The Checklist Manifesto
Atul Gawande is the son of Indian immigrants to the US
(a Urologist and Pediatrician), a Rhodes scholar and Associate Professor
of Surgery in Harvard School of Medicine. He temporarily left medical
school to be Bill Clinton’s health care lieutenant during the 1992
campaign. However, his first book "Complications" catapulted him to public
limelight and he is now famous as a medical writer. His latest book, "The
Checklist Manifesto" is based on the work of Peter Provonost, a critical
care specialist in Johns Hopkins.
Provonost drew inspiration from the aviation industry’s
great tool – the checklist, the kind which pilots use before take off. He
decided to tackle just one problem: infections in central venous
catheters. His checklist was (1) wash hands before procedure (2) clean
area with chlorhexidine (3) drape the entire body (4) wear cap, mask and
gown before procedure (5) sterile dressing over insertion site. This
checklist seemed absurdly simple, since this is taught in medical college
ad nauseum. But the truth is that some or other step is missed
almost a third of times. Nurses were given the authority to pull up
negligent doctors. The results showed that central line infection rate
dropped from 11 percent to zero. Two years later, it had prevented 43
infections, avoided 8 deaths and saved the hospital approximately $2
million.
Impressed by this remarkable idea, Gawande in his
capacity as director of WHO’s Global Patient Safety Challenge, conducted a
study in 8 hospitals all over the world ranging from a rural hospital in
Tanzania to a high-tech institution in Seattle. A 19 point checklist to
reduce infections in surgery was created. The results were startling.
Without adding a single piece of equipment or spending an extra dollar,
all eight hospitals saw the rate of major postsurgical complications drop
by 36 % in the six months after the checklist was introduced; deaths fell
by 47 %.
His book reaffirms a powerful insight that as we are
swept away in a technologically complex world, simple interventions which
cost nothing like a to-do list may have powerful impact on outcomes. (The
New York Times, 23 December 2009).
The Truth About Telemedicine
The cleverest defenders of a faith may be its greatest
enemies. Though doctors will always speak positively and enthusiastically
about telemedicine, they are often deeply reluctant to embrace it. For
many doctors, telemedicine seems to depersonalize the relationship and
sabotage trust.
A recent study by the University of Texas Medical
School in Houston set out to study how telemedicine would reduce
complications, mortality and hospital stay in ICU patients. Every ICU
patient in the study received the usual on-site care throughout the study,
as well as all the additional audiovisual and vital signs monitoring
offered by a remote critical care specialist 24 hours a day. In addition,
each patient’s physician could choose the degree to which the remote
specialists would be involved in delivering direct care — that is, giving
orders and intervening from afar.
Physicians allowed total authority to Tele ICU in only
31% patients, and authority to make changes only in life threatening
emergencies in the rest. After adjustment for severity of illness, there
were no significant differences associated with the
telemedicine intervention for hospital mortality
(relative risk, 0.85; 95% CI, 0.71 to 1.03) or for
ICU mortality (relative risk, 0.88; 95% CI, 0.71 to 1.08). However,
majority of doctors in the study chose to have as little remote
involvement for their patients as possible. Many were worried about
telemedicine’s effect on their relationships with patients and that it
might adversely affect care. Both doctors and nurses resented the feeling
of someone always looking over their shoulder. And this finally may play a
greater role in slowing the acceptance of telemedicine than anything else.
(JAMA 2009; 32: 2671-2678)