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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A little bit more about the benefits of In-situ simulation. It’s time we practice where we work

In-situ simulation has become increasingly popular and just recently there’s some evidence that it’s achieving the holy grail of simulation…simulation resulting in improved patient-centered outcomes. Intuitively it makes sense that more practice will make us better and probably practice within the exact place that we work, will be good too! Look at an Olympic downhill skier…they train several days in advance of their race on the exact same course as the race. Why? So that they can gain a better understanding about where every difficult turn is located or how they should navigate through a particularly challenging section. I mean, for such a high risk setting, why wouldn’t you practice where you work? Well I think the same can extend to resuscitation medicine. We should practice where we work! And at the very least, it won’t hurt us…and it will probably help. And maybe, just maybe it will benefit our patients too. 

This study was just published in Resuscitation. It’s a prospective study that implemented in-situ simulation in a pediatric setting with their emergency response team and they studied several clinical outcomes in a pre-post study design.

Their results included that after in-situ simulation, deteriorating patients were recognised more promptly and more rapidly escalated to intensive care (median time 10.5/5 h, p = 0.024). Furthermore there were additional trends (though not significant) towards decreased morbidity & mortality – which warrants further investigation.

The authors also note some key features of their team training & human factors considerations that may have contributed to the success of this intervention. Each of these 5 factors are EXTREMELY important for successful in-situ simulation:

(1) Regular training for all team members (4–10 times/year depending on rotation).

(2) Training in real clinical roles in real clinical environment.

(3) Key decision makers (paediatric registrars and charge/deputy charge nurses) from all wards participate in team and team training, building capacity to deal with evolving critical illness on the wards, even if the team as such is not called.

(4) Senior medical and nursing staff from many departments are team trainers – enabling trainers to address issues identified in clinical practice during team training and to facilitate acceptance of team and team training across traditional departmental boundaries

(5) Senior clinical and managerial staff support team and team training (willingness to respond early to calls from team; protected training time).

Finally, I’ve included the study abstract if you’re interested.

Regular in situ simulation training of paediatric medical emergency team improves hospital response to deteriorating patients. U. Theilen et al.  vol 84 (2):218-222

Aim of the study

The introduction of a paediatric Medical Emergency Team (pMET) was accompanied by integration of weekly in situ simulation team training into routine clinical practice. On a rotational basis, all key ward staff participated in team training, which focused on recognition of the deteriorating child, teamwork and early consultant review of patients with evolving critical illness. This study aimed to evaluate the impact of regular team training on the hospital response to deteriorating in-patients and subsequent patient outcome.

Methods

Prospective cohort study of all deteriorating in-patients of a tertiary paediatric hospital requiring admission to paediatric intensive care (PICU) the year before, and after, the introduction of pMET and concurrent team training.

Results

Deteriorating patients were: recognised more promptly (before/after pMET: median time 4/1.5 h, p < 0.001), more often reviewed by consultants (45%/76%, p = 0.004), more often transferred to high dependency care (18%/37%, p = 0.021) and more rapidly escalated to intensive care (median time 10.5/5 h, p = 0.024). These improved responses by ward staff extended beyond direct involvement of pMET.

There was a trend towards fewer PICU admissions, reduced level of sickness at the time of PICU admission, reduced length of PICU stay and reduced PICU mortality. Introduction of pMET coincided with significantly reduced hospital mortality (p < 0.001).

Conclusions

These results indicate that lessons learnt by ward staff during regular in situ team training led to significantly improved recognition and management of deteriorating in-patients with evolving critical illness. Integration of in situ simulation team training in clinical care has potential applications beyond paediatrics.

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.