Design is the key for human factors. Behaviour is a small bonus.

 Design is the key for effective human factors

In a recent famous case, one surgeon and two anaesthetists were said to be anaesthetising two patients at the same time; this would be risky and unnecessary for patients to be anaesthetised for longer than absolutely essential. It is unethical.

https://theworldnews.net/gb-news/derek-mcminn-patients-put-in-danger-so-scandal-hit-surgeon-could-perform-two-operations-at-same-time

The question is: how did this even happen? There must be policy in place to prevent this. There must have been people who could and should have questioned this and prevented this. Sure. Let’s assume we had policies and people in place – do they prevent for sure two patients being anaesthetised for the same one surgeon at the same time? No.

It happened because there was the structure, infrastructure and facilities to do it.

In UK hospitals there is something called the anaesthetic room which is separate from the operation theatre. This means for one surgeon, there could be a patient anaesthetised inside the operation theatre and another patient anaesthetised in the anaesthetic room.

This is a fairly unique UK NHS practice. Historically, the subsequent patient was brought into the anaesthetic room and the process of anaesthesia began or anaesthesia given when the patient on the table in the operation theatre was nearly done. This was thought to be efficient. It worked when the so called ‘registrars’ both anaesthetic and surgical were experienced. This anaesthetic room concept was then followed by UK private hospitals.

The presence of the anaesthetic room means that it would be physically possible for two patients to be under anaesthetic simultaneously for a single surgeon.

Recently, when designing the theatres of a private hospital, we argued for not having an anaesthetic room and prevailed.

This means that in that private hospital which does not have an anaesthetic room, there is no possibility of two patients being under an anaesthetic at the same time for a single surgeon because there is no physical infrastructure/facility that enables/allows it. No policy or person(s) would have been able to achieve this.

We cannot design a problem to be built into a system and then expect policies and people to overcome it consistently.

Design is the fundamental for human factors – people and behaviours are simply an add on bonus.

© Hemadri

Innovations in a small hospital

Have you heard of Goole Hospital? If you have not heard of it, that is not surprising. We generally don’t want you to hear about it/us.  It is a small hospital with about 30 beds and we do not do brain transplant.

We have a minor injuries unit, some medical in-patients, elective services in ophthalmology, orthopaedics, general surgery. There are outpatients and other services – you can check out the website http://www.nlg.nhs.uk/hospitals/goole/

What fascinates me is the number of innovations that have happened in Goole. Why it happens could be the subject of another blog post.

I am defining innovation as, ‘use of a better and, as a result, novel idea or method’ (Wikipedia).

Goole Innovations

Here I write about a dozen innovations that I have seen or been involved in at Goole.

1)      No clinic letter Clinic notes faxed to GPs as is

This when the general surgery clinic’s doctors’ handwritten notes are faxed to the general practitioner (mostly within 24 hours) instead of a letter first dictated then typed and then cross checked before signing and sending. Saves a load of secretarial time and money.

2)      Tests before OPD (USS OGD Flex Sig)

When we know by reading a general practitioner’s letter that the patient would undoubtedly need a particular test, such as an ultrasound scan, gastroscopy or a flexible sigmoidoscopy the doctor who vets the letter orders the test so that the result of the test is available for discussion at the patient’s first out-patient clinic consultation. Allows sensible discussion, often gives answers.

3)      Same day pre-assessment for general surgery and endoscopy patients

When the doctor tells the patient ‘you need a surgical procedure’, the patient if they have the time are pre-assessed at the same first surgical clinic visit. A kind of a one-stop service. Saves a lot of time for patients. We try to do this as often and as many patients as we practically can.

4)      Single Visit General Surgery

For general surgery patients who are suitable for day case surgery the Goole Single Visit pathway offers for suitable patients the option of visiting the hospital just once. Consultation and operative surgical procedure (occasionally some smaller additional investigations) all done in the same visit. Lumps and bumps right up to gall bladders.

See this link http://successinhealthcare.blogspot.co.uk/2011/12/single-visit-surgical-service.html that blogs about the single visit service

5)      Laser Haemorrhoidectomy

Formal surgical operation for piles done with local anaesthesia and laser with patients discharged in two hours. We have been doing this for a few years now. Brief blog about that can be found at http://successinhealthcare.blogspot.co.uk/2011/11/laser-surgery-for-piles.html

6)      Entonox for colonoscopy

Entonox, also known as gas & air can be used instead of sedation for colonoscopy. That is neither special nor surprising. In Goole, at the last look, we found approximately 35% of our colonoscopy patients opted for Entonox when the general published number is 17%. All I can say is our patients and staff are very special.

7)      Straight to test two week wait colo-rectal cancer referrals

Overwhelming majority of patients referred as two week wait cancer referrals end up having a colonoscopy. We have a system where suitable patients have their first consultation and colonoscopy at the same visit. http://www.nlg.nhs.uk/news/one-stop-service/

8)      Own reporting software for endoscopy

External software involves purchase cost, maintenance cost and annual licensing costs. We have created our own reporting software with Microsoft Infopath which was already available in trust computers. We have been using this for a few years. Spending your money responsibly, eh?

9)      Single length endoscopic accessories (0 error)

We use the colonoscopy length accessories for colonoscopy and gastroscopy. This has resulted in zero error hence zero waste (since there is no possibility of opening a gastroscope length accessory for a colonoscopy procedure)

10)  Home enemas

Patients who are for flexible sigmoidoscopy need an enema. To have someone unknown administer an enema in an unfamiliar environment and then have to use the unfamiliar toilet can be bothersome. We ask patients if they want to administer the enemas themselves in the comfort of their own homes.

11)   In-situ simulation training

First in-situ simulation training with two scenarios, two trainers, one volunteer ‘patient’ and a professional actor, in our organisation with three hospitals. Even before our nearest tertiary hospital could do it (they have since done it)

12)  Local Anaesthesia option for most inguinal and umbilical hernia repairs

Once the patient is considered suitable the patient has the choice to go for local anaesthesia (with or without sedation) or a general anaesthetic. A large number go for local anaesthetic repairs.

13)  Synchronised test-opd

When routine follow up ultra-sound scans are needed to monitor a situation, we used to get them done a couple of hours earlier than the clinic appointment time. Latest information available. One visit instead of two for the patient. We used to do this typically for patients who were being monitored for abdominal aortic aneurysms.

I said a dozen things done differently at Goole but have listed 13; that would be typical of Goole, we try and often tend to over deliver.

There are a number of innovations from our colleagues in orthopaedics, ophthalmology and other departments.

You will not hear too much from Goole, the people there are a bit shy of fame, a bit skeptical about awards, a shade reluctant to talk about themselves; it is a unique micro-culture - more on that later. There are very specific reasons why innovation happens at Goole (though I do not have too high a regard for CQC ratings you may be interested to know that Goole Hospital scores all greens ‘good’ www.cqc.org.uk/sites/default/files/new_reports/AAAA1778.pdf  for its services, we at Goole are neither bothered nor surprised about this).

At this point I have to say that I am one of the very few variant ones for Goole, talking and blogging about these things, I suspect my team often wonders why I am so vain.

Many hospitals in the country could be doing one or more of the above, but I do wonder if all these things happen in a small hospital.

©M HEMADRI 

Follow me on twitter @HemadriTweets

PS: We follow Noble prize winner's Kahneman's methods to improve our patients' experience, I have already blogged about this http://successinhealthcare.blogspot.co.uk/2014/02/kahneman-colonoscopy-and-goole.html

ROBOTIC SURGERY: THE FUTURE BECKONS...

ROBOTIC SURGERY: THE FUTURE BECKONS...

Guest Blog by

Dr. Soumyadeep Bhaumik MBBS 

GP, Independent Researcher and Medical Correspondent

 

In 1921 Czech playwright Kapel Clark introduced the concept of robots (and in the process coined the term robot too) in his science fiction epic Rossum’s Universal Robots. Domin, the lead character of the play describes the future of robots as, “all work will be done by living machines. Everybody will be free from worry and liberated from the degradation of labour. Everybody will live only to perfect himself.” Ever since then robots have captured the imagination as well as the reality of humans. Robots are used nowadays in specific, precise, speedier and often hazardous work in domains ranging from industries to research to warfare. The entry and progression of robots however has been comparatively slower in the field of medicine.¹

Robotic surgery is a new and emerging field that has taken the medical and particularly the surgical community by storm. Robotic surgery is a technique which in the simplest term can be described as a surgeon performing surgery using a computer that remotely controls very small instruments attached to a robot with multiple arms.

History of Surgical robots:

The background of development of robotic surgery is inherently intertwined with the development of minimally invasive surgery (MIS). MIS has various advantages like smaller incisions, lesser infection, shorter hospital stays, quicker discharge from hospital, decreased pain, better cosmesis, and better postoperative immune function^2-4  An inherent problem with current laparoscopic equipment is the loss of haptic feedback (force and tactile), natural hand-eye coordination and dexterity¹. Moreover laparoscopic instruments have restricted degrees of motion (usually 4) whereas the human wrist and hand have 7 degrees of motion. There is also a decreased sense of touch that makes tissue manipulation more heavily dependent on visualization (which is essentially two-dimensional). Finally, physiologic tremors in the surgeon are readily transmitted through the length of rigid instruments. These limitations make more delicate dissections and anastomoses difficult ⁵. Most surgeons harped over these limitations and argued the supremacy of traditional surgeries but biomedical engineers collaborated with a handful of surgeons and developed the Puma-650 which was first used in precise neurosurgical biopsies² and then in Trans-urethral resection of prostate (TURP)⁶. Robotic surgery gained rapid strides with the development of the PROBOT, ROBODOC, NeuroMate, PAKY-RCM, AcuBot and AESOP ^1,7.The da Vinci Surgical System ultimately made the robotic surgical system popular globally. More than 1752 da Vinci systems are already installed in across 44 countries of the world.⁷

Pros and cons:

Robotic surgery promises to overcome the traditional obstacles of surgery¹. They have better geometric accuracy, remain stable and do not get tired, can scale motion and offer more degrees of freedom than the human hand. They are precise and can access spaces or areas which a human hand cannot--thus making micro-anastomoses possible. Unlike humans, robots are not susceptible to radiation/infection or fatigue. Robots eliminate the fulcrum effect and also physiological tremors of the surgeon. Having fewer surgeons in the operating room and allowing doctors the ability to operate on a patient long-distance (tele-surgery) would also lower the cost of healthcare in the long term.⁷ More over because the surgical cuts are essentially smaller it provides all benefits of MIS, albeit in a greater dimension.

The prime disadvantage as of now with robotic surgery is not technology (which is bound to improve further in the future) but the costs involved. Robotic systems cost a whooping US $ 1 million to procure and recurring costs of $100,000/year. Such huge sums mean a lot if viewed in the light of public health measures in resource-poor developing and underdeveloped nations. Other concerns that have been raised are the requirement of extra staff to operate, steep learning curve and it’s yet to be proven cost-benefit ratio. A major cause of concern is the fact that robots do lack the capacity to earn the trust implicitly assumed in a surgeon-patient relationship⁸.What would be the psychological state of the patient peri/post operatively when he knows that his body parts is being handled by a machine made of ‘tins and oils’ ? What if the robot malfunctions? What if it is fed with the data for a wrong patient or for that matter even a wrong surgery? Who will be to blame in case something goes wrong?

What the future holds?

In spite of the fact that robotic surgery is fast spreading globally it is important to note that it is still in its infancy. The future of robotic surgery will take this current platform forward by improving haptic (touch) feedback, vision beyond the magnified eye, robot accessibility with a reduction of entry ports and miniaturizing the slave robot.⁷ In the near future robotic systems are expected to integrate various other technologies and modalities that are currently being used in the operating room. Efforts are already on to relay touch sensations from the robots to the surgeon and develop better suture less anastomoses⁷. Diagnostic modalities like USG, CT scan and MRI will soon be merged with robotic surgical equipments and guide the surgeon in better dissection and pathology identification. Nano-robots too are being developed across the world. Surgical training is also expected to radically change with robotic systems being used to rehearse procedures before doctors actually operate on a patient. Eventually tele-robotics will develop thereby enabling super-speciality surgeons to operate at inaccessible rural location without them being physically present in the operation theatre.

Evaluation of its safety, efficacy and long term effects vide randomised controlled trials is the need of the hour. Efforts to bring down costs should be specifically attempted. Unlike in industries or warfare clinical judgement is way too complex process which takes into account various factors beyond the operation table. The patient's socio-economic background, physico-intellectual status, his aspirations from life, emotional state, and cultural factors are issues which are taken onto account by the surgeon. Owing to the very nascent stage in which artificial Intelligence is currently the view that the automation age in robotic surgery has arrived and " it’s only a matter of time when it will run our lives for us” ⁸ is but a vision of the very distant future.

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Soumyadeep Bhaumik is a blogger and his blog Caffeinated Works & Random Musings is one of the largest healthcare blogs in India

You can get in touch with him via

in.linkedin.com/in/soumyadeepbhaumik
www.soumyadeepb.wordpress.com
https://twitter.com/DrSoumyadeepB

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References:

1. Lanfranco AR, Castellanos AE,Desai JP,Meyers WC.Robotic surgery: a current perspective. Ann Surg 2004;239:14-21
2. Kim VB, Chapman WH, Albrecht RJ, et al. Early experience with telemanipulative robot-assisted laparoscopic cholecystectomy using DaVinci. Surg Laparosc Endosc Percutan Tech 2002;12:34–40.
3. Fuchs KH. Minimally invasive surgery. Endoscopy 2002;34:154–159.
4. Allendorf JD, Bessler M, Whelan RL, Trokel M, Laird DA, Terry MB et al. Postoperative immune function varies inversely with the degree of surgical trauma in a murine model.. Surg Endosc 1997;11:427–430
5. Prasad SM, Ducko CT, Stephenson ER, Chambers CE, Damiano RJ Jr. Prospective clinical trial of robotically assisted endoscopic coronary grafting with 1 year follow-up.Ann Surg. 2001;233:725–732.
6. Davies B. A review of robotics in surgery. Proc Inst Mech Eng.2000;214:129–140.
7. Wedmid A,Llukani E, Lee DI. Future perspectives in robotic surgery. Brit J Urol Int ;108:1028-1036( Avalilable online http://onlinelibrary.wiley.com/doi/10.1111/j.1464-410X.2011.10458.x/pdf)
8. Nath NC.Robotics –the future of surgery. J Ind Med Assoc 2011;109:12-13

Increased Quality and Reduced Cost - Possible in India

I have a long held view that quality is inversely proportional to cost which means as for a given activity as the quality improves cost decreases. This is actually possible in India as well.

Let me share a clinical anecdote that may illustrate my point. It may be dated and trivial to many current readers but was very relevant to the patients and clinicians at that time.

In the late 1990s I was working as a surgeon in Sir Ivan Stedford Hospital, Ambattur, Chennai, India (http://www.ammfoundation.org/SirIvanStedefordHospital/index.html). This is a charitable hospital where we used to charge very small nominal amounts of money to provide services. A few rupees for out-patients, few tens of rupees for scans and so on. Being India, one of the commonest operations performed happened to be surgery for hydrocele. The way it was conventionally performed may be very familiar to many of you. The operation of course ended with a large bandage tightly applied to the scrotum with the purposes of avoiding problems like pain, infection, haematoma, oedema etc. These patients were also put on antibiotics for 10 days or more. Many of these patients used to come back with soiled dressings and the exact problems that doctors were trying to avoid. Doctors used to wonder what else could be done to improve the situation.

Not using a bandage was thought to remove an all important barrier that avoided exposure of the scrotal wound to the unhygienic toilet situation in India and despite using 10 days or more of antibiotics infections were happening. Barrier and antibiotics thought to be bulwarks against contamination and infections were not working.

I actually thought the tightness of the bandage caused oedema and increased pain. The presence of the bandage increased sweat and moisture in an already humid perineal area in a warm country. The bandage also easily became wet because of the toilet washing habits of the country and acted as a rich environment to create infections.

Having worked in England where the scrotal bandage was not routinely used after scrotal surgery, I took the bold step of not using scrotal bandages to hydrocelectomy patients much against the advise of my friends and colleagues. Of course, I suggested the use of the proper scrotal support clinical hosiery which was either not available or when available was very expensive. An alternative had to be found. I simply asked my patients to buy 7 of the cheapest 'A' or 'Y' front underpants from the shops opposite the hospital otherwise I would not operate on them. I used these normal commercially sold underpants over a couple of pieces of sterile gauze placed on the scar, changed once a day by the patients themselves, in the place of scrotal bandages for my patients changed by clinical people. Most of my patients found this very amusing. Some were resistant, perhaps hesitant, because the had not worn such a type of undergarment before. My colleagues were of course greatly humoured by what they thought was my naivety and enthusiasm.

In a few weeks, post operative follow up clinics were showing that my patients were walking in and walking out in super speed and for the rest of the surgical team there remained the usual levels of post op problems with pain, oedema, infections. Having eliminated the scrotal bandage which I thought was causing the problems, I then moved to single dose prophylactic antibiotic as I used to do in Britain.

Word of mouth and social observations in a local context those days was of course as fast as twitter or facebook now. The talk was about how patients spent less money on changing bandages and buying antibiotics while getting good results. Soon my colleagues avoided scrotal bandages, used undergarments as I recommended and moved to a shorter course of antibiotics often just 3 doses (instead of the usual 10 days).

Of course the people who charged for the change of dressings and the people who sold antibiotics were not happy. But I can tell you who were happy, the guys who sold the undergarments. They were really happy. 7 undergarments per hydrocelectomy patient in a hospital that did hundreds of hydrocelectomies, they must have been ecstatic. Well, I know they were, as one of them approached me and offered a commission to me (his bloody nerve) if I could recommend patients to buy the undergarments specifically from his shop – no different from the drug store chap then!

Clinical complications reduced – i.e. quality improved. Cost reduced.

Okay, this example is not about whole systems, scientific proof, published evidence and other high & mighty things. It is one little example. What I cared and what our patients cared is that we had lesser clinical problems and we achieved it by doing/using/costing less. Perhaps hydrocele surgeons in India are no longer using scrotal bandages and 10 days antibiotics - that is why this anecdote may be very dated but the general lessons are in my view still valid.

Increasing quality while decreasing costs can be achieved in India as well. Perhaps due to the large number of people who are around the poverty line this concept becomes even more relevant to India. We must remember that though the GDP is high the per-capita money is very low in India. Individual doctors are not dealing with the mighty high GDP India; individual doctors deal with the individual patients of low per-capita India. That is why low cost high quality care becomes essential.

©M HEMADRI 

Follow me on twitter @HemadriTweets

Single Visit Surgical Service

When we look at providing healthcare services we should look at it from a patient's perspective. For instance, ''how often would the patient have to travel to the hospital to obtain healthcare services?'' is not the top question in any providers mind when they design the service.

This results in the patients traveling often to secondary care services even for obviously clear problems such as hernias, varicose veins etc.

At Goole Hospital we provide a single visit general surgery service for patients who need day case and short stay surgical procedures. This may mean procedures likes superficial lumps and bumps, toe-nails, etc. This also means patients who have groin hernias including recurrent groin hernias and gall stones (needing laparoscopic cholecystectomy).  Obviously there has to be a clear cut diagnosis based on obvious findings followed by some appropriate investigations by the general practitioners. These patients visit Goole Hospital only once to obtain their surgical care. The patients are telephone pre-assessed. They come to the hospital at about 8 am and are seen by nurses, anaesthetists, surgeons and residual simple investigations are performed instantly; they are operated during the day and discharged when they meet clinical criteria often within the day. They are not offered specific follow up out patient appointments but can ring to make one if they felt they needed it.

We do inguinal hernia repairs, laparoscopic cholecystectomies and many other procedures as a part of this service. The service has been running for a good few years.

My personal calculations are that this saves money overall, especially saves on travel costs for patients and their relatives. My feeling is many of the services provided by healthcare are currently very hospital focussed. When the processes becomes patient focussed there is a good chance that quality could improve while saving on costs at the same time. It is up to us to manage our services and processes maturely - our poor design should not trouble the patients.

© HEMADRI

Follow me on twitter @HemadriTweets

Warning & Disclaimer:
We do not claim superior clinical results. We only describe our process/pathway. Not all patients with any of the conditions stated above or with other similar conditions are suitable for this service. Your GP is best placed to advice the kind of pathway that could be suitable to you. This blog/website does not give clinical/medical advice. The views expressed are my personal views and not those of my hospital or the NHS.

 

Laser surgery for piles

Many of you will be aware that piles is a very common problem presenting usually as bleeding and/or swelling from the anus. If the piles involves an external swelling at the anus along with the bleeding then a surgical operation may be indicated.
Currently the standard method of doing a piles operation involves a general anaesthetic, cutting out the piles (called open haemorrhoidectomy or Milligan-Morgan technique) and possibly an overnight hospital stay though more centres are doing piles operations as day cases.

We (Peter Moore, Consultant Surgeon, now retired and I) have been performing a technique called Laser Seal Haemorrhoidectomy for a few years where we use a local anaesthetic with mild sedation and use a laser to seal the cut edges of the piles. Patients are able to go home about 2 hours after the operation (they may be able to go home earlier but sedation guidelines kick in I suppose), we believe that this procedure gives better pain relief in the early days http://www.nlg.nhs.uk/services/laserhaemorrhoidectomy/default.asp  

We learnt this procedure a few years ago from Peter Thomas from Arizona  http://laserhemorrhoids.com/; of course we don't do it exactly like him and he has been doing it for 25 years.  A public thanks to Peter.

I think to change an operation that involves a general anaesthetic and often one or two nights of stay in the hospital to a local anaesthetic (with mild sedation) with a two hour stay is our local technical example of Success in Healthcare. Surely not an earth shattering example, only a small one but hopefully relevant for some. The point is to try and pursue every activity that improves quality and decreases cost at the same time.

 © HEMADRI 
Follow me on twitter @HemadriTweets

Warning & Disclaimer
1) There are many causes of bleeding from the anus and many causes of swelling in the anus, some of those may be more serious conditions than piles - please consult your doctor whose advise will be the only thing relevant to you personally. This blog does not give you medical advise.
2) We do not claim scientifically superior results. We describe only our process and some of our beliefs.We use the laser seal haemorrhoidectomy as a clinical process improvement example not as scientific proof of any treatment.

Amended on 30 August 2014