Give nurses the checklist

A New Yorker feature this week on intensive care units (ICUs) detailed the problems Peter Pronovost (right) is having getting a life-saving procedure -- the checklist -- adopted by doctors and hospitals.

The magazine has chosen not to place the story online but it reads like a movie script, with Pronovost getting incredible results from the procedure but an ossified medical establishment resisting it.

Checklists have been used in flying jets for over 60 years, and everyone is familiar with the checklists used in rocket launches.

By applying them to prevention of infection in an ICU, with simple steps like washing hands and cleaning the skin with antiseptic, Pronovost practically eliminated a problem which had been killing patients every day.

Checklists help with memory recall and make explicit the steps expected in complex procedures, Pronovost said, but he has gotten few takers among doctors and administrators for their use.

I think Pronovost might get better results if he bypassed himself. Instead of challenging doctors to adopt the checklists, empower nurses to create and demand them.

My big sister was, for many years, a surgical scrub nurse, and beyond the basic cutting-and-sewing everyone deferred to her. She knew what they needed, she knew where it was, and she knew the procedures as well as the surgeons, who asked for her by name.

She was, in many ways, a walking, talking (and attractive) checklist.

So why not give nurses control of the checklist process? Doctors and administrators can have input on what goes into the list, but make nursing staff responsible for having the list followed. Give them the power.

In the article Pronovost found that nurses did a better job with a checklist. It gave them authority. Where before they might have been timid in challenging a doctor's actions, the checklist gave them the backup to enforce the right procedure.

A New England Journal of Medicine article in December 2006 (the link is to Dr. Pronovost's absctract, a MS Word file) followed the Michigan Keystone Center's experience with checklists, studying 103 ICUs over 18 months. (Click here to see the video advertised above.)

The study found that infections were reduced to zero over three months, and two-thirds of the ICUs kept that up over the full 18 months of the study. Simply by using a checklist.

It was a great finding by a fine doctor, which should become a powerful tool in the hands of great nurses.