Monday, January 14, 2008

Checking On Health Care

As a people we like solutions that are BIG, BOLD, and JAZZY!!! Alas, all to often they are mundane, simple, and require a little effort on our part. (My favorite Thomas Edison quote: "Opportunity is missed by most people because it is dressed in overalls and looks like work.")

Case in point, Gov. Ed Rendell's Prescription for Pennsylvania (81 page pdf). One of his initiatives is to reduce hospital acquired infections. Here is an excerpt from the state's website:

The second initiative focuses on improving patient safety and containing costs by eliminating hospital- and health-facility-acquired infections. The Governor noted that most hospital-acquired infections are avoidable. In Pennsylvania, however, the number of hospital infections reported last year was 19,154, which led to nearly 2,500 deaths and more than $3.5 billion in hospital charges.

One example of a hospital- and health-facility-acquired infection specifically addressed in the Prescription for Pennsylvania is MRSA, a type of drug-resistant bacteria that is commonly carried inactive on the skin but can be deadly if it is introduced into the bloodstream. In 2004, there were 13,722 hospitalizations in Pennsylvania in which the patient had an MRSA infection – a rate of 7.4 per every 1,000 inpatient hospitalizations. Data shows that 8.9 percent of those patients, or 1,221 people, died as a result of contracting MRSA.

MRSA can be virtually eliminated from health centers through simple patient-safety procedures. Groundbreaking work by Pennsylvania’s veteran’s administration hospitals has resulted in the near elimination of MRSA infections in those facilities.

The legislation introduced that pertains to this effort is SB 968. A simple explanation is offered, in addition to the full text of the bill. It was signed by the governor on July 20, 2007.

There are, however, even simpler ways of controlling hospital acquired infections. This past December 10's issue of the New Yorker included an article, "The Checklist," by Atul Gawande, that discussed the amazing success of having emergency room medical staff use checklists when treating patients. Yes, a piece of paper, a clipboard, and a pencil. Pilots use checklists, why can't doctors and nurses? (Top item: wash hands).

Here was the result of a pilot project that used checklist for putting lines in patients:
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.

In another study:
In December, 2006, the Keystone Initiative published its findings in a landmark article in The New England Journal of Medicine. Within the first three months of the project, the infection rate in Michigan’s I.C.U.s decreased by sixty-six per cent. The typical I.C.U.—including the ones at Sinai-Grace Hospital—cut its quarterly infection rate to zero. Michigan’s infection rates fell so low that its average I.C.U. outperformed ninety per cent of I.C.U.s nationwide. In the Keystone Initiative’s first eighteen months, the hospitals saved an estimated hundred and seventy-five million dollars in costs and more than fifteen hundred lives. The successes have been sustained for almost four years—all because of a stupid little checklist.

And the cost?
I asked him how much it would cost for him to do for the whole country what he did for Michigan. About two million dollars, he said, maybe three, mostly for the technical work of signing up hospitals to participate state by state and co√∂rdinating a database to track the results. He’s already devised a plan to do it in all of Spain for less.

Unfortunately, in the time-honored fashion of bureaucracies everywhere, the program has been shut down because it is impossible to get the informed consent of all patients and doctors participating. Gawande outlines the problem in a Dec. 30th New York Times op-ed, "A Lifesaving Checklist," and suggests Congress step in.

This is the sort of thing that, if widely implemented, say in a state or commonwealth, could make a huge difference for a small amount of money.

I hope the informed consent issues can be worked out (let it be known that I formally grant my consent for a nurse to make sure a doctor has clean hands before treating me) and that the gov's folks take note of the possibilities inherent in mandatory medical checklists.

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