Demanding consultant delivered acute care

Who should deal with the most urgent and severe emergencies?

The following runs in every healthcare worker's mind but we usually do nothing about this. Let me describe it.

First time elective referrals at out patients for major conditions gets seen usually by consultants
First time elective major operations usually done by consultants (especially the major ones)

However,
Redo operations after complications due to first time elective surgery - quite often done by registrars or 'middle grades'
First time major emergencies in Resuscitation rooms and dire post operative emergencies in wards and ICUs are usually dealt with by registrars or 'middle grades'

Is that logical? Is that sensible?

Of course in some specialties like vascular, neonatal and a few other, the senior most persons often deal with the most dire things but I am talking about most specialties. For instance in internal medicine an elective referral for a chronic cough or chest pain will normally be seen by a consultant but a severe acid base imbalance, a pneumothorax, undiagnosed sepsis will be first seen often by very junior doctors fresh out of medical school or if the patient was extremely lucky by a registrar or middle grade.

This anomaly should be addressed. But it will not be easy to address. Clinical severity of the condition and clinical severity of any potential adverse outcomes should decide who will see/treat the patient and not mere availability, convenience, historical residual legacies and other administrative/managerial issues. This will demand consultant delivered care (not consultant 'led' care). People will rightly be concerned about the cost; it would be important to recognise that the improvement in clinical quality and the enhanced clinical accountability for outcomes could result in lower overall costs. If on the other hand there was a clear increase in quality the richer economies should accept that as the new benchmark for cost.

Success in Healthcare will depend on the proper utilisation of its very valuable human resource; the utilisation of the human resource should be exclusively based on clinical need - more severe the presenting situation - the more senior should be the primary attending human resource.

Here is where patients could play a part in improving the quality for themselves and in shifting the culture within healthcare. Patients and families could use the consent process to influence better care. Consent is a legal requirement before professionals can provide care hence any caveats in that legal process carries significant weight. Patients and families may or may not be able to define what should be done but they can define what cannot be done; for instance you cannot say you have to be given a blood transfusion but you can say that you should not be given a blood transfusion.  In the same manner I think patients probably cannot demand that only a fully trained healthcare profession should treat them but can possibly decline to accept care from anyone who is not fully trained without them being directly supervised.

For instance my living will or perhaps my consent to treatment form could say 'I, having worked hard and paid my taxes, when I am ill, expect to be treated and cared for at every stage by fully trained clinical staff; if that does not happen I will take it as having possibly received substandard care. Being a responsible citizen and supporter of NHS I am aware of the need for trainees to learn so that future specialists can be created; I will allow trainees to care for me at any time as long as their trainer is physically present and actively training the trainee in a hands-on manner. If the trainer is not physically present and actively involved (for instance if it is a surgical operation the trainer must be scrubbed up and assisting the trainee) I shall consider it as a breach of my right to have received the highest quality of healthcare that I expect and a breach of the consent that I have provided' (** Caution: Using aforesaid statement is likely to negatively affect your healthcare and risk an adverse outcome. The statement is used to make a point and not necessarily for practical use**)

It is patients' choice, let us take it seriously. If you thought this was a bit too assertive - pause for a few seconds and reflect on the day when my above sentences will be cut and pasted by every patient on to their consents and living wills. Or even better, pause and think of what you would want for your child, spouse or parent when they are facing the most dire emergency circumstances of their life perhaps after something that had already gone wrong. Would you want someone who has left medical school recently (though they are very good trainees and keen to learn) or someone for whom you have already paid upwards of £1million to become fully trained and employed to care for you, when you are facing a potentially resolvable life threatening condition? I rest my case.

©M HEMADRI

Healthcare not similar to aviation but lessons can still be learnt

Healthcare learning from other industries needs a much higher degree of sophistication

When are you in control and when are your patients in control?

When a plane is flying the passengers are not in control. It is the pilot who is in full control. The pilot also has controls on him/her but that control is not exercised by the passengers. Well, when there are 50 to 500 passengers in the cabin it will obviously be a problem to let individual passengers be in control of the flight itself. The passengers do get some control over their pre-made choices such as seats and meals; the passengers also get some control over when they use the toilets and when they can walk about as long as they are prepared to sit down and belt up as soon as they are instructed to do so. It is actually against the law to disregard pilot or cabin crews instructions; you do not have to harm yourself or others as a result, just not following the pilots orders is an offence.

Healthcare has made big noises about learning from aviation. We can argue that there are some similarities and some differences in the way passengers are treated and patients are treated. Just within the context of this short write up, can a chief exec of a small healthcare organisation or a chief clinician of a large unit say ‘we have a large number of patients to treat and hence we cannot accommodate individual patient choices’? Can clinicians tell patients ‘you have a choice over meals but for the rest of your healthcare you will do as you are told when you are in the hospital’? Will it ever become law that if patients’ disregarded their doctor’s instruction in a hospital they will be prosecuted (for potentially adversely affecting other patients care as a result)? Clinicians 'orders' are not orders at all. Of course it is an entirely different debate on whether the patients will get good results even if they followed their doctor's instructions completely.

The similarities between healthcare and aviation or any other industry for that matter are quite limited. This is for the simple basic reason that healthcare is direct and personal to the recipient – as direct and personal as a professional poking fingers and instruments into various orifices with consent in an attempt to make the lay patient better. That directness and ‘personalness’ does not happen in the often quoted ‘ultra-safe’ industries such as nuclear power plants, scheduled airlines, European railways and so on. It is a totally different empathetic human to human interaction where the 'relationship' is the main driver/lever. The synthetic 'have a nice day' with an artificial smile will not work in healthcare. Its a kind of relationship that a pilot or crew might have when the plane has crash landed and they are trying to rescue frightened and traumatised passengers; not something that they would wish to do everyday and that is something that many in healthcare do every day.


That does not mean healthcare cannot be safer than what it is now. It also does not mean that the ultra-safe industries have nothing to share with clinicians; of course we need to learn more from crew resource management methods, etc. It only means that the lessons and methods can only indirectly be applied; the principles have to be adapted and only then adopted. We are really poor in translating the lessons from other industries into healthcare.

I am very passionate about patient safety and quality enhancement. I have learned a lot from other industries including aviation. Healthcare is a risky business. If we attempt a direct application of the principles from other industries, healthcare will continue to remain a risky business. The translation and transfer has to be much more sophisticated than what it is right now. It is possible.


HEMADRI

No mosquitoes in UK so our healthcare is costly

No Mosquitoes in Great Britain, hence our healthcare is costly

A groin hernia is surgically repaired by placing a synthetic mesh on the weakness and fixing it in place. In UK the mesh currently costs from £20 to more than £100.

This is obviously a significant cost which the rural areas in the developing and poor countries cannot afford. The doctors face an ethical dilemma. Should they refuse to operate since the mesh is unaffordable? Should they do a non-mesh repair which is generally thought to have a many times the recurrence rate of the hernia compared to mesh repair?

Tongaonkar and Reddy, doctors from two small towns in India innovated by cutting mosquito net cloth to shape, sterilised it by autoclave and used it on patients (http://www.bioline.org.br/request?is03018). They had very good results that compare well with standard international/western results for groin hernia repair. They also had the mosquito net cloth mesh analysed by labs which generally showed it to compare well with commercially manufactured meshes like the ones we use in UK. 

The mesh costs a few pennies; it was 3688 times cheaper than the commercial mesh.

Of course surgeons in India accused the Indian Journal of Surgery of blasphemy for publishing Tongaonkar's paper.

Now here is the good news, a UK surgeon Prof Andrew Kingsnorth uses the mosquito cloth net mesh for hernia repair. The not so good news is that he does not use it in the UK, he uses it in a hernia charity in Ghana which he leads/supports www.operationhernia.org.uk  

One of my friends who has interacted with this blog wrote to Andrew Kingsnorth and the conclusion was that red tape will prevent us from using it in UK. I have discussed this with a number of people, at the very end of the discussion we always wondered why we in UK would not take this up even if we save money. Groin hernia mesh is only a £5million market with already many fingers in the pie. £5 million for the NHS is possibly small change. Our discussions normally end at that point.

We are a developed, rich economy, it may well be that our development and our wealth which prevents us from taking up innovations that save money. You would have never guessed that the lack of mosquitoes in UK was one of the reasons for our healthcare being costly!

Hemadri

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

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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.