Tuesday, 9 April 2013

Breaking down monuments

Here are a few examples of monuments that we can break down.

Ultra-sound scan room

There is no real need for in-patient diagnostic USS to be done in a specific room. Put them on wheels and take them to the patient on-demand. Doctors get bleeped for opinions for in-patients and they go to the patient, no reason why diagnostic USS cannot be done by the bedside after drawing the curtains around. This spares physical space for more work do be done (I think the managers call it creating capacity).

USS for outpatients - could it not be done at patients' home? District nurses do dressings at home why not USS?

Flexible Sigmoidoscopy

For in-patients diagnostic flexible sigmoidoscopy can be done in their own beds during ward rounds. For outpatients it should be done during the consultation at which it was thought to be required and in that same consultation's examination room. Why do we think we have the right to ask the patient to come back for something that can be done then and there?


In-patient diagnostic gastroscopy could very easily be done at the bedside or in the relevant ward's treatment room. Outpatient gastroscopy should be done in the consultation room at the same time as the consultation at which the gastroscopy was thought to be needed. Have we not heard of ENT surgeons doing nasal endoscopy in OPD? Have we not heard of ultra-thin scopes? Have we not heard of oral sedation if it was indeed necessary?

Oh, by the way, we have not obviously heard of companies willing to provide clean scopes by motorcycle courier delivery wherever we want.

We have this rigid old-world belief that patients should be moved around to where the 'facility' is and when that is not possible clinicians and others should become runners to connect patients and a variety of facilities. We have to stop such thinking and move with the modern world. We used to run to telephones

Arterial Blood Gas analysis

Hand held ABG analysers are available and these ought to be used as POCT (point of care testing). It is well known that blood gas results have to be acted upon within minutes if it needs to make any difference to patients. ABG analysers are situated as some centralised monuments when they should be available near the bedside of any acute patient anywhere in the hospital. We call for a demolition of this monument.
This blog has already argued for improved ABG turn around times as an example of clinical lean

Bedside Hemoglobin, WBC and other testing

Hemocue POCT hemoglobin testing has been available for a few decades and has been used by many para-medical services but still not used routinely in many hospital operating theatres and other areas. There is really no reason why this should not be available anywhere in the hospital or be carried around by doctors and nurses. When we can provide treatment in life and death situations using POCT blood sugar testing, we could do these couldn't we?

General Practitioners as Gate Keepers

In the modern world where information is provided in plenty by Dr Google, where patients are far too knowledgeable than when the NHS was created 60 years ago, patients must have the liberty of seeing any specialists of their choice without having to go through a general practitioner. Seeing the specialist directly happens in other parts of the world especially with post service self-pay patients, in UK having pre-paid patients do not get the same liberties or choices. There are innumerable myths on the gate keeper role of UK GPs which need to be challenged if clinical practice is to be compatible with current expectations.

This in no way an attack on the role of GPs as clinicians providing an invaluable service and is essential; I am only questioning if any value is really provided by the gate keeper function and whether there is any sense in putting hurdles in a particular patient's chosen pathway.

There will always be a 'this is too risky and against the rules/regulations' brigade. I am looking at how we can innovate and improve safely. Yes, if we put it that way, risk and improvement do not make comfortable bedfellows. 

Please add your ideas on what monuments that you would seen broken down in your hospital/clinic by leaving a comment below.

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