no such thing as a well patient
TRANSCRIPT
Simple
solution for
complex
problem or
complex
solution for a
simple
problem
NO SUCH THING AS A
WELL PATIENT
Jesse Spurr
“The more elaborate his labyrinths,
the further from the Sun his face.”
Mikhail Naimy, The Book of Mirdad: The Strange Story of a Monastery
Which Was Once Called the Ark
COMPLEX SYSTEM
THE GOOD OLD DAYS?
THE BAD NEW DAYS?
“People want to know how much you
care before they care how much you
know."
James F. Hind (Author)
PATIENT-CENTERED CARE
THE REASON WE HAVE A JOB
THE REASON WE HAVE A JOB
THE REASON WE HAVE A JOB
THE REASON WE HAVE A JOB
THE REASON WE HAVE A JOB
The patient is the one essential component of the healthcare system.
The system has become, to a degree, self serving.
New ideas in health are frequently met with skepticism.
CAN WE WRITE SOME GLOBAL TRUTHS?
WHAT MAKES A GOOD IDEA?
We appoint an expert. We invest money.
That expert researches the theories of
other experts. The expert designs a plan
based on the other experts’ theories. The
plan goes to a board of more experts.
These experts attempt to pre-empt what
will go wrong with the plan. The plan,
after months to years of expert
development, is ready for implementation.
THE GOD COMPLEX
How can we remove complexity
from our system?
IS THERE ANOTHER WAY?
We have some ideas. They seem like
they would make sense. Let’s try
them, evaluate them using a
systematic process and keep the bits
that work and throw out the bits that
don’t.
TRIAL AND ERROR
MEET NEW IDEAS WITH OPTIMISM
How about we try to catch
something bad happening to our
patients before it’s too late?
….there were some researchers that
managed to look at some data in just the
right way that suggested, that maybe,
there was a way to predict if someone in
hospital was going to become critically ill
before it actually happened…
ONCE UPON A TIME…..
There is suf ficient evidence that the fol lowing have arguably become accepted truths:
• Serious physiological abnormalities often precede cardiac arrest, unanticipated ICU admission or death – 6 to 8hrs earlier.
• Limiting human error can prevent serious adverse events.
• A significant number of deaths in acute hospital settings are preventable.
• Nurses have a professional responsibility to understand the significance of patient observations.
THE ISSUES
Vital signs are often neglected.
THE SCARIEST TREND
Feiselmann et al in 1993 found evidence that RR>27
breaths/min was the most prevalent predictor of cardiac arrest.
Subbe et al 2003 suggested that, in unstable patients, relative
changes in RR were much greater than changes in heart rate or
blood pressure.
Cretikos et al 2007 evidenced that just over half all general
ward patients who suffered serious adverse events (arrest or
ICU admission) had a RR>24 breaths/min and could have been
predicted as high risk up to 24hrs earlier with 95% confidence.
RESPIRATORY RATE – THE NEGLECTED
SIGN
SO WHAT?
There is no such thing as a well patient….
Kyriacos and colleagues 2011
- Literature review of vital signs monitoring with early warning systems (EWS).
No robust data to validate EWS
Paucity of data to evaluate, guide implementation and clinically test
EWS.
LET MY DATA SET CHANGE YOUR
MINDSET?
SO, WE’RE IMPLEMENTING THIS?
Moment for thought
Why are we doing this?
INSANITY OR REVOLUTION?
TALKING ABOUT EVIDENCE
I take less umbrage in being labeled
ignorant, than being accused as
negligent.
WHAT HAPPENS IF WE DON’T DO
SOMETHING?
Making mistakes in the right
direction.
http://www.youtube.com/watch?v=KR_mCvb-KyY - 3mins
WHAT IF THIS DOESN’T WORK?
1. Are we prepared to fail?
2. Can we survive a failure?
3. How do we spot a failure and fix it -early?
ARE WE WILLING TO FAIL?
Afferent Limb
Efferent Limb
WHAT IS A DETERIORATING RESPONSE
SYSTEM?
SENSING AND FEELING; ACTIVATING AND
RESPONDING
Afferent Evidence based track and trigger obs form
Escalation protocols
Efferent MET
Yet to see….
SO, WHERE ARE YOU AT?
Patient and family escalation.
Automated technologies – pathology, alarms, software.
A new focus in clinical education.
Improvements in end of life care.
More research.
ICU sans frontiers.
WHAT’S ON THE HORIZON?
It takes a strong person and an even stronger system to admit
that they are wrong…
Let’s meet new ideas with optimism, but hold them
accountable.
Recognising the deteriorating patient is patient -centred care.
SO REMEMBER
Fools ignore complexity. Pragmatists
suffer it. Some can avoid it. Geniuses
remove it.
Alan Perlis (American computer science pioneer)
COMPLEXITY
Questions
THANK YOU