Written by Daniel Theodoro, MD, MSCI, associate professor in the Department of Emergency Medicine at the School of Medicine
Infection prevention and aviation may seem like an odd couple to scientists who study germ theory and the ecology of biofilm on medical devices, but in clinical practice lessons from the flight deck may prove as important as the newest technological innovation. In today’s clinical environment the focus of infection prevention is on doing procedures the right way, every day, every time without missing a key step. While the busy clinician is sure to feel pressured when under constant scrutiny to perform seemingly rote procedures, tools from other disciplines may offer innovative approaches to streamline and improve clinical care if they can be successfully implemented.
In the case of my team, our goal is to explore ways to make placement of central venous catheters safer in the emergency room. Central venous catheters (or central lines) are long flexible tubes inserted into large veins in the chest and neck (think jugular vein) when a small vein in the arm or hand simply won’t do. The bigger and centrally located catheter allows providers to infuse large volumes of blood, fluids, and special medications, while making frequent blood draws less painful to the patient. The procedure has many small steps and involves long needles, thin wires and, as with all procedures, carries a risk of complication. In our previous work we showed that using ultrasound to guide the procedure decreased complications such as bleeding and collapsed lung and increased the chances of procedural success by about 15 percent. In addition to these “mechanical complications,” central line insertion carries the risk of an unintended preventable infection. When central line associated bloodstream infections (or CLABSI) occur, they result in prolonged treatment and recovery periods for our patients and cost the healthcare system billions to treat annually. Policy makers have taken note and legislated payment incentives to motivate institutions to promote CLABSI prevention initiatives.
One proposed solution by patient safety experts is to borrow a tool from aviation: the checklist. Dr. Atul Gawande’s book The Checklist Manifesto chronicles the development of checklists in aviation. When planes became more complex, flight fatalities increased because pilots simply forgot to do one of many small simple tasks during flight. Performing every step to prevent CLABSIs is somewhat similar. Some steps, like washing hands, are simple while others, like maintaining perfect sterile technique, are more challenging. Only when all infection prevention steps are consistently performed does the risk of infectious complications decrease.
“Intensive care units that adopt the checklist when inserting central lines can lower the rate of CLABSIs to zero and hold it there for many months.”
A checklist is disruptive technology for some who work in healthcare. It feels “like cookbook medicine.” It intrudes into many health care worker’s deep-seated sometimes sub conscious belief of heroic individualism and independent thinking. But to others it’s a relief because it reduces cognitive load. Cognitive load, in this context, refers to how many things one can keep in mind while performing a specific task. A checklist ensures that no critical steps are missed and, when something does happen, serves to remind everyone to take corrective action. Dr. Gawande’s book goes on to explore the inroads that checklists have made in medicine. Specifically, the work of Dr. Peter Pronovost, whose research in 2006 found that intensive care units that adopt the checklist when inserting central lines can lower the rate of CLABSIs to zero and hold it there for many months.
To many, the emergency room seems like a far cry from the controlled intensive care environment. Undifferentiated medical conditions, unstable patients, and the increasing reliance to diagnose and treat large numbers of patients (there are 136 million annual emergency room visits or 44 visits per 100 people in the United States) creates the impression the emergency room is a busy and risky environment. However, when our team followed nearly 1,000 central lines inserted in the emergency room, we found that our rate of CLABSI resembled that of other intensive care units in the hospital and, in some cases, was even lower. But despite this good news there is work to do. When we examined whether emergency room physicians would use a checklist included in their central line kits, the answer was that they would not. More troubling was they missed at least one infection prevention step in about 80 percent of cases although no patient suffered a preventable infection in the small group we observed.
The challenge to infection prevention in the emergency room (or any environment) is putting disruptive innovations into practice. Workflow issues, staff culture, and environmental issues all conspire to make it difficult. According to our findings, a top down “policy” approach to implementing a checklist is insufficient. Qualitative researchers from emergency room’s that have met some success find it requires executive leadership, staff buy-in, champions, immediate feedback, and ownership. In short, it requires more than a checklist. It requires a culture shift that isn’t easy to come by and would need rehearsal or practice. In the next phase of our implementation process, we look into cross discipline exercises where nurses, physicians, and technicians interact on a dummy and “practice” the right way to do the little things. Once again borrowing a tool from aviation, we plan to use a simulator to build confidence and help overcome challenges to infection prevention in the emergency room just like airline pilots do. Now if we could only wear those cool bomber jackets instead of our white coats!