The checklist revolution

The way hospitals think about central–line infections has changed in recent years, said James J. Gordon, M.D., chief of infectious diseases at Huron Valley–Sinai Hospital in Commerce, Mich. "If best practices are utilized, the vast majority of line infections can be avoided," he said. Medicare agrees: It no longer pays the extra costs associated with those infections.

The breakthrough came after years of research on effective steps in infection control, when Pronovost implemented this body of evidence in the unlikely form of a simple five–step checklist. The checklist translated the most effective known approaches into a common–sense series of hygienic precautions to follow when inserting, using, or removing a central line. The steps require equipment no more complex than hand soap, an antiseptic solution, and sterile drapes and garb. Other key components: giving nurses the authority to make doctors follow all the steps, and measuring and reporting infection rates.

Pronovost tested his checklist in 67 hospitals in Michigan, and the results, published in the Dec. 28, 2006, issue of the New England Journal of Medicine, were dramatic: a 66 percent reduction in central–line–associated bloodstream infections. It is estimated that the program saved more than 1,500 lives and $200 million in the first 18 months alone. In July 2009, Health and Human Services Secretary Kathleen Sebelius called on hospitals across America to use the checklist to reduce central–line infections in ICUs by 75 percent over the next three years.

Hamilton Medical Center, a 282–bed hospital in Dalton, Ga., uses the checklist and in August 2009 reported a zero central-line infection rate in its medical and surgical ICUs to the Leapfrog Group. "The checklist is not just a checklist," said Teresa Fox, infection prevention coordinator at the medical center. "The checklist gives accountability that you're making sure everyone is doing all the steps and doing them the same, so you get consistency."

What this kind of experience suggests, said Richard P. Shannon, M.D., professor of medicine at the University of Pennsylvania School of Medicine, is that "all central–line infections have a root cause that can be understood and prevented." Even the sickest patients, he said, can be spared such infection.

Though the checklist seems simple, it does demand time and attention in the high–pressure environment of an ICU.

Huron Valley–Sinai Hospital, which took part in Pronovost's study, has had no ICU central–line bloodstream infections during the past two years of using the checklist, said hospital infectious–disease chief Gordon. "If this practice wasn't continually discussed and recognized as a high priority, the protocols might lapse," Gordon said. "We'd start seeing infections. It's human nature."