Amongst the flood of comment and discussion on the Federal Government’s health care reform proposals, I’ve heard very little mention of what it might all mean for quality and safety of care. It’s an issue that’s too important for it not to be on the agenda.
Croakey’s North American correspondent, Dr Lesley Russell, says there is evidence from the US to show that relatively simple measures can make a big difference, in saving both lives and health care dollars. She writes:
“Last week at a Washington conference I attended, Dr Carolyn Clancy, the Director of the US Agency for Healthcare Research and Quality, shocked the audience by stating that in the 20 years that her agency has been in operation, it has had no ‘home runs’ in tackling health quality – it’s been very much about incremental improvements – with one exception: the Michigan Keystone ICU project. This is sometimes known as the Michigan checklist program.
For years, catheter-related bloodstream infections seemed to be the unavoidable complication of caring for the sickest patients in intensive care units (ICUs). The infections kill 17,000 patients annually in the US, and the average cost of caring for an infected patient is US$45,000.
But then a stunning thing happened: beginning in October 2003, Michigan hospitals implemented a relatively simple set of interventions, including a checklist of infection-control practices, and their average infection rate dropped 66% after one year. The median central-line infection rate fell to zero per 1,000 catheter days, compared with a national average of 5.2.
The achievement was due to hand washing, using full-barrier precautions when inserting central venous catheters, cleaning the skin with chlorhexidine, avoiding the femoral site for insertion, and removing unnecessary catheters. (New England Journal of Medicine article is here).
Three years after the project began, the Michigan ICUs had improved their success. The average infection rate had dropped 86%, while the median rate remained at zero. These results have been sustained through to the present. (BMJ article is here).
From 2004 to 2008, nearly 1,800 lives were saved and 129,000 extra days in the hospital were avoided due to this patient-safety initiative. Estimated savings were over US$200 million. Each hospital spent about US$120,000 in staff time to implement the safety changes and the intervention was implemented without the use of expensive technology or additional ICU staffing.
Checklists are definitely ‘in’, as evidenced by recent books from Atul Gawande (The Checklist Manifesto: How to Get Things Right) and Peter Provonost, who helped drive the Michigan study (Safe Patients, Smart Hospitals: How One Doctor’s Checklist Can Help Us Change Health Care from the Inside Out).
Dr Gawande has worked with the WHO to implement safe-surgery checklists covering items such as the risk of blood loss, antibiotic prophylaxis, and surgical-site marking in hospitals in eight cities (Toronto, New Delhi, Amman, Auckland, Manila, Ifakara, London, and Seattle – representing a variety of economic circumstances and diverse populations of patients) around the world. In 2007 and 2008, this approach cut the death rate in these hospitals in half to 0.8% and complications were cut nearly 60%, according to a published study.
Clearly these books and articles should be required reading for all those Australian politicians, policy makers, bureaucrats and hospital managers who are committed to improving health care quality and saving health care dollars.”
• Dr Lesley Russell is the Menzies Foundation Fellow at the Menzies Center for Health Policy, University of Sydney/ Australian National University and a Research Associate at the US Studies Centre, University of Sydney. She is currently a Visiting Fellow at the Center for American Progress in Washington DC.