Saving 28,000 Lives a Year

The New Yorker is running a piece by Atul Gawande that starts by describing the everyday miracles that can be achieved in a modern medical intensive care unit, and ends by making a case for a simple and inexpensive way to save 28,000 lives per year in US ICUs, at a one-time cost of a few million dollars. This medical miracle is the checklist. Gawande details how modern medicine has spiraled into complexity beyond any person's ability to track — and nowhere more so than in the ICU. "A decade ago, Israeli scientists published a study in which engineers observed patient care in ICUs 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." The article goes on to profile a doctor named Peter Pronovost, who has extensively studied the ability of the simplest of complexity tamers — the checklist — to save lives in the ICU setting. Pronovost oversaw the introduction of checklists in the ICUs in hospitals across Michigan, and the result was a thousand lives saved in a year. That would translate to 28,000 per year if scaled nationwide, and Pronovost estimates the cost of doing that at $3 million.

Comments

Re:Get rid of the dinosaurs

[NIckGorton]

They reflexively cry out against 'cookbook' medicine and 'socialized medicine' while ignoring sound scientific advice.

Huh? WTF has concerns about cookbook medicine to do with the need for universal access to health care? I am one of those physicians who reflexively cries out FOR universal health insurance. Of course I don't call that 'socialized medicine' because its not different than our 'socialized' school, EMS, Fire, Police, and Highway systems to name a few.

And while I think that there are a lot of potential problems with 'cookbook medicine' there are also a lot of potential benefits. Its like any tool that can be used to help or hinder the practice of medicine. For example, an EMR that reminds me my diabetic patient is overdue for annual eye screen and should be on an ACE-Inhibitor is a great idea. However if the same system forces my hand on the ACE-I when I know that patient has had multiple episodes of fainting due to low blood pressure (which an ACE-I would exacerbate) its a problem. Similarly, if I spend all my time inputting data into the EMR it becomes more of a hindrance than a help.

In the case of ICU checklists, nurses every year are required to do more and more documentation (an average of 18 pieces of paper for a new non-ICU admission to my hospital) and every checklist or additional page you add to that is taking time away from patient care. So what sounds like a great idea may in fact cause worse outcomes because it puts the nurses focus on a paper rather than their patient.

Of course what I always find to be funny is the very same people who have zero tolerance for any risk or error and decry doctors for an untoward fear of cookbook medicine are the first ones to ask you to depart from standard practice for their personal special case... the antibiotics they want for a virus, the expensive lab test or MRI that is really not necessary, the pricey new drug on TV they want when a safer older drug with a proven track record works just as well. That innate lack of trust of health care providers and assumption of laziness or ill will translates to their own relationships with their physician in different but recognizable ways.

The actual paper

[argiedot]

You can find the actual paper in the New England Journal of Medicine. I think many here are missing the point. Peter Pronovost's suggestion to use a checklist is to ensure that commonly done tasks are done properly, not that a surgeon will have to look at a piece of paper before he moves each vein aside. And, as he has demonstrated, it works.

It's not as glamorous as discovering a cure for some new disease, but it works great.

Notice the other things mentioned in the New Yorker article:

• Nurses were authorised by the hospital administration to correct doctors when they skipped part of a procedure.
• Mundane processes were pushed to a checklist, so recalling them was no longer a human task, letting the doctors focus on the parts that actually require them to think.

In fact, the most important part of the whole article is in these paragraph:

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.

Re:At $107 per life...

[khanyisa]

Yes the methodology is important - and in this case the article is a fascinating read - basically he compared the number of mistakes beforehand and afterwards, but also looked at the correlation with the number of deaths before hand and afterwards.

In this case the causes are a known problem (especially line infections) and they could directly correlate the adoption of checklists with a drop in the incidence of line infections, and subsequently with a lower death rate. Seems like fair enough science to me, and logical as well :-)