5 ms·

The Checklist: If something so simple can transform intensive care, what else can it do?

31 points by nickb 19y ago

ph0rque 19y ago
Reading this, it seems that maybe the first market for Trevor Blackwell's Anybots might be robo-nurses. Being computers, they'll be able to follow algorithms perfectly.
- nickb 19y ago
  Liability's way, way too high for that. Industrial uses where there's no chance (or a small chance) of injury to humans is a lot better application.
deleted 19y ago
[deleted]
Tichy 19y ago
Oh man, that story interests me, but why can't they just get to the bloody point??? I stopped reading after page two, and there still was no mentioning of a checklist...
- rms 19y ago
  The Boeing B-17 was an early four engine plane and was extraordinarily complicated. Previous planes were simple enough that checklists were unnecessary but the B-17 only became practical with the introduction of a pre-flight checklist. The current state of Hospital Intensive Care is compared to flying a B-17 before the checklist was used. Empirical evidence is given about IV line infections, a major problem in ICUs. A 5 step checklist lowers the 10-day line infection rate from 11% to 0% at Johns Hopkins, an almost unbelievable result. It is confirmed over 15 months. These results are again confirmed at an understaffed inner city hospital in Michigan with similarly dramatic results. The study from the Michigan hospital is published in the December 2006 publication of The New England Journal of Medicine. Despite these dramatic results, there is resistance against the increased use of checklists. The checklist study author says he can introduce ICU checklists across America for 3 million dollars at the most. Because of the resistance in the USA, the country of Spain will be the first country to use checklists nationwide. The study author hopes that the USA will not be the last country to start using ICU checklists. If anyone here has money to burn, lobbying for the increased use of checklists in intensive care units would get more net local social returns (in lives saved) than building Stanford a new emergency room and it would cost less money.
iamelgringo 19y ago
I moonlight as an ER nurse while I'm finishing my software engineering degree. I've worked ICU for a number of years as well. It sounds simple to institute a checklist, but the key issue isn't the checklist, it's about allowing nurses to hold doctors accountable and the hospital backing the nurses up in those disputes. Say you're a night shift ICU nurse. Your patient craps out at 3am, and your intensivist crawls out of bed to come and "line up" your patient and put them on life support. Do you think that Dr. Intensivist with 15 years of school wants to hear at 3am is a nurse with an associates degree tell him to stop what he's doing and start over because he didn't wash his hands properly before starting. I've had charts thrown at me for stuff like that. This issue is accountability and incentives. This plan places accountability on the doctors, but it puts a lot of strain on the doctor/nurse relationship when that nurse is the one blowing the whistle on the doctor. What we need is an incentive system for doctors. You need both a carrot and a stick. Doctors only get paid when the patient is sick. And, if the patient gets sicker, that doctor spends more time with the patient and bills more. There is no incentive to keeping the patient healthy, only payment for taking care of as many sick patients as possible. Doctors don't like it they generally want to take good care of patients. They just have to pay of $200,000 of student loans, and the only way to do that is to rush and see as many patients as possible. If the doctors received a large bonus every year if their lines did not get infected, or if their patients did not get a pneumonia when the patient was on life support, you better believe that complication rates would go down. If nurses got a small bonus every year based on our infection control practices, we'd all wash our hands a lot more often. But we don't. We're all paid by the hour on a patient assembly line. The doctors or nurses haven't set up this system, the insurance system has. It's just the unintended consequences of our third party payer system. Although, there are winds of change. Medicare is starting to threaten hospitals by not paying them if a patient gets an infection from the hospital.
- dcurtis 19y ago
  I don't think the reason doctors forget to wash their hands or create full-body sterile fields for inserting central lines is due at all to compensation systems. They just forget, or they get lazy, or they don't understand how important it is. They're rushed, too. It's human nature. Another, potentially profitable, solution to the problem would be relatively easy using something similar to those new Philips ICU monitors that modularly record pulseox, blood pressure, respiration, etc... When the doctor is about to insert a central line, the nurse can click "central line" and the computer will say, audibly, "wash hands." Then the doctor says "next" and it says "create full-body sterile field. All non-necessary personnel, leave the room now." Then, just before the needle insertion, it asks very quickly "Have you washed your hands, created a sterile field, cleansed with chlorahexadine, and removed all non-necessary personnel?" Again an auditory "yes" will make the machine turn green or something, signifying that the doctor can insert the central line. It will add maybe 10 or 15 seconds to the process, and can have these kinds of flows for every routine procedure. Many doctors would probably consider a machine doing that insulting. But if it saves "thousands" of lives, it's definitely worth it for someone to create a company and build them. I was visiting an ICU for a couple of weeks last month, and I noticed that the nurses almost always do things by memory-- one of them forgot to check the dressing of a central line, and when the doctor asked why, she said she forgot. It says on the piece of paper at her desk that she was supposed to check it, but she doesn't get to sit at her desk very often. There are lots of possibilities for technology to help improve the chances of critical care patients surviving. Like the auditory checklist above, why aren't scheduled things like dressing check/changes, IV fluid refills, and body movement/cleaning automated on some sort of central ICU computer which communicates with nurses using wireless PDAs? The airline Virgin America makes their flight attendants use wireless UMPCs so they are instantly notified when someone orders something from the in-flight entertainment system. When a a patient's IV bag runs out, the nurses PDA can vibrate and the task can be added to a list. Why is this so difficult? It's complicated, expensive, and tedious. But if it saves lives and reduces infection rates, it might pay for itself very quickly. My point is, even though the checklist procedure seems very stupid and simple, it should be integrated with sophisticated technology so it is never accidentally forgotten. I think that's where the future of healthcare is going, especially in critical care. It's too bad there aren't many (any) startups pursuing this field; it's dominated by Siemens and Phillips, and I think that's a reason there's so little innovation in hospital-based systems for patient care. So much money goes into research, as the article points out, but very little goes into implementing the results into practical patient care. That's where technology should come in, not just paper checklists.
edw519 19y ago
An incredibly powerful argument for the effectiveness of "low tech" approaches. Whether it's health care, business, or technology, it's almost always counter-intuitive. That's why it's often such a hard sell. (Case in point at a client of mine: When the parking lot was scheduled for paving, email was sent to everyone. For whatever reason, about half didn't read it or know about it. The next time, paper notices were posted on both sides of every door. Not one person parked in the lot. Who knew?)

31 points by nickb 19y ago

Reading this, it seems that maybe the first market for Trevor Blackwell's Anybots might be robo-nurses. Being computers, they'll be able to follow algorithms perfectly.

nickb 19y ago
Liability's way, way too high for that. Industrial uses where there's no chance (or a small chance) of injury to humans is a lot better application.

deleted 19y ago

[deleted]

Tichy 19y ago

Oh man, that story interests me, but why can't they just get to the bloody point??? I stopped reading after page two, and there still was no mentioning of a checklist...

rms 19y ago
The Boeing B-17 was an early four engine plane and was extraordinarily complicated. Previous planes were simple enough that checklists were unnecessary but the B-17 only became practical with the introduction of a pre-flight checklist. The current state of Hospital Intensive Care is compared to flying a B-17 before the checklist was used. Empirical evidence is given about IV line infections, a major problem in ICUs. A 5 step checklist lowers the 10-day line infection rate from 11% to 0% at Johns Hopkins, an almost unbelievable result. It is confirmed over 15 months. These results are again confirmed at an understaffed inner city hospital in Michigan with similarly dramatic results. The study from the Michigan hospital is published in the December 2006 publication of The New England Journal of Medicine. Despite these dramatic results, there is resistance against the increased use of checklists. The checklist study author says he can introduce ICU checklists across America for 3 million dollars at the most. Because of the resistance in the USA, the country of Spain will be the first country to use checklists nationwide. The study author hopes that the USA will not be the last country to start using ICU checklists. If anyone here has money to burn, lobbying for the increased use of checklists in intensive care units would get more net local social returns (in lives saved) than building Stanford a new emergency room and it would cost less money.

iamelgringo 19y ago

I moonlight as an ER nurse while I'm finishing my software engineering degree. I've worked ICU for a number of years as well. It sounds simple to institute a checklist, but the key issue isn't the checklist, it's about allowing nurses to hold doctors accountable and the hospital backing the nurses up in those disputes. Say you're a night shift ICU nurse. Your patient craps out at 3am, and your intensivist crawls out of bed to come and "line up" your patient and put them on life support. Do you think that Dr. Intensivist with 15 years of school wants to hear at 3am is a nurse with an associates degree tell him to stop what he's doing and start over because he didn't wash his hands properly before starting. I've had charts thrown at me for stuff like that. This issue is accountability and incentives. This plan places accountability on the doctors, but it puts a lot of strain on the doctor/nurse relationship when that nurse is the one blowing the whistle on the doctor. What we need is an incentive system for doctors. You need both a carrot and a stick. Doctors only get paid when the patient is sick. And, if the patient gets sicker, that doctor spends more time with the patient and bills more. There is no incentive to keeping the patient healthy, only payment for taking care of as many sick patients as possible. Doctors don't like it they generally want to take good care of patients. They just have to pay of $200,000 of student loans, and the only way to do that is to rush and see as many patients as possible. If the doctors received a large bonus every year if their lines did not get infected, or if their patients did not get a pneumonia when the patient was on life support, you better believe that complication rates would go down. If nurses got a small bonus every year based on our infection control practices, we'd all wash our hands a lot more often. But we don't. We're all paid by the hour on a patient assembly line. The doctors or nurses haven't set up this system, the insurance system has. It's just the unintended consequences of our third party payer system. Although, there are winds of change. Medicare is starting to threaten hospitals by not paying them if a patient gets an infection from the hospital.

dcurtis 19y ago
I don't think the reason doctors forget to wash their hands or create full-body sterile fields for inserting central lines is due at all to compensation systems. They just forget, or they get lazy, or they don't understand how important it is. They're rushed, too. It's human nature. Another, potentially profitable, solution to the problem would be relatively easy using something similar to those new Philips ICU monitors that modularly record pulseox, blood pressure, respiration, etc... When the doctor is about to insert a central line, the nurse can click "central line" and the computer will say, audibly, "wash hands." Then the doctor says "next" and it says "create full-body sterile field. All non-necessary personnel, leave the room now." Then, just before the needle insertion, it asks very quickly "Have you washed your hands, created a sterile field, cleansed with chlorahexadine, and removed all non-necessary personnel?" Again an auditory "yes" will make the machine turn green or something, signifying that the doctor can insert the central line. It will add maybe 10 or 15 seconds to the process, and can have these kinds of flows for every routine procedure. Many doctors would probably consider a machine doing that insulting. But if it saves "thousands" of lives, it's definitely worth it for someone to create a company and build them. I was visiting an ICU for a couple of weeks last month, and I noticed that the nurses almost always do things by memory-- one of them forgot to check the dressing of a central line, and when the doctor asked why, she said she forgot. It says on the piece of paper at her desk that she was supposed to check it, but she doesn't get to sit at her desk very often. There are lots of possibilities for technology to help improve the chances of critical care patients surviving. Like the auditory checklist above, why aren't scheduled things like dressing check/changes, IV fluid refills, and body movement/cleaning automated on some sort of central ICU computer which communicates with nurses using wireless PDAs? The airline Virgin America makes their flight attendants use wireless UMPCs so they are instantly notified when someone orders something from the in-flight entertainment system. When a a patient's IV bag runs out, the nurses PDA can vibrate and the task can be added to a list. Why is this so difficult? It's complicated, expensive, and tedious. But if it saves lives and reduces infection rates, it might pay for itself very quickly. My point is, even though the checklist procedure seems very stupid and simple, it should be integrated with sophisticated technology so it is never accidentally forgotten. I think that's where the future of healthcare is going, especially in critical care. It's too bad there aren't many (any) startups pursuing this field; it's dominated by Siemens and Phillips, and I think that's a reason there's so little innovation in hospital-based systems for patient care. So much money goes into research, as the article points out, but very little goes into implementing the results into practical patient care. That's where technology should come in, not just paper checklists.

edw519 19y ago

An incredibly powerful argument for the effectiveness of "low tech" approaches. Whether it's health care, business, or technology, it's almost always counter-intuitive. That's why it's often such a hard sell. (Case in point at a client of mine: When the parking lot was scheduled for paving, email was sent to everyone. For whatever reason, about half didn't read it or know about it. The next time, paper notices were posted on both sides of every door. Not one person parked in the lot. Who knew?)