"What really got us to zero was then we investigated every infection as a defect."
In our annual HealthLeaders 20, we profile individuals who are changing healthcare for the better. Some are longtime industry fixtures; others would clearly be considered outsiders. Some are revered; others would not win many popularity contests. All of them are playing a crucial role in making the healthcare industry better. This is Peter Pronovost's story.
Ask Peter Pronovost, MD, what prompted him to try to slay the dragons of hospital-acquired infections, a strategy credited with saving thousands of lives and millions of dollars. He answers first by talking about his father and why he went into medicine in the first place.
"Dad was misdiagnosed with a type of cancer when I was in college," the Johns Hopkins Hospital intensivist explains. "He was told he had lymphoma." A while later, he got a second opinion at Johns Hopkins and learned he actually had leukemia. "He might have been treated with a bone marrow transplant. But now he was beyond treatment. He was essentially told to go home and die."
Home hospice quality "was poor," and his father died "a horrible death, writhing in pain. They said we've given you all the pain medication we can, there's nothing more we can do. He died unnecessarily and miserably. And I became convinced that patients deserve better than our health system was giving them."
Working in a hospital clinic in Ogbomocho, Nigeria at the end of his medical school years, he saw "every day, literally three to four hundred people waiting in line to come into this clinic, with burns, broken bones, infections. It just seemed never ending. Yet people were drinking dirty water, walking around with lanterns on their heads and they would trip, fall, and get burned." Broken bones came from many vehicle collisions. "And many people were critically ill from drinking dirty water."
That's when, he says, he "developed a broader sense of public health" in his mission to be a doctor.
Pronovost is a professor at the Johns Hopkins School of Medicine in the departments of anesthesiology, critical care medicine, and surgery, and professor in the department of health policy and management, Johns Hopkins Bloomberg School of Public Health and School of Nursing. He also is a recipient in 2008 of the MacArthur Foundation "Genius Award."
But he is best known for his five-point checklist to prevent central line associated bloodstream infections: Wash hands; wear sterile gloves, hat, mask, and gown and cover the patient with sterile drapes; avoid placing catheter in the groin; clean skin with chlorhexidine; and remove catheters when no longer needed.
He developed that strategy and pilot-tested it from 2001 to 2003 at Johns Hopkins, where it virtually eliminated infections, he says. Pronovost then tested and perfected it in the state of Michigan in an effort that ran from 2003 to 2005 called "The Keystone Initiative," which most hospitals in Michigan participated in. Infection rates came tumbling down and the checklist—individualized to each hospital—is credited with saving 2,000 lives a year and about $200 million in avoided cost of care, he says.
Some of it was just using simple logic of what it takes to place a catheter, he explains. "When I walked through the process of the process, what I found was that there was no central place to store all the equipment you need. Gowns were in one place, masks were in another, and caps in another," increasing the opportunity for the process to carry infection.
"So we made a line cart. We got all the equipment and got eight steps down to one."
That made a huge dent in the infection rate. "But what really got us to zero was then we investigated every infection as a defect. That is, when infection occurred, we looked to see where the catheter was placed. Some placed in operating room, some in the emergency department," Pronovost says. "So we went to those places with the data to say, 'These are infections you guys own. You've got to put this program in place.'"
The checklist is only part of the strategy. Equally important is changing hospital culture so that any member of the care team—a nurse or physician's assistant—can stop the process if the doctor neglects one step.
Now, state-by-state, versions of the checklist are being adopted, and Pronovost notes "many states have cut their infection rates by more than half."
This past year, Pronovost has realized many successes from his efforts to improve hospital care.
First, health reform legislation now encourages hospitals to publicly report central line bloodstream infections starting in January 2011, and by 2013, those rates will be used to set Medicare reimbursement. Sometime between now and then those infection rates will be posted on www.hospitalcompare.hhs.gov.
"They get a pay increase if they report, so most hospitals likely will," Pronovost says.
Second, federal funding has been enhanced to improve the science behind infection prevention, an effort that has historically been abysmal, he says.
"We have traditionally spent two cents on the science of health delivery for every dollar we spend to on studying new genes and drugs. So it's no surprise that the science is poor. We haven't invested in it."
Third, throughout hospitals around the country, nurses are increasingly empowered to stop physicians from inserting central lines or catheters if they notice that infection control procedures have not been strictly followed. That has been a huge battle and is still under way, he says. "Nursing culture was not used to questioning physicians, and if they did, they got their heads bit off because doctors were not used to being questioned," he says.
Fourth, in February, Pronovost saw the publication of his book: "Safe patients, smart hospitals: how one doctor's checklist can help us change health care from the inside out." The book is dedicated to his father.
Pronovost says that while there's still more work to be done with hospital infections involving catheters, he's reaching out to some frontiers: creating similar strategies to reduce ventilator-associated pneumonia, pulmonary emboli, and deep vein thrombosis.