Pronovost shows how checklists can slash infections

If the infection fight has a national hero, that would be Dr. Peter Pronovost, a Johns Hopkins anesthesiologist who has convinced some of the country’s most prestigious hospitals to fight infections with a simple five-point checklist.

His message: If health care workers took five steps as easy as washing their hands and wearing sterile gloves and gowns, they could virtually eliminate one of the most lethal infections among their sickest patients.

Provonost took his checklist to Michigan for a 2003 field test at 108 hospital intensive care units, zeroing in on bacteria carried by feeding tubes inserted close to patients’ hearts.

With the use of checklists, infection rates plummeted as much as 66 percent and stayed low for 18 months—a finding that helped turn checklists into a staple in many hospitals nationwide.

The new popularity of checklists signals a sea change for hospitals, safety experts say.

Pronovost’s Hopkins-based safety group has teamed up with hospitals and public health officials in more than 20 states to spread the checklist program. He said in a November interview that he would gladly work with California’s hospitals but has not been invited.

Neither the state health department nor the California Hospital Association has promoted the idea of a statewide checklist campaign. Hospital officials say that’s because many California facilities are already using checklists successfully, including large collaborative in the Bay Area and Southern California. State health officials said that they have not received a formal proposal to work with Pronovost.

“It bears consideration if it were presented,” said Loriann De Martini, chief pharmaceutical consultant at the California Department of Public Health.

Key to the success of such programs is a shift in the hospital culture.

Checklists not only remind surgeons and nurses to wash their hands, Pronovost says, but helps shift the balance of power in an intensive care unit or surgical suite.

When a medical team introduces a checklist into its routine, he says, a nurse can remind a surgeon that he or she hasn’t done the requisite hand-washing—something that many nurses wouldn’t dare to do in a traditional hospital setting.

“In 1990, people wouldn’t have been talking about checklists at all. This whole approach to patient-centeredness and consumerism in medicine—those are all relatively new concepts,” said cardiac surgeon Dr. William Berry, a Harvard researcher who is working on the Safe Surgery Saves Lives Initiative with the World Health Organization.

Now the checklist is moving from the ICU to the operating room. Berry and his colleague, surgeon and New Yorker writer Atul Gawande, have been introducing workers to the use of checklists during surgery to prevent infections and other mistakes.

The South Carolina Hospital Association, for instance, recently invited Berry and his group to introduce surgical checklists to the operating rooms of the state’s 60 hospitals.

Key to the process is making surgical teams pause three times in a procedure: before it starts, before an incision is cut and at the end. Members introduce themselves and talk to one another, Berry said.

“Whenever I talk to lay people, they are aghast that that’s not what is normally done in an operating room,” Berry said. “Normally a surgeon walks to the table, nobody says anything and the surgery starts.”

Before the incision, the team pauses again to review plans and express any concerns “before the knife touches the patient’s skin,” Berry said. “This would be the time that the nurse says, ‘We don’t have the clamp you would normally use.’”

Finally, at surgery’s end, the team stops one more time to make sure no sponges or needles were left in the body and that specimen bottles are labeled correctly.

Such steps may sound trivial, experts say, but they are effective.

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