No Such Thing as a Well Patient

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