Home Analysis How a simple checklist changed one hospital’s approach to bloodstream infections

How a simple checklist changed one hospital’s approach to bloodstream infections

December 2004

Published in the December 2004 issue of Today’s Hospitalist

Talk about how to prevent catheter-related bloodstream infections, and the discussion will likely turn to techniques like coated catheters. Researchers at Johns Hopkins, however, have identified a much simpler “and incredibly effective “way to stamp out these deadly infections.

They took an 80-page CDC guideline and boiled it down to a checklist that focused on five basic points: Don’t insert a line if you don’t really need it. Wash your hands. Use full barrier precautions. Use an antiseptic like chlorhexidine. And avoid inserting lines in the femoral site if possible.

Researchers educated physicians and other clinicians about the importance of good infection control practices, but they went a step further. They gave the checklist to nurses and told them to make sure that every clinician followed it when inserting a central line.

Almost overnight, the rate of catheter-related bloodstream infections nearly disappeared. For a nine-month stretch, in fact, the ICU that pilot-tested the checklist didn’t record a single infection.

Here’s a look at how the checklist helped not only reduce catheter-related bloodstream infections, but changed clinicians’ approach to the deadly condition.

Independent check

Taking a lengthy guideline and condensing it to what amounts to a short checklist is not an entirely new idea at Hopkins. Last year, Today’s Hospitalist reported on a checklist created by the same researchers to help clinicians focus on patient care goals. (For more, see the November 2003 issue of Today’s Hospitalist)

The latest project to come out of the Hopkins ICU, however, takes the idea of a checklist a step farther by tackling complex clinical guidelines. While many of the recommendations in the guidelines reflect well-accepted principles of infection control, research shows that physicians follow them only about half of the time.

Peter J. Pronovost, MD, PhD, associate professor and medical director for the Center for Innovations in Quality Patient

Care at Johns Hopkins University School of Medicine, is an intensivist who helped lead the effort to distill the guidelines into a user-friendly format. While he acknowledges that the strategies in the checklist emphasize the basics of infection control, he adds that obstacles often keep physicians from following them.

The Hopkins researchers, for example, discovered that physicians had to go to eight different places in the hospital to gather the various equipment needed to comply with the CDC guidelines. To make it easier for physicians and clinical staff to gather the tools they needed, they created a “central catheter insertion cart” to reduce the steps.

Because clinicians face so many of these types of obstacles, Dr. Pronovost says, hospitals need an independent check to make sure that basic measures are being taken in all patients. That’s why Hopkins not only required that a nurse be present for all central line insertions, but gave nurses the authority to stop a procedure if a clinician is not following the guidelines on the checklist.

Forcing teamwork

Telling nurses to look over physicians’ shoulders may sound like a radical idea, but Dr. Pronovost says it’s a must to bring infection rates under control. “Doctors are busy and are pulled in a thousand different directions,” he explains. “We basically said, ‘We’ll have someone else make sure you’re doing it.’ ”

Dr. Pronovost says that the checklist also serves a bigger purpose, what he calls “a forcing function for teamwork.” “The items in the checklist are important in that they’re rooted in the evidence,” he explains, “but what’s really important is that they create a culture where it’s OK for nurses to question physicians.”

Dr. Pronovost acknowledges that initially, at least, the idea was less than well-received. Nurses worried that physicians would be angry when a nurse questioned their technique, and physicians said their credibility with patients would suffer if nurses second-guessed their judgment.

“We pulled everyone together and asked if it was tenable that we harm patients at Johns Hopkins,” he recalls, “and everyone said no. I asked how a nurse can see someone not wash their hands and let them continue working. By doing so, we’re increasing the risk of harm, and we have to stop them.”

Appealing to clinicians’ sense of duty worked. “We took the discussion away from power and politics to the higher level of the patient,” Dr. Pronovost explains. “We agreed that we’re here to serve patients.”

To make sure that everyone understood the new policy, Dr. Pronovost made it clear that nurses were to page him “any time of day or night” if a clinician resisted a nurse’s effort to make sure the checklist was being followed. “Unless it’s an emergency,” he told the group, “we need to make sure that patients receive this evidence-based approach. Because we explained it that way, we’ve never had a controversy.”

Eliminating infections

Before the checklist was rolled out, nurses observed how many physicians followed best practices in infection control. They found that when placing a new central line, only 31 percent of clinicians followed the infection control strategies on the checklist. When it came to catheter exchanges over a wire, 69 percent of clinicians followed good infection control procedure.

Since the checklist was implemented, those numbers have turned around. As a result, catheter-related bloodstream infections disappeared for nine months.

Researchers estimate that they have prevented up to 43 cases of infection and approximately eight deaths. They also project that the hospital eliminated nearly $2 million in additional costs of treating infections.

While clinicians still need to be reminded to follow the procedures on the checklist about eight times a week, the model has been so successful that other health care systems have adopted it. Dr. Pronovost says that 60 ICUs working with the VHA to improve ICU care used the checklist to dramatically reduce bloodstream infections. Many nearly eliminated the infections over a six-month period.

The importance of simplicity

Dr. Pronovost says that the initiative shows the importance of simplicity when trying to persuade clinicians to change their ways. In culling information from the CDC guidelines, for example, researchers focused on recommendations that were noncontroversial and underused by clinicians.

“We found the things that have the highest risk ratio for preventing a specific outcome, in this case infection, that are used the most infrequently,” he explains. “You have to focus on the things that are the big drivers for the outcome and that have the lowest prevalence of use. If you create a 20-page checklist, it’s no different than the guideline.”

Take the matter of deciding whether a central line is really needed. While the Hopkins team could have created a detailed algorithm to help physicians decide when a central line is really necessary, it simply asked physicians to consider the issue and left the matter to their judgment.

And while giving nurses the authority to stop physicians on the basis of a checklist represented a significant shift in the culture at Hopkins, Dr. Pronovost says the project ultimately led to an even bigger change. In an industry where physicians often debate whether these infections can be eliminated and talk about acceptable levels of infection, Hopkins has drawn a line in the sand.

“We no longer view these infections as acceptable,” he says. “We view them as a defect that ought to be prevented.”