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Check That

A simple checklist for intensive-care-unit doctors results in fewer infections and deaths.

Peter Pronovost
Photo by
Mike Ciesielski
No doubt, high-tech medical equipment, dazzling specialists, and miracle cures save countless lives. But there's a shadow side to the good work: Every year, as many as 1.7 million people fall prey to infections while being treated in hospitals, according to the Centers for Disease Control, and 99,000 of them die from those infections.

Enter Peter Pronovost. A Johns Hopkins professor of anesthesiology and critical care medicine, Pronovost, Med '91, SPH '97 (PhD), decided in 2002 to devise a way to lower the infection rate in the intensive care unit. Amid a department full of highly educated specialists, Pronovost trotted out an idea that more typically strikes the fancy of harried parents and party planners: a checklist. Why not have doctors use one to make sure that critically ill patients requiring intravenous lines get proper care?

Nationwide, 80,000 people become infected after intravenous lines are put into their bodies. The infections are fatal as often as 25 percent of the time. Those who survive average a week longer in the hospital than people who don't become infected. Many doctors claim to be too distracted or busy to follow best practices for installing lines. "Some have said that infections are just going to happen, that they're the cost of doing business," says Pronovost. "I think we owe our patients more than that."

So he turned to the checklist, an idea that dates back to the 1930s, when bomber pilots saw their crash rates plummet to zero once they began using a to-do list before takeoff. Pronovost's checklist reminded doctors to do five things: wash their hands; clean a patient's skin with chlorhexidine; put sterile drapes over the patient; wear a mask, hat, gown, and gloves; and place a sterile dressing over the site of a catheter once the line is in. He also persuaded doctors to allow nurses to make sure they completed each step every time.

At the beginning of the study, doctors skipped at least one step a third of the time. But in time, compliance improved and the intensive care unit's 10-day line infection rate went from 11 percent of patients to zero. During the study's full 15-month length, the checklist prevented 43 infections and eight deaths, and saved the health care system $2 million in costs. "Almost all of the things they've come up with have led to huge savings," says university President William R. Brody. "And all they've done is concentrate on improving quality and patient outcomes."

In 2003, a hospital association in Michigan asked Pronovost to bring the checklist model to three hospitals. In the first 18 months, the measure saved an estimated 1,500 lives and $75 million. He published those results in the December 2006 New England Journal of Medicine and soon after was profiled in The New Yorker. In that article, author Atul Gawande, a practicing physician himself, suggested that Pronovost's checklists heralded a new — if underappreciated — approach to health care. "Few other researchers are venturing to extend [Pronovost's] achievements. Yet his work has already saved more lives than that of any laboratory scientist in the past decade," he wrote.

This year, Time magazine named Pronovost one of the top 100 most influential people in the world; in September, he was awarded one of 25 "genius grants" from the John D. and Catherine T. MacArthur Foundation for his work on improving clinical practice. And his renown has gone international: Governments and organizations in England, Ireland, and Spain have begun checklist programs. Yet Pronovost worries whether his work has had enough reach. In testimony before the House of Representatives' Government Oversight Committee in April, Pronovost tied the lack of clinical science research in the United States to the relatively poor health outcomes for patients. For every dollar the federal government spends on research into diseases, it spends one penny on research that finds ways to deliver the best treatments. "It's completely out of balance," he says. "We could do nationally what we did in Michigan with $3 million, but money is hard to find." With health care costs for all types of hospital infections running at around $11 billion, a national checklist would be a bargain, he says.

Edward Miller, dean of the School of Medicine, echoes his concern. "I'd love to have a donor give me $12 million to $14 million for an Institute for Patient Safety here, a place where researchers from around the world could do projects on clinical work." But, he says, it's a tough sell because many donors prefer to give money to research aimed at curing disease.

But Pronovost's work has turned some heads. A hospital association recently awarded him a $3 million grant to expand his work. And in a coup for Pronovost and for Johns Hopkins, the World Health Organization plans to open its first office worldwide to be placed at a university, possibly as soon as this fall. Pronovost will lead an effort to study patient safety worldwide there, just a few blocks south of Johns Hopkins' East Baltimore campus. "It's a sign that we're changing some minds about this subject," he says.
—Michael Anft

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