A simple list of evidence-based procedures can take the complexity out of safe bedside care.
A recent New England Journal of Medicine article has revealed a startling fact: Hospitalized patients in the United States receive only half of their interventions. As alarming as this is,
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it shouldn't be too surprising, according to anesthesiologist Peter Pronovost, Hopkins Hospital's patient safety expert. "We spend 100 times more on understanding disease biology and identifying therapies than we do on ensuring that patients receive those interventions," he says.
The most common measure to ensure that patients get their medications is using clinical practice guidelines, developed by researchers who reviewed the evidence for a particular condition and created a flow chart of how that condition should be treated. But Pronovost contends that using these foundations for clinical decision making aren't always practical at the bedside. The National Guidelines Clearinghouse (NGF) Web site (www.guidelines.gov) lists more than 1,154 current guidelines, from preventing ingrown toenails to managing intravascular catheter-related infections.
Although guidelines are important, they are typically unwieldy, written by and for physicians, and are set up to cover all treatment possibilities for specific diseases or conditions. For example, the standard for managing intravascular catheter-related infections covers 24 pages with 210 supporting references. This complexity, Pronovost says, tends to shut out other care team members from applying a second set of eyes to therapy decisions.
Instead, Pronovost advocates a simple solution: Convert a guideline into a one-page checklist of interventions to ensure compliance with evidence-based therapies or procedures, which can be used and understood by physicians, nurses, pharmacists, respiratory therapists and-most importantly-patients and their families.
To reduce bloodstream infections, Hopkins Hospital care teams have developed just such a checklist for inserting central lines, using Centers for Disease Control guidelines. These include such evidence-based criteria as insertion site, sterile dressing and skin prep. Nurses assist physicians with this procedure and are empowered to intercede if the doctors don't follow the checklist. This intervention, along with training provided by Hospital Epidemiology and Infection Control, has dramatically reduced bloodstream infections in both the surgical and medical intensive care units. Other hospitals have applied these techniques to nearly eliminate surgical-site infections and hospital-acquired infections, according to Pronovost.
The Hospital and the Hopkins Medicine Center for Innovation in Quality Patient Care have teamed up on several cardiovascular risk-reduction projects, aimed at making sure that different coronary disease patient populations are receiving drugs and lifestyle counseling recommended by the American Heart Association and American College of Cardiologists. This checklist of scientifically based standards has resulted in the compliance rate increasing above national benchmarks on the Halsted 5 cardiac telemetry unit.
"Checklists have proven to not only ensure that patients are well protected against harm," Pronovost says, "but are a means to measure performance more easily and give constructive feedback to caregivers."
, December 2003
