attended a meeting of the Patient Care Assessment Committee at UMass Memorial Medical Center, where I serve as general counsel. This board-level committee focuses on monitoring and improving the quality of care in our hospital. At the meeting, committee members were reviewing several quality-of-care measures. One in particular caught my eye. It noted the rate of catheter-related bloodstream infections over an 18-month period.

A catheter — or central line, as it is often called — is a device used with about half of all intensive care patients in the US. It is a thin tube inserted into a large vein so as to deliver life-preserving medications and other fluids to a patient. While this serves an important clinical purpose, infections related to central lines can develop easily if certain precautions are not followed. And when an infection strikes a patient who is otherwise critically ill, the result is never good.

Studies have shown that up to 20 percent of patients who develop central line infections die from them. That amounts to as many as 28,000 patients per year. Even if a patient is lucky enough to survive the infection, he or she can expect to spend an additional seven days in the intensive care unit at an added cost of between $15,000 and $20,000. In total, these infections add $2.3 billion per year in health care costs to the system.

The data from my meeting showed that there were 12 central line infections in the intensive care units at UMass Memorial Medical Center for the quarter ending in December 2006 (out of 3,774 total days of patients with catheters). By the quarter ending in March 2008, there were only three infections (out of 5,022 days). Despite an increase in total days, there was a 75 percent reduction in the total number of infections over these six quarters.

As I looked further into the data, I discovered that since 2004 there had been a progressive decline in the rate of these infections from a high of about eight per thousand patient days to a low in March of 2008 of about 0.5 per thousand. In short, we were getting close to eliminating this type of infection from our hospital. The results were remarkable and there is no question that more people are alive today because of this improvement.

So how did it happen?

The story begins in 2001 at a place far from UMass Memorial. As brilliantly described in a December 2007 article in The New Yorker titled “The Checklist,” by surgeon and writer Atul Gawande, one innovative physician at Johns Hopkins by the name of Peter Pronovost borrowed the concept of a pre-flight checklist for use in the intensive care unit.

He identified the five key interventions for reducing infections and put them on a piece of paper. The first four have to do with the process for insertion of the line (the “pre-flight” portion), and the last one has to do with monitoring the line after it has been inserted (the “during-the-flight” portion). All five are remarkably simple:

• Wash your hands.

• Clean the patient’s skin.

• Ensure full barrier protection (sterile attire and drapings).

• Choose the optimal site. Note that there are three possible sites for central line insertion: the femoral or groin site, which is the easiest site for insertion, but the most prone to infection; the shoulder, which is the preferred site; and the neck, which is the second preferred site.

• Remove the lines as often as possible.

These five steps are quite difficult to implement, given the complexity of delivering care in an intensive care unit and the hundreds of caregivers involved. But just like in aviation, Dr. Pronovost found that making a habit of using this checklist every time, for every patient, by every caregiver, had dramatic results. He proved that use of this checklist in surgical ICUs had dramatically reduced the number of catheter-related blood stream infections in patients.

Could this be the cause for UMass Memorial’s success? Dr. Richard Irwin, our head of critical care and a specialist in critical care medicine, explained that the infection reduction was the result of a long series of events begun in 2004, including the development of a team approach to care and the implementation of an electronic ICU. The electronic ICU allows clinicians to supplement care by remotely monitoring patients, reviewing their vital signs, and sending ”smart alerts” to the bedside staff.

UMass Memorial also adopted a version of Dr. Pronovost’s checklist. It is a single page of paper noting the key steps in the process for insertion. It sits atop a cart containing all of the equipment necessary for the procedure. One of the providers, usually a nurse, checks a box as each step in the process is performed by the other provider. It is that simple.

Yet the checklist alone is not enough. As in aviation, the real lesson of the checklist, according to Dr. Irwin, is the “continuous, rigorous focus on its use, every time. The minute we take our eye off the ball — even in one case — we will have another infection.”

Dr. Irwin understood the lessons that I learned in flight school: Relying on individual human variation or individual memory was inimical to safety. Only through the rigorous and systematic use of standardized protocols could a pilot or hospital be able to achieve transformative results in safety.

Another notion underlies this success: accountability. In aviation, the pilot is accountable for safety. The best pilots have the humility to impose a “hard stop” on themselves when any aspect of their pre-flight checklist does not measure up. These pilots do not fly until every aspect of the safety list checks out.

This same accountability underscores the improvement at UMass Memorial. The critical care policy requires the completion of a written checklist for each central line insertion. More importantly, the nursing staff is empowered to override other clinical staff, including physicians, and impose a “hard stop” on the procedure if appropriate techniques are not being followed. No hierarchy or ego can be allowed to trump safety.

Despite the success of a checklist, many hospitals across the country (and I suspect some here in Massachusetts) do not systematically use a checklist or other measures to reduce central line infections. In 2007, the Leapfrog Group, an organization that promotes quality and safety in health care, conducted a survey of 1,250 hospitals across the country. They found that only 35 percent had fully complied with all of the recommended steps for prevention of central line infections.

Why is this so? Perhaps a profession that prides itself on rendering individualized, clinical judgments resists the notion of reducing medicine to a series of cookie-cutter solutions. I understand this resistance. But pilots need to render independent judgment as well. And pre-flight inspections do not vary based on the particular judgment or inclination of the pilot.

There continues to be a myth in health care that to improve quality you must increase cost. Dr. Pronovost shattered that myth. His method improved quality and reduced the unnecessary costs associated with an infection. Dr. Gawande also pointed out that Dr. Pronovost estimates it would take no more than $3 million to implement the checklist in all hospitals in the United States. That is about $600 per hospital, or about 4 percent of the cost of treating just one catheter-related blood stream infection.

Massachusetts is home to some of the best hospitals, medical schools, researchers, and physicians in the world. We are leaders in discovering new knowledge for treating disease. But what about our leadership in using the knowledge that already exists? There are many other procedures in medicine that could benefit from the consistent use of a checklist. Yet, just like with central lines, checklists are not universally employed.

Maybe it is time for a reevaluation of some fundamental notions in medicine. Independent clinical judgment will always be highly prized, and for good reason. But perhaps we should find the humility to acknowledge — as we do in aviation — that individual judgment should at times give way to the collective judgment that certain independent checks can save lives. If we do, central line infections, and many others like them, may soon be a thing of the past.

Douglas S. Brown is senior vice president and general counsel of UMass Memorial Health Care in Worcester.