Dragon: A Parable

I was also thinking, "that bit about concern for doctors is suspicious." But I couldn't figure out how to make it coherent. Frankly, it's bullshit - we have ample evidence that doctors who own up to their mistakes are less likely to get sued, not more. Plus the particular mistake this checklist is about, line insertion infections, is not something that would otherwise be missed - if it occurs, you know it (as seen in the example of the limo driver in the first article). So I'm not sure how not having a checklist keeps that sort of thing hidden.

From:

australian-joe.livejournal.com

Totally. If anything by admitting that was a factor in the decision I think they've made their legal situation worse.

I'm not sure I agree you'd need informed consent and patient trials to, say, be allowed to use a bandage that had been rolled up differently, though - and that seems to be what they're saying.

From:

digitalsidhe.livejournal.com

Someone behind this move seems to be a complete and total droid.

From:

I have to wonder, though...
The checklist becomes held as the gold standard of care: it's infallible, therefore I must be doing it right, and by following the checklist to the letter, I'm doing everything I need to be doing for this patient.
But is there something the checklist forgot? Is the checklist up-to-date with the latest research?
Nothing against the practice in general, but there was no mention of safeguards against practicioners getting railroaded into rigid lines of thinking.

(Off topic, but did anyone else notice the use of an umlaut in "cooperate" on page 8 of the New Yorker story?)

From:

It seems like the problem you mention already exists, only it's currently spread across multiple mental maps in multiple people who really don't have the time to update it regularly themselves. Having a physical checklist means you *can* have someone who updates it regularly based on the research - we will have to make sure it happens, true, but it isn't even a possibility with the current system. You also need to make sure that there's clear and open lines of communication between the people who do the checklist and the people on the ground - optimally some people would do/be both.

From:

I think the big issue I have with checklists (and I'm not saying I don't like to use them,) is flexibility to do something new.

I first learned of the value of compressions over ventilations in CPR at a conference, almost a year before the AHA released the new guidelines that call for a ratio of 30:2 instead of the well-known 5:1. (In a nutshell, the heart likes to keep going, and we use far less oxygen than 5:1 offers.) Were I still practicing, that knowledge might have made it to my patients. (I *really* hope it's a cold day in hell when they introduce checklists to CPR-- there really aren't a whole lot of steps, and if nothing else, time is of the essence in a serious way.)

On the flip side, there's checklists (in the prehospital setting) for stroke/STEMI, administering epi-pens, and a few other procedures, and I think in that arena, they make a lot of sense.

From:

Oh, I thought it was clear that the checklists were for procedures that have a lot of prep steps, such as putting in lines or putting a patient on a respirator, or things like making sure you've checked to see if the patient needs pain meds now, or things like making sure the hospital is ready to give a patient what they are going to need once they get in (like the Austrian girl, or "gunshot wound to $body_area", etc). After all, checklists don't tell pilots how to fly, they just make sure they don't forget something bloody obvious that they do every single day.

From:

mr-teem.livejournal.com

(Technically, that's a dieresis, not an umlaut. A dieresis is used to indicate a second vowel is pronounced separately; an umlaut changes the sound of the vowel. The mark is the same, though.)

From:

Yeah, I obsess over that kind of thing for a living (just yesteday, in fact, I was debating the merits of importing XML as unicode v. ISO 8859-1), which is probably why I caught it. But more people know what an umlaut is (some, a heavy-metal umlaut) than a diacritical mark.
Nice catch.

From:

mr-teem.livejournal.com

Well, I used to be an expert. I sat on the relevant ANSI and ISO committees back in the day.

From:

See http://www.cms.hhs.gov/apps/media/press/release.asp?Counter=1863

Also see http://www.leapfroggroup.org/for_hospitals/leapfrog_hospital_quality_and_safety_survey_copy/never_events

HHS and insurers are starting to not pay for the added cost of things that simply should never happen in hospital stays. The checklist article is bizzare. I know of many cases where deliberate steps are being taken to reduce the incidence of infections and other preventable complications, and the statistics are collected and used to prove those steps are effective.

I think the article is an abberation in what I'm seeing happen all over the place, in the US and elsewhere.

Edited Date: 2008-02-16 05:21 am (UTC)

From:

Honestly, I don't find it surprising that insurance companies would insist on better means to prevent the preventable, but as soon as someone tries to actually research what such means would be a government bureaucrat puts a stop to it because they need to piss on it first so it smells right. I find it sad and deplorable, but not surprising.

From:

I'm friends with the person in AHRQ (a department in HHS) that funds such studies, as I am with his counterparts in CDC that fund and oversee such studies. One of my co-workers is one a couple of national government-sponsored committees that work on such matters. And I am a co-chair of the national standards committee that defines the patient privacy aspects.

In other words, I have a real professional knowledge of the topic and those who are involved in it.

The op-ed piece you linked-to is simply mind-boggling. It differs strongly from what I have specific knowledge about from multiple sources. This bears some looking-into. So I'm going to forward the article to some of my contacts and find out more about it.

From:

Oh! My apologies, I failed to understand what you were getting at. That would be awesome and I would really appreciate you getting back to me with what you find out.

From:

Here's the response I got from my co-worker...

"The article's take on the ... consent requirement for the IHI sponsored program is bizarre. The techniques recommended are common practice (or should be, but are sometimes skipped). The issue seems to be the checklist. While the checklist is an obtrusive, time consuming way to have a nurse document common practice, it certainly shouldn't require consent from the patient.

"It is interesting this article just came out addressing the checklist. Last week, I provided comments for the Society of Healthcare Epidemiology of America to respond to the IHI about the program. My comments were that, although the practices (gown, gloves, mask and proper care of the insertion site) were laudable, the requirement of a checklist was not productive. My concern was not that of consent. However, there is no evidence that a checklist will improve practice; it will only increase the amount of documentation a nurse has to do and, perhaps, limit the nurse's ability to actually care for a patient. I recommended that IHI seek to encourage measurement for routinely captured care delivery processes that are proven or to focus more on outcomes rather than increasing the burden of process documentation.

"In short, the checklist is a cumbersome and not likely to be helpful. Can you imagine a nurse actually documenting anything but successful technique on a checklist?"

From:

But, that completely contradicts everything in the first article about the utility of checklists, including the statistics! Now I'm terribly confused.

(I'm also rather offended by the implication that nurses would outright lie on the checklist as a matter of course - apparently the doctor-nurse wars are far from over.)

From:

My colleague is directly involved in the issue, as you can see from his comments.

The basic idea is to eliminate sources of bias in data collection to improve the value of the data. There may be better/simpler ways to get the data, such as measuring actual patient outcomes following an emphasis on basic cleanliness techniques.

From:

etherial.livejournal.com

As do I, and I agree with your assessment.

From:

mr-teem.livejournal.com

WTF, over? Process improvement is not the same thing as new materials evaluation. I mean, its why doctors have been washing their hands since, what, the nineteenth century? Was someone complaining then about using too much water?

From:

citabria

I see it this way.

The procedures at issue had been proper medical practice for some time before anyone started using a checklist and recording results. Therefore, a hospital that decides to focus on following proper protocols, without using a written checklist and keeping written records of it, is completely within its rights, even under the government's decision.

As for getting permission, all it takes is getting someone's permission when they're admitted. The checklist is only being tested in ICUs, which means that a blanket permission upon admission wouldn't be that difficult to secure, at least in hospitals where most ICU admissions are not the result of trauma.

From:

From the standpoint of HIPAA, you don't even need permission. All you need is the signature of the patient or their representative that they have received a copy of the hospital's Notice of Privacy Practices. State laws and hospital policies may require more stringent consents, of course.

From:

I was pretty sure a goodly portion of ICU admissions were the result of trauma - certainly the first article mentions several gunshot-wound patients at Sinai-Grace as well as the Austrian girl, and I don't know if the limo driver would've ended up in the ICU if his surgery hadn't gone pear-shaped and given his behavior they wouldn't've gotten permission for, well, much of anything at the time he got there (so no prevention of that line infection for him). That's assuming getting permission is as easy as getting a form signed - I'm pretty sure there's more to it than that (like keeping track of the forms and making sure you do use checklists for signers and don't for non-signers).

But now I find myself thinking that in this case the protocol of ethics is getting in the way of actual ethics (particularly the doctor's creed of "do no harm"). Plus if it happens that trauma ICU patients tend more often to be minorities while non-trauma ICU patients tend to be white. . . things could get *really* messy, especially if it's as effective as it seems to be.

From:

I was pretty sure a goodly portion of ICU admissions were the result of trauma

Actually, consider the people who've had major surgery-- it's typical to spend some time in an ICU post-op. So, trauma, coronary bypass grafts, organ transplants...

From: