Alternatives to the medical checklist?

In Maryland, state leaders recently kicked off a program that will send 45 teams of observers to 47 hospitals to record the hand-washing habits of doctors and nurses. Governing Magazine calls the teams, spies. They have to be anonymous in order to alleviate the potential Hawthorne effect.

So far, the medical checklist is the most successful and best known nudge for improving hand-washing habits in hospitals, but the program’s FAQ makes clear it is open to other strategies that include “campaign branding, addition of new members to the multidisciplinary HH (hand hygiene) team, hand hygiene education, signage, environmental enhancements, improved reporting process, new tool development, enhanced communications concerning HH, and others.”

A reader’s proposal for more consistent handwashing in hospitals

Reader Calvin Freeman wants to combine technology and a cliff notes version of the medical checklist to reduce infections in hospitals.

Use an infra-red beam across the doorway to activate a large silent Red Message that says “Please wash your hands” every time someone enters the room. The sign should be placed so that the person entering cannot miss it and that it is visible to patients but not intrusive enough to wake a sleeping person. The sign would nudge not only busy hospital staff, but also visitors.

Choice architecture in the hospital

For those who weren’t reading the New York Times last May.

Medical researchers know that people on ventilators should have the heads elevated because it keeps bacteria from traveling up from the stomach to the breathing tube and into the lungs. But “when you have to rely on someone to do it, it’s not going to happen every time,” Dr. Michael Gropper, of UCSF Medical Center, told the paper.

So Dr. Gropper made a new rule. Unless there was a written order from a doctor saying that a patient should be lying down, every patient on a ventilator had to be sitting up.

The rule was one small part of a common-sense campaign to reduce infections in the intensive care unit over the last two years. None of it was cutting-edge science, but it has made a big difference: the incidence of ventilator-associated pneumonia has fallen more than 40 percent since 2005.

Medical checklist

Joseph Simmons of Yale’s School of Management points to a nudge from Atul Gawande’s New Yorker piece that reduces doctor error in treating hospital patients. Because a single patient’s medical care can require hundreds of decisions each day, some doctors and hospital administrators have experimented with using checklists for certain treatments. The checklists contain simple, routine actions, all of which doctors learned in medical school but may simply forget to follow because of time constraints, stress, or distractions. For instance, the checklist designed by a critical care specialist at Johns Hopkins Hospital for treating line infections includes the following items:

(1) wash their hands with soap, (2) clean the patient’s skin with chlorhexidine antiseptic, (3) put sterile drapes over the entire patient, (4) wear a sterile mask, hat, gown, and gloves, and (5) put a sterile dressing over the catheter site once the line is in.

Johns Hopkins’ doctors were stunned by the results from the line infection checklist.

The results were so dramatic that they weren’t sure whether to believe them: the ten-day line-infection rate went from eleven per cent to zero. So they followed patients for fifteen more months. Only two line infections occurred during the entire period. They calculated that, in this one hospital, the checklist had prevented forty-three infections and eight deaths, and saved two million dollars in costs.

The checklists provided two main benefits…First, they helped with memory recall, especially with mundane matters that are easily overlooked in patients undergoing more drastic events. (When you’re worrying about what treatment to give a woman who won’t stop seizing, it’s hard to remember to make sure that the head of her bed is in the right position.) A second effect was to make explicit the minimum, expected steps in complex processes. (The critical care specialist was) surprised to discover how often even experienced personnel failed to grasp the importance of certain precautions. In a survey of I.C.U. staff taken before introducing the ventilator checklists, he found that half hadn’t realized that there was evidence strongly supporting giving ventilated patients antacid medication. Checklists established a higher standard of baseline performance.