Primary Survey August 2017.

Clinical pharmacists improve practice in emergency departments

There are 2 studies in this month’s issue which show the benefits of clinical pharmacy input in the setting of an emergency department (ED). One from Spain and one from Belgium. It is a relatively high risk area for drug medication errors as there is a fast turnover of large numbers of patients, the use of drugs which include those with significant toxic effects as well as potentially life threatening impacts, plenty of opportunity of miscommunication and many interruptions to nursing and medical staff whilst carrying out prescribing duties and administrating therapeutic agents. Read the editorial here.

Clinical relevance of pharmacist intervention in an emergency department

The first study looked at the impact of a clinical pharmacist working between 8 am to three pm Monday to Tuesday over a non-consecutive 6 month period in an ED with over 100 000 attendees per year. There was an electronic prescription system and a short stay facility (for 24 hours maximum).

Severity scales that looked at the drug errors and their potential impact of patient’s well-being, the clinical impact of the intervention by the clinical pharmacist were used as outcome measures. About 10% of patients were reviewed, over one fifth of whom were in the short stay facility, of whom 13% were finally admitted to hospital.

The majority of activity was to prescribe drugs that the patient was on at home or to  give  a suitable alternative from the hospital formulary. Other trends noted included the ‘over prescription’ of certain drugs like omeprazole and simvastin. There may have been a Hawthorne  effect as there was not a rise or drop in the error rate of ‘high alert medications and increased errors or interventions’ as compared with other studies.

Developing a decision rule to optimise clinical pharmacist resources for medication reconciliation in the emergency department

The second study produced a clinical decision rule (CDR) for the identification of patients admitted from ED with discrepancy in the initial medical history taking about medications.

This was a study based on looking at 3592 patients and using  variables such as age, gender, the medical discipline who admitted them, when in the year they were admitted and if there were any high risk drugs administered, among other factors. The purpose was to reduce error and to save time in the ED (the gold standard of a complete assessment by a clinical pharmacist was 20 min, with an estimated average number of 20 such assessments being possible in a working shift.

The most common error found in validating this was the omission of drugs that the patient was taken when looking at routine clerkings. In the final CDR chosen for ED, there were the advantages that many of the fields were already included in routine data collection as part of the patient’s journey to being admitted (reducing time and the need for repeated history taking). Key features for future developments are to quantify the potential benefits associated with the use of the CDR from a patient perspective, and as with the first study, health economic modelling would be an important addendum in prospective work.

Validating the Manchester Acute Coronary Syndromes (MACS) and Troponin-only Manchester Acute Coronary Syndromes (T-MACS) rules for the prediction of acute myocardial infarction in patients presenting to the emergency department with chest pain

This observational study was to validate and compare both rules in an Australia and New Zealand ED settings. The results showed that both could determine low risk patients, with sensitivity results of 99%, MACE identifying 10.7% and T-MACS in 19.8% of patients with acute MI at 30 days.

‘The year of first aid’: effectiveness of a 3 day first aid programme for 7–14 year-old primary school children

Can you teach young children adult BLS, use an AED, managing an unconscious patient, deal with haemorrhage and calling for an ambulance?

The answer is yes to most of the parameters recorded- after teaching, by theoretical knowledge and skill teaching, there was a marked improvement in the delivery of performing BLS including giving ventilation and chest compressions and using of an AED in over 90% of children. The height, weight, age and BMI played a part in the ability to deliver adequate force required to have chest compressions. This is not surprising, given the change in muscle bulk and maturation of the fibre types with the onset of adolescence. This links to the annual Restart a Heart Day on 16th October when children across Europe are taught basic life support (www.erc.edu; www.resus.org.uk/events/rsah)- in the UK, last year over 150 000 children received training. The conclusions of the article that ‘beginning first aid education in schools is strongly recommended’ should be legally mandated- other studies have shown that although very young children may not be physically capable of producing adequate force for chest compressions, they are able to instruct others (and often teach their parents at home what to do, after learning about it at school!)

Emergency department care of childhood epistaxis

What works? This review looks at 32 articles after a comprehensive literature search and provides a framework of treating active and recurrent nose bleeding. A very practical and useful guide to a common problem.

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Ian K Maconochie, Deputy Editor

Olympians and Comedians #PerformanceLDN

Traditionally, human factors and performance psychology are low down the priority list (or non-existent) in medical training. Students graduate from medical school with ‘academic-style’ mindsets, arguably ill-prepared for the practical, performance-dependent branches of medicine. In short, our training predisposes us to the yips.

But change is afoot. On 24th June, I attended the London Performance Psychology Symposium at the Blizard Institute, close to the Royal London Hospital. Organised by the London Air Ambulance Service, it was the world’s first medicine-specific performance psychology conference. For a Kool-Aid drinker like me (I’ve blogged on mindset and performance here at the EMJ and over at St. Emlyn’s), it was unmissable.

The line-up included a Who’s Who of thought-leaders from the EM/critical care/prehospital community, along with elite performers in distant disciplines. All were united in their quest for performance optimisation. The day was jam-packed full of pearls, but my favourite take-home points came from the worlds of sport and stand-up comedy.

‘Focus on your processes’

The audience was inspired and riveted in equal measure when Olympic rower Mel Wilson delivered a TED-worthy presentation on the performance culture of the GB Women’s VIII at Rio 2016. Her message was beautifully simple:

Focus on your processes, not the outcome

She kept returning to this mantra. You have no direct control over the outcome of a rowing regatta, much like you have no direct control over patient survival from life-threatening illness or injury. There is always the chance, whether racing a boat or team-leading a paediatric cardiac arrest, that winning will elude you, despite performing at your maximum. The only controllable elements are how diligently you approach the steps required, and how well you sync up with your team. By placing all your focus on real-time practicalities (processes), as opposed to the overall goal, the result will usually take care of itself.

Fascinatingly, when Mel started to feel stressed or overwhelmed by the moment, it would physically manifest as a specific hand/grip position on her oar. When she noticed that happening, she would use it as a trigger for re-directing her attention to her basic processes and nothing else, which nipped any potential cognitive or physiological self-sabotage in the bud. This strategy can be applied to resuscitation. When a case becomes chaotic and unmanageable for the team leader, it should trigger a cognitive stop-point. That moment is an opportunity to summarise the case thus far (sharing his/her mental model) and to focus the team’s attention on crucial basics – e.g. good quality CPR, rhythm and pulse check logistics, a recap on interventions performed and when the next is due (e.g. next adrenaline push) etc. Reigning in the team from a state of entropy is achieved by getting back to basics. Once order has been established, more nuanced performance and clinical reasoning can be layered on top.

Team-GB-621915The reality for athletes, particularly in Olympics-centric sports such as rowing, is that 4-year training cylces culminate is as little as 6 minutes’ peak performance time. That is pressure of unmeasurable magnitude, and the danger of choking is real. In the 2016 Olympic final the crew were in last place until past the half-way mark and Mel described how she resisted the temptation to fixate on their position or obsess about how much time and energy she had invested in that short moment. Instead she focused only on her processes. She felt the team’s collective processes ‘strengthening’ as the race progressed, and in the final stretch they managed to pip the Romanians into third place and seize a historic silver medal. By taking complete ownership of the basic practicalities of their jobs and focusing on nothing else, they achieved sporting immortality.

In medicine, we do not have to wait four years for a big performance to be required – it is an everyday occurrence. But the same rule applies. We must take full ownership over our performance and never allow personal standards to drop because of perceived external pressures. If we resist the urge to dwell on how high the stakes are, how busy the department is, or the implications of a poor patient outcome, and remain doggedly focused on our processes, we will be better doctors.

Mel’s source of inspiration was her teammate and role model, five-time Olympian, Fran Houghton. Fran always claimed that rowing was an ‘art form to be mastered, not a series of races to be won’. Focusing on processes was such a core of Fran’s race mentality, that she is on record as saying she would rather lose with processes intact than win ugly. For an individual whose career will largely be judged on the number of medals won and nothing else, her attitude speaks volumes. Fran has recently retired as one of Great Britain’s most decorated female rowers, and her influence on Mel’s career was palpable.

Perhaps medicine is an art form to be mastered, not a series of patients to be saved. Whilst I am sure that reflection might not jive with how many doctors feel about their jobs overall, I firmly believe that the more we focus on our processes, as opposed to saving lives, the more lives we will save. We must recognise that medicine is a performance-dependent pursuit, particularly on the frontline, and our focus must be on ourselves before the patient, so that we can serve them to the best of our ability.

At the end of my career, I hope I will be able to reflect on a consistently diligent and disciplined approach to my performance at work, and an insistence on respecting the crucial basics, rather than on specific patients with good outcomes or any accolades won/prestige posts earned (still pending obviously!). I would like to think Mel and Fran would approve of that intention.

Best of luck to Mel who is now an FY1 (first year intern) at Hillingdon Hospital. It will be fascinating to see where she ends up.

‘Learning stand-up is like learning to play piano with a live audience’

Another standout moment of the day was when Dr. Tom Evens (London HEMS consultant, and Symposium Convenor) interviewed comedians Milton Jones and Sally Phillips. They were predictably hilarious, with my favourite gag being Milton’s opener:

I’m humbled to be here… a bit like a bird at an airport

I loved the contrast of having professionally funny people talking to a room full of serious types at a serious conference! They made the event feel beautifully light on its feet, whilst making hugely valuable contributions to the overarching conference themes of innovation and exploration.

My take home message from this session is that failure is important, and must be embraced, no matter how painful. Junior stand-up comedians spend night after night failing to make people laugh, but each of those failures is critical for eventual success. A poorly executed delivery or subject matter that falls on deaf ears provides invaluable guidance for iterating the following performance. Eventually, a hilarious session of comedy will have been sculpted from rubble.

I’ve blogged before about ‘Black Box Thinking’, and how healthcare has much to learn from the staggeringly brilliant aviation industry in terms of institutional attitudes towards failure and near-misses. The world of stand-up comedy might provide equally poignant insights. Comedians have nowhere to hide when they are bombing on stage, and it must feel like the loneliest place imaginable. I’ve heard it is the only job in the world where you are judged every five seconds. And yet they keep dusting themselves off and getting back on the horse, knowing that each tumbleweed moment, hurtful heckle or stuttered punchline, is a rite of passage and necessary self-harm en route to mastery. Without constantly putting themselves in a position to fail, and then honestly and actively reflecting post-failure, a comedian’s career would never get out of first gear.

milton jonesThe unfortunate reality of medicine, unlike the comedy club, is that there are plenty of places to hide when we fail, and so precious learning opportunities are frequently squandered. If elite performance is what they seek, junior doctors must take a leaf out of the stand-up comedy playbook and actively chase after moments of failure. Wrong decisions, bodged procedures and impossibly stupid questions should be celebrated for their lessons, and never be deemed unforgivable by supervising senior colleagues, the inherent nurturers of this process.

A novel way that Milton demonstrates mistake-ownership during his routine is to lead a collective ‘boo’ from the crowd when a gag falls flat (‘on three, everybody boo… one, two, three…’). He says it puts his audience at ease, and earns him a sure-fire laugh. What a pro. Mind you, I’m not sure I’ll adopt that strategy the next time I intubate the oesophagus!

Many thanks Dr. Evens and his team for a fantastic day of learning and inspiration. I’m already excited to see who they line up to speak next year.

Rob
@PonderingEM

Primary Survey July 2017

Last winter was a difficult Winter for Emergency Medicine (EM), ED and the staff who work within them. The unacceptable pressures that faced us have only partly gone away and many of us have probably not fully recovered. Stress levels were high, dissatisfaction wide spread, the patients kept coming, and few appeared to leave.

As the year rushes by and Winter can be seen on the not too distant horizon, this themed issue of the EMJ is timely and of significant relevance in focussing upon stress, psychological well-being and job satisfaction amongst a range of Emergency Department staff from both within this country and abroad. Four articles examine this subject and are supported by an excellent commentary from Liz Crowe and her colleagues.

Emergency medicine is a great career:

The first article is a qualitative narrative study interviewing a small number of Consultants from a variety of large EDs in Wales. The study was undertaken to deter- mine their views on both the positive and negative aspects of their jobs and to inform prospective trainees of the attractions of a career in EM. Reassuringly, and despite the pressures of the job, most Consultants were positive about EM, citing a range of factors to justify their opinions. Perhaps surprisingly, all were positive about a Consultants work-life balance, a view contrary to that held by both EM and non-EM trainees, a view that we need to promote to all students and trainees to consider EM as a viable career option.

EM consultant well being

The second paper by Fitzgerald et al is a further qualitative study, this time of a larger representative group of Consultants from the South West of England. The authors this time set out to determine the perceptions that EM Consultants have of their psychological health, factors that impact on this and how they attempted to cope with the pressures of being an EM Doctor. There is much within this paper of importance but for me the negative effect of external organisational issues on the well-being of EM Consultants stood out. This paper should be read by managers as well as Emergency Medics.

A view from abroad

Demonstrating that stress and job dissatisfaction are not unique to UK Emer- gency Departments, the paper by Jiang et al examines the rates of career satisfaction and burnout in a large group of ED nurses from China. In a questionnaire survey with an impressively high response rate, they showed that despite a relatively high percentage of nurses being satisfied with their jobs, there was a high level of burnout with worryingly, almost one in four nurses stating that they were likely to leave their job in the next year. While there may have been some cultural differences behind these findings, the study clearly showed again the relationship between the working environment and levels of stress and burnout.

It’s Not Us, It’s the Organisation

Finally, the systematic review by Basu et al from Sheffield brings together the existing literature on organisational issues that may negatively impact on the psychological well-being of ED staff, as well as adversely affecting their ability to care for their patients which ultimately results in burnout and early retirement. The authors decided to focus on organisational stressors rather than individual vulnerabilities as they felt that these were more likely to be amenable to change. The review found that, common to other specialties, high workload and work intensity as well as long hours negatively impacted on the staff’s psychological well-being and feelings of burnout. In addition, low levels of support from managers and non-ED colleagues, lack of professional recogni- tion and lack of educational opportunities were all important additional contributors not only to psychological well-being but also to compassion fatigue and the ability to care for our patients. While the authors found that studies examining interven- tions designed to alleviate organisational stress were lacking, the evidence presented provides an excellent base to develop interventions at an organisational level to support all ED staff, both in the short term and the long term.

The positive effect of GP’s reducing ED attendances

Undoubtedly one intervention that helps all ED staff is a reduction in the numbers of patients that are seen within an ED. An interesting study from the West Midlands examined the effect of a pre-hospital partnership between ambulance staff and GP’s. GP’s, according to pre-defined call criteria, either provided telephone advice and support to paramedics or attended patients at scene. Almost 10% of calls were able to be handled by GP’s with 80% of these patients not requiring subsequent transport to an ED. The sustainability of this project is supported by it continuing to function 4 years after its initiation.

Too hot, too quick

There appears to be increasing evidence that higher oxygen concentrations during resuscitative processes may lead to harm. This now appears to extend to the use of external exothermic warming devices used pre-dominantly in the pre-hospital setting. I must admit I wasn’t fully aware of these devices designed to externally warm patients, let alone being aware of the oxidative chemical reactions that are used to generate heat. In a neat mannequin study, designed to simulate the use of higher concentrations of inspired oxygen in an enclosed environment, the study by Brooks and Deakin clearly shows that the use of higher inspired oxygen concentrations not only accelerate the exothermic reactions used in the warming devices but result in excessively high temperatures that may lead to clinically significant burns.

Why Patients take the bus

Finally, a paper from Australia, examining the effect of a public health campaign on the use of Emergency Medical Services to transport patients with an Acute Coronary Syndrome to hospital. While the majority of patients with an ACS recalled seeing the campaign, disappointingly the campaign appeared to be unable to influence patients’ behaviour, with over 40% of patients using alternatives to EMS, believing them to be faster than waiting for an ambulance. The authors conclude that further efforts are necessary to inform the public of the medical benefits of EMS transport.

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Richard Parris