Jan 15, 2009

Not Just Great Ideas: The Surgical Safety Checklist and the ICU Walker

Deepa, you took the words right out of my mouth! Never underestimate the power of a checklist...

I'm a last minute packer. I usually don't open my suitcase and fill it until the night before I leave for a trip. Sometimes, I only give myself an hour before I have to bolt out the door. Because I tend to over-pack, bringing at least one extra set of clothes for unexpected events, forgetting something in the chaos of my packing process happens easily and often. After forgetting my cell phone charger, my headphones, my jump drive, my blue jacket, my laptop sleeve, a DVD, my tooth brush, and many other miscellaneous important items on various trips, I decided that I had to create a checklist.

I opened up Word and created a checklist that so far, has helped tremendously. Ever since I've created it, I haven't forgotten anything! Click here to see the list.

Years of psychological and human factors research have proven that we are fallible. As hard as we try or hate to admit it, human errors are bound to happen. So, why pretend it never happens? Especially when some kinds of forgetting endanger others and can lead to dire consequences. Several industries have transformed themselves with human errors in mind. The airline industry is a favorite example. As a result of air craft design, regulation, the use of checklists, and other systems designs, we are almost guaranteed to reach our final destination safely. According to data collected between 2000 and 2005, the chances of a fatality on a US airline flight was one in 22.8 million (1).

Health care is slowly following in the footsteps of the airline industry. Several interventions from preventing central line infections to preventing pressure ulcers capture best practices and allow for measurement of progress-- all to achieve desired results. Click here to see other such interventions.

At IHI's 20th Annual National Forum, Don Berwick and Atul Gawande made an announcement about the enormous potential of the WHO Surgical Safety Checklist to save lives. Click here to watch! A paper published in the New England Journal of Medicine, suggests that implementation of the checklist can reduce inpatient complications and prevent deaths. In a one year pilot study conducted in eight locations from across the world, inpatient complications were reduced from 11% to 7% and the rate of death declined from 1.5% to 0.8%.

Here are some more numbers: It is estimated that 234 million operations are performed globally every year. With the observed reduction in inpatient complications and deaths, the checklist could prevent 9,360,000 complications and 1,638,000 deaths (numbers calculated manually, not reported in paper). On top of that, the surgical safety checklist is a one page document with 19 steps-- a rather inexpensive intervention that is readily adoptable. That's amazing potential to save lives!

Checklists aren't the only type of systems redesign that can help improve health care. Taking a note from the airline industry again, there many processes in health care that can be redesigned and standardized to absorb human errors and make safe execution the only option (2). For example, buttons in the cockpit are color coded, of specific shapes, and can be manipulated in a standardized way. A cockpit is designed to be user-friendly. Shouldn't health care be user-friendly?

Let's look at a specific health care process: getting intensive care patients out of bed and walking. Research conducted by Dr. Dale Needham of Johns Hopkins School of Medicine has shown that ICU patients benefit from getting out of bed and walking from time to time (3). These benefits include preventing muscle atrophy, improving lung function, and even decreasing the length of ICU or hospital stay. But, as you can imagine, this is not an easy task. Most ICU patients are weak and are hooked up to several devices. The current process just to prepare for walking takes 40 minutes, two nurses, and probably great dissatisfaction from patients-- who would want to get out of bed if it took 40 minutes? On top of walking with the chaos of cords and wires at your side, this kind of venturing out of bed requires a respiratory therapist and someone to follow the patient closely with a wheelchair in case the patient slips or needs to sit down immediately.

This process clearly could use some systems redesign. Accepting the challenge were eight biomedical engineering undergraduate students at Johns Hopkins University (JHU). They decided to design a walker that would allow ICU patients to get out of bed and walk around safely. Joshua Lerman (JHU '08) and his team first conducted a little research and collected about 50 objectives from doctors, nurses, and patients including safety of the innovation, ease of use, comfort, and maintenance. The improvement innovation also had to be self-contained, accommodate several medical devices, and fit in typical hospital corridors. Patient safety was their primary objective.

After several draft ideas including large adjustments such as, avoiding stress on the wires connecting the patient to medical equipment, and minute design details such as, the type of cloth used for the built-in seat of the walker, Josh Lerman and his team finalized their design. The ICU walker, or more formally known as the ICU Mover Aid, consists of two parts: 1) a streamlined tower that consolidated all necessary life support equipment and 2) a walker/wheelchair combination.

The final product reduces the chaos of several life support devices attached to the patient making it safer to walk, requires only a respiratory therapist to monitor and walk with the tower and a physical therapist to stand behind the patient and walker, and can be easily maneuvered through typical hospital corridors. The ICU walkers are now in use at Johns Hopkins.

I'm continually inspired by the ICU walker project because the improvement was created by students. As Dr. Berwick mentioned in his 2008 Forum Speech, hospitals have at least a 100 processes that each have best practices. While learning about patient safety and quality improvement is important, I don't think students have to wait until after completion of professional school to become a part of improvement work. Students are sets of fresh and enthusiastic eyes-- why not participate in improvement now?

IHI Open School leaders, Andy Carson-Stevens from Cardiff University in Wales and Rachel Fesperman of University of North Carolina- Chapel Hill, while at the IHI Open School Congress on January 10th proposed a way for students to get involved in the implementation and adoption of the WHO Surgical Safety Checklist. Medical students around the world participate in a surgical clerkship where they have the opportunity to observe and sometimes participate in the operating room. Andy and Rachel believe that these medical students can be mobilized for quality improvement.

These medical students can take ownership of the WHO Surgical Safety Checklist (or an institution's own surgical safety checklist) by memorizing it and taking notes on adherence to the checklist. Not only will the medical students be indoctrinated in best surgical safety practices for their own future careers, but they will become an army of data collectors-- measuring the impact of the implementation of the checklist from quantitative patient outcome results to more qualitative communication improvements within the surgical team. Other professional students can also easily get involved by helping with the analysis of data and developing suggestions for improvement.

There's a quote by Margaret Mead that is immortalized on the walls of our offices just above my desk and it reads, "Never doubt that a small group of thoughtful, committed citizens can change the world. Indeed, it is the only thing that ever has."

The WHO Surgical Safety Checklist and the ICU Walker are not just great ideas for health care, but are improvement projects of great potential that if quickly adopted can change the world of health care. Any particular process in health care that you think desperately needs attention? What are some other great improvement projects? How can students get involved?

1. USA Today on Airline Safety

2. Leape, Lucian. Error in Medicine. JAMA. Volume 272(23), 21 December 1994, pp 1851-1857.

3. The New York Times on Dr. Dale Needham's research on walking and ICU care

More Information about the WHO Surgical Safety Checklist on IHI.org

Other articles about the WHO Surgical Safety Checklist and the ICU Walker:
The Washington Post on WHO Surgical Safety Checklist
USA Today on WHO Surgical Safety Checklist
The New York Times on WHO Surgical Safety Checklist
The New York Times on ICU Walker

Video of Atul Gawande Explaining the WHO Surgical Safety Checklist


Adam S. said...

Today, I had an opportunity to sit in on an Orthopedic Surgery Grand Rounds at Yale School of Medicine. Our guest speaker was professor Tian Wei, a leading spine surgeon in China and chairman of the Ji Shui Tin Hospital (JST) in Beijing.

His presentation was divided into three parts. First, he talked about the 2008 Wenchuan Earthquake in southern China and his institution's involvement with the rescue efforts. Secondly, he introduced JST Hospital, a modern 6,000+ bed teaching hospital in Beijing, which would dwarf any teaching hospital here in the U.S. by size.

The third part of his lecture resonated with me the most: a cataloging of the state-of-the-art techniques and equipment available at JST for orthopedic procedures (pedical screws, computer-assisted drilling, intro-operative 3D imagine, etc). Despite knowing nothing about what the state-of-the-art technologies are for orthopedic surgery, I couldn't help but feel as if Professor Tian was trying to impress the attendees and residents in the room with how advanced his institution is, while he knew full well that the technologies available to his audience here were just as advanced, if not more so. To reinforce that impression, every couple of slides on his powerpoint would show a very glamorous picture of some aspect of China (definitely not medically-related!), whether it is natural scenery of China, or the fireworks from the Bird's Nest during the Olympics, on track with mission: impress. And the whole time I remember thinking to myself, "What can we possibly learn about clinic practices and improvement from this presentation?"

This question was in fact already answered by Professor Tian's presentation, but I was just too dense to see it. Only when Dr. Yue, a Yale faculty surgeon who introduced Prof. Tian, closed the presentation, did I realize that we can, in fact, learn something important about patient care, safety, error-reduction, and best practices from Prof. Tian's institution. And that something was this: JST Hospital, as is the case with many hospitals in China, serves a patient population many magnitudes in size higher than what we deal with in the U.S. In 2008 alone, JST Hospital performed over 33,000 orthopedic procedures; for comparison, I overheard from a neighboring faculty that it would take Yale New-Haven Hospital over 10 years to achieve this landmark. And yet, the post-op infection rate was LOWER in JST than that of the U.S.

Dr. Yue remarked that when he visited JST last year, he was shocked by how sterile everything was. You were literally stripped down, he said, when you entered the surgery wing. Whereas surgeons here would simply put booties over their shoes, surgeons at JST would get new shoes that were completely sterilized. After scrubbing in, surgeons at JST cannot leave the OR, let alone reenter. These measures, along with many others, are why a hospital with a patient volume of 33,000 per year has fewer cases of infection than teaching hospitals in the U.S. with one-tenth as many cases.

What Dr. Yue observed—two environments of orthopedic surgery on two different continents, and the statistical difference in a patient safety marker between the two—can powerfully translate into clinical improvement for us. Despite the U.S.’s apparently superior health care industry, we can still learn how to improve by observing other countries, even developing countries such as China. And this is precisely where clinicians, especially young physicians and medical students, can contribute valuably, by being medical ambassadors who spread best practices abroad and who can bring foreign best practices back into the U.S.

Eva said...

The Robert Wood Johnson Foundation is sponsoring a contest to come up with ideas for improvements in choice architecture, or "nudges", that can improve health, broadly defined. Got an idea for the next medical checklist? The next smart pillbox? Submit your idea via the website. 3 winners will receive $5000 each to put their nudge into practice. Click here for more information!

Eva said...

Here's a link to the Data Collection Form Andy Carson-Stevens has created for the IHI Open School wide Surgical Safety Checklist initiative: http://surgicalsociety.net/Form

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