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?

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: http://www.hitchcocksrestaurant.co.uk/

 

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.

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.

© HEMADRI

Follow me on twitter @HemadriTweets

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

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.

Hand Washing compliance 100%

Hand hygiene 100% compliance at Ellis Hospitals. How did they do that?

Mary Ellen Crittenden, Vice President of Quality at Ellis told us that their board had a 'zero tolerance policy' for non-compliance.

They had a huge focus on clinician buy in and cultural issues developed over many months. They had 'secret shoppers' watching people and built it up the tempo gradually to a stage where they then announced a 'three strikes and you are out' policy.

If some one did not wash their hands:

first time - they were sent home with pay
second time - they were sent home without pay
third time - they were sent home and asked not to come back i.e. sacked

As an aside they had the same policy for their employed and visiting doctors, apparently they did not have to sack any of their more than 1000 doctors

Of course not all their deployments to improve quality were this harshly enforced.
Based on similar attitudes and healthcare lean methodology they have also achieved

495 continuous days without a single central line infection
0 - ZERO infections for hip surgery in whole of 2010 and till April 2011

They are looking forward to many other low or zeros soon (colonic surgery, caesarean sections, etc)

Ellis Hospital system in New York (http://www.ellismedicine.org/Home.aspx) is not exactly Mayo or Johns Hopkins but they have achieved great results.

When will we see this here at our work place? Most of us sooner or later are likely to end up as a patient in our local hospitals; well, it could happen tomorrow. We have to get it sorted before we occupy one of these beds!

The proven methods are available; we can do it if we want.

HEMADRI

PS: As recalled from what was heard at a conference in 2011

Homeostasis: The principle behind resistance to change. Doctors know all about it.

Homeostasis: The principle behind resistance to change. Doctors know all about it.

A software demo

In a session with a very enthusiastic innovator/early adopter group of people passionate about improvement; my own relationship with the group is they trust me but also find me intriguing; I offered the participants a particular software; the features of the software are as follows:

1) it was from a different producer and hence at a user level it was different (but not greatly different) from what they essentially use every day
2) it was at least 4 times quicker to switch on (pressing the button to start working with it) - this was proven to the group right in front of their eyes. It was also much quicker to shut down.
3) it does everything that their existing software does and it does more (with a little effort it will also run their existing software)
4) it is very stable - almost never crashes
5) it never gets a virus (not known so far in common use at least)
6) it is completely free (compared to £70 to £250 one off costs associated with their existing software)

The group consisted of 11 people. One person in the group who was already using it and vouched strongly for it.

Nobody (10 out of 10) said they would change to it; one person out of 10 said in a very tentative and cautious manner 'I would try it'. I have since tried with another group of nine people where again only one person said 'I will try it out'. This was the situation for a proven idea/software introduced by a 'trusted' peer.

Change management

Change management is a huge challenge. It is not just in the NHS alone (or may be it is) where we love or we may not love but we will continue to do things that are slow, unstable, complication prone and costly just because we are familiar with it (as an aside, in the NHS anyone who is suspected of doing even mildly unfamiliar things will be accused of behaving in a risky way). In this example of mine, it was only software - its kind of okay. Do we do this in our clinical practice? Though all of us would deny that, there is enough evidence that we show such unnecessarily resistant behaviour and very importantly we are actively supported in such behaviour by some of our authority holders.

There are specific ways of making changes happen and proven methods in healthcare are already available. Many of us are working on it. However, only when 8 out 10 people will be willing to hear, try and change easily for the purpose of improving the safety and quality we provide will be the day where we find Success in Healthcare!!

Change Management and Homeostasis

The origins of this behaviour is far deeper than we think. Most clinicians will be familiar with the concept of homeostasis; human bodies are created to 'maintain' a stable environment for themselves. If things are not working, the body restores it to get back to its previous normality. It is possible to achieve a new/different level of 'normality' (whether it is positive e.g. body building or negative e.g. dietary related obesity) even when there is nothing broken/ill, but for that the mind and body needs to put in specific additional effort - most of the time our mind and/or body does nothing of that kind (except of course in the case of children where there is a continuous effort voluntary and involuntary to achieve an improved status till they get to be adults). Further interestingly it is possible to achieve a newer level of normality on the negative side with not much effort at all but any positive change needs focused prolonged effort (refer back to the examples of obesity versus body building); to get unfit does not need effort, to get fit we need to work very hard.

In our work life, we display similar individual and organisational behaviours. We get to work with an explicit intention of doing a 'normal' days work. Fire-fighting - looking for things that are broken so badly that it will stop us from functioning and restore it to functional levels - we do that. We easily slip into bad habits and behaviours (e.g. employing people to run a bad process rather than redesigning the process) - we do that.

Only some of us take positive efforts to make changes to improve the service. There could be problems in that. Imagine this scenario - if our hospital was the equivalent of a relatively unhealthy human body and one particular organ, say the right arm decided to improve itself by getting fit and muscular - we will have an unfit obese hospital with a well developed strong muscular right arm. Now, is that normal or beautiful? Neither. So the right arm gives up sooner or later surely encouraged by the rest of the body which wants the right arm to 'fit in' with the majority.

How to resolve this issue?

Obviously if you are running an organisation and want to improve it you will be uncomfortable accepting a worsening scenario; justifying it by some logical argument about homeostasis would sound dubious. You may want to try to meaningfully measure the performance of various parts of your organisation and present it transparently. No one likes to be part of a worsening performance graph.

If there is then a desire to go ahead and do something to improve the situation you could refer to http://successinhealthcare.blogspot.com/2012/01/hemadris-four-fundamental-questions-for.html ; try to answer my four fundamental questions with a 'Yes'.

Hmmmm!!!!!

Fixing a big bleeding artery is probably a shade easier than change management but managing change is where the really interesting challenges are.


© HEMADRI

Follow me on twitter @HemadriTweets

 

NB: I was comparing Ubuntu (Linux based) operating system versus Microsoft Vista as exists in my laptop computer on a dual boot. For personal use, I have been mostly using Ubuntu since January 2011 and have found it very good. Would you try it?

PS: I have nothing against Microsoft which has served me well over many years. As of date I have no vested interest in MS or Ubuntu or in any other software company.

COMPLICATIONS OR HARM AND THEIR IMPACTS

COMPLICATIONS OR HARM AND THEIR IMPACTS

M HEMADRI

'Complication' is such a sanitised word. When doctors and nurses speak about complications the language is purely technical, distant and mostly third party. When the complication comes true, it is of course none of those, it is very personal; physically and emotionally hurtful with huge trauma to to the sufferers and their families, in so many ways that we can never understand or even describe.

The following is about a series of extraordinary real life happenings that relates to a normal British person from Portsmouth and his family. The words are a cut and paste from the court judgement with a few minor changes to help normal reading.

-----------------------------------begin of cut & paste----------------------------

• The patient was aged 39. His father had for several years been undergoing kidney dialysis treatment and was suffering from renal failure. The patient was anxious to give his father the opportunity of a better quality of life in his well earned retirement by donating his own right kidney, thus sparing his father further dialysis treatment. The operation was performed on 26^th February 2008. The hospital admits that the operation was performed negligently, and to a degree recklessly. There are proceedings before the General Medical Council against the surgeon in question.

• The consequences of the hospital's negligence have been catastrophic for the patient and his family: physically, psychologically, emotionally and financially. Although the patient's right kidney was successfully removed and transplanted, the patient suffered irreversible failure of the left kidney. In fact he should never have been advised to undergo the operation at all given the grave dangers involved. That negligent advice was compounded by serial mistakes during the operation itself. The patient's life was saved only after many hours on the operating table during which he received over 100 units of blood and fluid transfusions.

• During the course of the operation the patient suffered further complications which have had far reaching consequences: a minor myocardial infarction; ischaemic damage to the bundle of nerves known as the lumbo-sacral plexus, which supply the right leg and foot; a thrombosis of the inferior vena cava.

• The patient was left in total renal failure. He was in hospital for nearly two months, during which he started to receive haemodialysis. He developed a serious drug induced confusional disorder. There were further re-admissions to hospital in March and April 2008, following which he received dialysis treatment three times a week as an outpatient for a year. This treatment affected him profoundly. He became severely depressed, frequently contemplating suicide. He contracted serious infections, one of which necessitated a further admission to hospital for four days in October 2008.

• The patient's own act of altruism and family devotion in donating a kidney to his father, which cost him so dear, was reciprocated by the patient's sister. With the same outstanding altruism and family devotion she in turn donated a kidney to the patient, at very considerable psychological and emotional cost. That operation, performed on 27^th March 2009, was successful. It released the patient from an indefinite regime of dialysis. However, he lives with the constant fear that his body will reject the kidney and it is common ground that when he reaches his early sixties that kidney will require replacement. This uncertainty, and his experiences generally, have left him with an understandable obsession about his health.

• Unfortunately a recurrent infection was imported with his sister's kidney, cytomegalovirus viraemia (CMV). This is a constant source of worry. So is his blood creatinine level which, if raised, can be a sign of kidney rejection.

• The renal failure the patient suffered increases significantly the risk that he will suffer from ischaemic heart disease and a stroke. Consequently he adopts a very careful lifestyle and diet. He has had high blood pressure and high cholesterol levels which cause him constant worry. The immuno-suppressant drugs he takes, in particular to control the CMV, greatly increase the risk of his developing other debilitating and life threatening conditions. The consequence is that he has become fastidious to the point of obsessional about personal and general hygiene, which impacts upon the whole family. He can be irritable and overbearing. He is prone to bouts of weeping.

• There are further serious physical consequences. The nerve damage suffered during the negligent operation has resulted in altered sensation below the right knee. There is hyper-sensitivity, pain and loss of sensation in various parts of the right foot, and clawing of the first and second toes. He has had surgery on the first toe. Further surgery had been planned to straighten and fuse the toes but this drastic measure may be avoided by regular injection of botulinum toxin for life. The issue surrounding this problem with his foot has a bearing on his residual earning capacity. Currently he is unable to run, and walking on uneven ground and stairs presents some difficulty.

• The patient has also been much distressed by urinary difficulties. For a time self- catheterisation was attempted. He found it a dreadful experience. Urinary frequency bedevils his daily life, and results in broken nights for him and for his wife.

• The medication he takes has had unpleasant side-effects including the profuse growth of unwanted body hair, the development of skin acneiform lesions and the deposit of facial and abdominal fat. His inability to exercise has also led to undesirable weight gain. Prior to the operation, the patient was a healthy, fit and active 35 year old man. He took great pride in his health and fitness, running several kilometres each morning to set himself up for the working day. He had enormous energy. He was cheerful, optimistic and extrovert.

• Now the picture is very different. At the age of 39 his daily life revolves around his health worries. He is constantly fearful of infection or changes which may increase the risk of the kidney being rejected. Any venturing from the strictly enforced hygiene of the home is fraught with anxiety. He lives with the certain knowledge that the kidney will require replacement by the time he reaches the age of 61 and that this will be preceded by symptoms of progressive renal failure. It is agreed that his life expectancy has been reduced by 10 years.

• The patient's wife says that the patient is a shadow of his former self. He is lacking in energy. He is exhausted by 9 pm and generally has to be in bed by 10 pm. He is moody and irritable. Their marriage, though very strong, is constantly under strain. The children have been affected and distressed by their father's condition and behaviour and he has bridges to build there.

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The above example was of course extraordinary, further the issue reached the court of law otherwise we would not have heard it in such a profound and full sense. It might have reached us through the press in which case we would have discounted it for journalistic embellishment. In reality most if not every healthcare related 'complication' has impacts on patients' lives which are significant but we will never hear about it.

Perhaps it is time to start describing some of the possible known effects of complications on patient's lives should be described in a way that it really affects patients lives. Let me explain. Do you think the hospitals, doctors or nurses when explaining or consenting patients for surgery ever tell them 'if you had one of the severe complications your marriage could be constantly under strain; your children could be affected and distressed by your condition and behaviour and your may need bridges to be built with them as a result''?

For instance When we talk about surgery on blood vessels in the limb we mention 'amputation' as a possibility. Does that really describe anything to a patient who has never experienced or seen amputation before? Perhaps we ought to tell them how in the initial days even to move from side to side in a bed they would need support, their entire body will need to put in daily heroic effort to cope, they will not be able to do any sort of work for many months, if everything goes well it will hurt during wound healing, during dressing change, during physio, during limb fitting, when using the limb. When goes wrong it will hurt more, more often and for longer – if it goes wrong even more it will hurt every day of their lives (phantom limb pain). They will need to know that the pain will need strong pain killers, strong pain killers will cause constipation, constipation could cause fissure which will hurt even more. They would need to know that if the wound breaks down their raw cut bone could stick out. Well, even after these descriptions we haven’t even made a start on the long list and impacts in a proper way!! These are only physical.

Perhaps we need to tell them that they may not be able to drive a normal car; the pain could drive them to become an alcoholic if they are lucky and a drug addict if they are unlucky. Perhaps they need to know that their family and friends will provide sympathy which the patient could misinterpret and end up feeling patronised resulting in phenomenally strained relationships all around.

God help us avoid complications.

Complications are true complications only when every effort at our command is made to avoid them from happening and yet they happened, otherwise it cannot be called a complication; it is called harm. As an illustration, if a patient developed deep vein thrombosis due to omitted drug thromboprophylaxis, poor mobilisation, poor hydration or pelvic injury at surgery that DVT is healthcare caused harm; similarly if a spinal or epidural catheter was removed without regard to when chemical thromboprophylaxis was given and the patient developed spinal cord problems, that would be harm caused by heal. DVT prevention is an easy example, there are thousands of other ways that healthcare's omissions, commissions and disagreements hurt patients; they can no longer be euphemistically called complications any longer.

Here is something uncomfortable, a number of these problems happen because of us (organisation or individuals) though we are often unable to even recognise that.

Once again, the impacts of complications on peoples lives is something that healthcare professionals would not be able to even begin to understand, or describe. There are specific tried and tested methods to avoid harm or to reduce them to their minimum possible. Most healthcare providers do not have to do world beating cutting edge stuff, they only have to put in some effort to just avoid harm in healthcare. If it was done that would count as Success in Healthcare.

© HEMADRI

Follow me on twitter @HemadriTweets

Ref: http://www.judiciary.gov.uk/Resources/JCO/Documents/Judgments/xyz-judgment-14022011.pdf