As Easy as 1-2-3?

Checklists can reduce infections dramatically. The trick is getting doctors and nurses to use them.

By JACOB GOLDSTEIN

It seemed like a no-brainer innovation: a low-tech way to cut down on a sometimes deadly infection that strikes roughly 80,000 intensive-care patients in the U.S. every year.

Michigan hospitals dramatically lowered rates of bloodstream infections in their patients by following a five-step checklist, according to a study published in the New England Journal of Medicine. But nearly three years after the study appeared, meaningful use of the checklist remains limited.

The list prescribed steps doctors and nurses in the intensive-care unit should take when performing a common procedure—inserting a catheter into a vein just outside the patient's heart, to allow easy delivery of intravenous drugs and fluids.

The steps are simple: washing hands; cleaning the patient's skin with a disinfectant called chlorhexidine; wearing a cap and gown and using a surgical drape during the procedure; inserting the catheter through parts of the body other than the groin, when possible; and removing unnecessary catheters.

The Michigan study, which included more than 100 ICUs, found that putting the checklist in place lowered the rate of bloodstream infections related to catheter use by 66%.

But putting the checklist into practice is more complicated than it sounds.

The Wall Street Journal spoke with Peter Pronovost, the Johns Hopkins intensive-care specialist and patient-safety expert who led the study. Here are edited excerpts:

Culture Clash

THE WALL STREET JOURNAL: What were the main findings of the Michigan study?

DR. PRONOVOST: Prior to this, there was some uncertainty about how many of these infections were preventable versus inevitable. What this study showed was nearly all of them are preventable with some very practical and inexpensive interventions. But it's not necessarily simple, because it's not just the checklist, it's the culture piece.

WSJ: What do you mean by culture?

DR. PRONOVOST: Can we get the nurses to ensure that the doctors actually follow the items on the checklist? When I said that, you would have thought I was causing World War III. That's where the culture came into it.

The nurses said, "That's not my job to police the doctor, and if I do I'm going to get my head bit off." And the doctors said, "There is no way I can have a nurse second-guess me in public. It will make me look like I don't know something."

But nobody was debating the evidence. What they were debating was power and politics and hierarchy.

I pulled everyone together and said, "Would you harm patients?" Everyone said no. Then I said, "Well, how is it possible that you as a nurse would see someone not washing their hands and keep silent? You know they're increasing the risk of being harmed; we need you to speak up."

So then we say to the docs, "If the nurses say these things, they need to know that they're not going to get their head bit off."

When it was presented as a patient area rather than power or hierarchy, conflict melted away.

The Measurement Gap

WSJ: How widely has the checklist spread?

DR. PRONOVOST: Earlier this year, Congressman [Henry] Waxman held a hearing. He surveyed all 50 states and asked them if they were using the checklist.

All of the states said, "Oh yes, we're using the checklist." But only 11 said they were actually measuring infection rates, which is key. It's kind of like Lake Wobegon—everybody's above average, until you measure.

This has been frustrating. Imagine there was a disease that killed between 30,000 and 60,000 per year and researchers at Johns Hopkins found a way to eliminate it.

If that therapy was a drug or a device it would spread throughout the world rapidly. The private marketplace would produce it, its quality would go up, its cost would go down, and everybody in the country would be exposed to it.

WSJ: Why aren't the benefits more widespread?

DR. PRONOVOST: If it was as simple as handing someone a piece of paper that says "Here's a checklist, I've solved your problem," that would be easy. This was a complex intervention. It's feasible, but it takes some effort. It takes commitment to monitor these infections. It takes commitment to do this hard work of culture change.

Right now, these deaths are invisible. If every hospital had to publicly report their rates of infection, I guarantee you this problem would be solved.

Make Your Own Checklist

WSJ: Are there other areas of health care that would benefit from checklists?

DR. PRONOVOST: We're doing this for care of patients with pneumonia. We're doing it for how to diagnose various conditions. We're using it for preventing deep venous thrombosis.

We're using it in the operating room for timeouts before you start the procedure to ensure that all the correct things are done. But if I go one checklist at a time, I'm going to be long dead before I get anywhere. So I'm trying to build a checklist maker.

— Mr. Goldstein is a staff reporter for The Wall Street Journal in New York. He can be reached at jacob.goldstein@wsj.com