Healthcare Checklist… aviation parallel

31 Aug

 

THE CHECKLIST

If something so simple can transform intensive care, what else can it do?

http://www.newyorker.com/reporting/2007/12/10/071210fa_fact_gawande?currentPage=all

 

This is the reality of intensive care: at any point, we are as apt to harm as we are to heal. Line infections are so common that they are considered a routine complication. I.C.U.s put five million lines into patients each year, and national statistics show that, after ten days, four per cent of those lines become infected. Line infections occur in eighty thousand people a year in the United States, and are fatal between five and twenty-eight per cent of the time, depending on how sick one is at the start. Those who survive line infections spend on average a week longer in intensive care. And this is just one of many risks. After ten days with a urinary catheter, four per cent of American I.C.U. patients develop a bladder infection. After ten days on a ventilator, six per cent develop bacterial pneumonia, resulting in death forty to fifty-five per cent of the time. All in all, about half of I.C.U. patients end up experiencing a serious complication, and, once a complication occurs, the chances of survival drop sharply.


Here, then, is the puzzle of I.C.U. care: you have a desperately sick patient, and in order to have a chance of saving him you have to make sure that a hundred and seventy-eight daily tasks are done right—despite some monitor’s alarm going off for God knows what reason, despite the patient in the next bed crashing, despite a nurse poking his head around the curtain to ask whether someone could help “get this lady’s chest open.” So how do you actually manage all this complexity? The solution that the medical profession has favored is specialization.

The B17 Boeing 299

 The plane roared down the tarmac, lifted off smoothly, and climbed sharply to three hundred feet. Then it stalled, turned on one wing, and crashed in a fiery explosion. Two of the five crew members died, including the pilot, Major Ployer P. Hill.


An investigation revealed that nothing mechanical had gone wrong. The crash had been due to “pilot error,” the report said. Substantially more complex than previous aircraft, the new plane required the pilot to attend to the four engines, a retractable landing gear, new wing flaps, electric trim tabs that needed adjustment to maintain control at different airspeeds, and constant-speed propellers whose pitch had to be regulated with hydraulic controls, among other features. While doing all this, Hill had forgotten to release a new locking mechanism on the elevator and rudder controls. 

 

They could have required Model 299 pilots to undergo more training. But it was hard to imagine having more experience and expertise than Major Hill, who had been the U.S. Army Air Corps’ chief of flight testing. Instead, they came up with an ingeniously simple approach: they created a pilot’s checklist, with step-by-step checks for takeoff, flight, landing, and taxiing. Its mere existence indicated how far aeronautics had advanced. In the early years of flight, getting an aircraft into the air might have been nerve-racking, but it was hardly complex. Using a checklist for takeoff would no more have occurred to a pilot than to a driver backing a car out of the garage. But this new plane was too complicated to be left to the memory of any pilot, however expert.

 

 

Medicine today has entered its B-17 phase. Substantial parts of what hospitals do—most notably, intensive care—are now too complex for clinicians to carry them out reliably from memory alone. I.C.U. life support has become too much medicine for one person to fly.

 

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Of course, the B17 was an amazing aircraft, but it too was replaced in time with the advent of the jet age. Take a look at what Randy Sohn jas to say. http://www.enginehistory.org/wbn/WBN02.pdf

 

Sometime around the turn of the century (in an aeronautical sense, anyway), actually in

the late forties and early fifties, the USAF was the not so proud possessor of an abysmal

flight safety record. Jets were new but piston mentalities and methods still

predominated, after all, that was what had gotten everyone through the war years and

no “deskbound Flying Safety or Ops type can tell me how to fly airplanes”! “Break left –

power off – gear, flaps and boards, first one to the club is the hottest pilot”! Sounds

great, doesn’t it? Made great movies, bar stories and – – really b-a-a-d accident records.

Attempts to make pilots realize that no one was attacking their macho in asking for a

change in techniques were met with almost universal derision. The message

transmitted was “the characteristics of the machine have radically changed”, the

message was received/perceived as “those old guys can’t contend with these jets with

their increased speeds and all”.

 

No doubt a similiar mentality exists in the healthcare world.

 

The next step from jets was automation

 

The next step from automation was crew and resource management

 

The medical world is already poking at automation and CRM, just as the airlines did even going back to WWII, but just as then, it was a rather informal deal, only embraced by a few pioneers.

 

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