Too cool to care? Drivers for developing safer systems for hospitalised patients
Stuart cares. When he used to return from his shift he would think over the day. Did he put anybody at risk? Was his practice safe?
He would start work early in the morning and take handover from the night shift. They would discuss the 40 bays in Stuart’s unit. He would then start the shift walking around and take a set of measurements for each of them so temperature etc etc. He would send off same samples for electrolytes, review fluid balances, mark charts at eye height so abnormalities would be easily visible.
If he was concerned about anything in his patch he would call in the outreach team. They would sort things out, review problems, make sure units stayed safe, start off new ones, help to clean out some others.
The senior site manager would come around once during the shift. A summary of all units would be on a small card, a grid with all the safety critical numbers and the all important scores. There was electronic documentation, it would take 10 minutes at the end if the shift to fill in. His team would take documentation really serious, it was crucial for safety. Not least the safety of his teams. And because it was so important he and his colleagues made sure that it never went wrong. They believed in the importance of measuring, marking abnormalities in a visible place and the need of good quality handover.
Stuart had no experience in healthcare until he became critically ill and suffered from complications of a medical procedure. He never looked after hospital patients. He cared for reduction cells in an Aluminium smelter in North Wales. His ‘patients’ were 970 degrees hot.
Similarly to hospital-care aluminium production is a continuous process 24 hours a day 7 days a week all year around. To make Aluminium a process called electrolysis takes place in so called “reduction cells”. Electrolysis involves extremely high voltages and currents; the electricity used by an aluminium plant in a day would easily power a small city.
The aluminium smelter would have four sheds a third of a mile long and each containing 8 sections consisting of 40 reduction cell units (whereas hospital wards typically contain 24-30 units). Reduction cells although built from a common template had their own “personality”, some required little attention others as they became older needed more attention and adjustments. All sections and shifts have a scheduled amount of work to be done i.e. anodes need changing in each reduction cell approximately every 32 hours, the aluminium produced needs siphoning out in similar intervals to maintain a thermal balance etc etc. The senior technician would have to walk around the section in two-hour intervals to note any obvious visual changes (not just twice per week).
While the safety systems in an Aluminium smelter were devised for maximum efficiency and profitability they also needed to protect staff from occupational hazards and operate with a minimum of catastrophic incidents involving molten metal and strong electric currents.
There are some encouraging parallels with the way information and risk was charted and used within the aluminium industry and the work setting of critical care outreach teams. Of course the aluminium industry does not deal with patients. However this seems hardly an argument against increasing reliability in health care to the higher standard achieved in the metal industry.
The reasons for the higher reliability of a number of industries outside the medical world are complex. The bigger pressure on staff where profit is at stake seems hardly a dominant factor given that the majority of workers in the Aluminium/Airline/Nuclear industry are not stakeholders and that safety records in public and private health systems don’t seem to be necessarily different.
But maybe there is a difference in the amount of funding that is invested into safety training. Simulated catastrophes are the rule for Nuclear workers, air crews and fire men, but the exception for health care workers for most specialties, even for critical care or outreach teams who work with highly unstable patients in and outside ICU. While training of nursing and medical staff is by no means cheap it appears that the amount that is invested into the safety skills needed to reduce rates of harm is minute. This has led to team structures that have often not got the flat hierarchies required for safer working.
Another problem might be documentation. Information about risk is usually documented inside care records and administrative systems that have been in essence unchanged since the times of Florence Nightingale, when the majority of patients suffered from a limited number of conditions and diagnostic tests and therapeutic procedures were basic or non-existent. Our safety critical data is rarely visible. Patient at a glance boards are one way to structure an information rich environment and make key data ‘useable’. At the bed-side both patients and those caring for them are blind again to risks and threats: Abnormal physiology as summarised by Early Warning Scores, the need for re-hydration or latent risks associated with anti-coagulants are invisible. Health care documentation rarely respects hierarchy of safety critical information and instead buries the life saving within the trivial and redundant.
Critical Care Outreach teams are the eyes and ears of patients safety on general wards. It is obvious that their work would be so much easier if innovations in culture, training and process design from other walks of life could be adapted for hospital care. Arguably the view beyond our own area or work might make health care seem less unique but possibly encourage a more creative usage of ideas from other industries. And don’t you some times wonder whether we would be more careful with your patients, if they would be 970 degrees hot and spill over if we would not be cautious enough. Maybe patients are just too cool.
Note: This blog was first written five years ago with Stuart Stevenson who was a local and national patient safety representative. Stuart has been a guide for me for important projects during the last few years.
What drives safey in your unit? And why does it seem easier in other industries?