Patient safety strategies ready for primetime

This week, Annals of Internal Medicine published a critical review for strategies designed to enhance patient safety. The best part, the authors summarized their findings into a 1/2 page table outlining 10 “strongly encouraged” and 12 “encouraged” strategies…this makes  for a quick read! Extremely important for those of us who’s attention spans are so short that we can’t even wait in a line at the grocery store without checking our email twice, posting a tweet and reading the daily news.

Source: Shekelle et al. Ann Intern Med 2013 Ann Intern Med. 158:365-368. doi:10.7326/0003-4819-158-5-201303051-00001

Source: Shekelle et al. Ann Intern Med 2013 Ann Intern Med. 158:365-368. doi:10.7326/0003-4819-158-5-201303051-00001

I really liked this list and I think it’s great to publish  for people to review. You can look at what you’re doing at your own institution and if there are things missing, it provides a basis for advocacy.

It’s interesting that many strategies relate to intensive care medicine. I’m not sure if that’s a function of the interest by intensivists/anesthesists in patient safety, a result of funding bias towards ICU-level patient safety studies or maybe that’s where much of the difference can be made (at least from a mortality perspective). What this list also demonstrates is that there are many areas within primary care, trauma care and emergency care that require attention. 

The authors mention that “pre-operative checklists and anesthesia checklists” are strongly encouraged. I agree! But what about checklists during acute resuscitations? We simply don’t know because the evidence hasn’t been developed yet. Certainly I think this can act as a call to those funding and researching patient safety in acute care medicine . Cliff Reid wrote about the “Resus Room Life Guard” several months ago…we don’t know if this is a good idea or improves patient oriented outcomes because it hasn’t been studied. Though intuitively, it seems like a great idea!

There was also no mention about the importance of adequate discharge follow-up from the ED…some hypothesis generating studies that patients who don’t have great follow-up are at risk. But clearly more studies are needed.

Finally, for those of us interested in simulation, it offers additional support that team training and simulation exercises with a focus on patient safety are worthwhile undertakings. A recent study from demonstrated improved communication and teamwork in a trauma centre following in-situ trauma simulation training. In addition, there appeared to be some patient oriented improvements including improved speed without compromise in critical task completion.

The list of strategies is worth a read…see how you compare and see how your institution compares. If you’re not doing the “strong encouraged” items…its probably worth considering why not? Do you really need to put the femoral line in during the resuscitation or will the 2 large bore IVs suffice until the patient can be properly draped and line insertion done under fully sterile conditions? Do you wash your hands before and after every patient encounter? I know at our hospital we have people in the ED (maybe posing  with acute Percocet insufficiency) or hiding in the shadows…yet…they’re really monitoring our handwashing complicance.   While I have been known to get in arguments with them…they’re actually just trying to implement important patient safety measures.

#patientsafety.

That’s it for now. Feel free to post any thoughts/comments.

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Navigating the world of social media in clinical medicine

It’s great to see articles now about the impact and effects of social media in medicine especially in other specialities. This article titled “Social Media and Clinical Care” was just published in Circulation and deserves at least a brief review by any clinician who uses social media either to augment clinical care. It’s also encouraging to see this appear in the journal Circulation which has as a relatively high impact factor (around 14). Clearly the academic medical community and more importantly the general medical community is taking note of the importance of social media.

Whether you like it or hate it, I would argue we shouldn’t fight social media. It’s unlikely to disappear especially now with more than 1 billion smartphones on the planet.  Instead as clinicians we should use it in a way that helps us communicate with each other, with patients and ultimately improves care. That being said, social media does NOT equal good or better! (it can be ). We always strive to “do no harm” and social media in medicine should be no exception.

To borrow the Spiderman quote “with great power comes great responsibility“. The same applies to social media…in fact maybe I should try and coin my own modification “with great social media power comes great social media responsibility”! But as we increasginly engage in social media we must recognize it’s power…which is why we should continue to use it but also understand how it can be quite dangerous.

What this article does it outline the various ways that it can be used within clinical medicine. It also highlights the ethical challenges we face and provide some perspective using an ethical framework.  The great thing is that in the spirit of FOAM (free open access medicine) this article is free! Congratulations for Circulation for making this accessible to all.

Who should read this article?

  • Any clinician who has patients participating in social media as a source for medical advice
  • Any clinician who uses social media as a form of communication/education with other clinicians
  • Any clinician who engages with their patients through social media as a form of education
  • Any clinician looking for some good references of studies that evaluate the impact of social media within medicine/patients

Does this sound like all clinicians should read it? I would say unless you still think rotating tourniquets is the optimal method to treat heart failure, yes…you probably should at least give it a glance.

What I found interesting was the discussion about whether it’s appropriate to use specific patient cases on a blog. I haven’t taken up this practice, but I really do value reading other medical blogs when authors recount specific instances. It’s helpful to read these accounts – almost as if you’re speaking with a colleague about an interesting/challenging case…but now your colleague can be anyone in the world. Powerful stuff! But at the same time, I respect the issues of confidentiality that surround such discussions. What was interesting was the article quoted data that found

“medical educators…felt that writing a deidentified patient narrative using a respectful tone was never or rarely acceptable (61%)”

That is really quite high…61%! And impressively it was a “deidentified” patient described  using a “respectful tone”. I’m curious to know what others think but I personally don’t have a problem with it. I think it’s obviously better to have patient consent but what if the case was 2 years prior? Does that change anything? Pragmatically it would be hard to find that patient…and perhaps considerable learning can be achieved from the case. This is definitely a challenge for educators/clinicians in balancing the risks & benefits. More importantly, it doesn’t seem like our colleagues may support such actions!

The authors of this article outline some recommendations for physicians who have blogs/websites as well as those who engage in online social networks. None of these are revolutionary but they provide us with good reminders of how we can continue to uphold our commitment to improving patient care in an ethical manner.

Source: Chretien & Kind Circulation 2013

Source: Chretien & Kind Circulation 2013

 

Source: Chretien & Kind Circulation 2013

Source: Chretien & Kind Circulation 2013

 

 

NEJM commentary on service in medical education – They got it wrong.

Last week there was a very interesting perspective/editorial published in the NEJM. But one that I thought deserves some comment because I strongly disagreed with the authors. In fact, I thought it was unfortunate to see this commentary in such a widely read journal.

The title was “Service: An Essential Component of Graduate Medical Education“. It was authored by two Boston physicians (both appear to be oncologists). The authors outline their concern that service should be seen as an educational objective that shouldn’t be minimized, instead “resident duties that confer a high degree of service may still provide high educational value, in the form of genuine experience with patient care”. In essence they argue that seeing any/all patients is a learning opportunity! We will often joke about this on a shift when there’s a patient that likely won’t be a valuable learning experience for the trainee. I would agree that learning probably can gained from most patient interactions however, the quality and the yield may very often be low. Plus rather than subscribe to these authors’ belief  any patient presents learning opportunities and service should be viewed as learning, we should recognize that different learners have different needs. I would argue that in the emergency department, a surgery intern may gain very little from seeing a patient with chronic back pain that is seeking opiates and has considerable behavior issues. Patients like this can be challenging and often provide little learning especially when there are other patients to see. For instance, it’s very possible there’s a patient that needs to be seen that will better fulfill the pre-defined objectives of the surgery intern. However, this patient may be useful for the senior emergency medicine resident to manage as such patients will be their responsibility once they’re staff.

The authors then provide several examples of “service” which I found quite interesting.  One which particularly caught my attention…”A family practice resident misses a teaching conference in order to see her last clinic patient, who arrives late because of transportation problems“. They argue that a “didactic” teaching session is not nearly as valuable as seeing that final patient in clinic! I think this sets a dangerous precedent. Residents/trainees should not be made to miss preestablished learning opportunities for service. Whatever this “teaching session” is, it’s been integrated into the curriculum such that the resident can work towards achieving competence in their field. There may be exceptions but as a rule I would advocate against this mindset.

We have begun to move towards a competency-based approach to medical education with a set of competencies laid out for residents to achieve by the end of their training. As they work towards these competencies, there’s no doubt that they’ll be doing “service” and “less valuable” tasks but to think that simply seeing patients and doing scut work is valuable because you never know when that little piece of learning may occur is wrong.

The final words of the authors addressed the aspect of competency-based education head on: “many medical educators have worked to optimize the educational value of residency and protect trainees from engaging in menial activities from which they do not learn. As such reform continues, however, it risks going too far and sacrificing certain essential educational experiences that can emerge from service activities, as well as the opportunity to teach trainees about service’s importance to the profession”

Overall  the author’s argument came across as annoyed staff physicians who were having to do their own work and no longer being able to pawn it off on their residents.

In general, I strongly disagreed with the authors’ argument. In an era in medical education when time has become a commodity and duty hour restrictions have become reality, we must continue on the path towards ensuring trainees are competent based on pre-defined learning objectives. We should seek efficient and high yield methods for trainees to learn. To continue forcing a resident to do dictations for the same thing over and over simply because they need to learn the value of service seems to go against this approach. It will not help trainees become better doctors and as a result our patients will suffer. And as most of us agree, we became physicians to become experts in patient care and help those who can’t help themselves.

Role of the attending physician in medical education

Recently JAMA published a short viewpoint on the role of the attending physician on ward rounds. This was brought to my attention from a great blog/website that highlights what’s new in the world of medical education.

In medical education there’s been quite a bit about different teaching methods and how to incorporate new approaches like simulation and case-based learning. But this viewpoint brings up an interesting perspective that we rarely consider…the role of our teachers and how it should change. While I didn’t agree with everything that authors mentioned, the concept is important to address.

In the article, the change from “older” to “younger” attendings was discussed and how it will impact trainees. The authors argue the hierarchy has disappeared and younger attendings are more comfortable helping trainees out with the workload. This works well given the increased emphasis on duty hour restrictions. Furthermore, the authors describe older physicians as more likely to teach at the bedside and less comfortable with technology.

I was surprised, however, to read how little attention was paid to the impact of technology on trainee education. To discuss the changing role of the attending must also include the changing methods that trainees learn. Attending physicians are no longer the fountain of knowledge they once were. Wikipedia has quickly taken over this role!  Trainees can easily access the opinions of 100 attendings with a quick glance on their smartphone. The experience of attendings in stating “I had a similar case and this is how I dealt with it” is arguably less important now as evidence-based medicine has become pervasive in medicine. Technology has augmented the trainees ability to find 10 articles about how to manage a particular condition, often drawing on the results of several studies – this is significantly more than an “experienced clinician” can provide. I write this understanding this may be provocative and subject to disagreement but sometimes controversy is good! What’s more is that some have used this article to prove the utility of apprenticeship. It’s difficult to imagine that in an era where competency-based education has been repeatedly shown to be superior to the “see one, do one, teach one” method, we still have to continue talking about it. More studies than I care to cite have demonstrated that its no longer good enough to have “done a procedure” as a surrogate for competence. There should be a uniform approach where trainees meet a minimum standard. They’ll have knowledge of complications and ideally even demonstrate this in a simulation (without having harm come to a patient). Finally, they’ll be assessed as they perform the skill in the clinical setting – all stakeholders benefiting including the patient, trainee and teacher.

A reply to the article mentioned above was posted by another group of authors who have addressed teaching by staff attending physicians. These authors conducted a survey that identified  “Sharing of attending’s thought processes” as among the most important attributes an attending physician could share during rounds. This highlights nicely how trainees are changing and as a result how staff physicians should re-focus their teaching.

Trainees can be effectively taught by flipping the classroom and learning on the web. 30 years ago this wasn’t possible but now with exponential growth of technology, learning can occur before actually seeing patients. However, what must be learned from experienced clinicians is their cognitive reasoning. Learning such a skill from the web or a textbook is much more difficult. Rounds or bedside teaching sessions should focus on how clinicians avoid biases in their decision making. Trainees should be taught early on how to think like an expert.

Attending clinicians must focus their efforts on training new doctors to think like they do – employing a sound approach to each clinical decision . And teaching faculty should be taught how to teach these skills.  In an era when trainee clinical time has become a scare commodity, efficiency becomes paramount. Teaching core content has become increasingly inefficient especially during precious clinical rounds when both the trainee & attending have access to patients!  Trainees have no shortage of information to diagnose and treat patients but they must be taught to use it. This is the new role of the attending physician in medical education.

The time for checklists in medicine…is NOW!

I have written about checklists in medicine before, but in light of a recent publication in the New England Journal of Medicine, I was inspired again to write about it.

One of the leading advocates for checklists in medicine is Atul Gawande. His book “The Checklist Manifesto” is an excellent read for anyone interested in the topic and definitely well written for the lay-person. Notably he’s also the senior author on this randomized trial just published in NEJM. And while the NEJM is often busy publishing some questionably biased and often pharma-funded studies, this one deserves attention. But before I discuss more about the trial…I digress…

Just this week, while we were flying I observed something quite interesting. Typically when we fly in the helicopters, our pilots ask our crewman for landing checks. At which point the crewman will go through the checklist with the pilot answering appropriately. We were out on a job and the crewman was busy in the back of the machine so the pilot read the checklist himself. After each item on the list, the pilot would answer himself….basically talking to himself. I remember asking a pilot about the value of a checklist for both their critical and non-critical procedures. He told me that by doing a checklist, he could concentrate on the variables that may arise and not worry about forgetting something small or routine. This is interesting…

I can’t remember the last time I’ve seen a physician read off a checklist, answering to themselves that all everything required is present and functional.  In medicine, we have this idea that if we can’t remember everything then it’s a sign of weakness. We don’t use checklists. In our minds “checklists are for losers” (not sure who I’m quoting here). But this idea that we must remember everything during a critical event is unique to medicine. Obviously I’m not advocating that we shouldn’t commit anything to memory but why bother trying to remember mundane items when we should be concentrating on “owning the resuscitation” (A term coined by Cliff Reid from resus.me).

We should instead focus on identifying why the patient is crashing or what might make this particular intubation difficult. We should NOT be trying to remember whether we’re missing anything… “ok…so I have the BVM, suction, tube…anything I’m missing? Of course! We need RSI drugs!”…this is a useless conversation and waste of time. By using a checklist the cue for RSI drugs will happen and the focus can be on more important things like ensuring the patient is well positioned, critically evaluating the cause for clinical deterioration – then the clinician can focus on real problem solving.

It’s interesting that many of the HEMS services out there are using RSI checklists and yet few are used in EDs around the world. At our HEMS service, we use it because we work in often hectic conditions that can be quickly become uncontrolled situations with unstable patients…wait a second…that sounds remarkably like an ED around the world! So why not implement a similar protocol? A recent paper in J Trauma looked at a standardized approach to RSI in trauma…seems promising!

And as I mentioned above, the NEJM recently published a large randomized trial evaluating the use of checklists for high-fidelity crisis simulation in an operating room setting. The use of checklists resulted in a 75% reduction to adhere to critical steps in management. Most impressively, the difference in missing critical steps was 6% with checklists vs. 23% without checklists. That’s an absolute reduction of 17%! And a relative risk reduction after multivariate analysis of 28%. If there was ever a drug trial that showed similar results it would likely be put in the water (maybe fluoride?). But last time I checked, no one will be making much money by producing a checklist. And yet despite our inability to show much more than non-inferiority with new oral anti-coagulants (vs. warfarin), the increase in use is HUGE!

This figure below published in the article is impressive. It demonstrates how the same team behaved completely differently depending on the use of a checklist. Some of the instances where they failed to adhere to critical processes of care is unbelievable and certainly is NOT good for patient oriented outcomes! V.fib and no defib for 1.5min? WOW!

Prime example of how checklists can help during resuscitations! Published in NEJM

Prime example of how checklists can help during resuscitations! Published in NEJM

I agree that we should probably study the implementation of a checklist into emergency medicine…but we probably shouldn’t wait longer. Recent publications show adverse event rates (or near misses) of 10% during RSI in the ED. This is NOT acceptable. We can do better and we should do better. Time for checklists to become an integral part of our critical actions. We can assign the checklist to be administered by our resuscitation room safety officer (yes, another novel concept that also deserves consideration…check out Cliff Reid’s great blog post on the topic)

 

Medical error…an unbelievable story

This past year (2012) was apparently aviation’s safest year ever!

I’m not sure the same can be said for medicine. I don’t know if we have similar global data as aviation but my guess is that we haven’t made the impressive strides our pilot friends have made.  While considerable efforts are being made to improve patient safety, medical errors continue and often despite identified solutions.

I wanted to share this amazing & shocking video (see below), narrated by Martin Bromiley who is the husband of a woman (Elaine Bromiley) who died as a result of medical error during a routine surgery in the UK (around 2007). Martin is a commercial pilot and using his experience with crisis resource management, teamwork and critical decision making he sought to determine what factors lead to his wife’s death. More impressively, he developed efforts and programs within the NHS based around human factors.  Listening to Martin speak is quite remarkable and for a man who has suffered a such devastating loss, he has made an amazing effort to make medicine safer. His efforts should be congratulated and shared. Watching this video provides powerful evidence that educators must incorporate simulation that elicits stress among the participants. In medicine, we should practice scenarios where clinicians must function and make decisions in a high-stress environment. This must be implemented with caution however, as there is some emerging evidence (and another study) that when stress levels are too high, trainees may experience cognitive overload that actually inhibits learning.

Is it time for tranexamic acid in the pre-hospital setting?

Recently, we had an elderly patient brought into the ED after being involved in a fairly substantial motor vehicle collision. As we began treating her, I asked the trauma surgeon who was taking over the patient’s care whether he wanted tranexamic acid given (TXA). As she was relatively hemodynamically stable (despite several  transient hypotensive episodes), he declined providing her with TXA without elaborating.

C2logoNew

In my view, this patient was definitely someone who would have benefited from TXA especially after later imaging revealed retroperitoneal bleeding. I also wondered, whether this patient could have been given TXA in the pre-hospital setting? At ARHT, we’re not currently using TXA but there’s some question as to whether the pre-hospital setting may be an optimal place for initiation of therapy.

In 2010, the Crash-2 study was published. It was an unbelievably impressive undertaking that randomized trauma patients (a very broad cohort) to TXA or placebo. More than 20,000 patients were enrolled in 40 countries, many of which were resource poor settings. The results were quite remarkable with an absolute risk reduction in all cause mortality from 16% (placebo) to 14.5% (TXA). The authors concluded that “TXA should be considered for use in bleeding trauma patients”.

A closer look at the data suggests that this benefit is primarily if TXA is administered within 3hrs of injury. More recently, additional analysis revealed that death due to bleeding was significantly reduced when administered in <1hr (NNT 42) and between 1-3hrs. This re There was concern about harm if there was a delay >3hrs.

This time dependent effect has considerable ramifications for pre-hospital health care providers. As far as I can tell, there’s no data to support the use of TXA in the prehospital setting but our existing data would support early administration which could easily be provided for patients before arriving in hospital. In particular, patients with prolonged extrications, longer scene times or longer transport times may benefit the most.

A recent retrospective study (MATTERs) study looked at the use of TXA in a combat setting among patients who received at least 1 unit of red cells. They found an association with lower mortality for those who received TXA. Clearly the methodology of the study precludes immediate clinical adoption but it provides additional evidence of the possible benefits.

My bias is that if this was a drug that wasn’t off patent and that there was some pharmaceutical company that could make billions then we would be much more aggressive with its use. In cardiology, most statins have numbers needed to treat of 100-200 and yet with massive (an apparently effective) marketing campaigns, I’ve heard some cardiologists say it should be in the drinking water! I digress.

I think it’s time to consider TXA in the pre-hospital trauma setting in a well defined protocol. The relatively broad inclusion criteria used in Crash-2 which still resulted in impressive outcomes suggests that it would be reasonable to consider in many of our suspected bleeding patients prior arrive in hospital.  And clearly, there needs to be a move within the hospitals and trauma bays to actually implement protocols and give TXA early. Based on existing evidence, we will only be providing better patient care.

What’s the difference between a novice and an expert?

expert

A new study published in Annals of Emergency Medicine helps us better understand the differences between an expert clinician (practicing >5yrs) and 1st year emergency medicine (EM) residents.

Using interviews and qualitative methodology they examined participant responses to a variety of situations and incidents. They performed cognitive task analysis (fancy words for what someone actually does when faced with decisions & situations).

While they found there’s considerable differences between the two groups, they were able to summarize the findings:

  1. Experts are able to extract relevant information from a large collection of irrelevant data
  2. Experts focus on assessing the nature of the situation and NOT comparing various course of action (this leads to faster decision making)
  3. Experts can rapidly alter their diagnostic direction or treatment plan with new/unexpected information; novices are unwilling to accept new information if it disrupts their diagnosis or plan
  4. Novices rely heavily on objective data independent of the patient’s context
  5. Experts maintain high levels of spatial, temporal & organizational systems awareness; novices struggle with the “big picture”

What is important from this study is that we learn how novices & experts think. By simply accepting that once “novices” get smarter and more experienced that they’ll think like experts is doing a disservice to our trainees. We must impart early on the approach to thinking and diagnostic reasoning while acknowleding that factual information and experience will come with time.

The authors suggest that “targeted and frequent exposure to critical situations translates knowledge into expertise and bridges the expert-novice gap in clinical decisionmaking”.

We need more research in this field so that we can modify our educational approaches. We should be teaching trainees early on how to think like an expert.