The checklist’s beginnings: What led to Dr. Peter Pronovost’s ‘Safe Patients, Smart Hospitals'
CLEVELAND, Ohio — In 2001, Johns Hopkins Hospital in Baltimore was rocked by the death of 18-month-old Josie King, who was being treated for second-degree burns over 60 percent of her body. Complications from infections and miscommunication among care team members were to blame for her death.
Dr. Peter Pronovost, a critical care specialist at the hospital at the time, was not involved in her care, but her death shook him. He decided to tackle the problem of infections resulting from central line catheterization — when a tube is inserted in a large vein in the neck, chest or groin to provide fluids, medications or for medical tests — one of the infections that affected Josie and 80,000 other hospital patients in the U.S. at the time.
He went through the Centers for Disease Control’s 120 pages of guidelines and 95 recommendations, none prioritized, designed to prevent infection in central line catheterizations, looking for the “sweet spot” between being scientifically sound and practical, so he could implement the recommendations.
Pronovost ended up with five key checklist steps: Wash your hands with soap or alcohol before the procedure; clean the insertion site with a chlorhexidine antiseptic solution; completely cover the patient with sterile sheets, and wear a sterile hat, mask, gown and gloves; avoid placing the catheter in the groin if possible (which has a higher infection rate); and remove catheters when they are no longer needed.
But the checklist was only part of the battle, as Pronovost detailed in the 2010 book he co-authored, “Safe Patients, Smart Hospitals.”
Pronovost had to challenge the culture of medicine which, at the time, gave doctors near-absolute say in patient care, right or wrong.
To assure that the checklist was used, nurses were given the unheard-of authority — backed by hospital administrators — to tell doctors to follow every step on the checklist.
In the first test of the checklist concept, at Johns Hopkins, the infection rate for central line catheterization infection went from 11 percent to zero, preventing what could have been 43 infections and 8 deaths, and saving an estimated $2 million in costs.
The results were replicated when hospitals in Michigan applied the checklist concept in 2003: catheter-related infections dropped to nearly zero, saving an estimated 2,000 lives and $200 million a year.
The checklist proved its effectiveness over and over as hospitals in other states and countries used it successfully to address central line catheter infections and other procedures.