Wednesday, May 21, 2008

Milk, bread, insert catheter…

Making lists to guide medical procedures saves lives but is unethical, say Americans.

What if a way was found to rescue hun­dreds of thousands of the sickest people in the world’s hospitals, at the cost of a sheet of paper each? Michigan would take up the idea, Spain and a couple of US states would be interested, and then it would be banned in the US for being unethical.

Being in intensive care is dan­gerous. Not only because having all your organs fail or your brain bleed everywhere is unhealthy, but also because the care is, well... intense. To look after a person in intensive care for a day, a hundred and seventy eight pro­cedures have to be done on av­erage. Each procedure involves multiple steps and is performed by a collection of professionals struggling to keep their patients alive as different parts of their body fail. Small chances of in­evitable human error add up, no matter how good the doctors and nurses are, amounting to about two errors per patient each day.

Finger pointing and suing doesn’t work to reduce these fig­ures, so what will? You could say human error is inevitable and congratulate doctors and nurses for keeping it as low as they do in a hectic and complex situation. Or, as Peter Pronovost, a critical care specialist at Johns Hopkins Hospital, realised, you could take the same precautions with criti­cally ill patients as you do with shopping or making a cake.

He made a list. It was a list for one procedure: putting in a cath­eter, the tube for getting fluids in and out of people. Four per cent of catheters develop infections, which means some eighty thou­sand people per year in the US. Between five and twenty eight percent, depending on circum­stances, subsequently die.

The list had five steps. It seemed so simple as to be use­less. Surely people performing cutting edge surgery can remem­ber to wash their hands before they do a routine job? For the first month he just gave his list to nurses and asked them to note how often the doctors missed a step. It turned out they missed at least one in about a third of cases. He then asked the nurses to remind the doctors when they missed a step. The catheter in­fection rate over the next year at Johns Hopkins Hospital dropped from eleven per cent to nothing.

Pronovost made more lists and asked doctors and nurses to make their own. These lists proved so effective that the av­erage length of patient stay in intensive care dropped by half in a few weeks. Pronovost trav­elled to other cities to spread his astounding results. People were unenthused. However Michigan agreed to try the idea in 2003 and in eighteen months saved fif­teen hundred lives and two hun­dred million dollars. Since then Rhode Island, New Jersey and Spain have become interested, and there is a new project at the World Health Organization to institute checklists internation­ally.

At the end of last year, how­ever, the project ceased in America. The Office for Human Research Protections (OHRP), a bureaucratic appendage charged with overseeing ethics in re­search, decided it was unethical. Their reasoning was that since careful records were being kept of results, it was research, and should have informed consent from every patient. They even judged it ‘potentially dangerous’, as records meant doctors’ poor practice might be exposed. Pro­tecting doctors from having their performance evaluated is appar­ently more ethically weighty than ensuring patients aren’t need­lessly killed.

After some argument OHRP repealed their ban this February, a decision made more significant as it allows similar projects in fu­ture. The checklist is still getting nothing like the attention and funds ineffective bits of equip­ment for similar purposes have elicited.

Atul Gawande, a surgeon who originally alerted the public to this story through the New York­er, suggests the disinterest might be because we like the idea of gal­lant doctors deftly coping with the complexity and risk the es­teemed job entails. Standardised list checking doesn’t fit into any­one’s ideal of heroism. For what­ever reason, thousands of people can now die of negligence rather than unyielding complexity, for which we have a remedy.

Originally published in Woroni


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Being in intensive care is dan­gerous. Not only because having all your organs fail or your brain bleed everywhere is unhealthy, but also because the care is, well... intense.

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