Month: May 2019

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/

A Hebridean approach to Treatment Escalation Plans

‘I don’t want to be flown away. Can’t you look after me here?’ A frail elderly voice tries to start the hardest conversation in their lifetime. 

I work on a small Hebridean Island, and our practice covers our local community hospital. We have the extraordinary privilege of looking after our patients after they have been admitted to hospital. In many instances, we know our in-patients extremely well, their families and social networks, their occupation and their background.

We also have a very elderly population. In the last decade, the number of patients registered with our practice over the age of 90 has gone from one or two, to ten or twelve. More than a quarter of our population is over 65, and many have grown up with a much more paternalistic style of medicine, and live in hope that we will make the right decisions for them. 

For many, the first conversation about relevent and realistic goals is in crisis, at the bedside, in the community hospital. Most of us trundle through life, talking about shopping lists and the weather, keeping our fingers crossed that today, at least, no big decisions will be required. When the day arrives, the language and concepts are rudimentary for talking about life and death decisions. 

But for many Hebrideans, dying ‘off-island’ is the big fear. Away from relatives, from the gossip and visits of neighbours, away from the priest or minister, away from the Gaelic, and the comfort of being looked after by clinical staff who know just about everyone. Being transported home in a coffin on the ferry, and the relatives grieving at home without the remains to revere. 

So our discussion about transfer away becomes a discussion about many things. We can talk about the benefits of being in a big hospital with consultants and large radiology departments, whether knowing exactly what is wrong is going to be helpful. The community hospital can offer iv fluids, oxygen, antibiotics, time and care, which might be enough. We can talk about which clinical interventions might be useful. We can talk about the likelihood of dying, teh acceptance of risk, of using well-honed clinical acumen to guide treatment, and we can talk about what patients really want from their admission. 

On our Hebridean Treatment Escalation Plan, we have transfer at the top of the list, with all that it implies, with further investigation and intervention, leading the way for discussions about what goals the patient has for their clinical care. These are precious conversations between people who trust and know each other well. These are hard conversations, where neither patient nor clinician finds it easy to start talking about death as a possible outcome. These are the most important conversations that I have. 

So I answer: ‘No, we don’t have to fly you away, but we should talk about this.’ 

Practice Based Small Group Learning – a review of the Realistic Medicine module.

I’m a member of a PBSGL group. We are very small and select, because I work on an island in a small practice, and there aren’t that many GPs in the area. I love our group. We have great rapport, our discussions are free-ranging and we get to eat some great cheese.

Because I am very interested in bringing Realistic Medicine into the way we co-produce health with patients, I thought that this would be a good module to work through.

I was a bit disappointed.

At the heart of Realistic Medicine, there are a number of concepts. One is the balance between evidence-based medicine and the expectations and wishes of patients. Sharing clinical risk is in there, as is the redesign and presentation services in a way that puts patient need first. Reducing unwarranted variation, harm and waste is important.

I was a bit underwhelmed by this module – it could have been a module on multimorbidity and geriatrics, and the level of debate that the cases raised was well within our current scope of practice.

The three cases were all concerning elderly patients, and the tension between evidence based medicine, frailty and multimorbidity. While they were true to life and interesting, at the end of the session we felt we’d learnt more about community services for older patients, rather than about realistic medicine.

The background reading later in the module was of much greater value, and covered many of the concepts of realistic medicine. However, we found it tricky to include this material in the discussion of the cases.

In short, we did not feel that this module stretched our understanding and learning. Maybe that is our failing, rather than that of the module. Was this more about PBSGL jumping on the ‘Realistic Medicine’ bandwagon?