A Sure Way to Cut Medical Costs AND Save Lives

The New Yorker had an excellent article by Atul Gawande on how using something as simple as checklists (as airline pilots do) can save lives and lots of money in the hospital ICU. (You would think they used them already, but you'd be wrong.)

The checklists provided two main benefits, Pronovost observed. First, they helped with memory recall, especially with mundane matters that are easily overlooked in patients undergoing more drastic events. (When you’re worrying about what treatment to give a woman who won’t stop seizing, it’s hard to remember to make sure that the head of her bed is in the right position.) A second effect was to make explicit the minimum, expected steps in complex processes. Pronovost was surprised to discover how often even experienced personnel failed to grasp the importance of certain precautions. In a survey of I.C.U. staff taken before introducing the ventilator checklists, he found that half hadn’t realized that there was evidence strongly supporting giving ventilated patients antacid medication. Checklists established a higher standard of baseline performance.

These are, of course, ridiculously primitive insights. Pronovost is routinely described by colleagues as “brilliant,” “inspiring,” a “genius.” He has an M.D. and a Ph.D. in public health from Johns Hopkins, and is trained in emergency medicine, anesthesiology, and critical-care medicine. But, really, does it take all that to figure out what house movers, wedding planners, and tax accountants figured out ages ago? . . .

In December, 2006, the Keystone Initiative published its findings in a landmark article in The New England Journal of Medicine. Within the first three months of the project, the infection rate in Michigan’s I.C.U.s decreased by sixty-six per cent. The typical I.C.U.—including the ones at Sinai-Grace Hospital—cut its quarterly infection rate to zero. Michigan’s infection rates fell so low that its average I.C.U. outperformed ninety per cent of I.C.U.s nationwide. In the Keystone Initiative’s first eighteen months, the hospitals saved an estimated hundred and seventy-five million dollars in costs and more than fifteen hundred lives. The successes have been sustained for almost four years—all because of a stupid little checklist.

You would think this would be a no-brainer, but the idea of checklists and regimentation goes against the current medical culture in the U.S. (and elsewhere?), with its emphasis on the doctor as a kind of maverick.

It’s ludicrous, though, to suppose that checklists are going to do away with the need for courage, wits, and improvisation. The body is too intricate and individual for that: good medicine will not be able to dispense with expert audacity. Yet it should also be ready to accept the virtues of regimentation. . . .

“We could get I.C.U. checklists in use throughout the United States within two years, if the country wanted it,” he said.

So far, it seems, we don’t. The United States could have been the first to adopt medical checklists nationwide, but, instead, Spain will beat us. “I at least hope we’re not the last,” Pronovost said. . . .

(Emphasis added.)