ABELLO: A checklist for salvation



Oscar Abello

A gurney flies – not rolls but flies – through a massive set of double doors with a highly trained and intensely focused entourage floating around it like angels with white lab-coat wings over green hospital scrubs. Their angelic yet coldly precise hands direct a cast of tools like a perfectly choreographed performance.

Intravenous lines, nasal tubes, syringes and heart and breathing monitors do their dance and sing their song until the sole member of the audience has their vital signs stabilized, or dies. There is no room for mediocrity here.

Ninety-thousand times a day and five million times a year, this performance is repeated by modern-day intensive care units in hospitals across the United States, according to a December 2007 article in The New Yorker.

ICU patients require on average 178 individual daily actions, from inserting intravenous lines to suctioning lungs to administering drugs. A decade ago, a study by Israeli scientists observed that nurses and doctors made errors in only 1 percent of these actions.

Of course, that still amounts to an average of two errors per day per patient.

Intravenous line infections are so commonplace that ICUs consider them routine errors. ICU doctors and nurses insert five million intravenous lines each year, an estimated 80,000 of which become infected, according to the New Yorker article. They are not usually fatal, but when they happen, that patient typically spends an extra week in the ICU.

An extra week is an extra 178 daily tasks, extra medications as needed and less hospital space in a nation with chronically overcrowded and understaffed hospitals. And that’s only considering IV infections.

Sticking with line infections, Peter Pronovost, critical-care specialist at Johns Hopkins University Hospital in Baltimore, Md., created a modest experiment in 2001. It began with a simple checklist for avoiding line infections – only five steps and nothing beyond basic, but observing nurses found that doctors skipped one or more steps for roughly a third of patients.

The revolutionary part: for the second phase of the study, nurses were given authority to stop doctors from inserting lines if they did not follow the checklist. Typically, hospital culture dictates that nurses avoid or find difficulty in helping doctors remember their basic training. The checklist system changed that culture, with startling success.

In the next 15 months, only two line infections occurred. Hospital administrators estimated that the nurses’ new authority prevented 43 infections, eight deaths and saved over $2 million for Johns Hopkins University Hospital alone.

In 2003, the near-bankrupt Michigan Health and Hospital Association decided to give Pronovost’s checklist system – expanded to procedures besides line infections – a chance to save it from collapse.

In December of 2006, The New England Journal of Medicine published that over its first 18 months, the checklists saved the state of Michigan $175 million and saved over 1,500 lives.

Given health care’s prominence in the ongoing U.S. presidential election cycle, it is regrettable that politicians have resigned themselves to plans emphasizing insurance industry reform rather than focusing on making hospitals more cost-effective through innovations like Pronovost’s checklist system.

The crucial innovation is merely cultural – giving nurses power equivalent to their training in order to hold doctors accountable in the hospital setting. Such a change is not simple, but the savings it creates far exceed the costs.

Pronovost told The New Yorker that it would take roughly $2 million and two years to institute a national checklist system in the United States and next-to-nothing to maintain.

It is manna from heaven.

Beneath the radar of mainstream media, hospitals are adapting the checklists for their own needs around the country and even across the Atlantic Ocean, where Spain has requested consultation to institute the checklists in its hospitals.

Even if other proposed health care plans succeed in providing coverage for all Americans, those band-aids will not heal anything. Pronovost’s checklist system allows hospitals themselves to respond to the actual problem: rising health care costs.

That problem will take more than checklists to resolve, but it is time politicians stopped dancing around the elephant in the room.


Oscar Abello is a senior economics major from Philadelphia, Pa. He can be reached at [email protected]