Doctor Saved Michigan $100 Million Dr. Peter Pronovost saved the state more than $100 million and 1500 lives by teaching doctors and nurses to use checklists for intensive care unit procedures. We talk with Dr. Provonost, as well as Atul Gawande, who wrote about the success of the strategy.

Doctor Saved Michigan $100 Million

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ANDREA SEABROOK, host:

From NPR News, this is ALL THINGS CONSIDERED. I'm Andrea Seabrook.

Six years ago, Dr. Peter Pronovost made a radical improvement to the field of intensive care. His development drastically cut infection rates in hospitals where it's been tried, saving more than 1,500 lives and hundreds of millions of dollars. Dr. Pronovost's technique: the checklist, a step-by-step chart of every medical procedure from hand washing to keeping patients propped up.

The story of his low-tech breakthrough is told in this week's New Yorker magazine by writer and surgeon Atul Gawande, and they both join me now.

Dr. Pronovost, let me start with you. You are the ICU specialist at John Hopkins Hospital in Baltimore. Give me a sense of the activity in your modern ICU. Why did doctors and nurses need a checklist?

Dr. PETER PRONOVOST (Medical Director, Johns Hopkins Center for Innovation in Quality Patient Care): Well, the care there is exceedingly complex. We have an amazing number of technologies that can support the failing body. So if your lungs aren't working, your heart's not working, your kidneys aren't working, we could do things to restore them, or at least, temporarily. But those complexities add challenges and opportunities for failures. And so checklists help aid our often human and perhaps feeble minds to make sure that we do what we're supposed to all the time.

SEABROOK: Dr. Gawande, in your article, you liken modern medicine to an incredibly complex airplane where the pilot is sitting in the cockpit and has to switch dozens of switches and buttons and all these things, and any one that they don't switch could make everything go wrong.

Dr. ATUL GAWANDE (General and Endocrine Surgeon, Brigham and Women's Hospital; Staff Writer, The New Yorker): Yes. There was this fascinating study where engineers went into ICUs, and on average, they found that the doctors and nurses had 178 different things they had to do in a given day and do it right in order to help this person live. And on average, they had an error of about 1 percent of the time, which sounds great until you realize that means two errors a day with every patient.

SEABROOK: So Dr. Pronovost, is this where you got the idea for the checklist?

Dr. PRONOVOST: What we recognized is that putting a checklist then requires two critical pre-conditions. And the first is that the doctors and nurses have to accept that they're fallible. And that second factor is that you have to recognize that we work as part of a broader system. And so the physician alone trying harder is not likely going to lead alone to the good outcomes.

SEABROOK: It sounds like maybe it's been a little difficult to convince doctors and nurses to use these checklists.

Dr. PRONOVOST: A little bit difficult is a bit of an understatement. You know, we're not allowed to make mistakes. We have a medical legal system that expects perfection. We're accultured in school. And so for physicians to come up and say, you know, I'm a good doctor, but I'm going to get it wrong sometime is really, really difficult.

SEABROOK: Dr. Gawande, you described in your article Dr. Pronovost's use of a specific checklist for putting lines into people's veins. Could you tell me what's on that checklist, Dr. Pronovost?

Dr. PRONOVOST: Sure. And let me just clarify these are catheters that go into veins, but they're in one of the big veins around your heart. And the risk is that they get infected. The vast majority of them could be prevented with five simple things. And those things are washing your hands, cleaning your skin with a soap called chlorhexidine, using full barrier precautions, avoiding the femoral site, that is don't put the catheter in around the groin if possible because it has a much higher infection rate. And then finally, take out the catheter if you don't need it. Nothing quite technical but those things across the U.S. were done on average about 30 percent at a time.

Dr. GAWANDE: This was really what was striking to me about the story of what Dr. Pronovost was doing. And he carried it out in an entire state. He introduced it in the state of Michigan. And within about three months of their using this checklist, they went from that 30 percent likelihood of doing all those steps to nearly 100 percent. And their infection rates in their typical ICU went down to zero.

It was unbelievable because up to this point, our approach to this kind of problem was you just needed more technology. People were putting silver impregnated catheters together that cost about a third more, or other catheters coated with antibiotics. People were spending tens of millions of dollars in hospitals trying to buy these expensive new catheters. And really, it turned out you just needed a checklist.

SEABROOK: Dr. Pronovost, I want to ask you about the role of nurses in this. You really empowered them to enforce the checklist.

Dr. PRONOVOST: When we first put this checklist, Andrea, it was fascinating. Everybody agreed with the evidence. But the nurses said, I'm not going to question the physicians because, one, my rule isn't to be a police for them, and, two, if I do, I'm going to get my head bit off.

And the physicians, on the other hand, questioned me and said, Peter, you can't have these nurses questioning me in public. It makes me look like I don't know something. So we pulled everyone together, Andrea, and I said, is it tenable that we harm patients here. And, of course, everyone says no.

And so I looked at the nurses and said, then how could you see a doctor not wash their hands and keep silent about it. And also, you can't be exposed to getting your head bit off, so docs, let me be really clear. The nurses are going to second guess you and unless it's an emergency, you have to go back and fix the problem.

SEABROOK: You know, what I'm not hearing in listening to you all discuss working is the sort of sense of the art of medicine. Dr. Gawande, could a checklist distract a doctor from that - the intangibles of practicing medicine?

Dr. GAWANDE: It's the fear that we can turn medicine into a kind of cookbook medicine and you lose the humanity of it. But I don't think we're anywhere in danger of that. You know, in an ICU or in an operating room where I work, the basic stuff should just be happening, so that the uncertain stuff, the last minute decisions that have to be made can be attended to with everybody's attention.

Dr. PRONOVOST: We have failed to view the delivery of health care as a science. It's only viewed as an art. So we spend a hundred or two-hundredfold more on finding genes, in finding effective therapies, and then just let whether we use those therapies kind of diffuse out under their own.

Dr. GAWANDE: If there had been a drug that reduced infections by 66 percent, which is just what his checklist did, we would have that drug in everybody's hands in the country. We would have ads on television with Robert Jarvik. You'd have people jumping in, trying to come up with newer and better ways. So as much as there have been some states that have jumped in and said, hey, we'd be interested in finding a way to do this; I'm actually struck with how slow this has filtered into practice. It is still not the routine.

SEABROOK: Peter Pronovost is an intensive care specialist at John Hopkins Hospital in Baltimore. Atul Gawande is a staff writer at The New Yorker and a surgeon at Brigham and Women's Hospital in Boston. His most recent book is called "Better."

Gentlemen, thank you very much.

Dr. GAWANDE: Thank you.

Dr. PRONOVOST: Thank you, Andrea.

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