Simple checklists could save healthcare billions

By Cynthia E Keen

Intensive care units are associated with the best state-of-the-art technology and round-the-clock treatment from experts. However, patients who enter ICUs risk hospital acquired infections (HAI), which are not only very expensive to treat but also could kill them.

Photo: Simple checklists could save healthcare billions
In the USA alone, around 80,000 patients annually acquire catheter-related bloodstream infections during an ICU stay, costing about $2.3 billion to treat. They are fatal between 5-28% of cases and result in the avoidable death of around 28,000 people. European statistics are believed to be comparable.
Adoption and strict adherence to a simple five-step checklist, designed to enforce hygiene practices in intensive care units (ICUs), potentially could dramatically reduce, if not entirely eliminate, catheter-related bloodstream infections. The World Health Organisation’s World Alliance for Patient Safety (WAPS) is working with the Quality & Safety Research Group (QSRG) at the Johns Hopkins School of Medicine Centre for Innovations in Quality Patient Care, in Baltimore, Maryland, to implement this programme in Europe and other interested nations. Details of the programme are expected soon or early this summer, according to Christine Goeschel RN MPA, administrative director of QSRG. WAPS was organised in October 2004, with a mission to promote patient safety worldwide, and is headquartered in London.
The checklist was the brainchild of Peter J Pronovost, MD PhD, medical director of the Centre for Innovations in Quality Patient Care, and associate professor at the Departments of Anaesthesiology and Critical Care Medicine and Surgery at Johns Hopkins School of Medicine. 
The checklist requires that, when a central venus catheter is placed in a patient, the medical team involved: a) wash their hands with soap; b) clean the patient’s skin with chlorhexidine antiseptic; c) put sterile drapes over the entire patient; d) wear a sterile mask, hat, gown and gloves; and e) put a sterile dressing over the catheter site once the line is in. These are procedures taught in medical school and expected to be practiced in hospitals. But are they?
In 2001, Dr Pronovost initiated and oversaw the implementation of a programme at Johns Hopkins Hospital that mandated and monitored complete compliance of the checklist. Over a 27-month period, the 10-day line infection rate of patients in the ICU dropped from 11% to 0%. During that time, exactly two line infections occurred. Johns Hopkins Hospital estimated that use of the checklist prevented 43 infections and eight deaths, saving $2,000,000.
However, this hospital is one of the best in the USA, with a large staff and many resources. Could similar results be achieved in ‘ordinary’ hospitals? A study designed to evaluate the effect of the checklist utilisation for an 18-month period (March 2004-September 2005) was funded by the US government’s Agency for Healthcare Research and Quality. This received an unwieldy name: Michigan Health and Hospital Association Keystone Centre for Patient Safety and Quality Keystone ICU Project.
103 hospitals in Michigan State, representing 85% of all ICU Michigan hospital beds, participated in the programme. The results were remarkable. The median rate of catheter-related bloodstream infection per 1,000 catheter days dropped to zero from an average 2.7 infections — only three months after implementation — a 66% reduction. This achievement was maintained throughout the 18 months of monitoring. An estimated 1,500 lives and $175,000,000 were saved in a programme that cost $500,000 to administer.
Details of the Keystone ICU Project were published in the 28/12/2006 issue of The New England Journal of Medicine (Vol. 355, No. 26: 2725-2732). Those remarkable results were largely ignored by both the North American and international medical and consumer press.
Core elements of the program were teamwork and the anonymous nature of reporting data.  Hospital culture also changed. In his article published in The New Yorker on December 10, 2007. (, Dr Atul Gawande, a general and endocrine surgeon at Brigham and Women’s Hospital in Boston and Assistant Professor of Surgery at Harvard Medical School, stressed that a newly implemented ‘protocol’, stressing acceptability and encouragement by any member of the medical staff  to point out to any other member of the medical staff if they were not adhering to the checklist, enforced compliance and reinforced awareness. Senior level physicians were not exempt. Another important element contributing to the success of the Keystone project was the active hands-on involvement of and support by senior hospital administrators. According to Dr Gawande ‘…the State of Michigan’s infection rates fell so low that its average hospital ICU outperformed 90% of all other hospital ICUs nationwide’. This statistic incorporated the higher rates of the 15% of non-participating Michigan hospitals.
In 2005, a survey of infection control officers, conducted by the VA Ann Arbor (Michigan) Healthcare System in a random sample of 600 hospitals throughout the United States and all 119 US Veterans Affairs Medical Centres, revealed that fewer than 50% of non-government hospitals reported concurrent adherence to the items listed in Dr Pronovost’s checklist.
The catheter-related bloodstream prevention checklist is not the only one that Dr. Pronovost has created. ‘The question – still unanswered – is whether medical culture will embrace the opportunity,’ he observed.
Meanwhile, the results of another survey of VA hospitals, and a random sample of 600 hospitals representative of 2,671 larger than 50-bed hospitals with ICUs, has been published in the 15/1/08 issue of Clinical Infectious Disease. A team of patient safety experts, headed by Sanjay Saint, MD MPH, director of the University of Michigan Health System/Veterans Affairs Patient Safety Enhancement Programme, in Ann Arbor, has determined that 56% of all responding hospitals did not have a system to monitor patients who had urinary catheters placed, and 74% did not monitor the duration that patients had the catheters. Urinary catheter reminders were used in under 10% of the hospitals. 
25% of all patients in US hospitals have urinary catheters inserted. One in 100 will acquire a urinary tract infection from the catheter, requiring antibiotics and potentially other costly medical treatment. Urinary tract infections are responsible for 40% of infections related to hospitalisation. Dr Saint encourages hospitalised patients to ask their medical caretakers on a daily basis if they still need the catheter – but perhaps they should ask whether their hospital would like to use a checklist.


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