It’s the little things that matter…

There’s a lovely initiative kicking off in the Broome Hospital this year, thanks to my colleague Dr Casey Parker of BroomeDocs.  Have a read of Casey’s latest blog post yourself – the premise is simple – to ensure that junior trainees follow through their patients from admission to ward, not just in terms of their medical management – but in terms of the experience for the patient.  In essence Casey wants to make sure his emergency residents will “Own the Patient”.

  • At some stage in each shift our ED residents will be encouraged to “visit” their patients on the wards.
  • Ten or fifteen minutes during the inevitable lulls.
  • I want them to specifically visit the “standard” patients, e.g.  the ‘mild COPD’ or the ‘RUQ pain for investigation.’
  • When I say “visit”, that is exactly what I mean.  I want them to go to the bedside in the same way a concerned relative might do.
  • They should not check on the progress with their inpatient colleagues first – I want them to go in and get an untarnished patient perspective.
  • When they visit the patient whom they admitted I want them to ask 3 simple questions:
    1. How are the symptoms that lead to their ED presentation going?  Have they been relieved?
    2. Ask them to explain what has happened since admission – ask the patient to explain their understanding of what has happened to them OR what do they understand the treatment plan is going forward.
    3. Ask, “is there anything I can do for you?”
  • After visiting they can then go and do all the usual doctorly things – look at the CT, chase the bloods or get the 30 second thumbnail from the inpatient team.
  • As they walk back to ED I want them to meditate on what they could have done differently to make that patient’s experience easier, less painful or less confusing.

Silo Mentality and Interspecialty Bickering

Medicine is hopelessly siloed – whether between paramedics, nursing, doctors & allied health, or between specialties in each discipline.

Insightful and reflective clinicians will do all they can to break down these silos – Vic Brazil spoke eloquently at smacc13 on the need to break down tribalism as does Dharmaraj Karthikesan on the need for doctors to be kind to each other, a lesson applicable to all healthcare tribes.

I count my lucky stars that I moved into the practice of rural primary care in Australia – not only does it embrace all the ‘best bits’ of medicine, it allows a real sense of purpose within the community, the joy of practicing procedural skills and of course is a job in demand!  It’s also been interesting to view the practice of some of my specialist (or perhaps I should say partialist) colleagues from the perspective of a specialist in rural medicine (FACRRM).  I’ve had occasions to make for ways back into the hospital system to upskill in obstetrics, anaesthetics and prehospital care – and on each occasion was struck how constrained the practice of my specialist colleagues was compared to mine.

Sir Chris Hoy London 2012
The Aggregation of Marginal Gains

Intensive Care ward rounds were a good example – of course the intensivist brings all their knowledge and skill to these critically ill patients – but if a patient came out in a rash, or a skin lesion was noticed, there would be an immediate consult for a dermatology consult (which might take a day or so) and delay the discharge of that patient.  When moonlighting on ICU as a rural doc, I’d enjoy not only the critical care side of patient care, but also managing the more mundane aspects – diagnosing the rash, excising the skin lesion, tidying up their chronic disease, speaking to family etc.  Ditto in prehospital care – skills across emergency, anaesthesia and obstetrics seemed well-suited to this environment, over the skills of say a clinician trained purely in anaesthesia.  Common to these specialties was the fact that the LITTLE things matter – critical care (whether in the ICU or at the roadside) is mostly about doing the basics…but doing them well, consistently and ensuring good clinical governance. People often talk about the British Olympic cycling team and their coach, David Brailsford – leading into a discussion of the ‘aggregation of marginal gains’.  A small improvement of just 1% in any one area, when amplified across the complex system of either elite sport or healthcare, can lead to significant improvements – those 1%s all add up!

To my mind, holistic patient care is the key to those 1%s. And primary care is expert in this.

The Power of Primary Care

THIS is why I think Casey Parker’s notion of #ownthepatient is so important – it’s bringing that longitudinal generalist approach to bear in a hospital environment, breaking across the silos.  More importantly still, this is done with a solid emphasis on the patient perspective…because despite all of the technical brilliance that we aspire to achieve in whichever discipline, this is essentially useless if the patient is not cared for, informed and a fellow traveller in the journey to recovery.

“these outcomes will never be counted in audits, but they matter.  The only way to learn the 1-percenters is to close the loop.  Go and talk to your patients.  Understand their experiences and then try to do better.  This stuff is largely tacit learning – it is unteachable.  One must consciously try to experience the “little” problems in order to prevent them from recurring” – Casey Parker

I like to think that primary care clinicians have something to offer here – to be honest it rankles me somewhat that many tertiary partialists (and even some patients) have the perspective of ‘just a GP’.  Former rural locum Dr Penny Wilson has also written nicely on this (see her post copied in the Huffington Post) and it leads into a wider discussion of the true value of good quality primary care – whether practiced by doctor, nurse or paramedic.  Of course Casey, Minh and I have all made forays into the conference circuit, often talking to audiences of physicians, intensivists or emergency docs about our perspectives as rural docs/GPs (the smacc series is perhaps the best example). I think it’s invaluable to have generalists talking to partialists, rather than the usual ‘specialist-lecturing-to-ill-educated-GPs” education! Of course FOAMed means that knowledge is freely available and readily discussed, similalry breaking down silos and leading to real learning.

This extension of good ‘primary care’ skills into the hospital system, with a patient-centric focus as exemplified by BroomeDocs is fascinating – not only is the paradigm widely applicable from rural hospital to uber-specialised tertiary or quaternary centres, it also gets back to the very essence of why we are all in healthcare – to help the patient, and implicitly, to improve the lot of fellow human travellers.

My question is whether such ventures will translate into measurement of improved health outcomes; current systems of audit and indeed funding rarely measure the impact of such simple interventions. There ARE examples – the UK’s #hellomynameis campaign to ensure introductions between healthcare workers can improve teamwork, patient safety and is just plain courtesy.  But most healthcare funding is focussed on dollar savings and measurement of targets – time in ED, number of procedures, length of bed stay etc

Interestingly there IS evidence of the value of the rural generalist in cutting health costs (see this fascinating keynote from Professor Richard Roberts at the RMA15 conference – and forward to Health Minister Sussan Ley who needs to be reminded of the value of an effective primary care system).  Such care is characterised by patient-centredness, minimising inappropriate investigations and procedures and having an absolute focus on what is right for THIS patient, at THIS time in THIS place.

Whether the ‘Own the Patient’ paradigm will be taken up by other institutions and translate into improved patient outcomes remains to be proven – intuitively I think it is a good thing….I hope you will too.

References

Dear Doctors – Be Kind to Each Other from Dharmaraj Karthikesan http://dharmarajkarthikesan.com/2015/05/09/dear-doctors-be-kind-to-each-other/

Myths About General Practitioners – Penny Wilson writes on why she’s ‘not just a GP’ http://www.huffingtonpost.com/penny-wilson/myths-about-general-practitioners_b_3937618.html

Own the Patient – Brilliance from Casey Parker of BroomeDocs http://broomedocs.com/2016/01/own-the-patient-clinical-case-126/

Tribes, Timing & STEMIs – Vic Brazil at smaccGOLD (2013) lifeinthefastlane.com/timing-tribes-stemis

 

Keeping It Real – Forget ECMO, Crowdsourced Community CPR Is Needed

Advances in modern emergency medicine and critical care are amazing. Previously unsalvageable patients may be rescued, thanks to both attention to detail for the basics (FAST HUGS IN BED) and advances in ventilation, inotropic support, antimicrobial therapy and technology such as extra-corporeal membrane oxygenation (ECMO).

The latter has attracted some recent attention, especially in regard to management of cardiac arrest; rather than simultaneously diagnose and treat the causes (4Hs, 4Ts) of a failed heart in cardiac arrest management, putting the patient on VA-ECMO allows maintenance of oxygenation and perfusion. Not surprisingly, there is lots of discussion in prehospital fora on bringing early ECMO to patients undergoing cardiac arrest.

Horowitz

One recent comment on Twitter caught my eye – the notion that ECMO was the panacea to the currently poor survival rates from cardiac arrest

Whilst technological advances such as ECMO can appear attractive, I think a focus on such expensive technology kind of misses the point.  We see  similar situation in prehospital trauma care – it’s all very exciting to focus on retrieval services with helicopters, prehospital REBOA and so on – but as trauma guru Karim Brohi said to me at an Australian Trauma Society meeting “it’s better to be the fence at the top of the cliff, than the ambulance at the bottom”

All of which is a long-winded way of reminding primary care practitioners that they DO have a role to play in critical illness – with prevention better than cure! The work of the GP is not as glamorous as the trauma specialist or cardiac surgeon.  But it’s here in the simple interactions everyday during a GP consult that lives can be saved – initiating conversations about lifestyle, encouraging healthy diet and exercise, measuring and treating obesity, hypertension, hypercholesterolaemia.  These are obvious goals.

What’s not so obvious are taking the same preventative health measures out to the community.  Running outreach clinics for mental health, Pap smears and talking to sports clubs about drink-drug driving, wearing seatbelts, farm safety etc are also vitally important (although rarely remunerated).

The Scourge of Cardiac Arrest in Australia

Cardiac arrest is indeed low hanging fruit. There are an estimated 30,000 cardiac arrests per annum in Australia.  But survival rates from cardiac arrest remain poor, especially for out-of-hospital cardiac arrest (OOHCA), with only 9-10% surviving.

Screen Shot 2016-01-03 at 3.23.01 PM
Cardiac Arrest Chain of Survival – early AMBULANCE NOTIFICATION (000), early CPR, early DEFIB, early ALS & TRANSFER – DEFINITIVE CARE

Think about what happens when someone collapses in the street, cafe or shop today.  Passersby may or more likely, may not be comfortable in starting CPR.  A call is made to ambulance via 000 (can use 112 on mobile).  The call is taken by an ambulance call operator who may guide the caller through CPR whilst simultaneously calling an ambulance.  It is only with the arrival of trained ambulance officers that defibrillation is delivered (or CPR initiated if passersby have not started).  For a CPR-qualified person in the immediate vicinity, the sound of the ambulance siren may be the first awareness that something is wrong…by which time their services are not needed.

it’s pure luck whether a passerby is available & willing to deliver CPR or not

Take Heart Australia

It is said that survival drops by 10% for every minute delay to definitive treatment (defibrillation for the most common cause of OOHCA, ventricular fibrillation).

VF
ECG of Ventricular Fibrillation (VF) – The Heart Cannot Pump Effectively, Death Ensues Unless Treated

Have a think about that. A ten percent drop in survival for every minute delay to defibrillation.  Ambulance response times in the city are around 8 minutes for a priority one call – considerably longer in the bush.  No wonder OOHCA survival is so poor.

But it doesn’t have to be this way.  Some locations have got their collective act together; it is said that OOHCA survival rates in Seattle approach 62%.  How?  By ensuring that basic care is delivered early – via bystander CPR by trained community members and early defibrillation, often prior to arrival of the ambulance, through provision of public access automatic external defibrillators (AEDs).

Survival from cardiac arrest in Australia – 9%

Survival from cardiac arrest in Seattle – 62%

Many of you will have seen defibrillators in airports, shopping malls and sports stadiums.  But how many of the community are confident to either perform CPR or to use an AED? In 2015 the Kangaroo Island medical students & myself visited the bowls clubs on Kangaroo Island and taught members how to perform ‘hands only’ CPR and practice use of the defib. I would love to extend this program still further and make my community on Kangaroo Island a ‘heart safe’ community.  To do that requires several things

  • ensuring that as many of the community are trained in ‘hands only’ CPR as possible
  • ensuring that community members are prepared to use a defibrillator and that such AEDs are  available and easily locatable
  • ensuring ready back up of lay responders, through existing emergency services (we already have a network of volunteers in ambulance, road rescue, fire, coastguard) as well as many others with Senior First Aid or other certification (Parks & Wildlife, Tour Operators, off duty medical and nursing staff etc)

Saving the newly dead – via disco!

So – the challenge for 2016 will be to train as many of the community as possible in ‘hands only’ CPR (this obviates the usual reluctance to get involved in a collapse and the requirement to perform a ‘kiss of life’ or expired air resuscitation).  Hands only CPR to the beat of the Bee Gee’s ‘Staying Alive’ is the current paradigm for lay responders.

Screen Shot 2016-01-03 at 3.08.14 PM

The notion of ‘hands only’ CPR is being made available through several public service messages.  Omitting the need for breaths and using an easily remembered beat (Stayin’ Alive) aims to deliver effective CPR to as many people as possible, rather than confuse lay responders with compression:breathing ratios and concerns over performing EAR on an unknown patient, possibly with blood or vomit in their mouth.

American physician and comedian Ken Jeong shows the US audience how to ‘save a life with disco’ here :

Whilst former footballer, hardman and UK actor Vinnie Jones hams it up for a UK audience here :

Community responders could comfortably manage the first four steps of the ‘chain of survival’ shown below (image from Take heart Australia website)

TAKE-HEART_ff3-1024x249

There is no doubt that training of community members is achievable – and delivering ‘hands only’ CPR is better than doing nothing until the ambulance arrives!  There are many training organisations out there already who can train individuals or groups in CPR (eg St Johns Australia, Surf Life Saving etc).

Many workplaces require a Senior First Aid certificate for employ…and of course there is a pool of people who regularly train in CPR (off duty emergency service personnel, tour operators, parks & wildlife, teachers etc).  But what’s the point of being able to deliver CPR unless the person drops dead in front of you?  Some sort of activation system is needed…

Coordinating responders – use the power of smartphone in your pocket!

Training responders in CPR is only part of the paradigm. Ambulance response times are still going to be significant in rural areas (volunteers have to come in from home/work in order to respond to an ambulance call) This is where I think crowdsourcing extra help will be a game-changer.

Forget critical care technology such as ECMO – crowdsourced community CPR is the future to improve OOHCA survival

A former medical school friend of mine, Mark Wilson and programming genius Ali Ghorbangholi have come up with the FREE GoodSAMapp for smartphones.  Mark is a neurosurgeon and prehospital doctor, as well as a thoroughly nice chap (see him here explaining neurosurgery for everyone) :

Based in London, he was frustrated at the delay in delivery of simple measures (opening an airway, CPR) for patients before HEMS ambulance arrived. In a large city like London, you are probably never more than a few metres away from someone who is trained in CPR – but they may be in the shop next door, unaware. Wouldn’t it be great to be able to mobilise their skills prior to the arrival of ambulance and ensure early and effective CPR?

The premise is simple – modern smartphones contain GPS, maps, camera and communication capability (and so much more). Why not harness this power in your pocket to activate registered first aid providers, such as off duty paramedics, doctors, nurses, fire crew etc to respond to an out of hospital cardiac arrest?  Good Samaritans – hence GoodSAM (Smartphone Activated Medics).

Two free apps – the Alerter and the Responder app are available; general public can download the Alerter app; registered first aid providers can download both Alerter and Responder apps.

Screen Shot 2016-01-03 at 3.49.10 PM

The Alerter app is simple; using it activates emergency services using the appropriate number (999 in the UK, 000 in Australia) and the usual cascade of activation occurs.  But the alerter app also allows geo-tagging of public access AEDs through the ‘defibrilocator’ function, as well as activating the GoodSAM network when used.

 

Screen Shot 2016-01-03 at 3.49.31 PMThis is where the Responder app comes into play.  Holders of a recognised CPR qualification (which might be off duty clinical staff and holders of a industry qualification such as Senior First Aid) can register as GoodSAM responders.  By downloading the responder app, they will be alerted if there is a cardiac arrest in the immediate vicinity.  If available, they can respond.  If not, they can reject the notification and the next available GoodSAM responder is notified.

Both Alerter and Responder apps can be downloaded from the GoodSAM website for free.

Using the Alerter app does trigger both 000 and GoodSAM activations; ringing 000 direct just activates 000…meaning the CPR-qualified first aider next door may be oblivious of the incident until they hear the ambulance sirens…and chances of recovery are significantly reduced

Screen Shot 2016-01-03 at 3.50.03 PM
Navigate to GoodSAM app – use tab indicated by the green arrow to download Alerter and Responder apps for various platforms

“Crowdsourced CPR – it’s kind of like Uber – but for cardiac arrest!”

The app is available for Android, iOS, and Windows.  For those without a smartphone or poor reception, it also allows notification by text or an audible sound, showing the responder the precise location of an incident via GPS.

Crowdsourcing CPR via community responders not a replacement for ambulance by any means; rather it’s a social enterprise project to help deliver effective care such as CPR and defibrillation by registered and trained first aid responders when time critical.

Screen Shot 2016-01-03 at 3.46.59 PM

London Ambulance have integrated GoodSAM into their Emergency Operations Centre, ensuring a request for ambulance triggers both London Ambulance as well as activating the GoodSAM network.  I believe Sydney are looking at this also, and hopefully other Australian cities will follow suit.

Screen Shot 2016-01-03 at 3.46.36 PM
Map of GoodSAM responders in Australasia – Uptake has mostly been with emergency staff in hospital…I’d love to encourage use of GPs, fire, SES, Surf Life Saving etc – indeed anyone who can verify credentials to provide CPR. GoodSAM registration provided with Senior First Aid certification perhaps?

For a small rural community, setting up a local GoodSAM responder group allows easy registration and activation of any and all first aid trained individuals (ambulance, fire, rescue, coastguard, surf-life saving etc). Group administrators are able to see available responders  location on a map and send push notification messages within the group, adding to rural community resilience in an emergency.

“With the tyranny of distance in Australia, why would you not want to use such a system to mobilise any available help?”

Of course there are some concerns from naysayers.  Some medics have been reluctant to register for GoodSAM, on the basis that they may be held liable if unable or unwilling to respond to a call for help.  I find this perplexing – all primary care doctors undertake mandatory CPR training every triennium and use of GoodSAM seems s sensible way to harness their collective skills; especially if added to surf life savers, paramedics, nurses, coastguards, SES, CFS/MFS etc etc.  Fears of being sued for not responding to an app activation seem like scaremongering – here in SA as part of the Rural Emergency Responder Network, registered doctors can choose to decline an emergency page if unavailable. Similarly rejecting a goodSAm alert just flicks it on to the next available responder – and of course, the network is voluntary and in a ‘Good Samaritan’ mode of operation – ambulance services are still activated via 000.

If my family member or loved one was unfortunate enough to have an out of hospital cardiac arrest, I would be glad that someone had at least attempted CPR rather than delay until ambos arrive.  As the Australian resuscitation council make clear “any attempt at resuscitation is better than no attempt.”  Similarly as a health professional, I would feel terrible if I was available to help and yet unaware of the incident until I heard the sirens and saw the ambulance arrive.

Australian emergency law expert Prof Michael Eburn runs an authoritative blog and has excellent commentary on Good Samaritan legislation and other matters for those who wish to examine Good Samaritan law in each State in more detail.  For me, the benefits to community of being available to deliver CPR by a trained person far outweigh the risks.  If medical professionals are worried about liability if turn down a request for help, same logic dictates they should never carry a phone….or even have clinic phone number advertised, lest someone ring for assistance!

There are some sensible GoodSAM FAQs here

The way forward?  

  • More training of the lay community in hands only CPR
  • Logging the location of AEDs in the community and advocating for AEDs where needed
  • Harnessing the collective pool of first aid trained responders across agencies (ambulance, fire, rescue, coastguard, nursing, medical, tour operator, school etc)
  • Being able to crowdsource CPR for OOHCA by early activation prior to ambulance arrival – as such, free apps such as GoodSAMapp have much to offer!

I’d also be interested in ventures where training in CPR was offered at school and then updated throughout subsequent years – some have even suggested CPR certification needed to update drivers licence in Australia! They do this in Seattle! Take Heart Australia are advocating the same here.

 

More Info

Australian Emergency Lawblog from Prof Michael Eburn (academic researcher and lawyer) 

Australian Resuscitation Council – The ARC is a voluntary co-ordinating body which represents all major groups involved in the teaching and practice of resuscitation.

GoodSAMapp – Good (S)martphone (A)ctivated (M)edics uses the latest technologies to alert those with medical training to nearby emergencies so that potentially life-saving interventions can be given before the arrival of emergency services. we aspire to have the highest levels of governance; all responders are checked, approved and their training is confirmed. The GoodSAM system is built such that individual organisations can administer their own Responders, then with local agreements, the statutory ambulance service can harness these Responders when there is a life critical emergency near them.

St Johns Ambulance Australia – Leading First Aid Provider

Surf Life SavingSurf Life Saving offers public first aid and CPR courses all over Australia

Take Heart Australia – has a single mission…to dramatically increase the survival rate of Australians who suffer a sudden cardiac arrest.

 

DOWNLOAD GOODSAM APP HERE :

ALERTER for iOS

ALERTER for Android (GooglePlay)

ALERTER for Android (directly)

ALERTER for Windows Phone

If you are BLS-certified (and can prove as such eg: scan of certificate, organisation documentation, registration etc) then download the RESPONDER app too.

eg: doctors, nurses, paramedics, coastguard, fire, rescue, school teacher, tour guide etc etc

RESPONDER for iOS

RESPONDER for Android (GooglePlay)

RESPONDER for Android (directly)

RESPONDER for Windows Phone

 

NB: If you are based on Kangaroo Island, feel free to join the specific ‘Kangaroo Island responder’ group.  That helps keep track of who is where and when…

 

Coming soon to 2016…

Coming soon in 2016 – a road test of second generation LMAs, iLMAs and head-to-head trial of various devices as conduit for fibreoptic intubation (plan B of new Difficult Airway Society  Guidelines – DAS UK)

IMG_2372-1 (dragged)
In meanwhile, here’s wishing all readers out there in the FOAMed world a Merry Xmas and Best for New Year.

Stay safe.

Don’t Find A Fault – Find A Remedy

I’ve just been reading the latest Clinical Communique from the Victorian Institute of Forensic Medicine – stoked to see fellow FOAMed enthusiast Gerard Fennessey contribute, along with a reference to a paper written by Casey Parker (BroomeDocs) and myself on the value of FOAMed for rural clinicians. There’s also expert commentary from Ass. Prof Matt Hooper on retrieval services.  These clinical communiques are excellent resources and a great source of tacit knowledge sharing.  Check them out here

Screen Shot 2015-12-18 at 2.30.14 PM

All of which has made me think about the issue of audit in rural practice.  It’s very easy to ‘point the bone’ to failings in rural practice.  Of course highlighting failings is important – but all too often systems seems geared more towards punishment, rather than gaining a true understanding of causative factors.  And this is where audit (part of clinical governance) becomes relevant.

Clinical governance is really important.  One of the (many) things I’ve learned from the prehospital environment is how clinical governance is essential to driving quality improvement. At SA Ambulance-MedSTAR (South Australia’s retrieval service), cases were audited every week which has the potential to drive quality improvement.  As Hooper says in regard to retrieval services

clinical governance, audit and educational activities should be multidisciplinary such that referral and receiving teams and the retrieval service are able to share learning outcomes….
…It is only when this occurs that the outcome for individuals disadvantaged by the need for retrieval are improved irrespective of gradients in the level of care available

The problem of rural audit

Things in rural South Australian hospital are a little different to the finely-honed mechanism of a retrieval service.  Many hospitals are staffed by visiting medical officers who work on a ‘fee for service’ basis.  Some of the larger ones have salaried medical officers, but most are on a VMO basis – and are hence attend only to see hospital cases – and depart as soon as care is completed.  Participation in hospital audit is far down the list compared to the pressures of running their own practice and providing an oncall service to the hospital.

Yet one of the hardest thing that rural doctors do it manage critically ill patients – such work is often required to be done with inadequate equipment and of course is performed relatively infrequently.  It’s stressful and of course a potential for mistakes with adverse patient outcomes.  Of course the running of the hospital itself and the training of nursing/ancillary staff is the responsibility of Country Health SA.  The nursing staff across rural hospitals are, generally, of a good standard – with mandatory training and skills maintenance dictated by Country Health SA.  But how about the doctors?

IMG_8268
Source – EMCrit.org

 

Well, some rural doctors do this sort of work very well indeed. Most are average. Some don’t do so well, understandably deskilled by the relative infrequency of such events and the paucity of equipment  I am interested in how to make this better – whether through increasing access to appropriate equipment, training through in situ sim, upskilling opportunities or through reflective practice.  The development of  appropriate guidelines designed specifically for rural practice is best driven by audit of such cases (what works in a tertiary centre may not work so well in a rural environment- viz many massive transfusion protocols).

“The surviving sedation guidelines 2015 collaborative project is a good example of rural guideline development, taking the best evidence and applying to this environment to assist practice in an inherently high-risk clinical situation.  Safe sedation and management of the soiled airway is something we practiced as sim in the RDASA Rural Docs Masterclass”

But here’s the problem – it can be hard to give feedback on such cases to team members.  The retrieval service is busy and may not have time to report back. In turn the rural clinicians involved have often gone home or disappeared to clinic.  Worse they may not be receptive to feedback unless delivered sensitively. Moreover, such feedback may be confined to patient outcomes, and ignore the nuances of non-technical factors in the management of critical illness. In addition, the feedback may be given to an individual clinician – but there’s not necessarily an opportunity to feedback to the team as a whole.

It’s true that many times the team members train separately – for example, upskilling courses purely for doctors, in-hospital training delivered solely for nurses. This is inevitable when scant heed is paid by organisations to the importance of human factors and the benefits of in situ team training and regular audit.

So – I am increasingly interested in the concept of feedback from all members of the resus team – as part of audit and to help drive quality improvement.  Rather than look upon this as ‘finding fault’ it’s more about ‘finding a remedy’.  Is this part of the solution?

Debrief – as a routine?

The concept of debrief is not new – it’s almost de rigeur after a critical incident, a cardiac arrest or a significant event (paediatric resus etc).. these are times when emotions may be raw due to the impact of the resuscitation and debrief is seen as a good thing to help individual team members make sense of the events.

But should debrief be routine after any critical illness requiring retrieval?  Perhaps not in larger centres – but I think the answer has to be resounding “YES!” for small rural hospitals where managing critical illness is relatively infrequent and there is much scope for learning and improvement.

Such debrief needs to gather input from all team members in a non-judgmental manner, allowing exploration of technical and non-technical aspects as part of a commitment to quality improvement. Allowing time for all members of the team to highlight areas for improvement can generate meaningful and shared objectives for change.

Feedback and debrief can also allow positive reinforcement of practices and behaviours that worked well – rather than debrief descend into nit-picking over trivia, there’s a chance to reflect on what worked well and to praise individuals.  The corollary is that causative factors in ‘what didnt work well‘ can be explored and hopefully addressed.  This may be problems with communication (most often), with equipment, with clinical skills or knowledge.

There’s no doubt in my mind that the model of private VMO and salaried rural hospital staff doesn’t work well for regular team training nor audit, because such activities are unpaid extras for the VMOs – unless authorised by the hospital. This in turn leads to a disconnect, presenting a wasted opportunity for quality improvement.

“The team that trains together will improve together”

Moreover, there may not be an organisational imperative to seek feedback on such cases. I recall a comedy moment in recent years where one senior Health manager (with overriding responsibilities for one aspect of rural health) assured me that there was “no need for audit of emergency cases; we already get told what to do when the Coroner gives a report”.

So – how to overcome this?

The hot debrief

The hot debrief – immediate post event discussion amongst team members – is a good chance to drive quality improvement once the critically ill patient has left the rural hospital.  Advantages are that team members are immediately available and can, if the appropriate culture exists, have a quick group huddle and talk about what went well/what could be improved.

Of course such efforts may be sabotaged if there are other imperatives – more patients to see, a messy resus bay to clean, the chance to grab something to eat….or the fact that patient outcomes are unknown.  Hot debrief is a valuable tool, but can omit the ‘big picture’ of events before arrival and after levaing the rural facility.

Routine audit

I’ve been asking various people in Country Health SA for the routine audit of critical patients in rural hospitals for some time….of course it’s invaluable to have the input of the retrieval service (and this often happens).

Rather than wait passively for feedback, I believe that an extra dimension to local quality Improvement can be driven by rural hospitals using a structured tool.  Feedback can be given by all members of team, whether lead clinician, nursing team member, volunteer ambulance officers, ancillary staff etc … and gives an opportunity for reflective practice once further information on the case is available

“In sim, we debrief after every case – and yet we don’t after a real emergency”

Encouraging the routine (but of course voluntary) use of feedback forms post a retrieval or resus allows chance to examine both technical and nontechnical aspects of care with a view to driving quality improvement. It requires a culture of openness, honesty and free of fear of retribution.  Audit of cases is not a ‘test’ – but an opportunity to drive quality care.

Here’s one I’ve been playing with on KI  – RURAL AUDIT & FEEDBACK FORM.

It has received some good feedback from colleagues interstate and I’d be keen for further feedback from readers on how this form could be improved for rural practice.

Practice elsewhere

As stated above, the retrieval service SA (MedSTAR) already do audit of each and every case and do a bloody good job of it.  There model is one to aspire to.  Similarly many rural anaesthetic practices (interstate at least) have regular audits and teleconferences to discuss interesting cases or ‘near misses’.  This is a good thing – although as far as I know there is no involvement of rural hospitals in the National ANZ Airway registry – a wonderful initiative that has really driven change in the practice of emergency department intubation.

Wouldn’t it be awesome to have a robust system of proactive clinical governance, lead by rural clinicians, involving all involved staff – with a view to incremental improvements in quality?

Horse-and-stable-door
Review of cases only after a clinically significant incident is a case of ‘acting after the horse has bolted’

Currently, it seems that SA Health has no robust audit of emergency cases in rural hospitals unless there is reporting of a critical incident or a finding from the Coroner.  To my naive mind, such audit and reflective practice involving the whole team should be routine and part of our culture.  In an ideal world, I’d love it if

  • rural hospitals routinely audited emergency cases, especially those requiring retrieval or unusual levels of input (equipment staffing etc)
  • senior clinicians in the receiving facility were able to feedback dispoisition, as well as referring clinicians making it a habit to enquire after every case ‘sent to the big hospital’
  • it was easier for the busy retrieval service to ‘close the loop’

In addition to clinical feedback, meaningful audit should explore issues with communication, equipment and team dynamics.

Perhaps many of you are already routinely auditing your emergency and resus cases?  If so, how are you doing it?  Ad hoc? Structured? Multidisciplinary? Involving ambos, ancillary staff, nurses, doctors, admin?

I would be really interested in what is happening elsewhere in Australia – or overseas – for audit of critical care in rural locations, by rural clinicians.

RURAL AUDIT FEEDBACK FORM

 

References

ANZ Airway Registry –  http://airwayregistry.org.au

Couper K & Perkins G (2013) Debriefing after resuscitation Curr Opin Crit Care. 2013 Jun;19(3):188-94. doi: 10.1097/MCC.0b013e32835f58aa. http://www.ncbi.nlm.nih.gov/pubmed/23426138

Fogg T et al (2012) Prospective observational study of the practice of endotracheal intubation in the emergency department of a tertiary hospital in Sydney, Australia Emergency Medicine Australasia, 2012, Vol.24(6), pp.617-624

Fogg T (2015) et al Airway Registry: Closing The Audit Loop http://airwayregistry.org.au/acem-2104-rnsh-final.pdf

Leeuwenburg T. (2012) Access to difficult airway equipment and training for rural GP-anaesthetists in Australia: results of a 2012 survey Rural and Remote Health 12: 2127. (Online) 2012 Available: http://www.rrh.org.au http://www.rrh.org.au/publishedarticles/article_print_2127.pdf

Leeuwenburg T & Parker C (2015) Free open access medical education can help rural clinicians deliver ‘quality care, out there’ Rural and Remote Health 15: 3185. (Online) 2015 http://www.rrh.org.au/publishedarticles/article_print_3185.pdf

May N (2013) It’s Good to Talk – Debrief in the Emergency Department StEmlyns Blog http://stemlynsblog.org/good-to-talk-debrief-in-the-emergency-department/

Surviving Sedation Guidelines 2015 – see guidelines as a PDF at http://kidocs.org/wp-content/uploads/2015/05/SSG2015v6.pdf – also blogpost via BroomeDocs and podcast here http://content.blubrry.com/prehospitalpodcast/PHARM-2015-05-12-119.mp3

Victorian Institute of Forensic Medicine – Clinical Communiqué – December 14, 2015 Volume 2 Issue 4 December 2015

 

Safety in Resus – Use the Whiteboard!

There’s no doubt that for the small rural emergency department, a critically unwell patient can quickly overwhelm available resources.  Like many small rural hospitals in Australia, there is one doctor on call for emergency presentations, with the ward-based nursing staff (two in out location) responsible for ward care, assessment of outpatient attendances as well as care of patients in the ED. Not surprisingly this can be a big ask…and thankfully extra nursing and medical staff are available if needed (typically the oncall theatre team)

As we ramp up into the tourist season on Kangaroo Island, I’ve been thinking about how we deal with critical patients in our rural ED.  Having the appropriate training and equipment is obviously important – as well as an appreciation of resus room feng shui.

A recent retrieval case brought the issue of improved team communication to mind.  I wont go into details; suffice it to say that this case required the attention of two doctors, seven nursing staff, one paid paramedic and four volunteer ambulance officers….and subsequent retrieval.  The demands of one critically ill patient … plus several other ED attendees … plus ward care can quickly overwhelm local resources, without a robust oncall system.

But no matter how well equipped, how well trained or even how well staffed the ED is, there HAS to be effective communication between members. We did quite well, but on reflection afterwards I felt that it was hard to keep track of who did what and when. This is often the case in a resus team, particularly occasionalists or the ‘flash team’ or individuals who have not trained together.

The traditional and practiced role of a resuscitation team is based on that of team leader, with subsequent role allocation and closed-loop communication between members, all operating with a common goal or ‘shared mental model’.  This is the sort of stuff we teach on the ETMcourse, focussing not just on the technical skills of trauma care, but also on the nuances of effective teamwork in trauma.

In recent times I have become a fan of using the whiteboard as ‘glue’ to hold the resus team together.  In any resus, it is common to delegate one person to scribe.  It’s important to have a record of drugs given, interventions delivered and arrival/departure of team members etc. But many people, myself included, find that the furious writing by one team member of all events & drugs on a piece of paper that noone else can see does little to add to team effectiveness in a critically ill patient.  Scott Orman over at Auckland HEMS has posted a nice summary of why a whiteboard is so useful for prehospital handover – I think this applies equally for rural hospitals.

Why is that? Well – it’s pretty simple.  In a small team, we need every hand on deck – delegating a clinical member to scribe may take them out of circulation. But that’s a minor gripe – the main problem with the scribe is that noone else can see what he/she has written unless they take time out to read their notes. In short, there is no shared mental model when all documentation goes via the scribed notes.  Moreover, the scribe may accurately capture all the interventions and their timing from multiple sources – but this knowledge is not shared between team members.

“often the scribe has all the critical information – noone else does!”

This makes sense – the resus can be chaotic, especially when team members haven’t trained together and there is a lack of leadership or followership, unclear role allocation nor closed loop communication.  Instead there is frenetic activity, cross talk, repeated interruption and a requirement to re-hash essential elements of history and interventions with the arrival of each new team member…

This is where the resus whiteboard comes into play – I’ll be the first to admit that ours is not big enough – but it’s a start. I would hope that every rural ED has a whiteboard available at the head of the bed or adjacent.  Documenting initial prehospital handover, subsequent interventions and obs, as well as arrival/departure of key players can help the whole team.

A whiteboard gives a clear indication of who did what, when, and why…as well as response to intervention. New arrivals to the resus can stand back and get a summary without having to interrupt.

More importantly, I find that having a summary on the whiteboard where everyone can see it gives a shared mental model – of where the patient was on arrival, the therapeutic goals and the steps needed to get there – a readily available shared mental model for all team members without the need for repeated interruptions and cross-questionning which is inevitable as additional team members enter the resus.

“closed loop communication between team members and a dedicated scribe may work well in a single trauma team – but as team members come and go, vital information is lost.

Rather than have to re-hash information, the whiteboard can give a quick summary of where we started, where we are now…and where we want to be.

It can also help open up communication – how much easier is if for a team member to raise a hand and ask “Excuse me team leader…I see that we have a goal MAP of 70 but the current MAP is only 55. Do you want to do X, Y, Z?” or “Hey everyone, we’ve transfused four units of packed cells in the last 20 minutes – we’re now into the agreed trigger for massive transfusion protocol…can we organise as agreed earlier per protocol?

Of course we still need to keep a written record – I am not suggesting that the whiteboard alone will suffice – but in a resource-limited and time-critical resus, the whiteboard can truly be the glue to keep the team on target and ensure what needs to be done is done, and that everyone knows about it! Here’s how the ‘ideal’ resus flow of information would work via whiteboard…

Prehospital Notification

AT-MIST AMBO or ISBAR can be used as a structured handover tool, allowing anticipated needs to be identified and role allocation of team members.

AT-MIST : Age/Time/Mechanism/Injuries/Symptoms&Signs/Treatment provided&Trends

AMBO : Allergies/Meds/Background/Other

ISBAR : Identity/Situation/Background/Assessment/Response+Readback

Key equipment needs may be anticipated based on pre-notification eg: traumatic head injury means probably need blood, fluid warmer, TXA, RSI equipment.  Drugs such as ketamine (for both analgesia and induction) can be pre-drawn and emergency drugs doses calculated & written down (especially for paediatric cases or uncommon scenarios). This is a good time to call in other staff – especially if multiple injuries or if solo operator and one critical patient.  The more resus I do nowadays, the lower my threshold to call in a colleague. It’s just so much easier to share the cognitive load…

prehospital handover

Patient Reception & Pre-Hospital Handover

Unless in extremis, take 30 seconds for a structured handover from the ambos before the patient is transferred off their stretcher. This is a high risk time. There is usually a flurry of activity as well-meaning individuals attempt to take history, remove clothes, gain IV access and set up monitoring.  Seriously – stop!

Studies show that less than 50% of information relayed by prehospital services is retained by emergency department staff – this can be increased by use of a structured handover tool. Whichever handover method is used, this is a time for everyone to STFU and listen!

Unless the patient is in cardiac arrest or needs immediate intervention (airway at risk etc), take 30 seconds and use the whiteboard to confirm elements of prehospital handover history and baseline obs.

I use this to determine resus goals for the team.  You will be amazed at how much information is missed at handover – especially when the receiving team ‘get busy’ with lines, blood pressure and monitoring – when they should be listening and coming up with a game plan!  And don’t get me started on 1-2-3 vs ready-brace-move for the actual transfer!

Rural Resuscitation

Once obs are done and as the primary survey is completed (again, calling out the findings so can be scribed to whiteboard), ensure a shared mental model of early treatment goals is established. I don’t know about other rural docs, but I find that a rural resus is hard work – we do this stuff infrequently, yet attention to detail can make all the difference. Critical care is mostly about doing the basics, well.

Treatment goals may be as simple as “let’s keep the patient warm, maintain oxygenation, target MAP >70 and stop the bleeding” or may be a little more nuanced “Let’s secure the airway – we’ll optimise position and pre-oxygenate; use the challenge-response checklist whilst drawing up drugs – then once intubated immediately perform a finger thoracostomy and ongoing resuscitation with warm blood whilst packaging for transfer

Obs can be scribed to show trends and response to interventions.  Key times & doses of drugs given are recorded.

Having a shared mental model allows opening up of communication of goals aren’t being achieved.  Rather than challenge the team leader (which can be difficult where there is an actual or perceived authority gradient), this approach allows truly patient-centric team collaboration.

Of course this will be concomitant with closed-loop communication between team members, something that is easily practiced on courses such as ETM.  Subsequent or parallel scribing to clinical notes is possible when time allows.

Handover to Retrieval Team

As mentioned above, the whiteboard can serve as a good global summary for the arriving retrieval team (or indeed anyone who arrives to the resus after a period of time) and allows a structured handover with salient points highlighted.  A photo of the whiteboard summary can be forwarded to the receiving facility as an initial SITREP.  Whilst the camera is out, there’s also the chance to catch some selfies with long-lost friends…

photo 65
Handover with retrieval – important time to exchange clinical info…and catch up with old colleagues (NB : this photo taken AFTER handover complete and patient stabilised!)

Before team arrival use any spare time to ensure all documentation is in order (if not already performed) and for notes to be written (often as the referring clinician I have been too busy to write anything until retrieval team arrive!).  An ABC type transfer checklist can be a useful summary (mine runs from the letter A to the letter O!). Of course patient care should take precedence over documentation! In a real rush I’ve been known to write on the patient!

Debrief

A hot debrief can be useful after a resus.  At this stage Country Health SA doesn’t routinely audit resus cases locally, which means there is little chance to improve performance not have open and honest communication on what went well and what didn’t.  Most improvement will be about aspects of communication, equipment availability and use, as well as practice as a team for realistic scenarios. The feedback from peripheral team members can be very important – the volunteer ambos, the cleaner, the ward clerk…and again the whiteboard debrief can help identify any problems in patient care and improve team resilience.

“without honest feedback from team member on cases, there can be no audit…

…and without audit, no improvement in clinical care”

In short, the whiteboard can help improve individual situational awareness via the early establishment of a shared mental model, opening up communication between team members.  There should be one in every rural ED – use it!

Whiteboards have been shown to aid the following in a resus:

  • task management
  • team attention management
  • task articulation and tracking
  • resource planning and tracking
  • synchronous and asynchronous communication
  • multidisciplinary problem solving and negotiation
  • team building

References

Prehospital to ED Handover (inc use of whiteboard) from Auckland HEMS http://aucklandhems.com/2012/11/26/pre-hospital-to-ed-handover/

Talbot R & Bleetman A (2007) Retention of information by emergency department staff at ambulance handover: do standardised approaches work? Emerg Med J. 2007 Aug;24(8):539-42. http://www.ncbi.nlm.nih.gov/pubmed/17652672

The Importance of Shared Mental Model from TEAM STEPPS http://www.ahrq.gov/professionals/education/curriculum-tools/teamstepps/instructor/fundamentals/module5/igsitmonitor.html#m4SL13

Xiao Y et al (2007) What whiteboards in a trauma center operating suite can teach us about emergency department communication Ann Emerg Med. 2007 Oct;50(4):387-95. Epub 2007 May 11. http://www.ncbi.nlm.nih.gov/pubmed/17498845

Transfer Checklist A-O https://ruraldoctorsdotnet1.files.wordpress.com/2013/04/transfer-abc.pdf

TRANSFER CHECKLIST

Airway

Breathing

Circulation

Disability

Exposure

Fluids given

Gut (fasted/NG)

Haematology

Infusions

JVP (filled/under-filled)

Kelvin (temp)

Lines

Monitoring

Notes & Next of Kin

Other Stuff…

Big Syringe, Little Syringe

Safety is paramount in anaesthesia, wherever it is being performed (in theatre, in ED or at the roadside). Many of the non-anaesthetists joke about the apparent simplicity of induction agents in an RSI, without appreciating the nuances.

RSI is easy!

inject the big syringe first – induction

then the little syringe – paralysis

By far the most commonly used induction agent in Australia is propofol, although in the ED and prehospital environment many of us prefer ketamine, for reasons as made clear in the infamous ‘propofol assassins’ rant from Cliff Reid.  Whilst somewhat tongue-in-cheek, it does make the point that a nuanced approach to induction agent is sensible, voiding the potentially catastrophic drop in blood pressure for critically unwell patients by avoiding agents and doses commonly used in theatre.  Similarly paralysis for RSI is traditionally performed with suxamethonium, although there is an increasing appreciation of the use of other agents such as rocuronium to maintain adequate paralysis throughout stages of difficult airway plans.

Drug safety

Like many other clinicians, I meticulusly draw my anaesthetic drugs in a standardised manner – big 20ml syringe for induction agent, 5ml syringe for midazolam, 2ml syringe for fentanyl, 5ml red-barelled syringe for neuromuscular blocker. These and all other syringes are labelled according to ISO standards as set out in ISO 26825:2008 – but I like to think that if the lights went out, I could still be sure that the big syringe was my induction agent….

There has been a lot of effort into safety in anaesthesia – probably the most important is the understanding and training of the impact of human factors in crisis management.  Checklists for both crisis management and routine (such as the WHO Surgery Safety Checklist) have their role, although all too often such tools become a mere tick-box exercise with lack of training or deviation subverting the aims of such aids.

In terms of drug labelling, there is still a long way to go.  The efforts of the international team at EZdrugID are worthy of praise – they are mounting a campaign to reduce avoidable drug error by exposing ‘lookalike’ drugs and campaigning for an international standard on such packaging. Check them out at the website EZdrugID.org or on Twitter via #EZdrugID.

Pancuronium or Suxamethonium? YOU CHOOSE
Pancuronium or Suxamethonium? YOU CHOOSE

So this week I was delighted to receive a set of sample ‘rainbow’ trays from UK company UVAMed.  These are a simple design – a plastic base tray which is colour coded, to which disposable plastic insert tray sets can be placed and disposed of after each case.

Screen Shot 2015-11-18 at 6.33.00 pm

I had a fiddle with them today in theatre – they are quite straightforward and the OCD in me liked the fact that ISO-labelled colour-coded syringes could be placed in a standardised layout in coloured trays. They use the AAGBI & RCoA standards.

It’s taken my standard anaesthetic tray from this

IMG_1415

to this

IMG_1427
Spot the deliberate mistakes! Midazolam in the induction compartment (yellow), propofol in the ‘miscellaneous’ section (grey). Placing wrong syringe in wrong compartment may increase error! Always check…

The trays are stackable – with a reusable (up to 100x) coloured tray into which a single-use palstic insret tray fits. There are three trays which can either be used individually, laid out on the anaesthetic trolley or stacked.

The Main Tray is for :

  • hypnotics
  • opioids
  • induction agents
  • muscle relaxants
  • anti-emetics
  • miscellanous (eg antibiotics, oxytocics etc)
  • reversal agents
  • induction agent

The Emergency Tray is for :

  • vasopressors
  • anticholinergics

The Local Tray

  • local anaesthetics
IMG_1426
Main tray stacked on emergency and local trays – deliberate errors noted!

Sadly the greenie in me bemoans the wastage of plastic by use of such disposable trays.  I did kind of wonder if I could fashion my own standardised tray using an off-the-shelf product (such as a cutlery drawer divider, subsequently painted).  But a strength of the ‘rainbow’ tray is the modular design, the fact that it allows standardisation across an institution and hopefully goes some way to improving drug safety via avoidable error.

Of course, there is always the potential for INCREASED error, eg an antibiotic syringe, even correctly labelled, if placed in the wrong tray could inadvertently be given due to ‘cognitive forcing’ by the tray colour.  But I would imagine that if use was standardised across an institution and anaesthetists were diligent in both using the rainbow tray for standardised layout as well as the always present requirement to carefully check each drug before injecting, then inadvertent drug administration could be reduced.

The concept is similar to the colour-coded standard panels in the prehospital packs from Neann-RAPP in Australia; they can help locate agents in a crisis, but of course each syringe or ampoule still needs to be checked properly before administration.

CQRpAWnUYAA8x-Y-1
Neann-RAPP prehospital packs demonstrated at #PAIC2015

As far as I am aware the Rainbow trays are not (yet) available in Australia. I would be interested to hear others thoughts on such colour-coding – and particularly if anyone is already doing similar with a ‘home made’ solution (there MUST be an off the shelf solution)

References

Currie M,Mackay PMagan Cet al.  The ‘wrong drug’ problem in anaesthesia: an analysis of 2000 incident reportsAnaesthesia and Intensive Care  199321596601.

Morris GPMorris RWAnaesthesia and fatigue: an analysis of the first 10 years of the Australian incident monitoring study 1987–97Anaesthesia and Intensive Care  2000283004

EZdrugID Campaign – access via EZdrugID.org

Propofol Assassins rant from Cliff Reid – click HERE to listen

Rainbow Trays – UVAMed

 

[NB: I received these trays as a free demo courtesy of UVAMed – I receive no financial benefit nor other reward for mentioning them on this blog!]