Hospital Safety Report Provides Opportunity for Innovation

A new report into managing critical safety risks in the hospital system makes important recommendations and highlights the need to prevent patient injury and death in the first place, says a high-tech medical start up.

 

The just-released Duckett review into DHHS management of incidents, such as a spate of perinatal deaths in Victoria in 2013-4, underlines the ongoing national tragedy of 1800 Australians who die each year and another 6800 who are impacted by such adverse events.

 

Osler Technology, the brain child of intensive care and retrieval medicine specialist Dr Todd Fraser, provides real time, meaningful data on patient outcomes within the clinical workspace, and enables clinician leaders to respond rapidly and creatively to prevent future events.

 

By tracking individual training and activity data, it ensures all staff practice within their scope.

 

“The recommendations of the Duckett review create a better environment for patient safety across the wider health system but this is only half the battle. Left unanswered is how health systems prevent patient injury in the first place,” said Dr Fraser.

 

“If meaningful change is to be made, clinical staff will be the ones to make it, and they can only do so with the right tools and information at their disposal. This is where a system like Osler plays a role by taking the high level principles identified in the Duckett review and applying them at individual patient, clinical manager and clinician levels.”

 

Read the full media release here:

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Stephen Duckett’s report highlights need for new thinking on clinical governance

Background

The recently released Duckett Report was commissioned in response to a review of the role of DHHS in detecting and managing critical safety risks and clinical governance across the system following a cluster of perinatal deaths at Djerriwarrh Health Service in 2013-14.

 

The report highlights that while Victorians have a right to assume that healthcare is generally of a high quality across the system, there continue to be significant deficiencies in the system’s defenses against avoidable patient injury.

 

The report cites a 2014-15 review of hospital acquired diagnoses in Victorian Healthcare System, which concluded that “complications of care are far from rare in our hospitals”.  In fact, more than 300,000 patients per year suffer a complication in Victorian hospitals, at least 70,000 of which are potentially preventable such as malnutrition or pressure ulcers. Many of these result in fatalities.

 

This issue, to say the least, is huge.

 

The Duckett report was commissioned to review the role of the DHHS in preventing these events.

 

Essentially, the report calls for the department to better support Victorian Health Services in providing a high level of local clinical governance on safety and quality, to monitor outcome data more closely, and to respond more effectively when things go wrong.

Major Findings

To this end, the report makes several important recommendations, among them :

 

  1. The department must set a clear example to the wider health service that this issue is its number one priority
  2. The system should focus less on “meeting accreditation standards”, and instead greater emphasis placed on outcome monitoring
  3. The department better supports the boards of health services by reviewing the appointment and training processes for board members, to ensure they can effectively oversee hospital governance
  4. Performance of the health service is more effectively monitored, by making better use of available data and filling in gaps as they exist
  5. Improvements are made in the utilization of data, so that the entire system can benefit, and learnings are better shared
  6. All hospitals should be open to periodic external review
  7. That hospitals are held to account in only providing care that falls within its scope of capability
  8. Consumers and front line clinicians must have a louder voice in the quality assurance process.

 

What does this all mean?

Promoting a culture of transparency and accountability, and most importantly trust, are an excellent start, and to this end, the department is to be congratulated for the example it has set.

 

As Dr Duckett himself points out, the department acted immediately to support Djerriwarrh protect its patients, investigate the cluster of deaths and engage in an open disclosure process.  It then sought prompt external review of its own role in the process and made those results public immediately.  It is a high level demonstration of the transparent accountability required at clinician level.

 

The recommendations of the Duckett review create a better environment for patient safety across the wider health system but this is only half the battle. Left unanswered is how health systems prevent patient injury in the first place.  Albeit beyond the scope of the review, here lies the rump of the improvement curve – what are the hospitals and health services, their clinical managers and individual clinicians supposed to do to improve patient care?  The report provides few answers.

 

If meaningful change is to be made, clinical staff will be the ones to make it, and they can only do so with the right tools and information at their disposal.

 

Without appropriate tools, processes and culture in place, no amount of oversight will achieve the department’s lofty goal of zero preventable patient injury.  This is where ready-made systems like Osler plays a role by taking the high level principles identified in the Duckett review and applying them at individual patient, clinical manager and clinician levels.

How can Osler contribute to improved clinical governance?

Osler provides an opportunity for hospitals to be proactive in their patient safety efforts.  As Dr Duckett points out, hospitals should be operating within their defined scope of practice.  The problem is, few clinical managers have sufficient granular visibility of their activity to enable this to occur.  Using Osler to ensure all staff are adequately trained to perform invasive procedures, non-technical skills and basic equipment familiarity helps manage this clear and apparent risk.

 

By providing real time, meaningful and comparative data on clinical proficiency, complication rates and currency or practice, Osler enables hospitals to identify and respond to limitations in service levels and patient care.

 

And by creating a collaborative environment for clinicians, Osler can distribute these essential learnings across the healthcare system so that Victorians, indeed all Australians can be treated in a safer manner.

 

 

“You have to be willing to acknowledge your problems before you can remedy them. If I were to characterise the state of public and private hospital care in the state of Victoria, I’d have to say that this first step is lacking. Both the public and private hospital systems and the government regulators who oversee them are in a state of denial with regard to the level of harm being caused to the public by inadequate attention to quality and safety deficiencies.”

Paul Levy

former president and CEO of Beth Israel Deaconess Medical Centre in Boston, Massachusetts

Deakin University, Thinker in Residence, 2016

Training in Ultrasound – In the kingdom of the blind, the one-eyed man is King

In this special guest blog post, Dr Adrian Wong discusses the challenges surrounding the introduction and implementation of a new technology in healthcare, bedside ultrasonography.

 

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The application of ultrasound beyond the realms of the Radiology department is well and truly established. Ultrasound has evolved into an indispensable tool in the physicians’ armament – providing diagnostic, monitoring and procedural guidance within a neat package. Acute physicians, ED doctors, anaesthetists and critical care physicians have all embraced ultrasound as an essential part of their role.

 

The key to utilizing ultrasound successfully, in the hands of such a diverse group of specialties, lies in asking the right questions. Hence the development of focused examinations. Focused echocardiography is probably the best example of the use of ultrasound, permitting non-cardiologists to answer questions immediately relevant to their area of practice. The ability to confidently rule out (or in) pericardial tamponade in cardiac arrest or pneumothorax in trauma is pivotal in patient management. A word of caution though, as POCUS examinations are usually performed in a time-sensitive environment, getting it wrong can have significant repercussions. Urban legends such as a patient being thrombolysed because the LV was mistaken for the RV or a ‘leaking AAA’ taken straight to theatre only to reveal a normal caliber aorta are whispered in corridors as a reminder to the budding POCUSologist.

 

The proven clinical benefits of point-of-care ultrasonography has led to ongoing expansion of its role into uncharted areas. Whilst obviously exciting, this raises the issue of training and competency (to perform, interpret and act upon results). How best to become competent in ultrasonography makes for interesting and sometimes divisive conversation.

 

Reflecting on personal experience, my interest in POCUS coincided with the launch of CUSIC (Core Ultrasound Skills in Intensive Care), the UK’s own POCUS programme. A handful of centres in the UK offered fellowships with qualified trainers and suitable training opportunities. Apart from the guidance of experienced colleagues, my training was supplemented with online FOAMed resources. Videos recorded and shared (available free of charge) by esteemed teams of individuals such as @5minsono and @ultrasoundpod were instrumental in my professional development. Since then, the number of courses and fellowships available have continued to expand. I now help run our department’s POCUS fellowship and hence the issue of training is never far from my mind.

 

When one considers all the possible modules under the umbrella term of point-of-care ultrasound (POCUS) e.g. echocardiography, abdominal, etc. the concept of training and competency becomes even more nebulous. There are numerous POCUS accreditation programmes available from a variety of bodies. The ACCP, ESICM and ICS (UK) have developed their own programmes, all of which contain some overlapping similarities. As adult learners have different styles of learning, there is no single best way to learn the skill of POCUS.

 

As an example, the BSE (British Society of Echocardiography) accreditation for critical care requires a theoretical and practical examination with a logbook of 250 appropriate cases. In contrast, FICE (Focused Intensive Care Echocardiography) accreditation requires attendance at a course, a logbook of 50 cases and a triggered assessment. These two accreditations obviously differ in their resulting skillsets and breadth of clinical scanning experience, but this highlights the variation in training requirements for the module of echocardiography in critical care. Furthermore, BSE requires a regular logbook of cases to maintain accreditation, whereas no formal processes are currently in place to maintain FICE accreditation. In practice, any clinician with BSE or FICE accreditation is able to perform day-to-day echocardiography in an intensive care setting (although awareness of one’s own limitations is crucial in more complex cases).

 

Generally speaking, all the accreditation programmes are divided into theoretical knowledge and practical skills.

 

The theoretical component is generally comprised of basic physics, anatomy and a description of textbook views and pathology. A diagnostic algorithm is also introduced. This component can be delivered online or in person at courses. Each has its advantages and drawbacks.

 

Arguably the more important component of training is the practical aspect. This is where a face-to-face course/apprenticeship provides a useful starting point. Having an expert guide you through the scan – how to position the patient, adjust probe orientation etc is invaluable.

 

After the course, the accreditation systems available diverge. The UK’s POCUS accreditation (CUSIC) requires a specified number of scans in the presence of a mentor. It is the expectation of this programme that the supervised scans are performed until a minimum number has been achieved, thereafter triggering an assessment phase. Such an apprenticeship model is labour-intensive compared to other programmes which perhaps requires the uploading of scans onto an online logbook for review.

 

A recent survey of ESICM members showed that the main barrier to attaining POCUS training is the lack of trainers (personal communication). If there are insufficient trainers, the rollout of training and assessment will be limited / delayed. As mentioned above, an online platform (with minimal face-to-face interaction) is certainly one way of tackling the problem of a limited trainer base. But does this approach cheat the learner of the invaluable mentorship process? How do we ensure that the end product is a confident and competent physician which will ultimately benefit patients?

 

There is a need to improve access to trainers and this inevitably means increasing their numbers. In the UK, the number of ‘training the trainers’ courses has increased but is still rather limited and does not match demand. There is a danger of rushing these trainers through the process without the necessary checks in place. This benefits no one, least of all the patients.

 

Having completed the accreditation process, like the rest of medicine, the learning process does not stop. Without a universally agreed method of maintaining accreditation across various POCUS programmes, there is naturally concern that once accreditation is gained, physicians fail to maintain their skillset for example due to a lack of time or inadequate exposure to clinical variety.

 

Accepting that publication bias exists, the literature is full of manuscripts which demonstrate that learning the skill of ultrasound is not difficult. Their conclusion is often along the lines of “it takes X months for a complete novice to learn and attain a 95% agreement rate with scans performed by experts”. Such feasibility studies often hint at the potential of ultrasound to improve patient outcomes (without being able to confirm this), further adding to the feeding frenzy of colleagues wanting to learn and develop POCUS skills.

 

Underlying all these training principles and crucial for future development is a matching governance structure. How images are stored, indexed, reported and reviewed all need to be planned before training programmes launch locally.

 

In summary, there is a variety of accreditation programmes available. They vary in:

  • The modules covered
  • What is actually required in the modules
  • How training is delivered – face-to-face vs distance learning
  • The number of scans/logbook requirements
  • The assessment process
  • The reaccreditation/maintenance of competency process

 

In conclusion, when learning and performing POCUS, self-awareness is crucial. Being aware of one’s own limitations and indeed, the limitations of the scan being performed is of paramount importance. Putting your hand up and admitting that you need help or more expert opinion is a sign of strength not weakness. With that awareness firmly in place, go out there and learn!

 

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REFERENCES :

Expert Round Table on Ultrasound in ICU. Intensive Care Med. 2011 Jul;37(7):1077-83. Epub 2011 May 26 – International expert statement on training standards for critical care ultrasonography

 

United Kingdom’s Accreditation Programme, Syllabus and Logbook (FREE)

POCUS – http://www.ics.ac.uk/ics-homepage/accreditation-modules/cusic-accreditation/

ECHO – http://www.ics.ac.uk/ics-homepage/accreditation-modules/focused-intensive-care-echo-fice/

 

ESICM European Diploma in Echocardiography – http://www.esicm.org/education/edec

International consensus statement on training standards for advanced critical care echocardiography – http://icmjournal.esicm.org/Journals/abstract.html?doi=10.1007/s00134-014-3228-5

 

ACCP Critical Care Ultrasonography accreditation – http://www.chestnet.org/Education/Advanced-Clinical-Training/Certificate-of-Completion-Program/Critical-Care-Ultrasonography