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CE article: Are checklists the future of infection prevention?*

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After reading this article, you will be able to:

  • Identify the major parts of the ICU checklist
  • Explain why the checklist has been successful
  • Analyze accountability initiatives that accompany the checklist

The adjectives "simple" and "effortless" are rarely associated with the healthcare industry or infection prevention. Procedures or initiatives that might seem easy often end up being complex and time-consuming. Even the simple act of hand hygiene has become a compliance headache for healthcare professionals.

But a new wave of simplicity could be sweeping through the industry—and this one really is as easy as it sounds.

The use of checklists dates back to World War II, when pilots used them to conduct final assessments before takeoff. Variations of those checklists are still used by pilots today. Peter Pronovost, MD, PhD, FFCM, medical director at the Center for Innovation in Quality Patient Care at Johns Hopkins Medical Center in Baltimore, decided to translate that same preflight review for use in common medical procedures, such as inserting a central-line catheter.

Checklists have begun appearing in ICUs throughout the country as part of the "ICU bundle," a set of IC interventions specifically for the ICU, released by the Institute for Healthcare Improvement (IHI). Learn more about the IHI's suggestions for ICU care.

Other checklists have been used in the surgical suite to help prevent surgeons from operating on the wrong area, or for patients on ventilators. Although checklists help improve compliance throughout many areas of the hospital, they have yet to become a staple in healthcare. Pronovost says the United States has yet to fully invest in the science of healthcare.

"We spend a penny on healthcare delivery for every dollar we spend to find new genes and to find new drugs, and some of this stuff does take investment," Pronovost says.

Initial studies
In 1998, Pronovost began a four-year study at Johns Hopkins Hospital, compiling five interventions into a checklist to eliminate catheter-related bloodstream infections (CR-BSI) in the ICU. (See "The checklist," at the end of this article.) Results of the study, which were published in the October 2004 Critical Care Medicine, showed a decrease in the CR-BSI rate from 11.3 per 1,000 catheter days to 0 per 1,000 catheter days over the course of four years. Researchers estimated that the interventions may have prevented 43 CR-BSIs, eight deaths, and $1,945,922 in additional costs per year.

In 2004, Pronovost conducted another study through the Michigan Health and Hospital (MHA) Association Keystone Center for Patient Safety and Quality, which includes 103 hospitals across Michigan.

The study, which was published in the December 28, 2006 New England Journal of Medicine, implemented evidence-based interventions, including ICU checklists, over the course of 18 months and reported a 66% reduction in CR-BSIs.

"[What we learned from the Michigan study was that] we ought to centralize the work that is neither efficient nor effective for every hospital to do alone," Pronovost says. "And that turns out to be what the measures are and what the evidence is, because that's technical, that's the science work. And then we have hospitals innovate on how to improve those rates and how to implement the evidence."

Why the checklist works
Stephen Rupp, MD, an anesthesiologist at Virginia Mason Medical Center in Seattle, helped implement a checklist through IHI's 100,000 Lives Campaign. Rupp implemented a variation of Pronovost's checklist in different areas of his hospital, including the operating room and critical care unit, cutting infections up to 75%.

"The checklist is a healthcare delivery mechanism," says Rupp. "It deals with the fact that humans are fallible. They have multiple tasks, they have multiple distractions, and they are called upon to perform their practice at varying times during the day or night or weekend, at varying times of stress, and the fact is, memory fails people."

The checklist serves as a replacement for memory, ensuring that the caregiver follows through with certain precautions that have proven to reduce infections, Rupp says. In addition to the five steps outlined in Pronovost's checklist, Rupp and his staff members added two additional steps to avoid relatively uncommon, but highly traumatic, mechanical problems. Staff members at Virginia Mason are required to use an ultrasound to avoid arterial punctures and to measure the pressure afterward to confirm the catheter was in a venous system. Rupp's team also developed a system in which physicians performing central-line insertions set up appointments with IV therapy nurses who are on call around the clock. The nurse brings a central-line cart that includes all required materials.

"One of the things I've learned from being in hospitals and medical administration is you have to make things simple, they have to make sense, and to a certain degree, you have to require standard work," Rupp says. "That is new for the medical community, and I think it has to do with medical education. I believe it's the way people have been, or at least the way I was, trained in residency, that you are a doctor and you have discretionary decision-making over any policy or procedure, depending upon the situation at any time, and that creates a huge variation."

Striving for accountability
Although checklists play a crucial part in reducing CR-BSIs, they are ineffective without additional components. A big part of the package is ensuring the checklist is followed, which means everyone in the hospital must be held accountable.

"Checklists are not Harry Potter's wand," Pronovost says. "Just like guidelines don't work, to think you're going to hand a clinician a checklist and that solves all your problems is naïve."

There are three critical components to implementation: Summarizing what to do in an unambiguous way, gathering valid measurement and feedback, and creating a culture of teamwork in which other clinicians feel comfortable questioning physicians, Pronovost says.

"That third one has proved to be so elusive and difficult, and really, without it, these things don't work," Pronovost says.

The medical field has historically followed a strict hierarchy of power, with physicians perched at the top. But part of implementing the ICU checklists involves giving nurses the authority to speak up when they see a mistake.

"People don't like to tell someone they forgot something or made a mistake," Rupp says. "So that was a huge cultural barrier we had to overcome, and we made strides."

Click here to read more about the survey that found fewer than 10% of healthcare professionals would directly confront colleagues about their concerns.

Another key feature of the checklist is that it not only tracks infection rates, but presents evidence in a way that is easy to understand and trace back to specific behaviors.

"We asked Michigan docs, 'Why did you buy into this?' " Pronovost says. "They said, 'You were evidence-based in what you asked us to do and you had valid credible data for what we believed in.' So you can't have a lot of missing data that's noisy, because docs will push back, [and] rightfully so."

A 21st-century polio campaign
This leads to the question: If it's so easy, why isn't every hospital in the country adopting hospitalwide checklists? If it were a drug or a device, everyone would have jumped on board by now, Pronovost says.

"We've had a market failure here, and I think the reason why we have that is these deaths are invisible," Pronovost says. "[In] most states, you don't measure your infections, [in] most hospitals you can't go in and look at what they are, and because of that, they are kind of chalked up as inevitable; they are the cost of doing business. We know they are not, but that's how it is perceived, and there is no standard way of reporting."

Pronovost is trying to change that perception. After the success in Michigan, the Agency for Healthcare Research and Quality (AHRQ) selected 28 state hospital associations to implement the evidence-based checklist. The AHRQ has allocated $10 million during the 2009 fiscal year to fund initiatives in 10 states over three years. Roughly $10 million in grants from the Jewish Community Endowment Fund and the Sandler Foundation, given to the Johns Hopkins Quality & Safety Research Group and the MHA Keystone Center, will be used to fund the program in the other 18 states.

"Our goal, or the vision that I have, is that this is the polio campaign of the 21st century," says Pronovost. "There are a lot of ills that befall the U.S. healthcare system, and these infections are but one of them, but they are probably the one where the science of how to measure and how to improve is most mature. We don't have any global success stories in healthcare quality. We've been talking about it for 10 years, but what we have to show for it is frankly pathetic. And I think this is the polio story, that not only will save lives, but we will learn how to work together."

Click here to read about UNICEF and other group's ongoing efforts to eradicate polio around the world.

The checklist
The following steps are the major points of the central line insertion checklist created by Peter Pronovost, MD, PhD, FFCM, medical director at the Center for Innovation in Quality Patient Care at Johns Hopkins Medical Center in Baltimore.

Each checkpoint is derived from evidence-based practices recommended by the CDC. Although these steps might seem like no-brainers to a medical professional, Pronovost found that without the reminder, physicians skip at least one of the steps in more than one-third of patients.

  1. Wash hands prior to insertion. The accompanying nurse is required to directly observe this procedure or, if this step isn't observed, to confirm that the physician performed the procedure.
  2. Clean patient's skin with chlorhexidine antiseptic.
  3. Place sterile drapes over the entire patient.
  4. Wear a sterile mask, hat, gown, and gloves. This is important to ensure that sterility is not broken at any point during the procedure.
  5. Put a sterile dressing over the catheter.

1. Institute for Healthcare Improvement. 2009. "Intensive care: Changes." Retrieved June 17, 2009 from
2. VitalSmarts. 2005. "New study finds U.S. hospitals must improve workplace communication to reduce medical errors, enhance quality of care." Retrieved June 17, 2009 from
3. UNICEF. 2009 "Eradicating polio." Retrieved June 17, 2009 from

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