Coincidentally, a report in the Jan. 15 issue of Clinical Infectious Diseases by Sanjay Saint and colleagues at the Veterans Affairs Ann Arbor Healthcare System and the University of Michigan stated that 1 percent of hospital patients fitted with a urinary catheter developed a urinary tract infection. Forty percent of all hospital-acquired infections are urinary.
Saint's national study "found no strategy that appeared to be widely used to prevent hospital-acquired urinary tract infections." Nearly half of hospitals had no system telling them which patients had a catheter, and three-fourths had no system to show how long the catheter was in place or whether it had been removed. Furthermore, fewer than 10 percent of hospitals used any system to remind doctors to check daily on whether a patient's catheter was necessary; the longer one is in, the greater the likelihood of infection.
A nationally imposed checklist for safe urinary catheter insertion and removal could sharply reduce the risk to patients and the costs of hospital care.
But checklists need not be limited to reducing the risk of hospital-acquired infections. As Gawande and Pronovost explained, they could be used to enhance the safety of surgery and anesthesia, the treatment of patients with heart disease, diabetes, pulmonary diseases like asthma and a host of other conditions where certain approaches to care have been scientifically established as most effective but are still often neglected.
WHAT YOU CAN DO
The federal Office for Human Research Protections recently ruled that because this quality-control program constituted research on human subjects, every participating hospital must first get approval from its institutional review board. That ruling did not halt the use of checklists in the Michigan hospitals where they had become part of routine care. But it did stop the collection of data based on the lists, which Gawande described as "the driving force behind the effectiveness of the program," until each hospital's institutional review board approved it.
These boards meet monthly, bimonthly or quarterly. Sam Watson, executive director of the Michigan Hospital Association's Keystone Center for Patient Safety and Quality, a sponsor of the Michigan checklist program, said the need for their approval could seriously delay the use of checklists for other aspects of medical care, like preventing hospital-acquired urinary infections - something his center has been working on with Saint.
Gawande suggested that consumers write to their members of Congress and the Department of Health and Human Services, asking that the ruling be reversed. Pronovost suggested that consumers let Congress know that checklist programs "could have a profound impact on their health," ask local hospitals whether they are using checklists to reduce infections and write to state hospital associations asking for a statewide effort to reduce infections.
In addition, Pronovost said, hospital patients should be their own advocates, armed with their own checklist and asking medical personnel whether they are using it "to help assure that I don't get an infection" or asking, "Do I still need this catheter?"
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