Andrew Castle on innovations in patient safety

Andrew Castle

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Standardising clinical practice can go a long way towards improving patient safety, as one innovative programme in the US has shown. Andrew Castle explains

Johns Hopkins Hospital in Baltimore, Maryland is one of the best and most innovative hospitals in the US. Voted the number one hospital in the US for the last 17 years, it has, as the bookies might say, form.

It is also home to a clinician who was recently in the healthcare press and the blogging world for a programme he developed in 2001. Peter Pronovost is a practising anaesthetist and critical care physician, lecturer, patient safety researcher and medical director at Johns Hopkins.

On any given day in the US, around 90,000 patients are in an intensive care bed. Ove the course of a year, the figure is 5 million. ICUs put 5 million lines into patients each year. After 10 days, 4 per cent become infected. Line infections affect 80,000 people per year and are fatal between 5 and 28 per cent of the time. The patients who survive typically spend an extra week in ICU.

Standard practice

In 2001, Dr Pronovost conducted an experiment. He developed a checklist for successfully inserting a line. It includes five steps:

• wash hands;

• clean patient's skin with chlorhexidine antiseptic;

• put sterile drapes over entire patient;

• wear sterile mask, hat, gown and gloves;

• place sterile dressing on site.

For one month, nurses monitored doctors against this checklist and in more than a third of line insertions at least one step was missed. After the month of data collection, nurses were empowered to stop doctors if they missed a step. Data was collected for a further year to monitor the outcomes.

Dramatic results

The 10-day line infection rate went from 11 per cent to zero, so they monitored this for another 15 months, during which time there were only two infections. They estimated that they prevented 43 infections and eight deaths and saved $2m.

The checklist was rolled out across the state of Michigan. One of the hospitals adopting it, Sinai Grace in Detroit, had more central line infections than 75 per cent of US hospitals. The checklist was used and data was collected and monitored for three years.

A paper in the New England Journal of Medicine published in 2006 showed that in the first three months of using the checklists, infection rates dropped by 66 per cent, the typical ICU's quarterly infection rate - including Sinai Grace's - fell to zero, and Michigan's ICUs outperformed 90 per cent of the ICUs in the nation, saving $175m and an estimated 1,500 lives.

This is astonishing. If anyone reading this developed a drug or procedure that could deliver this level of return on the investment made - pen, paper and ability to follow standard work - organisations would be falling over themselves to use it.

So ask yourself, what lessons can be learned from this? Where can similar methods of standard work be developed? How might they improve the quality of the care that is delivered to patients? While your first reaction might be "every patient is different", the work of Dr Pronovost goes a long way to demonstrating that work can be standardised and that when it is the outcomes can be dramatic.