Ward rounds and relatives.

The Uist and Barra Hospital is a small community hospital in the Outer Hebrides, providing in-patient care to a population of just under five thousand. The population has a high proportion of older people with multimorbidity and emerging frailty.

Around five years ago, the hospital was struggling with increasing admissions of older people with complex needs. Every week, there were challenges discharging patients safely, and the process of getting patients fit for discharge was slow.

We responded by making a number of changes to the running of the ward, aiming to identify and act on functional problems early in the admission process. The nursing team were also keen to relax the visiting hours for patients, and we looked at ‘John’s Campaign’ as a model for involving carers on the ward if they wished.

After a slow start, the concept of open visiting started to bed in. For example, one patient with dementia started eating better when her usual family member helped her at mealtimes. Another patient was able to have a ‘film night’ with her daughters for her birthday.

One of the barriers at the start was disruption to the ward round. Waiting for family members to leave the room to allow clinical review, or coming back after the round to see patients who had been busy with visitors, meant the round was getting longer and inefficient.

Around the same time, I started testing a structured ward round approach, with one of the checks being to ask the nurse and the patient what their key concerns were. Patients started asking if their relatives could come back in for particular discussions, and the culture started to shift towards a more patient-focussed ward round in which relatives could be present. Goal setting started to improve, and decisions concerning escalation and onward referral were communicated more effectively to families.

Now, relatives and carers are positively welcomed on ward rounds. Patients and families are more involved with the decisions made about care, and trust in the hospital has grown. The best way to describe how it works is with an example.


Mr A is a very frail man in his 80s. He has slowly progressive metastatic cancer, and he came in with suddenly worsening shortness of breath. On initial assessment, we thought he probably had a pulmonary embolus. When I did the ward round, his sister was present. When I came into the room and introduced myself, she got up to leave. I hesitated, and checked with Mr A whether he wanted her to stay, as I was going to discuss his results with him. He was keen for his sister to stay, because he felt that he wouldn’t remember what I had said properly, and would be unable to explain to her what was going on.

His sister was invited back into the room, and I went over the results that indicated that a pulmonary embolus was a possible cause of his breathing problems, and that the best way to check this was to fly him up to Stornoway for a CT scan. We discussed Mr A’s frailty and considered the stress and difficulty of flying up without the support of his family, against the risks of possible over- or under-treatment without the scan. We also talked about the treatment options for pulmonary embolus. Mr A was able to decide not to fly off the island, with the support of his sister. We agreed a treatment escalation plan that included his wish not to be flown away.

Mr A and his sister felt well-supported, she was able to understand the clinical dilemma, and act as an advocate for her brother. They had been able to express their concerns openly, and were fully involved in the ward round discussion about prescribing and planning further care. In addition, his sister had not needed to arrange to speak to me at a separate time. I did not have to set aside additional time to speak to relatives, or worry that further decisions might be required once more information was available.   

MAKING SENSE OF HEALTH INEQUALITIES

I attended the recent RCGP meeting that debated the role of General Practice in addressing the Health Inequalities that afflict many communities in modern Scotland. The papers presented were the product of years of reflection, effort and involvement. The debate was free-ranging and well-informed, there were many ideas to assimilate, and many questions that arose.

This is my personal reflection on the day (and yes, this is going into my appraisal portfolio).

What is deprivation? The term socio-economic deprivation refers to the lack of material benefits considered to be basic necessities in a society.

Deprivation, poverty and adverse health outcomes: The meeting discussed various aspects of deprivation, poverty and adverse health outcomes, but the relationship between the three is complex. For example, rural fuel poverty creates very real suffering, but the communities that it affects do not always suffer from lack of a supportive society, which mitigates this. Rural life expectancy is longer than might be anticipated given the compounding effects of isolation and financial difficulty, but dispersed deprivation is a lonely place, and is becoming more prevalent. Pocket deprivation is evident, but it is not so easy to compare the adverse outcomes from pocket deprivation with blanket deprivation. The three are linked, but the outcomes are not predictable. 

Austerity has had a significant impact, through the exacerbation of poverty, and the entrenchment of deprivation. It is therefore no surprise that the policy of austerity has been associated with worsening of health outcomes, especially in areas of blanket deprivation. Austerity has affected individuals in our communities through reducing their economic freedom, and it has also affected those who wish to mitigate and counter deprivation by reducing their resources and effectiveness.

Core General Practice: My experience of exchanging roles with an urban practice taught me that the core strengths of General Practice lie with Barbara Starfield’s ‘4Cs’; first Contact accessibility, Coordination, Comprehensiveness, and Continuity . They are as effective in rural and urban settings, in areas of affluence and of deprivation.

An effective partner in all primary care settings has a deep connectedness with their community, a commitment to co-ordination of the care for their population. This long-term relationship with a community and the individuals who reside within it brings benefit to everyone. This is as true of rural as it is of urban general practice. The hardest part of participating in my exchange was the feeling of being disconnected with the follow up of new clinical relationships, the inability to sustain the contact into continuity, or to affect the comprehensive nature of care, or its co-ordination.

A principal GP has ownership of the problems and solutions for the delivery of health care in their practice.

I also learned much about how the exchange practice has addressed their challenges of providing effective health care in their setting. Meeting their link worker was inspiring and I have made some lasting friendships.

A forest or a bonsai collection?

We talked about how expansion of the multidisciplinary team is part of the effort to support General Practitioners, to free their time to lead primary care. The models that the envisioned MDT is based on include projects like Govan SHIP. The link workers, pharmacy support, physio and CPN teams, treatment room teams and vaccination programs need accommodation, and the sense of membership of the team.

Underfunding these MDTs, failing to provide adequate accommodation, or resource for the IT, is a substantial risk. A tree in a small pot, with only just enough water each day, and with growth pruned to stay within the resource, is a small and contorted tree. If we want General Practice to provide a forest canopy of health resource across Scotland, we need to nurture it with strong roots, and the space and resources to grow.

Investment in the General Practice of the future must address accommodation as well as teams.

Moving forward: Tackling the hard problems

The Deep End project has shown us that tackling the hard problems, or even just one hard problem, provides benefit for all, the evidence shines a light on how we work. There is great potential for spread of good practice through the worked example. This is a model for moving forward; resourcing the right people, and giving them appropriate goals. More funding for General Practice is not just about fair pay, it is about building resource, supporting and inspiring GPs to use that resource to tackle their own hard problems.

We also need data, and we need to ask for the data that describes where we are, and can be used to show change. An important part of the way forward is to ask for information and data, and to share that unflinchingly, to create a landscape of information that can show where we have been, and where we should direct our attentions.

Heroes and pedestals: As I sat in our meeting, I heard many eminent people speak honestly about their aspirations for what General Practice can deliver. I had arrived feeling an imposter, I had not produced a paper, or had time to assimilate the many papers that arrived in the few days before the meeting. I have not been elected to a high office, nor am I an academic GP. It then struck be that if we put our heroes on too high a pedestal, they become remote, and we fail to see that we are like them, and lose the courage to believe in our own contributions.  I had been invited for a reason, because I have something to add to the conversation.

Being a GP partner fulfils my idea of myself as a clinician, and I would advocate that demonstrating and describing this fulfilment should be a beacon to the young GPs who will become the leaders in our profession in the future. We must continue the work of identifying and describing the methods whereby future General Practice can bring the best healthcare to all of Scotland’s people. We must also show that what we do is achievable and applicable everywhere. We must harness the ambitions of GPs to drive forward our agenda, the high energy of collective ambition.

Don’t talk to me (an evidence-based poem)

Don’t talk to me about facts and figures,
In a way that gives me medical jitters.

I understand evidence, really I do,
But you don’t make it easy, do you?

A bit less, please, jargonese,
And legalese, in PILs and SPCs*.

On paper so transparently thin,
It’s easily thrown into the bin.

Where’s the benefit information?
A risky business, this medication.

I don’t mean to poo poo your peer review,
It’s just… I don’t trust you.

Especially if you’re big pharma,
Face it: you’ve got bad karma.

Help us to talk to you,
We’ve much to offer, too.

Our words are woven,
With experiences, human.

Medical proof can only get better,
Working together, boxing clever.

Don’t talk to me, without my family,
They’re part of my thinking alchemy.

My brother, my sister, by blood or by water,
My mother, my lover, next door’s daughter.

That queue behind me?
I trust them, implicitly, even when we disagree.

And if I’m in a minority,
The queue is much much longer than three.

Don’t talk at me, speak to me,
Tell me a symptomatic story,

Alive with compassion and care,
Some science too, with creative flair,

One proven in life’s laboratory,
Not given to flights of fantasy.

“The plural of stories is culture”;
Testimonies lend us structure,

Narrative data to inform,
Metaphorical and evidential brainstorms.

Don’t tell me: drugs are the only medicine,
Fine fettle is more than a regular regimen.

A roof over my head, a warm comfy bed,
An honest job, that won’t make me sob.

Food in my bowl,
Food for my soul.

Perhaps most importantly?
My other humans in relation to me.

By Bella Starling

Poems in the waiting room

This isn’t really about patient pathways, or co-production, or reducing variation, or personalising care. It is something that occasionally lends me great joy, and I wish to share it. We have had poems in our waiting room for over ten years. To begin with, we had a bit of a push back. Many of the poems were on weighty issues, life and death, pain and survival, and I think they had been chosen to help share the troubled paths that some of our patients follow.

Now, PitWR has regular issues, often around seasonal themes. They share poems of great sweetness. There seems to be no agenda other than to make sitting in the waiting room a more enlightened and lovely experience. They’ve been chosen to promote well-being and a sense of calm. I suppose just that, in its own way, produces better consultations.

VIEW FROM THE HILL by Fiona Larkin

I could convince myself 
we drew the river's curve
right there, and wound
it across the water meadow
with a flourish of buttercups,
just for the pleasure
of clothing our story
in cow parsley and hawthorn,
and of letting May's green energy
propel us further upstream,
beyond the tidal surge,
past a trio of fruit trees
flawlessly blooming;
and I could be persuaded
that its braided promise
flowed from honeyed limestone
where two tributaries met.

Patient safety and co-production, from the BMJ

I was very excited when I read about this study, about improving inpatient safety by systematically improving communication with patients and families during ward rounds. I could see immediately how this could be transferable to our own setting in the community hospital.

The entry in the paper BMJ is quite short and humble, and it is worth visiting the online version for more detail, and to see the short video clip introducing the key researchers, who describe the design and outline of the project.

https://www.bmj.com/content/363/bmj.k4764

Structured ward rounds aren’t new, and neither is the concept of ‘no decision about me without me’. No-one would deny that families are an important part of the team providing care to patients. Using a structured communication tool has been embedded in our practice for many years. Teach-back is an excellent way of ensuring that the person receiving information has truly understood. The genius idea was to do all these things as a single process, and designing the intervention with service users.

 

 

 

The lead researchers are from the Children’s Hospital in Boston, Harvard Medical School, Mothers against Medical Error, and the Patient-Centred Outcomes Research Institute. They set out to introduce a method of improving communication with families. Their theory that this would improve outcomes was based on the observation that improving communication between clinicians improves safety, and that poor commmunication is a leading cause of adverse events.

The study group was made up of over 100 people, patients, nurses, family members, doctors, health literacy experts, researchers and medical educators. They co-produced the structured ward-round tool, to be used on ward rounds where the family is present. The communication tool is called I-PASS. They also produced a training package and a range of support tools including patient information leaflets.


A word about communication tools: We use SBAR locally, whereas I-PASS is the tool used in the study. It is designed to be used for structured communication with patients and families. It focuses more on the recommendations, and adds synthesis and teach-back as part of the communication tool.

I–Illness severity (family reports if child was better, worse, or same); nurse input solicited
P–Patient summary (brief summary of patient presentation, overnight events, plan)
A–Action list (to-dos for day)
S–Situation awareness and contingency planning (what family and staff should look out for and what might happen)
S–Synthesis by receiver (family reads back key points of plan for day, prompted by presenter, supported by others as needed)


The measures used were:

  • Outcome measure: Looking at error rates, and harmful errors
  • Outcome measure: Patient and family satisfaction
  • Balancing measure: Length of ward round
  • Balancing measure: Amount of teaching on ward round.
  • Process measure: Communication processes on ward round.

Although overall error rates were unchanged, harmful medical errors decreased and Satisfaction scores rose and communication processes improved. There was no significant impact on ward round length or teaching on ward rounds.

My own experience over the years has been that I have shifted from asking family members to leave the room during rounds, to asking if they can stay. The conversations around progress and plans for care involve families and patients equally. Bringing in students adds a dimension of teaching, usually in patient-centred language, and it enriches the discussion. These conversations lead to patient-centred decisions, which are understood by relatives as well as the patients.

In the words of Helen Haskell, president of Mothers against Medical Error, one of the lead researchers, ‘It doesn’t just feel good, it can help improve the safety and quality of care – I would add, improve health literacy, agency and opportunity for realistic, patient centred care to be forefront of care planning. This study is a model of how families and care provides can co-produce an intervention to make care safer and better.’

And more realistic.

 

The Handbook of Non-Drug Interventions

Thank you to the British Journal of General Practice for pointing me in this direction. HANDI is a project launched by the Royal Australian College of General Practitioners in 2013, to promote effective non-drug treatments. Now the RCGP is partnering with the RACGP to bring this approach to the UK.

https://www.racgp.org.au/clinical-resources/clinical-guidelines/handbook-of-non-drug-interventions-(handi)/handi-interventions

The HANDI resource collects evidence based non-drug interventions relevent to and practical for GPs. Many of the interventions on the webpage are common-sense, and practical. Many of them are treatments I already use or prescribe, like the Epley manoevere, or wet combing for headlice. There are other recommendations that I had previously dismissed, not realising that there was an evidence base.

Delivering non drug interventions in practice promotes health literacy and reduces clinical dependence; for these interventions to be effective, patients and families will need to understand how they will help, and can apply the learning in the future.

Personalising Realistic Medicine

This year’s annual report from the Chief Medical Office has been published. I commend it to you.

Over 2000 years ago, Hippocrates observed that:

‘it is more important to know what sort of person has a disease than to know what sort of disease a person has’.

Read it here: https://www.gov.scot/news/personalising-realistic-medicine/