APIC: Checklist revolutionaries Gawande and Pronovost tell IPs their time is now
"Shift from being the infection control 'police' to being a driver of a process that brings teams together."
By Gary Evans, Senior Managing Editor
Infection preventionists must seize an extraordinary moment in health care, when divergent forces are aligning to redesign a system that has failed to contain costs and protect the lives to which it has been entrusted, Atul Gawande, MD, MPH, said recently in New Orleans in the keynote address at the 37th annual educational conference of the Association for Professionals in Infection Control and Epidemiology (APIC).
"In many ways we must completely redesign what we are doing because what we are doing is killing people," said Gawande, an influential author, a surgeon at the Brigham and Women's Hospital (BWH) in Boston, and an associate professor in the Department of Health Policy and Management at the Harvard School of Public Health.
"This is an extraordinary moment and time in American medicine, where under the pressures of needing to contain costs, needing to recognize that the quality level could be better and starting to reform our payment system the interest in the idea of system redesign is growing," he told some 3,400 APIC attendees. "This is the moment. This is the moment where this work is beginning to be done. And there is no work more important for our patients than what you do."
In an era of rapidly emerging multidrug resistant infections, IPs can no longer be reduced to infection control "cops" stalking the halls and admonishing the noncompliant, he stressed. Indeed, his comments coincided with a recent Centers for Disease Control and Prevention public health warning that a new pan-resistant strain of Enterobacteriaceae has been detected in the United States including, somewhat ominously, in an isolate of Escherichia coli. As IPs are well aware, the history of such emerging pathogens does not bode well for containment efforts.
"The evidence is that rising infection rates from super-resistant bacteria are now the norm not just in the U.S. but globally," Gawande said. "The first outbreak of vancomycin resistant Enterococcus was in 1988 in a renal dialysis unit in the United Kingdom. By 1990 it had gone abroad including to four in [every] 1,000 American ICU patients. By 1997, 23% of American ICU patients were colonized with this bacteria. That's how fast and widely these spread."
If such threats are to be met, infection preventionists must take critical team roles in a system redesign that includes all health care workers and draws keen attention to the critical moments when medicine breaks down and patients are exposed to harm.
"We can't leave [the IP] all on her own," Gawande said. "The work of infection control almost can be rethought of as the work of process control, of seeing what the most vulnerable moments of care are in the hospital and then working together with [other] clinicians. You recognize that there are a few key moments in the ICU process of care, in the operating room, in the delivery room and the floor, at discharge."
Checking hubris at the door
Intervening in such moments say prior to insertion of a central venous line or before the scalpel cuts the skin can mean, quite simply, life or death for the patient involved. In such moments, checking your hubris at the door and reading off a list can make the difference. The idea came out of the smoke and ash of air plane crashes, with the realization that everything may hinge on the one thing that was left undone.
A frequent contributor to the New Yorker, Gawande took a literal page from aviation and called for development of "pre-flight" checklists for critical moments in health care delivery. The increasing risks, complexity and costs call for such essential tools, whose simplicity belies the fact that they really represent a radical culture change in traditional medicine, said Gawande.
"What we don't see behind this piece of paper is the cultural change that is also part of it," he said. "A world where a nurse and a doctor can work together and a nurse can say, 'Halt. I think we have forgotten to actually wash our hands.' ... In order to bring this about we have to have the knowledge to create these checklists, but even more than that you have to have the support of leadership, including top people in the hospitals and clinics where we work."
Gawande is having success implementing such programs for surgery, beginning with the key moments (i.e., administration of antibiotic prior to incision) as discussed and decided upon by the team of clinicians and IPs.
"You have to have teamwork and culture change to have the people like the surgeons, anesthesiologists, nurses all sitting at the table and beginning to ask how are we to change these key moments in care?" he said. "This is work that has not been valued. If you could create a drug that could lower infections by the amount that any of these kinds of programs that have implemented have done there would be ads on TV: 'Ask your doctor. Are they using the checklist?' There would be multibillion dollar industries built around this thing. But that's not what we've seen so far."
However, with 100,000 patients a year dying of health care associated infections (HAIs), Gawande is not going unheard, nor are the other new voices in infection prevention calling for widespread culture change. Foremost among those is Peter Pronovost, MD, PhD, medical director of the Center for Innovations in Quality Patient Care at Johns Hopkins Hospital in Baltimore. As previously described in Hospital Infection Control & Prevention, Pronovost and colleagues dramatically reduced bloodstream infections through an intervention that included a checklist for proper insertion of central venous lines.1
Dramatic VAP reductions next
At an APIC press conference, Pronovost said he has designed a similar program that shows striking results in reducing ventilator associated pneumonia (VAP). The results have not been published yet, but there are clearly checklist implications for many other infections which historically have been too easily accepted as a byproduct of delivering medical care.
"VAP is notoriously hard to measure and there are many definitions," Pronovost told HIC. "But given that, we achieved the exact same reduction in VAP as we did in BSIs. It is breathtaking truly breathtaking. Now we are working with the CDC and professional societies to tighten up the measurement. Yes, we have accepted VAP as inevitable and yet we reduced it by 70%."
While key interventions for VAP (i.e., elevating the head of the patient bed) are fairly well established, checklists for other infections must go through development and trials much like a new drug, Pronovost said.
"With many of the other infections we still need to do that phase one. We need to invest in how to adequately measure the evidence summary, and do the pilot testing," he said. "The concerning thing is our lack of investment in the science of health care delivery. We as a country spend a dollar finding new genes or finding new drugs for every penny we spend to make sure we can deliver them safely and effectively."
In other areas like preventing catheter-related bloodstream infections (CR-BSIs) the evidence is so clear that the failure to intervene amounts to an accountability issue in healthcare, he emphasized.
"We are quite confident with CDC definitions that we have the ability to accurately measure these [CR-BSIs] and largely prevent them," Pronovost said. "Given that these infections cost $30,000 to $36,000 [each] the average hospital saves about a million dollars for doing this [checklist prevention]. Regardless of the cost saving, it is really a moral accountability issue. The knowledge is there. The ability is there. What we need is the will and the accountability."
There is resistance to this checklist revolution, in part because it suggests a "dumbing down" of medical care, Gawande conceded.
"It's misunderstood," he said. "We see a checklist as dumbing things down in medicine, but we have to understand that its's about making sure the basics happen so that clinicians can focus on the more complicated stuff you could never turn into a checklist. [Then] you begin to understand that this is not dumbing down medicine. This is actually essential. Great medicine is not possible without these kinds of checks carefully designed, supported and put in place."
Such lists of key actions for critical moments reflect nothing less than "a set of values," Gawande explained.
"One value is humility the humility to recognize that errors occur again and again," he said. "Our brains no matter how expert we are, how many years of training we have, how senior we are will forget these steps at key moments along the way. The second value is self discipline. The recognition that we all do not have the will and self discipline to do everything right in the right way without a process in place of doing it the same way of doing everything the same way every time for those key moments in care. The third value very different from what we have had before is that a checklist is about the idea of teamwork. That we believe in checking on one another. This is not police work. This is part of the fabric of what it means to be a clinician."
IP is not a person, but a culture
Checklists and culture change for key medical moments may certainly prevent a lot of infections, but then there is the excruciatingly simple yet elaborately complex problem that has undermined infection prevention since it's inception: hand washing. Gawande recounted his experiences walking around with infection preventionists, observing the difficulty of the problem first hand, which like the second one, goes unwashed about half the time at any given hospital.
"The fascinating thing to me is that this is nothing new. This has been the battle since Semmelweis in the mid-19th century," Gawande said. "This does not seem to be a conflict or a clash between lazy care and punctilious care. It seems instead to be a conflict between doing everything that's important for infection control and the process of doing all of the other stuff that is important to meeting a patient's needs. "
Watching the flow of health care workers in and out of rooms, he saw them inevitably cut corners and admitted he had done as much himself.
"Alcohol rubs have made things considerably better," he said. "It has improved our hand washing compliance from 40% to 50% to 70% to 80%. But that's not remotely good enough. You still have the typical patient touched by someone who has not washed their hands virtually 100% of the time. Furthermore, this is only one aspect of a complex process of trying to ensure that dangerous viruses and bacteria are not getting to the people who come to use our facilities."
The answer in part is that infection prevention is not a person, but a culture; infection prevention is not an addendum to care, it is care. Advocating infection prevention education in medical and nursing schools and empowering patients, Gawande reiterated that the time is now to make infection prevention a critical function of a redesigned health care delivery system.
"One call to action is teamwork," he said. "The problem now is to shift from being the infection control 'police' to being a driver of a process that brings teams to work together to solve [problems]. How do we make that moment in care go better? With that, you will be part of making great care."
"Welcome to our team," responded APIC President Cathryn Murphy, RN, PhD, CIC.
Reference
- Pronovost P, Needham D, Berenholtz S, et al. An intervention to decrease catheter-related bloodstream infections in the ICU. N Eng J Med 2006; 355:2,725-2,732.
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