Peter Pronovost’s checklist was so obvious it was almost embarrassing. Five steps for putting a central line, a tube into a large vein, into a patient in intensive care. Wash your hands with soap. Clean the skin with antiseptic. Drape the whole patient in sterile sheets. Wear a sterile mask, hat, gown and gloves. Put a sterile dressing over the site.
These steps had been taught for years. In 2001, at Johns Hopkins Hospital, Pronovost asked the nurses in his ICU to watch doctors for a month and record how often each step was done. In more than a third of patients, at least one was skipped.
So the next month, the hospital changed who was allowed to speak up. Nurses were authorized to stop a doctor who missed a step. They were also to ask every day whether any line could come out.
A year later, the ten-day line infection rate in that ICU had gone from 11% to zero. Pronovost and his colleagues were so unsure of the result that they kept watching for another 15 months. There were two infections in that whole period. By their calculation, the checklist had prevented 43 infections and eight deaths in one hospital.
Other doctors were not convinced. Johns Hopkins had money, staff and Pronovost himself walking the halls. What would happen in an ordinary hospital where everyone was stretched thin?
The answer came from Michigan. Starting in 2004, more than 100 ICUs, most of them in the state, took up the approach. Gawande visited one in inner-city Detroit, where morale had been low and staff were leaving. He found nurses doing rounds with clipboards, checking that every central-line checklist had been filled in. They had been doing it for more than three years.
The list alone was not the whole story. Each unit was assigned a senior hospital executive who had to visit at least once a month. In the first month, the executives found that the antiseptic soap the checklist called for was stocked in fewer than a third of the ICUs. Within weeks, every ICU in Michigan had it.
The results appeared in the New England Journal of Medicine in December 2006. Within three months, the typical ICU’s infection rate had dropped to zero. Over 18 months, the rate fell by up to 66%. By an estimate Gawande reported, the hospitals saved some $175 million and more than 1,500 lives in the first 18 months.