Peter Pronovost is a different kind of medical hero. An anesthesiologist who is making an impact on hospital care far greater than almost any new pharmaceutical or high-tech surgical technique.
Implementation of Pronovost’s simple checklist for prevention of catheter-related bloodstream infection – the infection that can arise from intravenous lines inserted into the central circulation – has resulted in a dramatic reduction in these infections in a large group of Michigan hospitals. In many hospitals, the incidence, quite astonishingly, dropped to ZERO, sustained over a period of months.
The checklist is treated as an all-or-none affair. You only score points for doing everything right. It looks like the simple concept of doing ALL the things on the checklist (also known as a “bundle”, pioneered by the Institute of Healthcare Improvement) to secure any credit in the accompanying measurement system is key.
The commonsense checklist is as follows:
- Wash hands with soap.
- Clean the patient’s skin with chlorhexidine antiseptic.
- Put sterile drapes over the entire patient.
- Wear a sterile mask, hat, gown and gloves.
- Put a sterile dressing over the catheter site.
You may wonder why on earth hospitals haven’t been doing these things before now. The truth is, most are done, but not in a reliable, “systematic” way, and not all the time. The reason why, linked to the factors that make modern medicine, even in the most sophisticated hospital settings, a sometimes haphazard affair, include physician autonomy, lack of teamwork, no “safety culture”, inadequate information systems, few outcome measures and lack of accountability and incentives. All of that is changing, albeit slowly. We can expect hospitals to make a major push to improve in this area as CMS (Medicare) will later this year stop paying for various hospital complications.
One of the problems is that research into handwashing or antiseptics just isn’t glamorous or well-funded (if funded at all) or paid much attention by leading journals. Handwashing isn’t done consistently as doctors, nurses and other staff move from patient to patient. Chlorhexidine is a better antiseptic than iodine-povidine which was until recently the standard in North America. But the evidence that it is better has been around for years.
Sterile drapes have always been used, but not the kind that cover most or all of the patient. That just didn’t seem necessary but was shown to reduce infection rates and advocated by guidelines produced by the CDC. Gloves have always been standard, but not necessarily the hat and mask. (In fact masks become ineffective germ barriers quite quickly). I must admit I’ve never seen a central line site without some form of sterile dressing.
The Pronovost checklist creates awareness, and simplifies the organizational challenge of behavior change in hospitals, perhaps the hardest thing to do in health care, or any large organization.
What isn’t common sense is the recent ruling by the US Federal Office for Human Research Protections that hospitals must obtain informed consent and Institutional Research Board approval before measuring the results of these interventions. This threatens the widespread implementation of these programs which in Michigan is estimated to have saved 1,500 lives saved and 400 dollars for every dollar spent on the program. Quality improvement is impossible to do without routine data collection, and its hard to see how patients are threatened if the IRB is bypassed. On the other hand it is now plain to see that thousands are being harmed by the barrier suddenly erected to dissemination of these life-saving hospital practices.
What You can do about it
In the US, write to your congress representative to suggest that the Federal ruling be reconsidered.
Look for signs that your hospital is monitoring and promoting handwashing, such as notices to staff and patients, and dispensers of antiseptic solution widely available.
Pronovost P. An intervention to decrease catheter-related bloodstream infections in the ICU. NEJM Dec 2006.