This is the 96th #WILTW

This week the Academy of Medical Royal Colleges published “Quality Improvement – Training for Better Outcomes” the output of a group set up to enhance quality improvement training for all doctors.

Quality Improvement could be considered a healthcare zeitgeist. When I was at medical school the zeitgeist was “Evidence Based Medicine”. I remember thinking at the time it seemed a bit odd that we weren’t already being taught about treatments that were based on evidence.

It now seems ridiculous that the terms ‘Quality’ and ‘Improvement’ were not part of my undergraduate curriculum. I wonder if current medical students listen to lecturers talking about delivering quality care and think, “errr…. of course?”

But changing practice and/or improving care is hard. It is especially hard as a junior doctor, not just because the NHS remains a hierarchical organisation but also as result of the frequent movement between different departments, and even hospitals within a region. However just because something is hard does not mean it is impossible and innovations can result from persistence and determination.

In the document I share my experience of working on the Paediatric Observation Priority Score (POPS) at the Leicester Royal Infirmary. I aim to demonstrate that you can successfully get involved in quality improvement work without having to be the Clinical Director or Chief Executive to make things happen!

My tips for success:

1) Find and support your first followers. If you are the only person promoting change then it will only happen when you are there (and even that will be hard!). As Derek Sivers explains “Followers of change tend to follow other followers not necessarily the leaders“. I focused on engaging a number of key nursing staff at the outset of the project. I listened and responded to their concerns and gave ownership to them. It wasn’t ‘my’ project it was ‘ours’

2) Use rewards sparingly but consistently. I wasn’t sure it was going to work but it was suggested to me that those who completed the POPS training package should receive a metal lapel badge. Such has been the success we have been through two large bags already. I am still not sure what the real motivations were behind having a badge but it worked.

(please click here is video fails to play)

3) Be prepared to fail. If you don’t take risks at trying different initiatives you will never know what works or doesn’t. The initial year of POPS was very hit and miss and my “Top of the Pops” campaign an utter failure. The more you try the more likely you are the something will succeed. Be prepared to quickly mobilise and run with the successes!

These are all pretty obvious but they probably wouldn’t make as much sense to me unless I had experienced undertaking them. Quality Improvement is very easy to teach. It is much harder to actually ‘do’. And in the same way that you will never diagnose a heart murmur from a lecture alone, it is only by doing improvement work in clinical environments you will ever be able to change practice for the better. So while students and juniors may think it is obvious it is only by real experience they will learn its true art.

What have you learnt this week? #WILTW

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This is the 95th #WILTW

It is late at night. Your shift should have ended a while ago. The department has started to quieten down. You check there are no more patients needing your input, acknowledge the hard work of the team and say goodnight. As you walk out the door a concerned looking mother walks into the department cradling a small infant in her arms. They are clearly not critically unwell but as the mother books the child in you overhear the anxiety in her voice. 

The team on overnight are not unskilled and are appropriately trained to deal with the emergencies that will present during their shift.

They are also not you. They may unnecessarily over investigate resulting in a prolonged hospital stay and increased maternal anxiety.  Or could they miss the subtle signs of serious illness meaning the child receives delayed treatment?

Most importantly is this arrogance on your behalf or a strong sense of moral duty to ensure high quality care? This is not a scenario specific to paediatrics, or even medicine. In any busy department or office the senior decision maker will leave in a state of mind determined by their personality and experience. This will range from anxiety to relief or an emotion absolutely nothing to do with the prior shift but just looking forward to what is for tea. Certainly my mindset at being able to leave that last patient has changed considerably in the short time I have been a consultant. Every so often though I get a twinge of guilt. A feeling I shouldn’t be leaving, a desire to complete what I had seen begin.

But there is little point delivering care that is dependant on having certain individuals present. All departments, emergency or otherwise, should be focused on ensuring their junior staff are developing the attributes and skills to provide set standards of care around the clock. While obviously a non sequitur in some ways consultants should have trained their staff so they don’t need to be there. It is also non-sensical to ensure that you see all the patients yourself. This is the fast road to burnout.

As departments become more crowded, as patients present later and later into the evening and as public expectation increases the judgement call on when to leave becomes more challenging. There are units with 24 hour consultant cover; typically the intensive and critical care specialties but there is a workforce challenge in applying this principle across acute care as well.

Precedents in demand seem to be broken every day. This is not a situation that is going to improve quickly. Only through political will, adequate funding and health care professional engagement will solutions be found. But in the midst of this there remain individual patients who are more than numbers presenting in a given time. And there are health care professionals with these individual patients in their minds all the time.

What have you learnt this week? #WITLW

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This is the 94th #WILTW

I have been examining medical students this week. They are high stake exams which may alter the student’s progression through the course and do have an impact on the allocation to a Foundation School (initial placements or internships).

Being observed by someone who is openly judging you is an uncomfortable experience. Becoming nervous can make the most simple of tasks almost impossible. While talking to the volunteer patient who was assisting with the exam station I was assigned to I was reminded of a piece I wrote on exam technique a while ago. It refers to the Paediatric membership exam which is needed to progress to the later stages of training. While the exam is obviously harder than medical school finals the impact of nervousness is exactly the same.

“There is something distinctly unusual about having your every word and movement monitored. Just this act of observation can reduce good paediatricians to the level of a newly qualified doctor. The only other time you are observed in this way, with so much pressure riding on the result, is your driving test. I am no longer ashamed to say that I passed my driving test on my seventh, yes seventh, attempt. At the time I was the laughing stock of my peers. A seemingly intelligent, motivated and able sixth form student cracking under the pressure of a three point turn. In hindsight there were a few reasons why this occurred. I failed my first test with a D (dangerous driving!) as a result of just not being ready for the exam. I was practically much improved on the second attempt but I had this nagging doubt in my mind. Most of my peers passed first time, or at the worst second time round. What would happen if I failed? With that small seed planted I spent most of the test paranoid that every little mistake I made was being held against me. At one stage I thought I had pulled out in front of someone and glimpsed the examiner placing a cross on his sheet. I was furious, stopped concentrating and then made a string of small but costly errors. In fact I had not failed for my initial mistake and had I not got so distracted by this I probably would have passed. Unfortunately my obsession with what the examiner was doing resulted in failures in tests 3,4,5 and 6 as well. There are numerous lessons to be learnt here:

1. Don’t let me drive you anywhere
2. Do not sit the exam until you are ready. You must seek an honest opinion from a senior colleague who knows you well and has seen you examine patients. You are doing yourself no favours by failing badly on your first attempt. It will damage your confidence and you lose the benefit of having taken the exam early to speed up your time through the system
3. You must learn to stop thinking about the examiner and concentrate on the patient. Be truly interested in diagnosing the condition the child has. This sounds cheesy but unless you are focusing all your efforts on the child then you are wasting the knowledge and time you have spent getting to the exam.
4. You have not failed until the college sends you a letter telling you, “You’ve failed!.” I realise this is flippant but there is no point spending months revising to give up after two stations because you feel it is all over.
5. Although it is unusual to be allowed to take the exam seven times in a row; if you truly believe in yourself you stand a much better chance of passing. I have seen candidates go into the exam with that seed of doubt already planted; it will sprout very quickly in the heat of the exam circuit.”

Being nervous about being observed is not something that goes away. However experience delivers confidence and perhaps the belief  it doesn’t really matter what others think as you believe you are doing something the right way. Losing insight at this level of expertise is clearly a real danger and why peer feedback is so important. Would I mind being re-examined on clinical skills and procedures I believe I am expert in? Would I be nervous about it? I hope I wouldn’t as there no longer is a seed of doubt but there is still a willingness to learn.

What you have you learnt this week? #WILTW

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This is the 93rd #WILTW

I saw two children this week who were, by any measure of illness severity, both well. They were not in discomfort,  were both interested in their surroundings and had no derangement of their physiology (i.e normal heart and breathing rates). While some would have you believe their presence in an Emergency Department was inappropriate this was not the case. In fact one of the children attended on my specific instructions.

Currently most Emergency Departments are under considerable pressure. In-flow (the number of patients arriving in a given time frame) is high and out-flow (the transfer of patients to the wards) is slow.

(click here if the video doesn’t play)

Exit block and high inflow stretches the capacity of departments with the potential to result in patient harm. The situation is much worse in  adult practice than in paediatrics but considerable effort has gone into both streams to  reduce some of the pressures departments are under. This attention has resulted in an unfortunate phrase, “the inappropriate attender”. There isn’t a clear definition but most people would understand it to mean the patient who doesn’t need to be there. To use old parlance – It is neither an accident or an emergency.…

So why were the patients I’d seen not inappropriate? Well here is the thing. Medicine is not black and white; even between experienced professionals there are differences of opinion on magnitude of illness. Why should we then expect parents to always make good judgement calls with no medical knowledge; especially when they have such an emotional bond invested in the situation? Furthermore there is an information balancing act that we are exposing families to which isn’t always equal. As explored in a previous #WILTW we simultaneously highlight the risks of sepsis, but tell people not to attend Emergency Departments and then denigrate  NHS 111.

One of the children had returned from a visit the previous day as she had developed symptoms I’d described to the father as things to look out for. Safety net advice should be given to all families or carers of children who are discharged home, especially those who are at risk of serious bacterial illness. While the patient had returned to the department very well she hadn’t passed urine in a considerable period of time. I had mentioned this in a safety net list prior to their discharge the previous day.

Had I been too concrete in my explanation? Had the father over-reacted and could they have gone to another health care service? While these are all concerns a commissioner of services may have expressed, the fact that I am (allegedly) experienced in safety netting and that the child had spent considerable time in the Emergency Department the previous day being observed, I think it would be churlish to criticise in this situation.

The second child had been brought to the department as their sibling had died of pneumonia the previous year. Having been unwell for a week with a cough and potential breathing difficulty the mother had become anxious he was becoming more unwell. It was late at night and she was very concerned about her son. The relief in her face on being told that he didn’t have a serious illness was obvious. Certainly perhaps an out-of-hours General Practitioner (Family Doctor) could have provided similar reassurance but I don’t think her attendance in an emergency department was unreasonable either.

I will be honest, I have seen children where I am surprised any form of health care has been sought let alone the Emergency Department. However in the context of increasing health care demand and changing public expectations I tend to find explanations behind many of our presentations which may be labelled ‘inappropriate’. I think it is time we removed this term and considered system wide interventions to best serve the patients who believe, and often do, need our help.

What have you learnt this week #WILTW

Details have been amended to ensure patient anonymity 

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This is the 92nd #WILTW

“But one structural change that hasn’t been seriously tried and might well raise a cheer within the service would be to find a means to separate the NHS from politicians. There is a theory that the most politicised health services around the world do the worst. The short timetables, constant change, and demand for instant gratification that are features of politics do not sit comfortably with running a huge and complex service”

Richard Smith wrote this in 2002 in an editorial for the BMJ entitled  “Oh NHS, Thou art sick“. I think the sentiment is still shared by many almost 15 years later. If the NHS was ill then it may be considered to be on intensive care at the moment. Roy Lilley has described a perfect storm of challenges:

@RoyLilley it’s actually slightly more difficult to define what to call the circles than you’d think… pic.twitter.com/KBalYtW3v3

— Damian Roland (@Damian_Roland) February 17, 2016

Clearly the debate over the imposition of the junior doctor contract is dominating both corridor and digital conversation with it being described as unsafe and unfair. At the risk of being squashed by the social media anger train I’m not convinced that what I have seen proposed is any more, or less safe, than anything that has gone before it. Unfair it is though, even for a mild mannered, sit-on-the-fence person like me. I have listened carefully to the argument put forward by Jeremy Hunt and repeatedly there is confusion between what is wanted of the NHS at a weekend and the role that junior doctors play in providing it. The NHS operates differently at the weekend but only in part because of insufficient funding to have the same numbers of doctors rostered on seven days a week. Firstly there certainly isn’t an excess of appropriately experienced ‘junior’ staff (remember the term junior doctor describes anyone from first day after medical school to just before becoming a consultant) to provide universal cover even if the department of health were willing to give all doctors a huge pay rise. Furthermore while I don’t buy into some of my colleagues frustration at mis-use of statistics (the medical profession have been arguing internally about cause and effect for the better part of this century) it is outrageous that without any form of evidence or research a national directive should be put in place that assumes slightly adjusting rota patterns will improve mortality.

The contagion creeping through the NHS at present appears to be more than a poorly managed negotiation though. There is a conundrum that despite ever increasing demand and expectation there is not the funding that correlates with it. Certainly efficiencies can be made but there is no breathing space in the system to implement the kind of interventions and ideas which could be transformative. The NHS is ill, and it doesn’t even have time to take its medication, let alone start any form of rehabilitation.

Health care professionals often enjoy dark humour to get them through difficult times but I sense at the moment a universal pattern of reduced resilience. While it may be that the soul of the NHS is at the whim of politicians; at its heart is its staff. They, and not just doctors but all employees, cannot remain in a critical condition  for ever. The NHS is ill and it needs to start getting better.

What have you learnt this week #WILTW

An excellent review of “The 7 Day NHS” by the BBC can be found below

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This is the 91st #WILTW

Spotting the ‘sick’ child is, by and large, a relatively simple task. My training involved developing a visual library of well and unwell children which I needed to burn into my cerebral cortex. Now as an experienced paediatrician I apply pattern recognition to the children and infants I see to make decisions on who can go home and who needs further treatment. Experience, research evidence and previous errors keep me healthily skeptical so I don’t make snap judgements and communication skills ensure I am engaging with families not dictating to them. I hope I do a relatively good job in this regard.

However the term ‘sick’ child is usually reserved for those with medical or surgical illness. The infant with sepsis, the child with appendicitis, for example. But it is easy to overlook a less overt, sometimes less socially accepted, form of illness. Mental illness. Young people especially are often put into a one size fits all category, whereby grades of illness are not recognised so even the most distressed are given no more care and attention than anyone else. I think we  probably do badly at spotting the ‘most sick’ in relation to deliberate self harm and depression. Uncomfortably what I learnt this week is I might do a further group an even greater disservice.

Max Davie is a paediatrician with a strong interest in Mental Health and writes a blog at paedspoliticsbiscuits. He posted an eye opening blog for Children’s Mental health week. Max eloquently describes the lack of appreciation for children and teenagers with conduct disorders:

In one cubicle sits Clare, a 15 year old who has cut herself, then, in panic, told her mother and has been brought in. She’s upset, and talking animatedly with her mother. Next to her is Kyle. Kyle, also 15, has been stabbed in a fight outside a youth club, and sits sullenly alone waiting to be patched up. The evidence, as far as it exists, is that, of the two, Kyle is at a far higher risk of suicide. But it is Clare who will be admitted for a psychiatric assessment, while Kyle is stitched up and sent on his way as soon as his furious mum arrives.

Conduct disorders are, to use Max’s words: persistent patterns of anti-social or defiant behaviours that really get in the way of people’s lives. There are more precise definitions but I think this is as good an explanation as anything. Children with conduct disorders can be challenging. They make people feel uncomfortable. Sometimes the more you reason with them, the more they become agitated. It is all to easy to therefore limit your interaction with them, especially those with overtly aggressive behaviours.

So am I spotting the “child with the conduct disorder” in the same way as I do with other illnesses? Well probably only when it is patently obvious. Do I treat and react to these children in the same way as I do for the child with sepsis? Shamefully I suspect not. And while the conditions are treated differently ( importantly there is a immediate threat to life for a child with severe sepsis) Max’s blog is a reminder that conduct disorders and mental health problems may be no less deserving of our care and attention than other conditions. You may even argue more so…

What have you learnt this week? #WLTW

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This is the 90th #WILTW

Health Education East Midlands have recently reconfigured their leadership and management programme for trainees and I assist on delivering some of the curriculum. I generally present the Quality Improvement workshop but was assisting with the Transition to Consultant/GP session this week.

The half-day is framed in understanding leadership, resilience, appraisal and mentoring. I must admit ‘lecturing’ on leadership is something I find very uncomfortable and I am often honest to the participants about this. As a trainee I really brought into the rapidly developing leadership zeitgeist. Numerous events, courses and organisations made you feel as if you really ‘got’ leadership and were part of a vanguard of doctors who wouldn’t make the mistakes previous generations had.

The art of leadersheep pic.twitter.com/m0ig8mNUdX
(HT @WhoseShoes @WeDocs)

Like idea of sheep talking to elephants in the room..

— Damian Roland (@Damian_Roland) November 15, 2014

I then went through a phase of thinking the whole thing was a lot of rubbish. “The leadership lie” was a phrase I would use to describe the dissonance between what was taught and what could actually be delivered. My main concern was that a body of experience is needed to not only apply, but probably and more importantly, understand how leadership skills are utilised in the workplace. That’s not to say that early learning isn’t invaluable. In fact there is a real argument for introducing leadership and management concepts in the first year of medical school. But that bringing together a small group of trainees and delivering what is in essence an audit does not then mean you can successful lead a change initiative in a multi-disciplinary setting across a hospital department.

I have since mellowed and actually some of the experiences I had as a trainee, in particular chairing large meetings, have been utterly invaluable to me as a consultant. But am I definitely left with a sense that much of what I do, which some may describe as leadership, is unconsciousness. Body language in tense meetings, phraseology when making referrals, quick corridor conversations when hospital capacity is at a premium may all result in improved outcomes but are never intentional. Setting agenda items, process mapping, allocating responsibilities – these are the conscious management task that take place day in and day out. While I accept that there are domains to leadership my day-to-day observation is that many traits are implicit so the moment we start thinking about being a ‘leader’ we might actually be doing anything but.

What have you learnt this week? #WILTW

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This is the 89th #WILTW

This week we learned about the tragic death of William Mead, a young boy who had sepsis. His mother writes extremely powerfully in her blog  and I was struck by this quote she used in a posting in early January

“The days will always be brighter,
because you existed.
The nights will always be darker,
because you are gone.”

Last year I reflected on the case of Sam Morrish where again the system failed to adequately respond to ‘red flag’ signs and symptoms. I have heard Sam Morrish’s mother speak and it is humbling to listen to the eloquence with which she describes her concerns at the time and how we (the healthcare system) didn’t hear her.

It appears, although the full report into William’s death isn’t available at the time of writing, that in both cases there was a dissonance between the features of serious illness the children had and the response to them.

Sepsis is not a simple, or indeed, binary condition. To die of sepsis infers you have an infection in your body that has overwhelmed your bodies abilities to fight it. However a human’s response to infection is not predictable. The same two children could have exactly the same bug and while one might actually clear the infection by themselves the other may become critically unwell [1].

The vast majority of children presenting to their GPs, urgent care centres or emergency departments don’t need any treatment. That is not saying their presentation is not necessary, parental concern is a vital component of the diagnostic process that clinicians use, but unwell children generally have simple viral illnesses that self-resolve. There is though a cross over between some features of illness such as an increased heart rate, looking a little pale, feeling miserable that may be present with either a virus or sepsis i.e it is not the case a child with a virus only has some features of illness and a child with sepsis has different ones. To compound the problem there is evidence that having a virus may increase your risk of catching a more serious bug that could cause sepsis. This means you could present to your GP (Family Doctor) on one day and have a virus but in a couple of days become increasingly unwell and be seen in a hospital with sepsis. It may be that the GP did nothing wrong to send you home in the first instance.

This is why safety-netting is of vital importance. The delivery of information to patients, parents and carers that lets them now what to expect if the health care professional is right with their diagnosis and what to do if the situation changes. Many organisations including the UK Sepsis Trust, NICE, individual hospital trusts and academic groups are working hard at creating systems that ensure we recognise and respond to sepsis in a prompt and timely fashion to reduce the number of children dying from it each year.

There are things we can do now though to potentially turn Sepsis into a eucatastrophe; a term apparently first coined by J.R.R.Tolkien to describe a turn of events which saves someone from meeting a predictably nasty outcome.

1. Health care professionals instead of asking simply what’s wrong should enquire: “what are you particularly concerned about in your child“. The question is the same but there is an important inference on determining whether it is the behaviour of the child the parent is worried about or a symptom. Parents of child with serious illness often describe knowing their child just isn’t right.
2. Health care professionals need to consider sepsis in every encounter with an unwell child however minor the symptoms seem to be. Documentation of the features which make sepsis unlikely are important. The restricted rule-out method is a great way of doing this.
3. We need to be more confident at discharging children who are well. There is a dichotomy at present. In the same day the #NHS is under pressure to be hyper-vigilant for sepsis but reduce the number of children presenting to Emergency Departments or being admitted to paediatric wards. This can only be squared if we don’t overload the system with children who have no features of illness. Starting from tomorrow senior medical staff, whether GPs, Consultants or clinical commissioners need to ensure their staff are sepsis aware but also know the features supporting discharge and how to give good safety net advice.

There will always be children who succumb to sepsis regardless of what health care professionals do. However we must be sure that we can have a eucatastrophe in all cases where it is possible to do so.

What have you learnt this week? #WILTW

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[1] I appreciate this is an old paper. I would be grateful for more up to date versions as I couldn’t find any in my quick medline review.

This is the 88th #WILTW

Health care professionals values’ are usually pretty similar. However when it comes to their vision of how to improve services things can vary widely.

This dichotomy causes great challenges for health care organisations. Take a group of clinicians and ask them why we should treat condition ‘X’ well and you’ll get consensus. Ask the same group to agree on a guideline to treat ‘X’ and you will be there all day.

One of the challenges I face as a consultant in their early years’ of practice is not allowing practicality to get in the way of purpose. Experience brings with it a potential belief that the way you do things is the best way to do things. It is a fact of life that there will always be two different ways of doing things, and both will be ‘right’ in the eyes of those promoting them. Once entrenched, and this is where I sincerely hope reflection will always keep me open minded, it can be difficult to see another person’s view point.

This is no more evident than in the gun ownership debate as demonstrated in a medical education discussion group I am part of. The mostly American participants were discussing the responsibilities of the medical profession to promote gun safety. I’d suspected the debate would have centred around public health responsibilities but it quickly became apparent that some in the group are passionate advocates for very liberal gun control. The prospect of not having guns at home seemed abhorrent to some. While this is a view I can not understand, I’d believed, arrogantly as it appears, it was from an angry, poorly educated part of society. I was wrong. Adam Goplik, writing 3 years ago, described the underlying challenge well

Given how differently the same situation is viewed by different groups, and the incredulity with which they view each others positions, leads me to wonder if I have ever been on the ‘wrong’ side. Unfortunately that very reflection infers a value judgement that there is a right way. While different negotiation styles are clearly necessary to relieve severe impasses I think it is also beholden on all of us to think – Why does my vision of what is ‘right’ make your vision ‘wrong’?

What have you learnt this week? #WILTW

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This is the 87th #WILTW

Pain is an interesting phenomenon. Last weekend I aggravated an old, but not particularly serious, back injury. I  came into work on Monday and hobbled around the department feeling pretty stupid as intermittently the spasms would go away and I would be completely pain free. Not quite sure what my colleagues made of me.

It is very easy to be judgemental about pain. Even with no medical training the inconsistencies between reported pain, and its actual physical manifestation, are obvious to spot. Conversely I have yet to treat a child who has had a very serious limb fracture who even moans about it. They tend to be extremely quiet; the only sign of severe pain is their frightened face.

Despite the prevalence of pain we are still relatively information poor on how best to treat it, especially in children. There was a time when open heart surgery in neonates was performed with minimal anaesthetic.  Public health doctor and avid information sharer Ash Paul posted a link from the Canadian Institute of Health Research this week. Published in September it describes an initiative to improve awareness of pain management strategies in children.

(click here if the video doesn’t automatically appear)

The techniques described in the video should not be new to any health care professional who deals with children. Parents though aren’t always aware of some of the easy things that can be done. Distraction is a very powerful technique and rather than feeling and looking anxious it is helpful to the treating team for the parent to engage with their child. One of our play specialists reinforces this important role by saying to parents:

“As calm as you are, is as calm as she’ll be”

(or he obviously)

Anxiety about your child often promotes supra-rational responses. Not irrational because you are rightly worried about your child but often the profusely bleeding finger or the large bump to the head provoke near hysteria. Children are never helped by seeing their parents crying more than they are. “As calm as you are, is as calm as she’ll be” is sound advice.

It is also sound advice for health care professionals. No one likes someone who panics, especially in emergency care. In fact it is pretty sound advice generally. Start ranting at a meeting and it’s likely you will start getting other people raising their voices as well. Get frustrated with someone you are referring a patient to and they will get frustrated to.

As calm as you are, is as calm as they’ll be

What did you learn this week? #WILTW

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