Medical Blog - "Blue Sky Thinking"!!!!!!!!

In my previous medical post I mentioned the Health Care Commission. It had an important role in ensuring that health care was delivered "safely" in England. It was pivotal in revealing some important health care scandals including that at the Mid Staffs Hospital. Well, about 2 weeks ago the Health Care Commission was wound up, and disappeared. But do not despair. It has been replaced by the Care Quality Commission. This is like the Health Care Commission, but with wings. They state "The Care Quality Commission is the independent regulator of health and social care in England. Our aim is to make sure better care is provided for everyone, whether that’s in hospital, in care homes, in people’s own homes, or elsewhere." They go on to say "We regulate health and adult social care services, whether provided by the NHS, local authorities, private companies or voluntary organisations. And, we protect the rights of people detained under the Mental Health Act." From April 2009, every NHS trust in England that provides health care directly to patients must be registered with the Care Quality Commission. They have new found powers and they can force hospitals to maintain high clinical standards, including issues around cleanliness and infection control.
Now readers of this post and the previous one, especially those who take the time to visit the included web links, will very quickly realise the importance of independent regulation for hospitals. You can imagine what might happen if this regulation were not in place. Well, thankfully in England it is.
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Medical Blog - Health Care Commission and ICNARC.

In March 2009 the Health Care Commissions published a report which referred to the “appalling care” delivered by Mid Staffordshire NHS Trust in the UK. The report states that there were deficiencies at "virtually every stage" in the care of people admitted as emergencies to the Mid Staffs Hospital. Sir Ian Kennedy, the Commission's Chairman, said: "This is a story of appalling standards of care and chaotic systems for looking after patients. There were inadequacies at almost every stage in the care of emergency patients.  There is no doubt that patients will have suffered and some of them will have died as a result. We look regularly at rates of mortality across the NHS in England. This statistical analysis served as a trigger - it raised questions which the investigation sought to answer".
This was an example of how careful monitoring of patient outcomes (audit) quickly enabled a failing hospital to be identified in the UK. The problem is, if you don’t audit you can’t trigger! If you don’t collect relevant data on patient outcomes, then how will you know if you are doing well, OK or really badly? Patients could be dying more often than they should but there would be no way of knowing. Take Intensive Care for example. Currently over 80% of adult, general Intensive Care Units (ITU) in the UK participate in ICNARC (Intensive Care National Audit and Research Centre). Critical care units volunteer to join and collect information about all the patients they admit to their unit. These data are sent to ICNARC. ICNARC validates and analyses these data. ICNARC generates reports which show how the unit compares with other ITUs, and helps the unit understand more about the care they deliver. It aims to assist them in decision-making, resource allocation and most importantly, to ensure patient well being and safety is maintained. Most of all, they know if they are doing a good job or not. Unfortunately, not all ITUs participate in ICNARC ......

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Medical Post - Less than 40%!

I've been a Doctor now for 21 years. Back then the Doctors were King and the Consultants were Gods. The Consultants hadn't quite achieved immortality, but in every other respect their words were law. During that time things have changed, allot! Now, the nurses are in charge. The vast majority of hospital managers are nurses. It is a natural career progression for them and they are trained to do it. The same cannot be said of Doctors. Very, very few managers have a medical background. Nearly all the day to day organisational decisions within a hospital are made by nurses. But, is there a downside?
I read recently that on one busy surgical ward, the average nurse would spend less than 40% of his/her time looking directly after patients! I don't know what they were doing the rest of the time, but I suspect there would be allot of writing involved. The UK NHS Institute for Innovation and Improvement is so concerned about this trend that it has set up its Productive Ward scheme. This scheme claims to be "Releasing Time to Care -The Productive Ward focuses on improving ward processes and environments to help nurses and therapists spend more time on patient care thereby improving safety and efficiency." They have developed a step by step "Toolkit" to help the struggling Director of Nursing re-engage his/her staff with the patients.
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Medical Post - Points!

I'm at a medical conference in London entitled "Emergency Medicine". It's being held in the rather idyllic setting of Regents Park College. There'll be 3 days of solid lectures, all delivered by experts in their field. There are up to 12 lectures per day.
The idea is to keep up to date and make sure that you remain at the top of your game. However, it has to be said that the 18 educational points I will earn are equally important. What you may not realise is that all Consultants must achieve on average 50 points per year, and these are mostly earned by attending educational meetings.
We are all appraised each year and the points are added up. Failure to achieve the correct quantity could leave the Consultant in breach of contract for which he could be dismissed! Soon, these points will also form part of Doctors revalidation and recertification. Without these two processes the Doctor cannot practice anywhere. And so you can see that there is plenty of incentive to turn up for the lectures. At the end of the 3 days I will be given the all important certificate. Total cost to the hospital; about £2500.
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Medical Post - Open versus Closed ICU.

The concept of an Intensive Care Unit (ICU) was first developed over 50 years ago during the Copenhagen polio epidemic. This produced a large number of very ill patients with breathing difficulties who needed special life support. The practice of putting all the most ill patients into one area in the hospital was established. Over the years some doctors and nurses began to spend more and more of their time treating these very sick patients. They developed an "interest" in intensive care. In 1999 ICU was finally recognised as a medical specialty in its own right . As a result specialty trained “intensivists” were employed to care for patients in ICU. In the UK these intensivists are usually anaesthetists, and this reflects the leaps in technology which occurred allowing support for heart, lungs, circulation, kidneys etc. in very sick patients. Soon, these intensivists specialized in an area of acute medicine that had advanced so far that general physicians and surgeons no longer retained the competencies to practice ICU.
An "open" ICU is one where the attending physician or surgeon continues to care for his patient(s) even after they have deteriorated enough to require ICU admission. A "closed" ICU is one where a fully trained intensivist takes over most of the care of the patient whilst in the ICU. He/she makes decisions relating to the care and medical management of the patient until they finally leave the unit and return to the care of the original physician or surgeon. Evidence shows that changing from an "open" to a "closed" type ICU model can lead to a 30 to 60% reduction in patient deaths! That means that for every 10 patients who die on an ICU, 3 to 6 could survive if this change were to be made! It hardly seems surprising that having a specially trained intensive care doctor, managing patients day in day out on an ICU might be better than a "generalist" who dabbles now and then! Consequently, around the developed world, the vast majority of ICUs have changed from the "open" to the "closed" type model.
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Medical Post - Early Warning.

Early Warning Scores have swept across hospitals in the British Isles and beyond. They help warn hospital ward staff of the severity of a patients illness, and whether their condition is getting better or worse. Most focus on recording heart rate, breathing rate, blood pressure, temperature, the amount of oxygen in the blood and how awake the patient is. A number is derived and if high enough this can tell the medical staff that the patient needs to be transferred to a high dependency or intensive care unit. Lower scores however, can tell the hospital staff that the patient is getting worse and measures need to be taken. These could include giving more fluids, blood, oxygen etc.
This all seems very sensible. There is good evidence that these scores help doctors and nurses identify sick patients more quickly. Earlier acute treatment has been shown to save lives. However, Early Warning Scores have only been proven to reduce the number of deaths in hospitals if at the same time you also introduce a Critical Care Outreach Team or Emergency Medical Team. These are groups of specially trained doctors, nurses, physiotherapists etc. who know how to treat very sick acutely ill patients. It does seem obvious that it's not enough to just score a patient and realise how ill they are if you then do not know what to do about it! In July 2007 NICE published it's guidance "Acutely Ill Patients in Hospital" in which it recommended that there should be a "team with critical care competencies and diagnostic skills. The team should include a medical practitioner skilled in the assessment of the critically ill patient, who possesses advanced airway management and resuscitation skills. There should be an immediate response."
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