Safety checklists have been adopted by numerous industries to prevent errors and save lives. Checklists have been used for decades by industries as diverse as the aviation industry, construction companies, and professional chefs to prevent mistakes. In medicine, checklists have been used in the operating room to prevent surgical errors and for central line placement to prevent catheter-related blood stream infections (CRBSIs).
The pioneer of safety checklists in medicine is Dr. Peter Provonost who spearheaded the Michigan Keystone ICU Project that ended in 2006. The checklist used for central venous catheter placement is simple and involves only five key steps that are rooted in evidence-based medicine: wash your hands; cleanse the insertion site thoroughly with chlorhexidine; maximal barrier precautions (wear a mask covering the nose and mouth, a cap covering all your hair, sterile gown, sterile gloves and use a wide sterile drape over the patient); a nurse or observer is empowered to stop the procedure if there is any break in sterile technique; and there is a daily review of central line necessity.
The checklist summarizes all of the vital elements required to minimize the risk of CRBSIs. However, implementation requires intensive staff education and buy-in as well as a system-wide culture change. Nurses must become emboldened to stop a procedure when doctors don’t wash their hands or thoroughly cleanse the insertion site with chlorhexidine. In addition, healthcare providers must believe that CRBSIs are preventable and no longer inevitable.
In the Michigan ICU Collaborative, Dr. Provonost introduced this safety checklist and changed the culture within the Intensive Care Units of over 100 hospitals in Michigan. Over an 18 month span, the rate of CRBSIs decreased from 7.7 infections per 1,000 catheter days to 1.4 infections per 1,000 catheter days. This project was estimated to save 1,500 lives and $175 million.
How important is this area? In the United States, roughly five million central lines are placed each year. CRBSIs are reported to occur at a frequency of between 3-8% depending on the region studied. Approximately 80,000 CRBSIs occur each year in the U.S. which either cause or contribute to 28,000 deaths per year. The estimated cost of treatment of a single CRBSI is approximately $45,000 which equates to an annual cost of $2.3 billion to treat these infections in our country. If this checklist can be successfully implemented nationwide and lead to an identical reduction in CRBSIs as was seen in the Keystone Project, the intervention would save 23,000 lives and save our country roughly $1.65 billion each year.
This proven program will now be rolled out in at least 28 states in the United States with the goal of reducing CRBSIs by 75% within 3 years. This is an ambitious project that is being supported by the US Health and Human Services Secretary Kathleen Sebelius, but is well worth the effort. None of these interventions is particularly new and it is unclear which of the interventions is of the most benefit. What is known, though, is that compliance with the entire bundle and a sustained change in the culture of a hospital to a “culture of safety” will definitely lead to a reduced incidence of CRBSIs and will ultimately reduce mortality and healthcare costs.
Joseph Esherick, MD, FAAFP is the Associate Director of Medicine and the Medical ICU Director at the Ventura County Medical Center in Ventura, California. He is also an Associate Clinical Professor of Family Medicine at The David Geffen School of Medicine at UCLA. He received his medical degree from Yale University School of Medicine, New Haven, Connecticut, and completed a family practice residency at the Ventura County Medical Center, Ventura, California. He is board certified in family medicine and the author of the Tarascon Primary Care Pocketbook and the Tarascon Hospital Medicine Pocketbook. He instructs the Hospitalist Procedures course for the National Procedures Institute and is an editorial board member for Tarascon Publishing and for Elsevier’s First Consult.
Dr. Esherick is the author of some of Tarascon Publishing’s best-selling titles including:
the Tarascon Medical Procedures Pocketbook, Tarascon Hospital Medicine Pocketbook and Tarascon Primary Care Pocketbook. These titles are available in print and mobile (iPhone, Android and Blackberry
 Zingg W et al. Impact of a Prevention Strategy Targeting Hand Hygiene and Catheter Care on the Incidence of Catheter-related Bloodstream Infection. Crit Care Med. 2009; 37: 2167-2173. Link.
 Laurance J. Peter Pronovost: champion of checklists in critical care. Lancet. 2009; 374: 443. Link.
 Frasca D et al. Prevention of Central Venous Catheter-related Infection in the Intensive Care Unit. Critical Care. 2010; 14: 212-219. Link.