Sunday, 25 March 2012

EWTR - Sleepy Tired Doctors are Unsafe Doctors

A major newspaper ran a campaign last year in association with one of the surgical royal colleges against the European Working Time Regulation for doctors especially for surgeons. I am finding it uneasy that we seem to have lost balance on this issue and chosen to take the campaign mode. We learn that the Government could ask for an exemption from EWTR for British doctors. Having done training posts in the pre-EWTD era and regularly worked more than 80 hour weeks in surgery, I welcome the European Working Time Regulation especially for doctors in training; but it not just a matter of opinion.

Acute sleep deprivation has been shown to result in more errors, longer time to complete tasks, slower reaction times resulting in a deterioration in clinical performance. This is the case in both In simulated and real time environment. There are important consequences for chronic sleep deprivation as well. The issue is not just about the duration of sleep but also the importance of quality of sleep, which is indirectly reflected in some of the rules of the EWTR regarding continuous uninterrupted rest periods. Healthcare claims to be learning from the airline industry, the airline industry recognised the issue of working hours and rest and has very strict rules for the pilots regarding flying hours; it is well known that scheduled commercial airlines rank very high in safety.

Since the gradual implementation of the working time directive, now a regulation, this country has not seen any objective worsening of clinical standards such as mortality or complications; in fact most parameters have shown an improvement in standards of care, obviously there is no implication of cause and effect here. However, surveys showing perception that patient care has possibly become unsafe are not really borne out by objective evidence; as a profession based on science we must be aware of both the power and limitations that perceptions can have. Further, I am not aware of even a single consultant level doctor appointed in recent times who has stopped being a consultant and gone back to training due to any recognition that the EWTD allowed poor training. 

If indeed, as a country we wanted to act on a survey perception that EWTR is affecting training, instead of putting patients at potential risk by asking doctors to work longer hours, the powers in charge of training should have addressed the issue by prolonging the period required to complete the training. Part-time trainees do this all the time while providing equal quality of care and with the changing gender profile of the medical profession this becomes even more relevant.

Europeans, in consideration of a better quality of life have taken a societal direction to work lesser hours and for British doctors to some how claim that we are very different from the society we live in, is an attitude incompatible with modern life. Doctors are not super human, though it may seem some of us ardently wish to be so.

There is no scientific, operational or societal reasons to oppose the EWTR. I think it is time to recognise this before the society begins to wonder if there were considerations other than these in the medical profession's decision making; that would damage the image of the profession. There have also been recent suggestions that we can ignore the law, such a thinking does not bode well for a profession held in high esteem by the public. The issue is about safer healthcare, longer duration of working which is highly likely to result in sleep deprivation impacts adversely on safety. 

If I had the opportunity to choose my doctor I would obviously opt for a well qualified and experienced one who is not tired, I am not sure anyone would choose otherwise. Is it unreasonable to ask the government to ensure the same for me through the NHS?

Monday, 19 March 2012

Personalise your cuisine in this restaurant

Personalise your cuisine in this restaurant. Where can you get truly personalised healthcare?

There is a very unique restaurant in Hull that works on amazingly innovative concepts. Its purely vegetarian which in itself is a rare thing for a native British restaurant, it is open only when they have enough bookings, serve only buffet, the first person to book for the day gets to choose the buffet menu, the menu can be from anywhere in the world and many more extraordinary features. Recommend that you checkout their website:
I have been there, it is certainly not the greatest place on earth in terms of decor, service or food. But I still hold that their concepts are unique, praiseworthy and successful.
Wonder what is the lesson from this to healthcare? How can I learn from this? How can I personalise the care I provide to the patients I deal with in a way that is determined by the patients at a very low price, close to home, be profitable, while at the same time having my individuality stamped on it?

I have no personal interest of any sort in this restaurant. I am just amazed by their fabulous and exclusive concepts.

Sunday, 11 March 2012

DVT Prophylaxis for Day Case Surgery

DVT/PE results in 25000 deaths annually (House of Commons Health Committee report 2004-2005)
DVT happens in 15% to 20% of patients having surgery with a risk of 0.5% of PE (Thrift Consensus Group BMJ 1992) Sweetland et al in BMJ 2009 showed that 1 in 815 women who had day case surgery will develop DVT/PE but that study included biopsies etc and in that study only 60% day case rate was seen.

Many procedures that used to be done as in-patients are routinely done as day cases (and short-stay) these days due to different approaches in technique (e.g. laparoscopic), anaesthesia (e.g. not using opioids), pain control, support arrangements, government directives and societal expectations.

Taking the example of laparoscopic surgery it is different but leaves the patient with an equal or higher risk of hypercoagulable state (Caprini et al Surgical Endoscopy 1995).

On the above basis and the fact that many UK hospitals currently perform a high proportion of our surgery as day cases would lead me to believe that about 0.25% of our day cases are at risk of PE (potentially life threatening). It is one too many any way. We must also consider that most DVTs are silent and many PEs are sudden and many PE related deaths are also very sudden. Further many tend to happen within a 12 week period rather than 30 day mortality which we count.

NICE and DoH guidelines state that patients who are over 60 are at risk. They also state that if there was a risk of reduced mobility and acute illness the patients are risk. Normal logic would mean that we will not be able to predict if any individual patient would not have reduced mobility after surgery (especially the ones that involve general anaesthesia); again once a surgical assault has happened by definition the patient is acutely ill for a temporary period even though recovering quickly.

Cost benefit is an important issue DVT prophylaxis is $100 per day (much lower in many UK hospitals) vs treating an uncomplicated DVT $5000 to $8000. According 2005 House of Parliament health committee report the cost of treating DVT/PE is thought to be £640million (hence extrapolated to about £3.7million for a typical trust). It seems that DVT prophylaxis provides good cost benefit.

DVT general prophylaxis reduces complications and costs at the same time.

I suggest that ALL DAY CASE PATIENTS WHO HAVE A SURGICAL OPERATION UNDER A GENERAL ANAESTHETIC MUST HAVE CLEXANE (unless contraindicated)' This is very simple rule to operationalise in the healthcare world where complexity rules.

It is important to note that -
Not provide prophylaxis at all is not option to be considered as it goes against every available evidence and guideline.
-Selective prophylaxis brings it down to individual complex judgement resulting in variation which is most often harmful.
-General prophylaxis for all day case patients having a surgical operation under a general anaesthetic is probably a better option.

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Note: This blog is not the epitome of high science. I would like to think about balanced practical operational views. 

Tuesday, 6 March 2012

Arterial Blood Gas turnaround times

Clinical Lean

Blood gas analysis revolutionised ICU, respiratory and sepsis management. The thing about ABG (arterial blood gas) result is that unless we act upon it quickly, it becomes a total waste of time.

The current turnaround time for blood gas analysis is thought to be 10 minutes; when a point of care testing hand held blood gas analyser is used the turn around time can be reduced to 30 seconds.

The so called total cycle time for blood gas analysis can be reduced from 20 minutes to about 3 minutes when a hand held analyser can be used.

A colleague and friend of mine asked if I would rather have an accurate ABG result in 10 minutes or an inaccurate result in 30 seconds.He went on to state that the hand held blood sugar machines are not used to make a diagnosis of diabetis because they are inaccurate. This line of argument is of course very important. If an inaccurate result is going to harm the patient, a faster inaccurate result will harm the patient very quickly - not good. On the question of POCT (point of care testing) blood sugar, it is very common to use such machines to recognise and treat hypos and hypers though I accept that they are not used for a primary diagnosis of DM. Could the POCT ABG machines used to commence a line of action which could be validated later by a 'proper' machine?

Of course there are pros and cons to this and consequently safety, quality and training issues. The point though is to overcome the reasons why POCT blood gas analysers cannot be used and enable their use safely. After all we moved blood sugar to point of care and now even to patient's homes - at that time arguments about similar issues would have raged. There is no reason why Blood Gas Analysis should not be done at the point of care on a routine basis.It fits in with the broader need to breakdown monuments.

It is a simple and great example of clinical lean in healthcare.