In the delivery of HIV/AIDS care in sub-Saharan Africa, clinicians, nurses, and counselors execute their work via checklists.  The generation of dozens of these checklists - photocopied, laminated, and displayed prominently on caregivers' desks - is promoted by international organizations attempting to simplify the steps required of given clinical scenarios.  Their rationale makes sense.  If an HIV test counselor has a checklist in front of her, detailing each point she should cover with each patient, there is a greater chance that she will hit each one.  Or so the theory goes. 

A handful of outspoken American physicians say that we should all be using checklists in the routine course of patient care.  Perhaps the best known of these checklist enthusiasts is Atul Gawande, the Boston-based surgeon and author of Complications and, most recently, Better. In a December 2007 article published in The New Yorker entitled "The checklist:  If something so simple can transform intensive care, what else can it do?" Gawande passionately and convincingly argues for the implementation of procedural checklists. 

Take what we know about average nosocomial infection rates in American hospitals.  Of the total number of patients who get central or peripheral lines placed during their hospital stays, four percent will develop infections within 10 days.  Since bacterial invaders must find a point of entry in order to proliferate and cause trouble, it stands to reason that during four out of 100 line placements a mistake was made somewhere along the infection prevention pathway.  What if, in all 100 hypothetical cases, a nurse was standing by the bedside ticking off the necessary steps in a prefab infection-prevention checklist? How many infections would result then?

Based on research conducted by Peter Pronovost, a Johns Hopkins Hospital physician, researcher, and checklist promoter, we can reliably estimate that none of those patients would develop an infection.  That's right.  Zero.  As Gawande writes, "If a new drug were as effective at saving lives as Peter Pronovost's checklist, there would be a nationwide campaign urging doctors to use it."

Nurses and clinicians may rankle at the idea of checklists.  We actively resist the concept of medicine as the robotic use of prescribed, static formulas.  We believe in nuance and individual discernment.  Gawande agrees.  Yet he reminds us that the enormous, ever-increasing volumes of information each provider must absorb and apply "are now too complex for clinicians to carry out reliably from memory alone."

The hospitals in which Pronovost has implemented his system of routine checklists have witnessed dramatic improvements in patient outcomes.  At Sinai-Grace Hospital in Michigan, for example, the use of a line insertion checklist has decreased the overall patient infection rate by 66 percent.  This has, in turn, saved hundreds of thousands of hospital dollars. 

Yes, checklists increase paper and time burdens for health care staff.  But hospitals employing Pronovost's system are willing to shoulder them.  Even the government of Spain, so impressed by his findings, hired Pronovost to adapt his checklists for Spanish hospitals.  Perhaps the US as a whole would do well to follow suit.

Reference:

Gawande, A. (2008, Dec 10). The checklist:  If something so simple can transform intensive care, what else can it do? The New Yorker.

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