Friday, December 21, 2007

Annals of Medicine - The Checklist

Annals of Medicine
The Checklist
If something so simple can transform intensive care, what else can it do?
by Atul Gawande December 10, 2007

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If a new drug were as effective at saving lives as Peter Pronovost's
checklist, there would be a nationwide marketing campaign urging
doctors to use it.

If a new drug were as effective at saving lives as Peter Pronovost's
checklist, there would be a nationwide marketing campaign urging
doctors to use it.

Intensive-Care Units (I.C.U.s);
Pronovost, Peter;
Johns Hopkins Hospital;
Sinai-Grace Hospital

The damage that the human body can survive these days is as awesome as
it is horrible: crushing, burning, bombing, a burst blood vessel in
the brain, a ruptured colon, a massive heart attack, rampaging
infection. These conditions had once been uniformly fatal. Now
survival is commonplace, and a large part of the credit goes to the
irreplaceable component of medicine known as intensive care.

It's an opaque term. Specialists in the field prefer to call what they
do "critical care," but that doesn't exactly clarify matters. The
non-medical term "life support" gets us closer. Intensive-care units
take artificial control of failing bodies. Typically, this involves a
panoply of technology—a mechanical ventilator and perhaps a
tracheostomy tube if the lungs have failed, an aortic balloon pump if
the heart has given out, a dialysis machine if the kidneys don't work.
When you are unconscious and can't eat, silicone tubing can be
surgically inserted into the stomach or intestines for formula
feeding. If the intestines are too damaged, solutions of amino acids,
fatty acids, and glucose can be infused directly into the bloodstream.

The difficulties of life support are considerable. Reviving a drowning
victim, for example, is rarely as easy as it looks on television,
where a few chest compressions and some mouth-to-mouth resuscitation
always seem to bring someone with waterlogged lungs and a stilled
heart coughing and sputtering back to life. Consider a case report in
The Annals of Thoracic Surgery of a three-year-old girl who fell into
an icy fishpond in a small Austrian town in the Alps. She was lost
beneath the surface for thirty minutes before her parents found her on
the pond bottom and pulled her up. Following instructions from an
emergency physician on the phone, they began cardiopulmonary
resuscitation. A rescue team arrived eight minutes later. The girl had
a body temperature of sixty-six degrees, and no pulse. Her pupils were
dilated and did not react to light, indicating that her brain was no
longer working.

But the emergency technicians continued CPR anyway. A helicopter took
her to a nearby hospital, where she was wheeled directly to an
operating room. A surgical team put her on a heart-lung bypass
machine. Between the transport time and the time it took to plug the
inflow and outflow lines into the femoral vessels of her right leg,
she had been lifeless for an hour and a half. By the two-hour mark,
however, her body temperature had risen almost ten degrees, and her
heart began to beat. It was her first organ to come back.

After six hours, her core temperature reached 98.6 degrees. The team
tried to put her on a breathing machine, but the pond water had
damaged her lungs too severely for oxygen to reach her blood. So they
switched her to an artificial-lung system known as ECMO—extracorporeal
membrane oxygenation. The surgeons opened her chest down the middle
with a power saw and sewed lines to and from the ECMO unit into her
aorta and her beating heart. The team moved the girl into intensive
care, with her chest still open and covered with plastic foil. A day
later, her lungs had recovered sufficiently for the team to switch her
from ECMO to a mechanical ventilator and close her chest. Over the
next two days, all her organs recovered except her brain. A CT scan
showed global brain swelling, which is a sign of diffuse damage, but
no actual dead zones. So the team drilled a hole into the girl's
skull, threaded in a probe to monitor her cerebral pressure, and kept
that pressure tightly controlled by constantly adjusting her fluids
and medications. For more than a week, she lay comatose. Then, slowly,
she came back to life.

First, her pupils started to react to light. Next, she began to
breathe on her own. And, one day, she simply awoke. Two weeks after
her accident, she went home. Her right leg and left arm were partially
paralyzed. Her speech was thick and slurry. But by age five, after
extensive outpatient therapy, she had recovered her faculties
completely. She was like any little girl again.

What makes her recovery astounding isn't just the idea that someone
could come back from two hours in a state that would once have been
considered death. It's also the idea that a group of people in an
ordinary hospital could do something so enormously complex. To save
this one child, scores of people had to carry out thousands of steps
correctly: placing the heart-pump tubing into her without letting in
air bubbles; maintaining the sterility of her lines, her open chest,
the burr hole in her skull; keeping a temperamental battery of
machines up and running. The degree of difficulty in any one of these
steps is substantial. Then you must add the difficulties of
orchestrating them in the right sequence, with nothing dropped,
leaving some room for improvisation, but not too much.

For every drowned and pulseless child rescued by intensive care, there
are many more who don't make it—and not just because their bodies are
too far gone. Machines break down; a team can't get moving fast
enough; a simple step is forgotten. Such cases don't get written up in
The Annals of Thoracic Surgery, but they are the norm. Intensive-care
medicine has become the art of managing extreme complexity—and a test
of whether such complexity can, in fact, be humanly mastered.

On any given day in the United States, some ninety thousand people are
in intensive care. Over a year, an estimated five million Americans
will be, and over a normal lifetime nearly all of us will come to know
the glassed bay of an I.C.U. from the inside. Wide swaths of medicine
now depend on the lifesupport systems that I.C.U.s provide: care for
premature infants; victims of trauma, strokes, and heart attacks;
patients who have had surgery on their brain, heart, lungs, or major
blood vessels. Critical care has become an increasingly large portion
of what hospitals do. Fifty years ago, I.C.U.s barely existed. Today,
in my hospital, a hundred and fifty-five of our almost seven hundred
patients are, as I write this, in intensive care. The average stay of
an I.C.U. patient is four days, and the survival rate is eighty-six
per cent. Going into an I.C.U., being put on a mechanical ventilator,
having tubes and wires run into and out of you, is not a sentence of
death. But the days will be the most precarious of your life.

A decade ago, Israeli scientists published a study in which engineers
observed patient care in I.C.U.s for twenty-four-hour stretches. They
found that the average patient required a hundred and seventy-eight
individual actions per day, ranging from administering a drug to
suctioning the lungs, and every one of them posed risks. Remarkably,
the nurses and doctors were observed to make an error in just one per
cent of these actions—but that still amounted to an average of two
errors a day with every patient. Intensive care succeeds only when we
hold the odds of doing harm low enough for the odds of doing good to
prevail. This is hard. There are dangers simply in lying unconscious
in bed for a few days. Muscles atrophy. Bones lose mass. Pressure
ulcers form. Veins begin to clot off. You have to stretch and exercise
patients' flaccid limbs daily to avoid contractures, give subcutaneous
injections of blood thinners at least twice a day, turn patients in
bed every few hours, bathe them and change their sheets without
knocking out a tube or a line, brush their teeth twice a day to avoid
pneumonia from bacterial buildup in their mouths. Add a ventilator,
dialysis, and open wounds to care for, and the difficulties only

The story of one of my patients makes the point. Anthony DeFilippo was
a forty-eight-year-old limousine driver from Everett, Massachusetts,
who started to hemorrhage at a community hospital during surgery for a
hernia and gallstones. The bleeding was finally stopped but his liver
was severely damaged, and over the next few days he became too sick
for the hospital's facilities. When he arrived in our I.C.U., at 1:30
A.M. on a Sunday, his ragged black hair was plastered to his sweaty
forehead, his body was shaking, and his heart was racing at a hundred
and fourteen beats a minute. He was delirious from fever, shock, and
low oxygen levels.

"I need to get out!" he cried. "I need to get out!" He clawed at his
gown, his oxygen mask, the dressings covering his abdominal wound.

"Tony, it's all right," a nurse said to him. "We're going to help you.
You're in a hospital."

He shoved her—he was a big man—and tried to swing his legs out of the
bed. We turned up his oxygen flow, put his wrists in cloth restraints,
and tried to reason with him. He eventually let us draw blood from him
and give him antibiotics.

The laboratory results came back showing liver failure, and a wildly
elevated white-blood-cell count indicating infection. It soon became
evident from his empty urine bag that his kidneys had failed, too. In
the next few hours, his blood pressure fell, his breathing worsened,
and he drifted from agitation to near-unconsciousness. Each of his
organ systems, including his brain, was shutting down.

I called his sister, who was his next of kin, and told her of the
situation. "Do everything you can," she said.

So we did. We gave him a syringeful of anesthetic, and a resident slid
a breathing tube into his throat. Another resident "lined him up." She
inserted a thin, two-inch-long needle and catheter through his
upturned right wrist and into his radial artery, and then sewed the
line to his skin with a silk suture. Next, she put in a central line—a
twelve-inch catheter pushed into the jugular vein in his left neck.
After she sewed that in place, and an X-ray showed its tip floating
just where it was supposed to—inside his vena cava at the entrance to
his heart—she put a third, slightly thicker line, for dialysis,
through his right upper chest and into the subclavian vein, deep under
the collarbone.

We hooked a breathing tube up to a hose from a ventilator and set it
to give him fourteen forced breaths of a hundred-per-cent oxygen every
minute. We dialled the ventilator pressures and gas flow up and down,
like engineers at a control panel, until we got the blood levels of
oxygen and carbon dioxide where we wanted them. The arterial line gave
us continuous arterial blood-pressure measurements, and we tweaked his
medications to get the pressures we liked. We regulated his
intravenous fluids according to venous-pressure measurements from his
jugular line. We plugged his subclavian line into tubing from a
dialysis machine, and every few minutes his entire blood volume washed
through this artificial kidney and back into his body; a little
adjustment here and there, and we could alter the levels of potassium
and bicarbonate and salt in his body as well. He was, we liked to
imagine, a simple machine in our hands.

But he wasn't, of course. It was as if we had gained a steering wheel
and a few gauges and controls, but on a runaway eighteen-wheeler
hurtling down a mountain. Keeping his blood pressure normal was
requiring gallons of intravenous fluid and a pharmacy shelf of drugs.
He was on near-maximal ventilator support. His temperature climbed to
a hundred and four degrees. Less than five per cent of patients with
his degree of organ failure make it home. And a single misstep could
easily erase those slender chances.

For ten days, though, all went well. His chief problem had been liver
damage from the operation he'd had. The main duct from his liver was
severed and was leaking bile, which is caustic—it digests the fat in
one's diet and was essentially eating him alive from the inside. He
had become too sick to survive an operation to repair the leak. So we
tried a temporary solution—we had radiologists place a plastic drain,
using X-ray guidance, through his abdominal wall and into the severed
duct in order to draw the leaking bile out of him. They found so much
that they had to place three drains—one inside the duct and two around
it. But, as the bile drained out, his fevers subsided. His
requirements for oxygen and fluids diminished. His blood pressure
returned to normal. He was on the mend. Then, on the eleventh day,
just as we were getting ready to take him off the mechanical
ventilator, he developed high, spiking fevers, his blood pressure
sank, and his blood-oxygen levels plummeted again. His skin became
clammy. He got shaking chills.

We didn't understand what had happened. He seemed to have developed an
infection, but our X-rays and CT scans failed to turn up a source.
Even after we put him on four antibiotics, he continued to spike
fevers. During one fever, his heart went into fibrillation. A Code
Blue was called. A dozen nurses and doctors raced to his bedside,
slapped electric paddles onto his chest, and shocked him. His heart
responded, fortunately, and went back into rhythm. It took two more
days for us to figure out what had gone wrong. We considered the
possibility that one of his lines had become infected, so we put in
new lines and sent the old ones to the lab for culturing. Forty-eight
hours later, the results returned: all of them were infected. The
infection had probably started in one line, perhaps contaminated
during insertion, and spread through his bloodstream to the others.
Then they all began spilling bacteria into him, producing his fevers
and steep decline.

This is the reality of intensive care: at any point, we are as apt to
harm as we are to heal. Line infections are so common that they are
considered a routine complication. I.C.U.s put five million lines into
patients each year, and national statistics show that, after ten days,
four per cent of those lines become infected. Line infections occur in
eighty thousand people a year in the United States, and are fatal
between five and twenty-eight per cent of the time, depending on how
sick one is at the start. Those who survive line infections spend on
average a week longer in intensive care. And this is just one of many
risks. After ten days with a urinary catheter, four per cent of
American I.C.U. patients develop a bladder infection. After ten days
on a ventilator, six per cent develop bacterial pneumonia, resulting
in death forty to fifty-five per cent of the time. All in all, about
half of I.C.U. patients end up experiencing a serious complication,
and, once a complication occurs, the chances of survival drop sharply.

It was a week before DeFilippo recovered sufficiently from his
infections to come off the ventilator, and it was two months before he
left the hospital. Weak and debilitated, he lost his limousine
business and his home, and he had to move in with his sister. The tube
draining bile still dangled from his abdomen; when he was stronger, I
was going to have to do surgery to reconstruct the main bile duct from
his liver. But he survived. Most people in his situation do not.

Here, then, is the puzzle of I.C.U. care: you have a desperately sick
patient, and in order to have a chance of saving him you have to make
sure that a hundred and seventy-eight daily tasks are done
right—despite some monitor's alarm going off for God knows what
reason, despite the patient in the next bed crashing, despite a nurse
poking his head around the curtain to ask whether someone could help
"get this lady's chest open." So how do you actually manage all this
complexity? The solution that the medical profession has favored is

I tell DeFilippo's story, for instance, as if I were the one tending
to him hour by hour. But that was actually Max Weinmann, an
intensivist (as intensive-care specialists like to be called). I want
to think that, as a general surgeon, I can handle most clinical
situations. But, as the intricacies involved in intensive care have
mounted, responsibility has increasingly shifted to super-specialists
like him. In the past decade, training programs focussed on critical
care have opened in every major American city, and half of I.C.U.s now
rely on super-specialists.

Expertise is the mantra of modern medicine. In the early twentieth
century, you needed only a high-school diploma and a one-year medical
degree to practice medicine. By the century's end, all doctors had to
have a college degree, a four-year medical degree, and an additional
three to seven years of residency training in an individual field of
practice—pediatrics, surgery, neurology, or the like. Already, though,
this level of preparation has seemed inadequate to the new complexity
of medicine. After their residencies, most young doctors today are
going on to do fellowships, adding one to three further years of
training in, say, laparoscopic surgery, or pediatric metabolic
disorders, or breast radiology—or critical care. A young doctor is not
so young nowadays; you typically don't start in independent practice
until your mid-thirties.

We now live in the era of the super-specialist—of clinicians who have
taken the time to practice at one narrow thing until they can do it
better than anyone who hasn't. Super-specialists have two advantages
over ordinary specialists: greater knowledge of the details that
matter and an ability to handle the complexities of the job. There are
degrees of complexity, though, and intensive-care medicine has grown
so far beyond ordinary complexity that avoiding daily mistakes is
proving impossible even for our super-specialists. The I.C.U., with
its spectacular successes and frequent failures, therefore poses a
distinctive challenge: what do you do when expertise is not enough?

On October 30, 1935, at Wright Air Field in Dayton, Ohio, the U.S.
Army Air Corps held a flight competition for airplane manufacturers
vying to build its next-generation long-range bomber. It wasn't
supposed to be much of a competition. In early evaluations, the Boeing
Corporation's gleaming aluminum-alloy Model 299 had trounced the
designs of Martin and Douglas. Boeing's plane could carry five times
as many bombs as the Army had requested; it could fly faster than
previous bombers, and almost twice as far. A Seattle newspaperman who
had glimpsed the plane called it the "flying fortress," and the name
stuck. The flight "competition," according to the military historian
Phillip Meilinger, was regarded as a mere formality. The Army planned
to order at least sixty-five of the aircraft.

A small crowd of Army brass and manufacturing executives watched as
the Model 299 test plane taxied onto the runway. It was sleek and
impressive, with a hundred-and-three-foot wingspan and four engines
jutting out from the wings, rather than the usual two. The plane
roared down the tarmac, lifted off smoothly, and climbed sharply to
three hundred feet. Then it stalled, turned on one wing, and crashed
in a fiery explosion. Two of the five crew members died, including the
pilot, Major Ployer P. Hill.

An investigation revealed that nothing mechanical had gone wrong. The
crash had been due to "pilot error," the report said. Substantially
more complex than previous aircraft, the new plane required the pilot
to attend to the four engines, a retractable landing gear, new wing
flaps, electric trim tabs that needed adjustment to maintain control
at different airspeeds, and constant-speed propellers whose pitch had
to be regulated with hydraulic controls, among other features. While
doing all this, Hill had forgotten to release a new locking mechanism
on the elevator and rudder controls. The Boeing model was deemed, as a
newspaper put it, "too much airplane for one man to fly." The Army Air
Corps declared Douglas's smaller design the winner. Boeing nearly went

Still, the Army purchased a few aircraft from Boeing as test planes,
and some insiders remained convinced that the aircraft was flyable. So
a group of test pilots got together and considered what to do.

They could have required Model 299 pilots to undergo more training.
But it was hard to imagine having more experience and expertise than
Major Hill, who had been the U.S. Army Air Corps' chief of flight
testing. Instead, they came up with an ingeniously simple approach:
they created a pilot's checklist, with step-by-step checks for
takeoff, flight, landing, and taxiing. Its mere existence indicated
how far aeronautics had advanced. In the early years of flight,
getting an aircraft into the air might have been nerve-racking, but it
was hardly complex. Using a checklist for takeoff would no more have
occurred to a pilot than to a driver backing a car out of the garage.
But this new plane was too complicated to be left to the memory of any
pilot, however expert.

With the checklist in hand, the pilots went on to fly the Model 299 a
total of 1.8 million miles without one accident. The Army ultimately
ordered almost thirteen thousand of the aircraft, which it dubbed the
B-17. And, because flying the behemoth was now possible, the Army
gained a decisive air advantage in the Second World War which enabled
its devastating bombing campaign across Nazi Germany.

Medicine today has entered its B-17 phase. Substantial parts of what
hospitals do—most notably, intensive care—are now too complex for
clinicians to carry them out reliably from memory alone. I.C.U. life
support has become too much medicine for one person to fly.

Yet it's far from obvious that something as simple as a checklist
could be of much help in medical care. Sick people are phenomenally
more various than airplanes. A study of forty-one thousand trauma
patients—just trauma patients—found that they had 1,224 different
injury-related diagnoses in 32,261 unique combinations for teams to
attend to. That's like having 32,261 kinds of airplane to land.
Mapping out the proper steps for each is not possible, and physicians
have been skeptical that a piece of paper with a bunch of little boxes
would improve matters much.

In 2001, though, a critical-care specialist at Johns Hopkins Hospital
named Peter Pronovost decided to give it a try. He didn't attempt to
make the checklist cover everything; he designed it to tackle just one
problem, the one that nearly killed Anthony DeFilippo: line
infections. On a sheet of plain paper, he plotted out the steps to
take in order to avoid infections when putting a line in. Doctors are
supposed to (1) wash their hands with soap, (2) clean the patient's
skin with chlorhexidine antiseptic, (3) put sterile drapes over the
entire patient, (4) wear a sterile mask, hat, gown, and gloves, and
(5) put a sterile dressing over the catheter site once the line is in.
Check, check, check, check, check. These steps are no-brainers; they
have been known and taught for years. So it seemed silly to make a
checklist just for them. Still, Pronovost asked the nurses in his
I.C.U. to observe the doctors for a month as they put lines into
patients, and record how often they completed each step. In more than
a third of patients, they skipped at least one.

The next month, he and his team persuaded the hospital administration
to authorize nurses to stop doctors if they saw them skipping a step
on the checklist; nurses were also to ask them each day whether any
lines ought to be removed, so as not to leave them in longer than
necessary. This was revolutionary. Nurses have always had their ways
of nudging a doctor into doing the right thing, ranging from the
gentle reminder ("Um, did you forget to put on your mask, doctor?") to
more forceful methods (I've had a nurse bodycheck me when she thought
I hadn't put enough drapes on a patient). But many nurses aren't sure
whether this is their place, or whether a given step is worth a
confrontation. (Does it really matter whether a patient's legs are
draped for a line going into the chest?) The new rule made it clear:
if doctors didn't follow every step on the checklist, the nurses would
have backup from the administration to intervene.

Pronovost and his colleagues monitored what happened for a year
afterward. The results were so dramatic that they weren't sure whether
to believe them: the ten-day line-infection rate went from eleven per
cent to zero. So they followed patients for fifteen more months. Only
two line infections occurred during the entire period. They calculated
that, in this one hospital, the checklist had prevented forty-three
infections and eight deaths, and saved two million dollars in costs.

Pronovost recruited some more colleagues, and they made some more
checklists. One aimed to insure that nurses observe patients for pain
at least once every four hours and provide timely pain medication.
This reduced the likelihood of a patient's experiencing untreated pain
from forty-one per cent to three per cent. They tested a checklist for
patients on mechanical ventilation, making sure that, for instance,
the head of each patient's bed was propped up at least thirty degrees
so that oral secretions couldn't go into the windpipe, and antacid
medication was given to prevent stomach ulcers. The proportion of
patients who didn't receive the recommended care dropped from seventy
per cent to four per cent; the occurrence of pneumonias fell by a
quarter; and twenty-one fewer patients died than in the previous year.
The researchers found that simply having the doctors and nurses in the
I.C.U. make their own checklists for what they thought should be done
each day improved the consistency of care to the point that, within a
few weeks, the average length of patient stay in intensive care
dropped by half.

The checklists provided two main benefits, Pronovost observed. First,
they helped with memory recall, especially with mundane matters that
are easily overlooked in patients undergoing more drastic events.
(When you're worrying about what treatment to give a woman who won't
stop seizing, it's hard to remember to make sure that the head of her
bed is in the right position.) A second effect was to make explicit
the minimum, expected steps in complex processes. Pronovost was
surprised to discover how often even experienced personnel failed to
grasp the importance of certain precautions. In a survey of I.C.U.
staff taken before introducing the ventilator checklists, he found
that half hadn't realized that there was evidence strongly supporting
giving ventilated patients antacid medication. Checklists established
a higher standard of baseline performance.

These are, of course, ridiculously primitive insights. Pronovost is
routinely described by colleagues as "brilliant," "inspiring," a
"genius." He has an M.D. and a Ph.D. in public health from Johns
Hopkins, and is trained in emergency medicine, anesthesiology, and
critical-care medicine. But, really, does it take all that to figure
out what house movers, wedding planners, and tax accountants figured
out ages ago?

Pronovost is hardly the first person in medicine to use a checklist.
But he is among the first to recognize its power to save lives and
take advantage of the breadth of its possibilities. Forty-two years
old, with cropped light-brown hair, tenth-grader looks, and a
fluttering, finchlike energy, he is an odd mixture of the nerdy and
the messianic. He grew up in Waterbury, Connecticut, the son of an
elementary-school teacher and a math professor, went to nearby
Fairfield University, and, like many good students, decided that he
would go into medicine. Unlike many students, though, he found that he
actually liked caring for sick people. He hated the laboratory—with
all those micropipettes and cell cultures, and no patients around—but
he had that scientific "How can I solve this unsolved problem?" turn
of mind. So after his residency in anesthesiology and his fellowship
in critical care, he studied clinical-research methods.

For his doctoral thesis, he examined intensive-care units in Maryland,
and he discovered that putting an intensivist on staff reduced death
rates by a third. It was the first time that someone had demonstrated
the public-health value of using intensivists. He wasn't satisfied
with having proved his case, though; he wanted hospitals to change
accordingly. After his study was published, in 1999, he met with a
coalition of large employers known as the Leapfrog Group. It included
companies like General Motors and Verizon, which were seeking to
improve the standards of hospitals where their employees obtain care.
Within weeks, the coalition announced that its members expected the
hospitals they contracted with to staff their I.C.U.s with
intensivists. These employers pay for health care for thirty-seven
million employees, retirees, and dependents nationwide. So although
hospitals protested that there weren't enough intensivists to go
around, and that the cost could be prohibitive, Pronovost's idea
effectively became an instant national standard.

The scientist in him has always made room for the campaigner. People
say he is the kind of guy who, even as a trainee, could make you feel
you'd saved the world every time you washed your hands properly. "I've
never seen anybody inspire as he does," Marty Makary, a Johns Hopkins
surgeon, told me. "Partly, he has this contagious, excitable nature.
He has a smile that's tough to match. But he also has a way of making
people feel heard. People will come to him with the dumbest ideas, and
he'll endorse them anyway. `Oh, I like that, I like that, I like
that!' he'll say. I've watched him, and I still have no idea how
deliberate this is. Maybe he really does like every idea. But wait,
and you realize: he only acts on the ones he truly believes in."

After the checklist results, the idea Pronovost truly believed in was
that checklists could save enormous numbers of lives. He took his
findings on the road, showing his checklists to doctors, nurses,
insurers, employers—anyone who would listen. He spoke in an average of
seven cities a month while continuing to work full time in Johns
Hopkins's I.C.U.s. But this time he found few takers.

There were various reasons. Some physicians were offended by the
suggestion that they needed checklists. Others had legitimate doubts
about Pronovost's evidence. So far, he'd shown only that checklists
worked in one hospital, Johns Hopkins, where the I.C.U.s have money,
plenty of staff, and Peter Pronovost walking the hallways to make sure
that the checklists are being used properly. How about in the real
world—where I.C.U. nurses and doctors are in short supply, pressed for
time, overwhelmed with patients, and hardly receptive to the idea of
filling out yet another piece of paper?

In 2003, however, the Michigan Health and Hospital Association asked
Pronovost to try out three of his checklists in Michigan's I.C.U.s. It
would be a huge undertaking. Not only would he have to get the state's
hospitals to use the checklists; he would also have to measure whether
doing so made a genuine difference. But at last Pronovost had a chance
to establish whether his checklist idea really worked.

This past summer, I visited Sinai-Grace Hospital, in inner-city
Detroit, and saw what Pronovost was up against. Occupying a campus of
red brick buildings amid abandoned houses, check-cashing stores, and
wig shops on the city's West Side, just south of 8 Mile Road,
Sinai-Grace is a classic urban hospital. It has eight hundred
physicians, seven hundred nurses, and two thousand other medical
personnel to care for a population with the lowest median income of
any city in the country. More than a quarter of a million residents
are uninsured; three hundred thousand are on state assistance. That
has meant chronic financial problems. Sinai-Grace is not the most
cash-strapped hospital in the city—that would be Detroit Receiving
Hospital, where a fifth of the patients have no means of payment. But
between 2000 and 2003 Sinai-Grace and eight other Detroit hospitals
were forced to cut a third of their staff, and the state had to come
forward with a fifty-million-dollar bailout to avert their bankruptcy.

Sinai-Grace has five I.C.U.s for adult patients and one for infants.
Hassan Makki, the director of intensive care, told me what it was like
there in 2004, when Pronovost and the hospital association started a
series of mailings and conference calls with hospitals to introduce
checklists for central lines and ventilator patients. "Morale was
low," he said. "We had lost lots of staff, and the nurses who remained
weren't sure if they were staying." Many doctors were thinking about
leaving, too. Meanwhile, the teams faced an even heavier workload
because of new rules limiting how long the residents could work at a
stretch. Now Pronovost was telling them to find the time to fill out
some daily checklists?

Tom Piskorowski, one of the I.C.U. physicians, told me his reaction:
"Forget the paperwork. Take care of the patient."

I accompanied a team on 7 A.M. rounds through one of the surgical
I.C.U.s. It had eleven patients. Four had gunshot wounds (one had been
shot in the chest; one had been shot through the bowel, kidney, and
liver; two had been shot through the neck, and left quadriplegic).
Five patients had cerebral hemorrhaging (three were seventy-nine years
and older and had been injured falling down stairs; one was a
middle-aged man whose skull and left temporal lobe had been damaged by
an assault with a blunt weapon; and one was a worker who had become
paralyzed from the neck down after falling twenty-five feet off a
ladder onto his head). There was a cancer patient recovering from
surgery to remove part of his lung, and a patient who had had surgery
to repair a cerebral aneurysm.

The doctors and nurses on rounds tried to proceed methodically from
one room to the next but were constantly interrupted: a patient they
thought they'd stabilized began hemorrhaging again; another who had
been taken off the ventilator developed trouble breathing and had to
be put back on the machine. It was hard to imagine that they could get
their heads far enough above the daily tide of disasters to worry
about the minutiae on some checklist.

Yet there they were, I discovered, filling out those pages. Mostly, it
was the nurses who kept things in order. Each morning, a senior nurse
walked through the unit, clipboard in hand, making sure that every
patient on a ventilator had the bed propped at the right angle, and
had been given the right medicines and the right tests. Whenever
doctors put in a central line, a nurse made sure that the central-line
checklist had been filled out and placed in the patient's chart.
Looking back through their files, I found that they had been doing
this faithfully for more than three years.

Pronovost had been canny when he started. In his first conversations
with hospital administrators, he didn't order them to use the
checklists. Instead, he asked them simply to gather data on their own
infection rates. In early 2004, they found, the infection rates for
I.C.U. patients in Michigan hospitals were higher than the national
average, and in some hospitals dramatically so. Sinai-Grace
experienced more line infections than seventy-five per cent of
American hospitals. Meanwhile, Blue Cross Blue Shield of Michigan
agreed to give hospitals small bonus payments for participating in
Pronovost's program. A checklist suddenly seemed an easy and logical
thing to try.

In what became known as the Keystone Initiative, each hospital
assigned a project manager to roll out the checklists and participate
in a twice-monthly conference call with Pronovost for
trouble-shooting. Pronovost also insisted that each participating
hospital assign to each unit a senior hospital executive, who would
visit the unit at least once a month, hear people's complaints, and
help them solve problems.

The executives were reluctant. They normally lived in meetings
worrying about strategy and budgets. They weren't used to venturing
into patient territory and didn't feel that they belonged there. In
some places, they encountered hostility. But their involvement proved
crucial. In the first month, according to Christine Goeschel, at the
time the Keystone Initiative's director, the executives discovered
that the chlorhexidine soap, shown to reduce line infections, was
available in fewer than a third of the I.C.U.s. This was a problem
only an executive could solve. Within weeks, every I.C.U. in Michigan
had a supply of the soap. Teams also complained to the hospital
officials that the checklist required that patients be fully covered
with a sterile drape when lines were being put in, but full-size
barrier drapes were often unavailable. So the officials made sure that
the drapes were stocked. Then they persuaded Arrow International, one
of the largest manufacturers of central lines, to produce a new
central-line kit that had both the drape and chlorhexidine in it.

In December, 2006, the Keystone Initiative published its findings in a
landmark article in The New England Journal of Medicine. Within the
first three months of the project, the infection rate in Michigan's
I.C.U.s decreased by sixty-six per cent. The typical I.C.U.—including
the ones at Sinai-Grace Hospital—cut its quarterly infection rate to
zero. Michigan's infection rates fell so low that its average I.C.U.
outperformed ninety per cent of I.C.U.s nationwide. In the Keystone
Initiative's first eighteen months, the hospitals saved an estimated
hundred and seventy-five million dollars in costs and more than
fifteen hundred lives. The successes have been sustained for almost
four years—all because of a stupid little checklist.

Pronovost's results have not been ignored. He has since had requests
to help Rhode Island, New Jersey, and the country of Spain do what
Michigan did. Back in the Wolverine State, he and the Keystone
Initiative have begun testing half a dozen additional checklists to
improve care for I.C.U. patients. He has also been asked to develop a
program for surgery patients. It has all become more than he and his
small group of researchers can keep up with.

But consider: there are hundreds, perhaps thousands, of things doctors
do that are at least as dangerous and prone to human failure as
putting central lines into I.C.U. patients. It's true of cardiac care,
stroke treatment, H.I.V. treatment, and surgery of all kinds. It's
also true of diagnosis, whether one is trying to identify cancer or
infection or a heart attack. All have steps that are worth putting on
a checklist and testing in routine care. The question—still
unanswered—is whether medical culture will embrace the opportunity.

Tom Wolfe's "The Right Stuff" tells the story of our first astronauts,
and charts the demise of the maverick, Chuck Yeager test-pilot culture
of the nineteen-fifties. It was a culture defined by how unbelievably
dangerous the job was. Test pilots strapped themselves into machines
of barely controlled power and complexity, and a quarter of them were
killed on the job. The pilots had to have focus, daring, wits, and an
ability to improvise—the right stuff. But as knowledge of how to
control the risks of flying accumulated—as checklists and flight
simulators became more prevalent and sophisticated—the danger
diminished, values of safety and conscientiousness prevailed, and the
rock-star status of the test pilots was gone.

Something like this is going on in medicine. We have the means to make
some of the most complex and dangerous work we do—in surgery,
emergency care, and I.C.U. medicine—more effective than we ever
thought possible. But the prospect pushes against the traditional
culture of medicine, with its central belief that in situations of
high risk and complexity what you want is a kind of expert
audacity—the right stuff, again. Checklists and standard operating
procedures feel like exactly the opposite, and that's what rankles
many people.

It's ludicrous, though, to suppose that checklists are going to do
away with the need for courage, wits, and improvisation. The body is
too intricate and individual for that: good medicine will not be able
to dispense with expert audacity. Yet it should also be ready to
accept the virtues of regimentation.

The still limited response to Pronovost's work may be easy to explain,
but it is hard to justify. If someone found a new drug that could wipe
out infections with anything remotely like the effectiveness of
Pronovost's lists, there would be television ads with Robert Jarvik
extolling its virtues, detail men offering free lunches to get doctors
to make it part of their practice, government programs to research it,
and competitors jumping in to make a newer, better version. That's
what happened when manufacturers marketed central-line catheters
coated with silver or other antimicrobials; they cost a third more,
and reduced infections only slightly—and hospitals have spent tens of
millions of dollars on them. But, with the checklist, what we have is
Peter Pronovost trying to see if maybe, in the next year or two,
hospitals in Rhode Island and New Jersey will give his idea a try.

Pronovost remains, in a way, an odd bird in medical research. He does
not have the multimillion-dollar grants that his colleagues in bench
science have. He has no swarm of doctoral students and lab animals.
He's focussed on work that is not normally considered a significant
contribution in academic medicine. As a result, few other researchers
are venturing to extend his achievements. Yet his work has already
saved more lives than that of any laboratory scientist in the past decade.

I called Pronovost recently at Johns Hopkins, where he was on duty in
an I.C.U. I asked him how long it would be before the average doctor
or nurse is as apt to have a checklist in hand as a stethoscope
(which, unlike checklists, has never been proved to make a difference
to patient care).

"At the current rate, it will never happen," he said, as monitors
beeped in the background. "The fundamental problem with the quality of
American medicine is that we've failed to view delivery of health care
as a science. The tasks of medical science fall into three buckets.
One is understanding disease biology. One is finding effective
therapies. And one is insuring those therapies are delivered
effectively. That third bucket has been almost totally ignored by
research funders, government, and academia. It's viewed as the art of
medicine. That's a mistake, a huge mistake. And from a taxpayer's
perspective it's outrageous." We have a thirty-billion-dollar-a-year
National Institutes of Health, he pointed out, which has been a
remarkable powerhouse of discovery. But we have no billion-dollar
National Institute of Health Care Delivery studying how best to
incorporate those discoveries into daily practice.

I asked him how much it would cost for him to do for the whole country
what he did for Michigan. About two million dollars, he said, maybe
three, mostly for the technical work of signing up hospitals to
participate state by state and coördinating a database to track the
results. He's already devised a plan to do it in all of Spain for less.

"We could get I.C.U. checklists in use throughout the United States
within two years, if the country wanted it," he said.

So far, it seems, we don't. The United States could have been the
first to adopt medical checklists nationwide, but, instead, Spain will
beat us. "I at least hope we're not the last," Pronovost said.

Recently, I spoke to Markus Thalmann, the cardiac surgeon on the team
that saved the little Austrian girl who had drowned, and learned that
a checklist had been crucial to her survival. Thalmann had worked for
six years at the city hospital in Klagenfurt, the small provincial
capital in south Austria where the girl was resuscitated. She was not
the first person whom he and his colleagues had tried to revive from
cardiac arrest after hypothermia and suffocation. They received
between three and five such patients a year, he estimated, mostly
avalanche victims (Klagenfurt is surrounded by the Alps), some of them
drowning victims, and a few of them people attempting suicide by
taking a drug overdose and then wandering out into the snowy forests
to fall unconscious.

For a long time, he said, no matter how hard the medical team tried,
it had no survivors. Most of the victims had gone without a pulse and
oxygen for too long by the time they were found. But some, he felt,
still had a flicker of viability in them, and each time the team
failed to sustain it.

Speed was the chief difficulty. Success required having an array of
equipment and people at the ready—helicopter-rescue personnel, trauma
surgeons, an experienced cardiac anesthesiologist and surgeon,
bioengineering support staff, operating and critical-care nurses,
intensivists. Too often, someone or something was missing. So he and a
couple of colleagues made and distributed a checklist. In cases like
these, the checklist said, rescue teams were to tell the hospital to
prepare for possible cardiac bypass and rewarming. They were to call,
when possible, even before they arrived on the scene, as the
preparation time could be significant. The hospital would then work
down a list of people to be notified. They would have an operating
room set up and standing by.

The team had its first success with the checklist in place—the rescue
of the three-year-old girl. Not long afterward, Thalmann left to take
a job at a hospital in Vienna. The team, however, was able to make at
least two other such rescues, he said. In one case, a man was found
frozen and pulseless after a suicide attempt. In another, a mother and
her sixteen-year-old daughter were in an accident that sent them and
their car through a guardrail, over a cliff, and into a mountain
river. The mother died on impact; the daughter was trapped as the car
rapidly filled with icy water. She had been in cardiac and respiratory
arrest for a prolonged period of time when the rescue team arrived.

From that point onward, though, the system went like clockwork. By the
time the rescue team got to her and began CPR, the hospital had been
notified. The transport team got her there in minutes. The surgical
team took her straight to the operating room and crashed her onto
heart-lung bypass. One step went right after another. And, because of
the speed with which they did, she had a chance.

As the girl's body slowly rewarmed, her heart came back. In the
I.C.U., a mechanical ventilator, fluids, and intravenous drugs kept
her going while the rest of her body recovered. The next day, the
doctors were able to remove her lines and tubes. The day after that,
she was sitting up in bed, ready to go home. ♦


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