Contents
A central venous catheter is a thin tube that is threaded through a large vein to just short of the heart. In intensive care units, it is part of everyday practice. If it is inserted carelessly, germs get straight into the bloodstream. In the United States, experts estimate that around 80,000 patients are infected this way every year, and about 31,000 of them die. The knowledge of how to prevent this had long existed. It just didn’t reliably reach the bedside. This is where Peter Pronovost, then an anesthesiologist and critical care physician at Johns Hopkins University in Baltimore, stepped in – an example of Simplicity.
The problem wasn’t a lack of knowledge
Situation
Every doctor in an intensive care unit knows that you wash your hands before the procedure and work under sterile conditions. Even so, in everyday practice individual steps get skipped: under time pressure, at night, in an emergency or when something happens to be missing. Each single omission seems harmless. Together, they cause infections that could have been avoided.
Link to the principle
Carl von Clausewitz described this pattern in his work “On War”: “Everything in war is very simple, but the simplest thing is difficult.” The answer to such friction is not even more knowledge. The answer is a form that holds even under pressure.
Five steps on one sheet
Situation
Pronovost writes down what is already considered correct and condenses it into five steps: wash your hands with soap; clean the patient’s skin with the disinfectant chlorhexidine; cover the entire patient with sterile drapes; wear a sterile gown, cap, mask and gloves; put a sterile dressing over the insertion site. Added to this is the advice to avoid the groin as an insertion site, because more infections occur there.
Link to the principle
The list contains nothing new. Its strength lies in the fact that it fits on one sheet and leaves no room for interpretation. Here, simplicity means stating the most important things so concisely that they still apply in the worst minute of a night shift.
Behind the list is a clear rule
Situation
According to reports on the project, including those by the surgeon and author Atul Gawande, the sheet alone was not enough. Nurses were given the task of following the steps and were allowed to stop a doctor who skipped one. The necessary supplies were gathered in one place so that no one had to search for them.
Link to the principle
Simplicity concerns not only the text but also the process. If you first have to open several cupboards, sooner or later you will skip a step. Clear responsibility (who checks, who stops) turns a recommendation into an assignment.
Michigan: a whole region joins in
Situation
In 2003, the Keystone project starts in Michigan, funded by the U.S. Agency for Healthcare Research and Quality (AHRQ). A total of 103 intensive care units, most of them in Michigan, introduce the checklist and report their data. The results appear in the New England Journal of Medicine in December 2006. The median infection rate falls from 2.7 to zero per 1,000 catheter-days within three months. The decline lasts throughout the study’s 18 months; at the end, the rate is up to 66% below the baseline. For the first 18 months, those involved estimate that more than 1,500 lives and over $100 million in costs were saved. A follow-up study in the British Medical Journal in 2011 finds about 10% lower mortality among older intensive care patients in Michigan than in 11 neighboring states. The researchers stress that this cannot be attributed with certainty to the project alone.
Link to the principle
A simple plan can be transferred. It needs no specialists to explain it, and it works in a university hospital just as well as in a small county hospital.
What simplicity does not mean here
Situation
Medicine in an intensive care unit remains highly complex. Pronovost does not simplify treatment, but the one procedure in which things go wrong particularly often. In 2008, he receives a MacArthur Fellowship, and in the same year, Time magazine names him one of the 100 most influential people in the world.
Link to the principle
Simplicity is not a shortening of reality. It is the decision to put in place, at the critical point, a form that everyone understands and no one has to interpret.
Key takeaways
Key lessons
- First ask whether you lack knowledge or only reliable implementation.
- Condense the most important things into so few steps that they still apply in the worst hour.
- Give someone the right to stop things when a step is missing.
- Make the right way the most convenient way.
- Simplify the critical point, not the whole of reality.
Summary
Catheter infections were not a knowledge problem but an implementation problem. Peter Pronovost solved it with a list of five familiar steps, clear responsibility and supplies gathered in one place. In Michigan, the median infection rate fell to zero within three months. The example shows the core of the principle: a simple assignment that everyone understands survives everyday life better than any expert knowledge that exists only in people’s heads.
Sources
- Peter Pronovost et al.: An Intervention to Decrease Catheter-Related Bloodstream Infections in the ICU. In: New England Journal of Medicine 355 (2006), No. 26, pp. 2725–2732.
- Atul Gawande: The Checklist Manifesto: How to Get Things Right. New York: Metropolitan Books 2009.
- Carl von Clausewitz: Vom Kriege (in German). Berlin: Dümmler 1832, Book I, Chapter 7.
