Same Child, Different Room, More Risk? #WILTW

This is the 152nd #WILTW

In just under 2 weeks time we will move into a brand new Emergency Department (ED).

Picture via @LeicChildHosp

Although daunting we’re really looking forward to it.  It’s an exciting prospect for our patients as we are optimising the ‘front door‘ of the patient pathway to improve clinical input and patient experience. We will further improve access of children and young people to an appropriate healthcare professional following an initial assessment in a common triage area. The co-location of services is a recommendation of the Royal College of Emergency Medicine and in the new build we will have General Practitioners, working along side ED staff (many who initially trained as Paediatricians), both having easy access to the Children’s Hospital admitting teams.

One of the consequences will be the need for senior staff to recognise the challenge of being able to stratify risk appropriately between patients assigned to to different clinical staff. Why? Well, whether they realise it or not, all clinical staff who make diagnostic decisions apply a form of Bayesian statistics (Great summaries by St.Emlyn’s and Casey Parker) in nearly everything they do.

Patients arrive with a ‘pre-test‘ probability of disease. This is essentially the total  number of patients who have a specific diagnosis over a given time period i.e. it might be that 10% of children who present to the ED have a chest infection. After taking a history and examining the child, and maybe preforming some investigations, a clinician will make a decision on whether they think a chest infection is present or not. Those with a high ‘post-test‘ probability of disease will be more likely to get treated (‘test‘ in Bayesian Statistics doesn’t necessarily mean a blood test but could be any number of interventions including simply what the person’s gut feeling is about the presence of disease).

For example if you work somewhere where very few children have urinary tract infection (let’s say 2%) and you see a child with no relevant history or symptoms  at all it’s really unlikely this child has an urinary infection. Their post-test probability will be even less than 2%. Conversely if a urine dipstick comes back positive this will increase their post-test probability of having an infection. But remember this is just probability. The mistake made by many is that a positive test means a positive diagnosis. No! It just increases the probability of having a disease – there are few absolutes in medicine.

Pre-test probability varies between clinical settings. The risk of sepsis in children who go to a General Practitioner is very very low. There are 11 million children in the UK and in 2012/13 only 1000 were admitted to intensive care as a result of severe sepsis (100 died as a result). This clearly makes it vital we have systems to recognise sepsis promptly and avoid the tragedies that have occurred in the last 5 years. But the challenge is that a General Practitioner may go through their entire career and never see a child with sepsis. The risk of having sepsis increases if you are seen in an ED (this isn’t because an ED makes you ill but because parents are a good judge of their children’s health so are more likely take them straight to the ED when they perceive them to be very unwell). Finally because the ED screens and discharges a number of patients with more simple illness your pre-test probability of having sepsis will be highest if admitted into hospital.

So back to our new department. The same child, with the same signs and symptoms seen by a General Practitioner, ED doctor or Paediatricians will be perceived as having a potentially different risk of illness by the 3 doctors. This is because they are consciously, or unconsciously, aware of what the pre-test probability is for their normal working environment. If the GP asks a question of the Emergency Department Consultant (as is likely to happen in a co-located department) that Consultant will need to acknowledge their different frame of reference of risk. While the phenomenon of differential risk assessment is not new (GP colleagues often phone for advice) this is going to be at at a very different scale and pace. Something everyone is going to need to be mindful of to protect patients from both over- and under- investigation.

What have you learnt this week? #WILTW

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The dangers of Formophilia #WILTW

This is the 151st #WILTW

There appears to be a genetic hangover from the evolution of mankind which resists change. Shortly after the invention of the wheel came the invention of the ‘form’ (probably to describe the correct use of the wheel and situations it couldn’t be used). The ‘form’ seems to be embeded in the consciousness of many institutions and its dangers were brilliantly encapsulated by Prof. Davina Allen in a recent editorial.

“Checklists, pathways, algorithms are a tempting way for organisations and healthcare professionals to signal to the outside world that they are making a good faith effort to ensure service quality. Yet the popularity of these everyday tools has not been matched by their systematic and critical analysis, leading to concern about the potential impact of a growing epidemic of ‘polyformacy’ on healthcare systems.” AllenFrom polyformacy to formacology 

Prof. Allen calls for us to take stock of these simple but often very powerful tools and views them as ‘actors’ that do things rather than simple inorganic material. These ‘actors’ also require ‘scripts’ of the necessary information needed to make a tool work. Many assumptions are made about how easy these scripts are to read or enact. The example cited, one that is close to my heart, is the reliance on Early Warning Scores to be used by staff  who must adequately, and appropriately, collect the right vital signs at the right time. If this script isn’t followed correctly, the actor i.e. the score performs poorly.

A mis-understanding of actors and their interaction with scripts makes formophilia a dangerous pre-occupation. In his powerful book, the Seventh Sense, Joshua Ramo highlights the amazing ability for younger generations to develop powerful algorithms that connect the world in ever more intricate ways. But while they are immensely technologically proficient, do they have the context, insight and life experience to know the impact they are having? He quotes Joseph Weizenbaum (a MIT computer scientist) as saying: “Programming appeals most to precisely those who do not yet have sufficient maturity to tolerate long delays between an effort to achieve something and the appearance of concrete evidence of success

In the same way that simple programming is easy to learn, it is a very simple thing to produce a form. It is much more challenging to take time to decide whether the form is even necessary and a whole different endeavour to work out whether it actually works.

What have you learnt this week? #WILTW

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When experience doesn’t help learning #WILTW

This is the 150th #WILTW

Grace Hopper apparently was behind the quote:

..the most dangerous phrase in the language is, “We’ve always done it this way”

It’s usually used to describe the persistence of organisational blindness to repeated but ineffecient processes. However there are individual practices, especially in medicine, that despite evidence to contrary persist throughout a clinicians whole career. Some of this is pure bloody mindedness, and some ignorance, but a small proportion is related to personal experience, often a result of being burnt.

I’m generally not an over-cautious doctor but children I see with a history of abdominal trauma definitely get over-observed. I can’t help it. I am completely aware of the cognitive bias my experience with a single patient has placed in my diagnostic armoury but its difficult to shake. While I have always tried to explain this to students and juniors I can’t be sure I always do so.

It is only now I understand some of the odd habits of senior doctors who have taught me in the past. These probably weren’t eccentric foibles but more likely the product of the one instance, in a very specific but probably un-reproducible case,  when a sign was missed or an investigation not ordered which unfortunately had a bad outcome. The learning for the individual obvious and profound. But perhaps this context may have been lost on all the doctors subsequently taught by them…

What have you learnt this week? #WILTW

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The Helicopter Hover: Counterfeit Cognition #WILTW

This is the 149th #WILTW

-“Stop being a helicopter consultant..

-“What?”

-“..just standing around and hovering

I’d been called out by a colleague for something I’d never heard of but which made perfect sense.

There is a perception that Emergency Medicine is a dynamic, all action job in which you are constantly on the go with no time to think or reflect. This can certainly be true but while there are periods of high intensity the reality is not always as shown in popular television series. There are also times when a particular patient or situation can take up a disproportionate amount of time. You might be heavily involved in delivering a treatment or intervention, you might be having difficult discussions with other specialties, or you might be closely supervising a junior member of staff.

But sometimes you’ll find yourself ‘hovering’. This can be an almost subconscious endeavour, perhaps noticed more by other staff than yourself. A sign perhaps of not quite wanting to leave at the end of a handover leaving you just standing at the end of the bed drumming your fingers against the bed rail. The cause of this ‘action in inaction’ is multifactorial (and inconsistent) but there are some common themes:

  • Active Thinking

This is typified by a difficult clinical case. You are creating space to weigh up available evidence so that you can make the most informed decision.

  • Passive Thinking

This is essentially procrastination. You are not sure what the best course of action is or perhaps feel there is not one best approach. If enough time passes it’s likely the correct management will become clear. While it might appear to others you are deep in thought you are actually just killing minutes.

  • Counterfeiting

This is the least easy hover to admit to. Although it may look like you are focused on one patient you are actually listening into a conversation about another. Or another method involves excessive tidying up, or record keeping, allowing you stay and see what happens to a patient you are keen to see the outcome of. Perhaps you feel like you’ve dropped a ball earlier in their care? You don’t need to stay but find a reason to.

The counterfeit hover is not always a bad thing and passive thinking may well be in the patient’s best interest. It is an interesting behaviour though. One I will be watching out for in others, and certainly in myself.

What have you learnt this week? #WILTW

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Five soft markers of organisational aptitude #WILTW

This is the 148th #WILTW

Some people appear to be inherently efficient. With no more hours in the day than anyone else they have extensive outputs, meet deadlines and never seem flustered. Pre-internet this was, in large part, due to hard work, dedication and perhaps cognitive skills suited to rapid processing of large amounts of information. Post-internet workloads are dominated by electronic communication and technology which has now become a blessing and a curse. The tools to deal with e-mails, documents and knowledge translation (whether that be from an academic or managerial perspective) are ubiquitous and you can spend hours organising information on how to organise information.

Key influencers in my personal learning networks are often asked to share how they stay so productive while simultaneously staying sane. Some examples below:

Getting sh*t done by @emcrit

How I work smarter from @ALiEMteam 

I come no where near achieving half of what is suggested in these blogs. However I have noticed in my role as a clinical supervisor a few indicators which demonstrate someone has considered how they manage their time. The absence or poor use of them is not a damning indictment of their organisational skills but helpful for framing conversations.

1) Folder Organisation

How quickly can you find a document you wrote 3 months ago? Is it pasted somewhere on the 112 items you have on your desktop or in a sub-folder labelled well enough to find via a search or side-bar?

2) Out of office notification

Not sure this counts as being a method of improving productivity but it is a common courtesy to highlight you won’t be responding to e-mails for a set period. Responding to e-mails when you have the notification active is a different issue…

3) Number of e-mails waiting to be triaged

This is controversial I know.  However I’m not convinced it is possible to say you are on top of things if you have 1324 e-mails in your inbox. Smarts phone often show the total number waiting to be read so a glance at someone’s front screen (aside from potentially being an invasion of privacy) can tell you a lot.

via http://lifehacker.com/5977441/how-i-cleaned-1328-emails-out-of-my-inbox-in-an-hour

4) How you record your jobs and/or to-do list 

I’m not convinced there is a right or wrong way of doing it but you should have some way. Watching someone trying to find a scrap of paper to start scribbling a list of jobs on doesn’t inspire confidence (which is why I’m gutted when I end up doing it!)

5) Ability to share documents 

This is the least discriminatory of the indicators but I’ve seen a definite increase in the last couple of years of using Google Docs/Dropbox etc as a means of avoiding file version hell. At least three colloborations I am part of will say this is a bit rich as I am not a paragon of virtue in this regard. However suggesting, “How shall I share this?” says a lot about underlying mindset and experience in my humble opinion.

Be interested in thoughts and very happy to take criticisms!

What have you learnt this week? #WILTW

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Dogmalysis and Pragmatogenesis #WILTW

This is the 147th #WILTW

I was first introduced to the idea of dogmalysis by Cliff Reid. It’s the break down (-lysis) of a widely held belief (dogma-). As Cliff points out numerous cognitive biases “prevent us from conducting an impartial analysis of objective clinical data“.  Essentially some of the things we do in clinical practice have no real foundation and persist despite evidence to the contrary. When I started in paediatrics all children with wheeze received a dose of steroid and a nebuliser regardless of age or severity of illness. This practice has altered significantly in my career but dogmaphiles still do exist.  Whether Cliff truly invented the term might need to  be subject to some dogmalysis itself but it’s a wonderful concept to consider in medicine.

I reviewed a recent publication with two registrars this week.

Wilson et al. Is Tachycardia at Discharge From the Pediatric Emergency Department a Cause for Concern? A Nonconcurrent Cohort Study. Ann Emerg Med 2017 doi: 10.1016/j.annemergmed.2016.12.010.

This concise paper takes on a very common issue which has been surprisingly under explored. The last decade has seen a huge increase in the value placed on observations as markers of severity of disease. This is in part driven by the increase in Early Warning Systems but also repeated demonstration that physiological changes which may predict death often occur in patients hours before they deteriorate.

It’s a relatively well designed study in which, although the disposition and treatments of patients in North America may be different from the UK and Europe, the number of patients and granularity of the reported data make the study findings externally valid.  While there was a slight increase in return rates for children discharged with high heart rates; overall outcomes were not different i.e. in isolation a high heart rate at discharge was not predictive of patient harm.

Admittedly it’s retrospective study (A non concurrent cohort study sounds a little more sexy), we don’t know the interplay of a high heart rate with other physiological features and the overall incidence of serious negative outcomes was low. This for me means that the dogma you should never discharge a child with a tachycardia can not be ‘lysed’ just yet. But even before reading this paper I’d not had a high heart rate and do not pass go attitude myself. There are rarely absolutes and contextualising each case you see is vital.

Pragmatism is really important. When you realise that admission is not always the safe option basing your judgements on one clinical finding doesn’t seem to be in the patients’ best interest. This study supports a balanced approach to the care of the acutely unwell child and should help aid decision making around the discharge process. Why am I sending this child home with these observations?  In the absence of other identified risks, and appropriate experienced review, then it’s probably safe to send the child home.

I’m looking forward to reading some more pragmatogenic papers in the future.

What have you learnt this week? #WILTW

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Related Reading:

A Pre-mortem to prevent a post-mortem 

Sepsis and Self-Doubt

Have we forgotten to teach doctors how to think? 

Do you know why the parents are concerned? Why not? #WILTW

This is the 146th #WILTW

When one of my team presents a case to me I obviously want to hear about the history, examination and suggested plan for the child. Within the history I am looking for the answer to a vital question:

What is the parent really concerned about? 

This is a key teachable moment even though it might seem inherently obvious. Clearly any health care professional would want to find out why a patient had been brought to hospital.

Wouldn’t they?

Well it’s worth pausing for thought here. The presenting complaint is not the same as parental worry. A baby may present with a history breathing difficulty and reduced feeds, they may examine with no other finding than a running nose. But what the mother is truly worried about is whether her baby will stop breathing when she goes to sleep at night. Some families will tell you this up front, but not all will. Sensitivity is key to finding the best management options for the family.

Fever phobia is the most obvious manifestation of a symptom that masquarades as a complex set of health beliefs. A child may be completely well appearing, in fact laughing and smiling during the consultation, but if the families cultural instinct is that fever causes you great harm, they will be fearful out of proportion to their child’s appearance.

Many symptoms: diarrhoea, vomiting and fever in themselves are of little consequence. They indicate the presence of illness rather than its severity. I am far more concerned when the parent can’t explain to me what they think is wrong with their child: “They’ve had a cough and cold, a bit of fever. He even vomitted last night. But he’s not right, doctor, he’s just not right

Parents and carers have never been more aware of the grave consequences of some diseases but the risks of succumbing to those same illnesses are probably the lowest they have ever been. As our most serious diseases become rarer they will be even more difficult to spot if attendances for other conditions increase.  Without truly listening, and educating, we are probably perpetuating the very problem we are trying to solve.

What have you learnt this week #WILTW

You can now follow WILTW on Facebook by liking this page . Browse previous posts here or insert your e-mail address in the box on the right hand side to receive future posts. 

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