The Art of Managing Extreme Complexity in the ICU

Another brilliant article by Atul Gawande called The  Checklist in the New Yorker's Annals of Medicine.

Intensive-care medicine has become the art of managing extreme complexity—and a test of whether such complexity can, in fact, be humanly mastered.

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On any given day in the United States, some ninety thousand people are in intensive care. Over a year, an estimated five million Americans will be, and over a normal lifetime nearly all of us will come to know the glassed bay of an I.C.U. from the inside.

Wide swaths of medicine now depend on the lifesupport systems that I.C.U.s provide: care for premature infants; victims of trauma, strokes, and heart attacks; patients who have had surgery on their brain, heart, lungs, or major blood vessels.

Critical care has become an increasingly large portion of what hospitals do. Fifty years ago, I.C.U.s barely existed. ...The average stay of an I.C.U. patient is four days, and the survival rate is eighty-six per cent. Going into an I.C.U., being put on a mechanical ventilator, having tubes and wires run into and out of you, is not a sentence of death. But the days will be the most precarious of your life.

They are precarious because the average patient requires 178  individual actions per day and every one involves risks.  One of the biggest risks is that of a line infection, infections that are so common they are considered a routine complication.  80,000 people get line infections each year and of those between 5 and 28% die.

The I.C.U., with its spectacular successes and frequent failures, therefore poses a distinctive challenge: what do you do when expertise is not enough?

Intensive care is now too complex for clinicians to carry out reliably fro memory alone.  Taking a page from the pilot checklists, designed to help pilots fly planes too complicated to fly from memory alone, Peter Pronovost, a critical care specialist at John Hopkins, designed a checklist to take care of the problem of line infections.

Pronovost and his colleagues monitored what happened for a year afterward. 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.

Checklists help people with memory recall and make explicit the minimum, expected steps in complex processes.

As the tagline on the New Yorker article says, If something so simple can transform intensive care, what else can it do?