Recipes for checklists and bundles: one part active ingredient, two parts measurement.

To cite: Chopra V, Shojania KG. BMJ Qual Saf 2013;22:93–96. Central venous catheter-related bloodstream infection (CVC-BSI) is common, costly and potentially fatal. For decades, conventional wisdom regarded these infections as inevitable complications of care. This view changed following landmark studies 3 that demonstrated substantial reductions associated with the CVC-BSI ‘bundle.’ 5 Investigators at Johns Hopkins University designed an improvement model that featured (1) a checklist, or bundle, of evidence-based practices (proper hand hygiene, chlorhexidine for skin antisepsis, use of maximal sterile barriers, avoidance of the femoral site); (2) education regarding these infectioncontrol practices; (3) a catheter-insertion cart; (4) daily review and prompt removal of unwarranted CVCs and (5) empowerment of nurses to enforce adherence to these practices. An initial evaluation of this bundled intervention revealed an impressive decrease in CVC-BSIs from 11.3 infections/1000 catheter days to 0/1000 catheter days at Johns Hopkins. Seeking external validation, investigators partnered with the Michigan Keystone Health and Hospital Association to evaluate the CVC-BSI bundle in 103 intensive care units (ICUs) across 77 hospitals. This study again showed a large and statistically significant reduction in CVC-BSIs, from a baseline mean of 7.7 infections/1000 catheter days to 1.4/1000 catheter days. The CVC-BSI bundle had arrived. The success of the CVC-BSI bundle stimulated interest in checklists for surgical safety. WHO’s Surgical Safety Checklist led to substantial improvements in operative outcomes in diverse clinical settings. A study of multiple checklists at different stages in the perioperative period showed impressive improvements in surgical complications and mortality at six hospitals in The Netherlands. These dramatic results—in ICUs and operating rooms— made checklists virtually synonymous with safer innovative care.