I’ve been the ICU reg, critical of ED referrals. I’ve been the ED reg, critical of prehospital care and low quality primary care referrals I’ve been the primary care doc, frustrated with “GP to chase…” letters from tertiary centres and the lack of information in discharge summaries (and sometimes the lack of a summary!)
This is of course silo thinking – we only see a minority of ‘misses’, not the ‘saves’. It’s easy to fall into the trap of inter-specialty bashing when we perceive that the baton is dropped. But sometimes we have to speak up.
I was amazed to receive a discharge summary this week with the disclaimer “This summary was prepared by a clinician who had no involvement in the care of this patient.”
Speaking to my junior colleagues, they regaled me with tales of discharge summary ‘parties’ – a group of medical students, interns and RMOs being rostered on after hours, fed with party pizzas and being told by their bosses to wade through piles of outstanding discharge summaries for patients cared for in the Big Teaching Hospital.
Is it acceptable that discharge summaries are completed days or weeks after the patient has been treated? And is it not a serious safety issue if they are being done as an almost after thought, often by juniors not involved in care?
So – what can be done?
“If it’s YOUR name at the head of the bed, you are responsible for all aspects of that patient’s care“
Kudos to a colleague who frames this well. Rather than think of discharge summaries as an afterthought, often delegated to the most junior member of the team, we should think of them as clinical handovers. There are specific standards for clinical handover. It’s useful to consider them and reflect on how well current practices measure up.
Here is a stock response he suggests when receiving an inadequate discharge summary :
Suggest that they notify a “near-miss” to the hospital’s insurer and of course, “reflect” on their approach to the Standard, remedy the situation, re-train the staff and work towards “patient-centred care” (which is probably in their strategic plan anyway).
Request a response in writing and suggest they conduct an audit of, say, 100 discharge summaries completed by clinicians not involved in that patients care.“
Set a period of 4 weeks for them to compete the audit cycle and report back.
If no response, refer them to the ACQSHC.”
That’s fighting talk. I wonder how my colleagues in tertiary hospitals view this issue? Is it acceptable to delegate the writing of a discharge summary? Should specialty teams not ensure an effective clinical handover back to primary care?
I understand we are all busy and that delegation of tasks is required for both training and practical purposes. But quality control is an issue – and if the specialist team is too busy to provide a handover, then the system is broken and presents a foreseeable risk…
I recognise that primary care is not blameless in this. There are sadly still a minority of “Please see and do the needful…” type referrals to ED and my impression is that the quality in primary care is extremely heterogeneous….something many of us are keen to address.
So we are looking for TWO new doctors to join our wonderful practice here on Kangaroo Island
GP-Obstetrician (available immediately) comfortable with routine delivery, instrumental (vacuum and forceps) as well as elective and emergency Caesarean section. Birthing on Kangaroo Island is important to the locals ad we have approx 60 deliveries per year (ie not crazy busy). Well-supported by the Island Midwives’, we run Antenatal Clinic once per week and have birthing room and delivery suite at the Hospital, next door to our Operating Theatres. Generous oncall allowance paid under standard CountryHealthSA contract, plus fee-for-service for deliveries and obstetric care.
Rural Doctor / GP-EM (available Nov/Dec 2016 or earlier) – basic skill set of a rural doctor with responsibility for emergency care. 14 bed hospital, 4 bedded ED, ultrasound, X-ray, blood, theatre
We primarily work a four day (or less!) week, from 9-5 in mixed billing private rooms (Kangaroo Island Medical Clinic). There are five current Associates and one registrar who is awesome. We are looking to replace one GP-EM who is leaving end of the year, and to recruit an additional GP-OBS.
We all participate in the oncall roster. There are always three of us on (one for EM, one for Anaes and one for Obs). Emergency oncall is shared equally (currently 1:6); the quiet procedural oncall is shared between proceduralists (anaes 1:3), obs would be 1:2
The work is typical rural medicine ie: interesting and varied. We like to look after our patients locally where possible and are well supported by 24/7 RNs at the Hospital doing triage and many procedures to ensure doctors are only called in if necessary after hours.
There are currently three days per year of subsidised upskilling for EM and 10 days per year for anaesthesia or obstetrics.
Needless to say Kangaroo Island is a fantastic place ot live and work. We enjoy a close-knit community of 4500 Islanders, plus 200,000 tourists per annum who come to enjoy Kangaroo Islands unique beauty, wildlife, fishing, diving, fine food and wine. Unspoilt beaches etc
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:
How are the symptoms that lead to their ED presentation going? Have they been relieved?
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.
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.
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.
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.
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.
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.
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).
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.
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)
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.
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.
This 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
“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.
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.
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!
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.
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.
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)
In meanwhile, here’s wishing all readers out there in the FOAMed world a Merry Xmas and Best for New Year.