When my friend John’s daughter was admitted to hospital with nausea and vomiting late in her pregnancy she was not particularly worried. She had been unwell with what she thought was a virus for a couple of days. And on the day of her admission she had felt a bit faint. On arrival to the well reputed hospital she was taken into the emergency department and assessed. Her blood pressure was found to be a bit too low and her heart was going a bit too fast. Doctors diagnosed dehydration. A cannula was inserted into her arm, she was hooked up to a drip and a litre of electrolyte infusion was rapidly infused. She was starting to feel a bit better.
That’s when the trouble started. The evening had descended on the department. She was now in the bowels of the Emergency Department. Staff in various coloured uniforms were whizzing past. She started to feel the need to go to the toilet to pass water. But she was lying on a trolley with both protective sides pulled up high. At her stage of pregnancy she was unable to climb over the barriers. But nobody came to her room to attend to her. And she was unsure how to attract the attention of staff. Which colour uniform was meant to look after her? Who was a nurse, doctor, technician, janitor or caterer? But then she had an idea. She remembered that she had her mobile on her. She managed to find the number of the hospital she was in. She dialled and was connected to the Switchboard. And she managed eventually to get through to someone from the Emergency Department to release her. She was shortly after discharged home and did well.
A fairly unusual way of communication in hospital. And in retrospect funny, given that nobody was harmed. But at an abstract level the communication pattern is worth a second look. John’s daughter knew what she needed. But she was unable to manouver the complex system of uniforms. By communicating with the staff via phone she got the care she required. What if she would have needed a review of her medication? Would she wait for the ward round the next morning? Or would she ask the nurse to ask for a doctor sometime in the evening? Or given that she might know what is required could she just contact her doctor on her mobile to discuss options? In the community that would the course of action: we ring our General Practitioner, and depending on how proactive the practice is we get an appointment to see the GP or can speak to the GP on the phone. In hospital patients can call the nurse either with a bell or a telephone system. But never the doctor. The doctor is shielded from questions for reasons of tradition and I guess work overload. But as a consequence key information might get lost.
The implication of this is clear from the recently published report by the KingsFund Organising care at the NHS front line (https://www.kingsfund.org.uk/sites/files/kf/field/field_publication_file/Organising_care_NHS_front_line_Kings_Fund_May_2017.pdf). The report contains a number of essays edited by Chris Ham and Don Berwick by staff from the Western Sussex NHS Foundation Trust. In one of the essays Gordon Caldwell described the events that lead to the death of a patient under his care. The patient gets admitted with shortness of breath and and a swollen leg and despite a number of investigations and repeated reviews by senior clinicians collapses on the 6th day of the hospital stay and subsequently dies from a pulmonary embolism. What makes the case tragic is the fact that the patient and family had made the connection between the breathlessness and the swollen leg. The family of the patient had googled the symptoms and was worried about a deep vein thrombosis, a clot in the deep veins of the leg, that could brake off and block the circulation in the lung. They shared their concern with the nursing staff in the Emergency Room, but for some reason this piece of information about the swollen leg did not register. And nobody in the next five days had a reason to review the swollen leg. As a consequence the patient did not receive the right dose of blood thinning drugs and on day six collapsed after the clot breaks off and blocks the lung.
The family had no access to records to check whether their safety critical piece of information had been documented or acted on. And must have assumed that something so important would have been documented and considered for the right tests and treatments. The filtering and interpretation of data with omission or loss of items that staff did not mark as safety critical being somehow the real cause of death.
And now the questions for system re-design:
Should patient countersign the record of their illness in the same way that witnesses countersign a police statement?
Under which circumstances do you feel it would be desirable for patients and relatives to be able to access the relevant doctor directly?