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    John Sullivan

    Tick the Box Medicine
    The National Health and Medical Research Council (NHMRC) is revising its’ guidelines for infection control in health care. One potentially revolutionary finding which may find its’ way into the new guidelines is the checklist idea advocated by Peter Pronovost and associates. The checklist study was conducted in 2006 and is currently referenced on the guideline revision wiki page of the Healthcare Infection Control Special Interest Group, who consulted with the NHMRC on the review. The study included 103 hospitals and demonstrated that using a five item evidence based hygiene checklist for inserting a central venous catheter produced a sustained 66% decrease in bloodstream infections from baseline after 18 months. Associated with this reduction was an estimated saving of one hundred and seventy five million USD and one and a half thousand lives. These are some of the most significant reductions in catheter associated infection rates since the rise of antibiotic resistant bacteria, and all achieved by the simple expedient of ensuring that basic steps like hand washing, gowning and gloving before inserting a catheter are followed consistently.
    Yet as Pronovost himself acknowledges, implementing a simple checklist is far from easy. In the experience of the study team it requires open communication at every step, coordination of management, staff and adequate logistical support. Perhaps the most challenging factor however is that adoption of the checklist was found to require a cultural shift. One feature of the project was that nurses were empowered to stop doctors who missed a step on the checklist and make them start over; an innovation which many doctors, rightly or wrongly, may believe has the potential to undermine the doctor patient relationship, causing a loss of face and possibly creating an undercurrent of antagonism between doctor and nurse. Logically these hypothetical objections should carry little weight in the face of a demonstrable saving in both lives and money, but rarely is pure logic the force it should be in the decisions of individuals and organisations.
    As Pronovost freely admits, such objections matter a great deal in his experience, and must be addressed if a checklist is to be successfully implemented. They are not insurmountable as the success of the 2006 study attests, and they should be surmounted given the enormous benefits that can potentially be reaped. In the example above a simple and obvious remedy would be to restructure the nurse-doctor interaction to be more overtly cooperative. A nurse or intern could simply read out the checklist as the procedure in being performed, giving doctors the opportunity to respond or acknowledge, in much the same way that a pilot and co-pilot interact when they run through a takeoff or landing checklist. This avoids any undertone of antagonism or conflict, in contrast to the situation where the checklist holder looks silently on, ready to pounce on any error.
    Some doctors have more concrete objections to the checklist, they view it as redundant, insulting and yet another example of the bloated medical bureaucracy, because hygiene standards are perceived to be of a high level already. In fact studies have shown that, in a busy and stressful intensive care unit, errors in hygiene can run as high as 30%. Such errors are often neither noticed nor remembered because they are typically made when staff are busy or distracted, as is often the case in hospital work. Unlike a surgical error if you make a hygiene error most of the time there will be no obvious consequence. The patient will not usually become infected and the minority of times when they do symptoms will manifest days or even weeks later. Cause is separated from effect and people just aren’t good at connecting the dots in these sorts of scenarios with the result that no lack of standards is perceived. Yet due to systemic factors such a time pressure and the stressful nature of hospital work these errors do happen, and the checklist is an effective way of ensuring that they do not.
    The potential applications for evidence based checklists in medicine are vast. They can potentially be used not just for procedural tasks, but for diagnosis and ongoing management as well. However, it is easy to visualise a scenario where doctors are swamped in checklists with no consultation, follow up or logistical support. Introduction of even one checklist protocol without such supports is likely to fail, and if the NHMRC does decide to recommend their use, they will need to further recommend that adequate human and other resources are provided to maximise the chance of a successful introduction.

    – John Sullivan.

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    Is the evidence for surgical checklist conclusive?

    A critical review of the paper presenting the findings from the WHO pilot study on surgical checklists (1) questions the value added by surgical checklist to Australia and other high-income countries. Of the four sites in high-income countries, only one site showed statistically significant improvement in outcomes following implementation of the surgical checklist. Yet, this site did not change practice for the better as a result of the intervention. It is also not clear from the paper whether income-level of country was adjusted for as a confounder of the causal relationship. We must then ask ourselves, is there conclusive evidence that surgical checklists in high-income countries are effective in improving patient safety?

    The point of drawing ones attention to these methodological issues is to highlight the importance of evidence in policy making. It appears from discussions that there is no up to date baseline measure in Australia to quantify the problem of surgical error. John Sullivan has alerted us to some of the difficulties of implementing checklists in medicine.

    If our agenda is to improve patient safety, it is necessary to develop policy based on evidence.

    1) Haynes AB et al. “A surgical safety checklist to reduce morbidity and mortality in a global population” N Engl J Med 2009;360(5):491-9.


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