You say sepsis, I say blood poisoning

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A few weeks back I was invited to the Senedd for world Sepsis day. The event was organised by Terence Canning who champions the cause of sepsis in Wales. Terence lost his brother to sepsis. He shares his story here.

At the event another story was told, about a young girl who had also died. Her parents were there to bear witness in the hope that their loss might be given at least some meaning by encouraging health care professionals to be more alert to the early signs of sepsis.

Terence is a much valued contributor to our Leading Improvements in Patient Safety Programme and his story never fails to remind all present just how devastating a missed opportunity can be.

It is estimated that sepsis kills 37,000 people each year in the UK. It is thought that more than a third of the deaths could potentially be prevented.

So what is sepsis? It is a life-threatening condition that arises when the body’s response to infection starts to damage its own tissues and organs. Unfortunately infections which can cause sepsis are common ones like pneumonia, water and wound infections or bites and problems like burst ulcers.

Sepsis is very treatable but hinges on early identification. There is a set of treatments called the ‘Sepsis Six’ which doctors and nurses can administer which will save lives. But the key remains early recognition that a patient may be developing sepsis.

As I mingled with the people at the Senedd it was clear that we in Cardiff and Vale have many experts in this field, one of whom, we have recently appointed as our Sepsis Clinical lead. Dr Paul Morgan is absolutely passionate about improving outcomes in this area. The key remains however early recognition.

What can we do about early recognition?

I have an idea.

I don’t think the general public know what sepsis is. But I do think people know what blood poisoning is. So how about using a term that people understand? It may not be scientifically accurate but it is something that people have heard about.

If we use a term that people understand maybe we can encourage people to be on the look out for signs.

Do you think there is mileage in adopting a more easily understood term to help us educate the public?

I’d be interested in you views.

Keep Well

5 Big Questions

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If you have a clinical background I’d like you to imagine yourself in two situations.

  1. You are the father/mother of a young child who has been unwell for a couple of days. The child is running a fever and you are becoming worried. You are sitting in the waiting room about to see your GP. You can’t put your finger on it exactly, but something about your child isn’t right.
  2. You are the son/daughter and your father is unwell. He has been suffering with a bad chest for a few days and has become a little bit confused. You are sitting in the waiting room about to see your GP. You can’t put your finger on it exactly, but something about your parent isn’t right.

Thank you for thinking about that for a moment. What are the questions you might ask the GP? Would the possibility that your relative may be developing sepsis have occurred to you?

Let’s change the scenario a little and take you to the EU. It’s Friday evening and the department’s busy. What questions will you ask the doctor who is assessing your relative?

I don’t have a clinical background, but I’ve sat through enough case reviews to know that nudging the doctor by asking him/her what my relative’s NEWS score is might be something I’d do. NEWS is the National Early Warning Score and can assist in identifying whether something serious might be brewing.

OK, now imagine you’re the next door neighbour but all of the relevant facts are the same. Would the neighbour be able to ask about the NEWS score? No. They will just have to assume that in that crowded and busy department, the fact that they are worried about their loved one, the sense they have that this is unusual will in some way be communicated to the doctor and that the doctor will remember to think about doing a NEWS score.

Of course it is entirely possible the patient will not have sepsis, or that there is a very clear alternative diagnosis. But allowing for that, we still have a potentially unreliable situation. Will the doctor remember to think about the NEWS score?

I don’t want you thinking I’m being critical here, I’m not. I recognise just how pressurised the front line can be and how complex making a diagnosis under pressure is.

How can we address this issue? There are two ways of looking at this.

  1. Do more to drive NEWS into the organisation where it is needed by educating and training staff.
  2. Find a way of enabling patients to ask about their NEWS score.

We do a lot of the first, but nothing about the second. I’m wondering whether there are Five Big Questions that we could suggest patients or relatives ask whenever they meet a health care professional and they are worried someone they love might be very sick.

I’m thinking about a 5 Big Questions ‘cut out and keep coupon’ we could put in the local newspaper for example. There are lots of other ways we could publicise something like this.

What I’m wondering is whether we can engage the people we serve to help us to do the right thing when it is really important more reliably.

So to all the clinicians who read this post, would you please give some thought to what 5 Big Questions might be please and let me know?

Alternatively, if you think it’s the worst idea you’ve ever heard, have you an alternative idea?

Thank you very much.

Keep Well

#5bigquestions

www.gettingbetter.website

Courage to Trust

I’m reading a book entitled ‘Willpower’ at the moment by Roy F. Baumeister and John Tierney. I heartily recommend it!

One of the stories told in this book is when a psychologist, who had been invited to give a talk about managing time, met an elite group of generals at the Pentagon. To get them going, the psychologist asked them to write a summary of their approach to managing their affairs. To keep it short, they were instructed to use no more than 25 words.willpower

Several minutes later, all bar one of the generals was completely stumped: given the vast complexity and range of their responsibilities, how was it possible to boil this down to 25 words or less?

It was the only female general in the room, a person with a distinguished military career, who had worked her way through the ranks and been wounded in Iraq, who alone managed to complete the task. Here’s what she said:

First I make a list of priorities: one, two, three and so on. Then I cross out everything from three on down.

It’s true: we have a finite capacity for attention which when coupled with an equally finite amount of time and energy at our disposal means that we must prioritise. In the present moment how many things can any of us actually focus on anyway? Study after study demonstrates that multitasking is no more than a fantasy: a story we like to tell about how busy we are and our capacity to handle so many competing priorities. In fact we can task switch, but doing this too frequently can contribute to something called ‘ego depletion’: when we stop making judgments and substitute reactions instead.

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Staying with the military theme, Napoleon did not win his many battles by making a better plan than his foe. No army has ever been managed into battle either. It is only the events leading up to the battle that can be planned – or as another General (Helmuth von Moltke) put it:

No plan survives contact with the enemy

Napoleon had a goal of course (whether you agree with it or not) but when it came to the battle itself his plan was to:

Engage, and then …  wait and see.

In similar vein, Admiral Nelson at the instant before the Battle of Trafalgar ran a message up his flag ship for all to see. His order was the simple instruction:

Engage the enemy!

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What do these two examples have in common?

It is that both Napoleon and Nelson understood that a battle is both complex and unpredictable. That to prevail will require the courage to trust the front line.

Each will have worked together with their chosen commanders perhaps over many weeks leading up to the moment when battle commences. During this period they will have built a clear understanding of what the overall objective is and will have considered the various ways in which the enemy might respond.

However, at the moment of truth, each knew they must place their trust in the commanders on the ground or on-board, to do the right thing under pressure, remaining true to the end objective while responding as circumstances dictate. In both cases a combination of much rehearsed tactics blends with a deep level of trust that the right responses will be made in any given moment.

Courage and Trust.

That is what defined them both. An ability to allow fluid responses to emerge under pressure which turns into a decisive advantage even when over-matched by an opposing force.

Back to our female general.

I think I’m going to follow her lead – here’s my list of priorities.

  1. Deliver our strategy
  2. Trust our people
  3. There is no three.

Keep well.

Read my Getting Better Blog or Explore YOU(v2.0)

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The robot habit

r2d2 iconHaving successfully completed the challenge (thank you Abi) of finding something good to say each week about Cardiff and the Vale UHB for a year, I allowed myself a break from writing these blogs. There’s been a gentle murmuring however … some people are missing them. So I thought I would pick up my pen, so to speak and get back into the habit.

Some of you might know that I had a bit of a health scare over the summer. You can read a bit more about here if you’re interested. As a result I’ve been ruminating a bit about why we do the things we do and whether I’m being consistent about focushabitsing on what’s most important. I’ve been reading a couple of good books which discuss why we behave the way we do. The  ‘The Power of Habit’ by Charle Duhigg, explores the science behind habit formation and the ways in which our lives are often governed by these unconscious patterns of behaviour.

Habits it turns out are all based on the same simple
neurological sequence: a routine, a reward and a cue, something which the researchers at Massachusetts Institute of Technology called the ‘habit loop’. The person habit loopwho habitually bits their nails will have a cue – perhaps feeling a snag when running her thumb over a nail, which triggers a routine, hands to mouth and a reward, nibbling off the offending nail. To change this requires an amendment to one or more of these three parts. Some people have changed this habit by responding to the cue by rubbing their finger tip vigorously on their thigh until the cue stimulus subsides.

The other book is ‘Thinking, Fast and Slow’ by Daniel Kahneman which is equally fascinating. The brain it turns out has two systethinking fastms … which Kahneman calls System 1 and System 2.

System 1 is fast; it’s intuitive, associative, metaphorical, automatic, impressionistic, and it can’t be switched off. System 2 on the other hand is slow, deliberate, effortful. But System 2 is also lazy and tires easily (a process called “ego depletion”). The greater the cognitive load on System 2, the more susceptible we are to being governed by System 1.

If you want to test this for your self here’s a test you can do.

Step 1: Sit in front of your computer and open a browser.

Step 2: Attempt to do the following calculation in your head 13 x 27

Step 3 go to theinvisiblegorilla.com/videos.html and follow the instructions very carefully.

While System 1 allowed our ancestors to stay alive and is good at some things like responding to danger (think how we respond to a snarling dog) it unfortunately also loves to simplify, to assume WYSIATI (“what you see is all there is”). It’s hopeless at the kind of statistical thinking often required for good decisions, it jumps wildly to conclusions and it’s subject to a fantastic suite of irrational biases and interference effects. One you might have heard of is the halo effect – when interviewers make their minds up immediately in the first few seconds after the candidate appears.

All in all we’re astonishingly susceptible to being influenced – controlled even – by features of our surroundings in ways we don’t suspect. In plain speak for a big part of our day we are flying on automatic pilot.

So why am I going on about this then? Well, we are working towards a safer health care system, where we do everything we can to make errors harder to make, where we use good processes that give reliable results when appropriate, and where we respect each other and encourage openness and show a commitment to learning from our mistakes.

We often talk about human factors in systems – which actually means that we are rather error prone. We are in other words, not robots. These two books provide some of the reasons why.

Keep well.

P.S.

If you’d like to have a look at another blog I’m starting or my attempt to get my life under control – you can do so here.

What’s it all about anyway?

Here’s a quote from Simon Sinek:

‘Our goals should serve as markers, measurements of the progress we make in pursuit of something greater than ourselves.’

‘Something greater than ourselves…’ I really like that because it means that we shouldn’t forget why we do what we do. It can be easy to forget how you felt when you first started to work in the NHS. I can remember as a young law graduate feeling so privileged to be rubbing shoulders with people who were doing such (to me) unbelievably good things. I mean ‘good’ in the way that a spiritual person might mean it, or the way someone who has shown character under fire might be seen, or a charity worker who feels compelled to work in a disaster area. I suppose I mean virtue.

There is so much that people who work in the NHS do that is virtuous. I know it’s a job, and that we all have to earn a crust. I also know that for some people work can become a prison, or it can feel oppressive or difficult. But I still can’t remove myself from the thought that people who I work with on the whole tend to be kind, thoughtful, caring, and respectful. I admire them – plain and simple.

It’s our job to care – even me. I care about how we treat our patients, whether we are helping people get what they need from us to help them keep well. I care about our organisation and the people in it. It’s my job.

What about those people though who aren’t paid and for whom being virtuous is reward enough in itself? People who aren’t employees, who we don’t have a right to expect anything from, but who nevertheless quietly and without a fuss just get up in the morning and want to do something good. I’m talking about the people who volunteer to help us and help the people we serve.

Pics Tim Dickeson 13-03-2015 - 2015 Staff Recognition Awards
Pics Tim Dickeson 13-03-2015 – 2015 Staff Recognition Awards

I was at an event in Barry last year and met a community first responder – someone who lived locally and who had decided he wanted to participate in a rota of people who would be called if someone might have had a cardiac arrest. I sat talking with this young man for a while and I learnt that he was unemployed currently, but lived in a street he’d been brought up in. One morning, he noticed one of his elderly neighbours struggling to open her gate. He went across and helped her and as he watched her walking away he thought about how long he’d known her, and remembered when she’d once looked after him when he’d fallen playing in the street as a boy. He saw how old she’d become and how frail she’d was and he started to worry that at some point something might happen to her. He felt like he would want to know what to do – and it was this thought that had led him to investigate becoming a first-responder. As we chatted he mentioned in passing that he went swimming each week on a Thursday and that was something else he really enjoyed. Slightly intrigued I asked him why, and he told me that that was when he took a group of people with learning disabilities swimming, acting as a volunteer. He said he loved the way they enjoyed it and he said he felt good afterwards. There’s that word again – ‘good’.

We’ve been celebrating the work of our volunteers over the past week. You can read what the Western Mail had to say about here. Our volunteers include some staff members who have retired but still feel the urge to do something good. I’d like to salute them, one and all. There’s a really interesting book I once read by a man called Jonathan Haidt called The Happiness Hypothesis. He examines the evidence for the causes of happiness. One of the things the evidence tells us we should do is: improve our connection to something beyond ourselves. He goes on to say: ‘Happiness is not the shallow state of feeling pleased and chipper all the time. Happiness is the state of a human being that has achieved cross-level coherence within herself, and between herself and the people, challenges, and institutions around her. Happiness comes from between’.

I’m guessing this is something our volunteers have worked out for themselves. If we want to increase our happiness potential he has a word of advice:

‘Join an organization that has a noble purpose and a long and noble past. Any volunteer work can take you out of yourself. But one that has history, traditions, and rituals is an easier place to find “vital engagement”’

Aren’t we lucky?

Keep well.

The Future is Another Country

There are lots of ways of saying that, when we want to change the results we are getting, we should think about what we might need to do differently. Einstein is often quoted as saying: ‘the definition of insanity is doing the same thing and expecting different results.’ Tony Robbins (not remotely in Einstein’s league I know) has another spin on this: ‘there is no such thing as failure – there are only results.’ What he means by this is that if we are not getting the results we want the first step is to acknowledge that results don’t just happen – we make them happen. In fact, we might say that we are rather good at getting the results we are getting even if we don’t like them. I find this rather empowering because if we can learn to do one thing, there is no reason to believe we couldn’t in time and with some effort learn how to do another thing.

We can’t know what will happen in the future, just like we can’t change what happened in the past. If we want to modify what happens in the future, the best advice is to change what we do now.

When we look around us at the way things work and how we work together to make those things happen, how often can we say that the way things work is really the result of a whole series of choices we have made consciously to do things in that way? One simple definition of culture is that it is ‘the way we do things round here.’ Why things are done the way they are is not set in stone. It is possible for example to have two wards side by side, with roughly the same group of patients being cared for and for these two wards to feel remarkably unlike each other. What makes the difference is often the leadership in each ward which changes the setting on what is OK and what is not OK.

SRC therapist and patient

In the Stroke Rehabilitation Centre at Llandough Hospital the team are faced with the challenge of supporting patients with very complex needs as they make the transition from the person they were before they became a patient with a stroke to the person they have become as a result. The evidence for helping people make this transition back into their lives away from hospital as soon as possible is very good and this is why the team became focused on delays in managing this transition which highlighted the need for a different kind of support at ward level. The team considered a range of possibilities and were tempted to appoint a ward based social worker. In the end however, they went in a different direction and tried something new. They appointed a Discharge Support Officer (DSO). The DSO is a member of the Integrated Discharge Service, commissioned via Age Connect to support patients over the age of 60 to prepare for discharge from hospital. By working with patients and their families Discharge Support Officers help promote safe and timely discharge.

Laura Thomas commenced in the DSO role in February 2015 for a four month trial period and currently works three days a week with the multidisciplinary team in the Stroke Rehabilitation Centre, UHL. Evaluation of her role for the initial six week period showed that she had received 19 referrals in total, 15 of those being for family support including assisting families through the discharge process, decision making and signposting to relevant services. The evaluation also demonstrated time spent meeting with families, telephone contact, attending/arranging meetings – DST’s and goal planning as well as arranging Unified Assessments (UA). All of this was previously undertaken by the nursing staff who struggled to dedicate time to the process due to competing clinical demands.

The team on SRC have embraced the DSO role and further discussion will be had regarding sustainability of the role on a more permanent basis. The benefits identified within the four months include:

  • DSO is ward based and therefore gets to know patients and their families personally without the need to await a referral
  • DSO is recognised as a point of contact for patients and families in relation to discharge plans
  • picks up referrals during the early stages of rehabilitation
  • provides support on-site for patients and relatives from time of admission to the Stroke Rehabilitation Centre
  • attends UA reviews which has noticeably reduced length of review meetings and the speed at which these are completed; and provides additional support for patients who have no family support
  • sign posting staff/patient/relatives to appropriate services often Third Sector in the community
  • completes the consent process as part of the UA process
  • provides active assistance and increased momentum with discharge co-ordination
  • an Advocate for patient’s, and,
  • releases clinical staff time, previously occupied with some of the administrative side of discharge planning.

Overall the role is viewed very positively by all concerned and the team are continuing to evaluate the impact Laura’s role is having.

Time will tell whether this role will be one that the team conclude they need. What I like about this story is that they were prepared to try something out, to experiment based on what their wisdom and experience told them about what might work better for the people they are serving. I like that they are evaluating and adapting as they go. My hope is that this team continues to explore why things are done the way they are and to question whether the way we have always responded is necessarily the right way to do so now. I think of teams and people like this as explorers, people who are prepared to venture a little into the unknown and see what lies beyond.

Keep Well

Hitting the sweet spot

There are around 20,000 people in Cardiff and the Vale who live with type 2 diabetes and this is one of the reasons we have focused our attention as a health board on this particular health issue. Diabetes is one of those long term health care illnesses that are sometimes referred to as ‘long term conditions’.

In some parts of the world, there has been a move to downplay the disease specific treatment pathways and at least in planning terms try and aggregate up the care that people with many different kinds of long term conditions need. There are good reasons for this – not least that many people have to contend with more than one form of long term condition. Indeed in our health board the Primary, Community and Intermediate Care Clinical Board has done some fantastic work looking at some common conditions that are amenable to treatment without a need for admission to hospital and have shown that it is possible to organise some of these treatments along pathways that overlap or share many similar components.

diabetes-528678_640However there is a dilemma: how can we balance the depth of knowledge required about possible treatment options for individual patients with the growing patient numbers and increasing treatment complexity?

Sharing knowledge and sharing the care we offer is a challenge when the knowledge that individual practitioners have of necessity is getting deeper, but arguably narrower too. It is worth persevering with as doing so helps us see the whole patient rather than responding to the patient one illness at a time. All of this is the natural territory of primary care which is where the vast majority of our population’s contact with our services takes place. The fact that the public continue to see primary care as a real strength of our system is a real tribute to those who work in this part of our NHS. There is no denying that the pressure on primary care is rising due in part to the ageing of the population but also as the result of more complex and demanding treatment choices – which includes diabetes.

So how can this dilemma about the depth of knowledge acquired by a few and the breadth of knowledge required by many be handled?  That was the question that our physicians who look after patients with diabetes asked themselves. The facts are startling: the prevalence of type 2 diabetes is around 5% in South Wales but the condition accounts for 9% of our expenditure and audit data shows that 18% of all inpatients will have diabetes. Recognising the increasing demands that diabetes places on the NHS, the physicians are in the final stages of developing an integrated model of type two diabetes care with closer integration between primary and secondary care providers than has been possible in the past. The model aims to deliver care as close to the patients home as possible and to provide support and education to primary care (General Practitioner and Practice Nurse primarily) as well as allowing secondary care to better understand the difficulties of managing a complex chronic disease such as diabetes in the community.

The model is centred on the principle that each of six consultants in diabetes will be attached to between eight and ten named general practices and will remain with those practices for community clinics, case notes review and advice by email. The expectation is that this will allow primary care physicians to get access to senior decision making in a timely manner and without having to make a formal referral to the hospital outpatient clinic with the delays that may be incurred. Having a named consultant will offer continuity of care and will facilitate the development of closer links between primary and secondary care. GPs will quickly develop enhanced skills through discussion with the hospital specialist that will allow them to feel more confident in managing patients with increasingly complex needs.

Because of the increasing number of patients with type 2 diabetes and the increasingly complex treatment options and algorithms available it is often difficult for general practitioners to decide on the best treatment for an individual. Capacity in secondary care clinics is limited and increasingly restricted to managing the most complex type 2 diabetes cases as well as type 1 patients. It is important to recognise that each person’s diabetes management and treatment targets needs to be individualised and as patients are often taking many other drugs for other co-morbid conditions it can be challenging to decide on the best option. Giving access to consultant Diabetologists for help with complex decision making will allow most patients to have their treatment delivered by their GP in the practice without the need to travel or wait.

The physicians have a big and positive vision for the future. They aim to facilitate the delivery of high quality care to patients, whilst reducing inequalities in care from area to area and assuring an accountable and auditable service is maintained. This project is one of the biggest reorganisations of service delivery in the field of diabetes for many years and as such offers the opportunity to be innovative and forward thinking, keeping the patient at the heart of the service.

You might say that really is hitting the sweet spot.

Keep Well