Chapter 16. Working as part of the system of care
The good doctor 439
Clinical governance 440
Patient safety and risk management 440
Healthcare-associated infection 441
Audit 443
Evidence-based medicine, statistics and guidelines 445
Diversity, religion, culture and disability 448
Primary and secondary care interface 451
Epidemiology, screening and health promotion 452
Rehabilitation 455
Complementary and alternative therapy 456
THE GOOD DOCTOR
Imagine you are the patient and you discover a potentially cancerous lump. How do you choose a doctor? Do you care that they are ‘nice’ or do you want someone who runs a good and quick service, knows their stuff and delivers good results?
You are now in the clinic room waiting to be seen. You are sitting undressed behind a flimsy curtain. Does it matter if the doctor marches in with a collection of juniors and students unannounced? Do you excuse the roughness of the internal examination on account of their professorial title? Do you leave uncertain of what is happening next, but too intimidated to ask?
Duties of a doctor
The general public often assume that the doctor they are going to see knows how to treat them. This trust in the doctor’s clinical capability is closely interwoven with their trust in him or her as a person. Just as some doctors can elicit a placebo effect by a kind touch or word of reassurance, others can hinder the recovery of their patients through poor communication or an insensitive manner.
The importance of the doctor–patient relationship and its contribution to successful medical treatment is acknowledged in the GMC’s outline of the ‘duties of a doctor’.
• make the care of your patient your first concern
• protect and promote the health of patients and the public
• provide a good standard of practice and care: keep knowledge and skills up-to-date; work within the limits of your competence; work with colleagues in the ways that best serve patients’ interests
• work in partnership with patients: listen and respond to their concerns and preferences; give them information in a way they can understand; respect their right to reach decisions with you about their treatment and care; support them as they try to improve and maintain their health
• be honest and open and act with integrity: act without delay if you have good reason to believe that you or a colleague may be putting patients at risk; never discriminate unfairly against patients or colleagues; never abuse your patients’ trust in you or the public’s trust in the profession.
Some of your colleagues might expect ‘special treatment’ when they or their families become unwell. In this situation, some might suggest that a good doctor treats a sick colleague just as they would any other patient. Perhaps, however, a good doctor should treat all patients as if they were a colleague.
CLINICAL GOVERNANCE
Clinical governance is the structured process through which systems, and the staff working within them, identify lessons to be learned, with the aim of improving care. This is done through evaluation of clinical service structure and outcomes and of the staff delivering them. Substandard care can present in a variety of different ways:
• completely unexpected adverse events, not directly attributable to the clinical systems within which they happened, e.g. the accidental administration of the wrong drug
• patient or staff complaints regarding chronic service suboptimal performance, e.g. incidence of MRSA
• potentially poor staff performance, e.g. unexpectedly high postoperative mortality rates.
The lessons learned could be good examples of clinical care for broader dissemination, areas where systematic modification of clinical practice can be used to improve service delivery and areas where serious incidents or complaints have highlighted a need for new approaches.
Regular clinical audit and recognition of the importance of evidence-based medicine (EBM), e.g. as outlined in clinical guidelines, are central tenants of clinical governance: EBM theoretically ensures uniformity of access to quality care based on scientific research instead of established local practices.
PATIENT SAFETY AND RISK MANAGEMENT
Ensuring patient safety is of paramount importance in clinical practice. As doctors, what we cause to happen intentionally, or in error, impacts directly on the health of individuals and their eventual outcome. Equally, working in the health service can be hazardous to staff and issues related to safety in the workplace are as applicable to medicine as they are to other industries.
The principle
Errors occur either because of individual mistakes or because of failings in the system. Risk management is the process through which NHS staff can analyse errors that have occurred, or were narrowly avoided, and thereby reduce the risk of them happening again.
A structured risk management approach, first developed in the commercial aviation industry, has been integrated into the NHS in recent years. The process may seem laborious and even threatening to busy clinicians, but its purpose is not to apportion blame or identify poor performers. Rather, it is designed to identify systematic failures in working practice and to protect patients.
Definitions
• hazard: something that potentially causes harm or loss
• risk: the possibility that the hazard will cause harm or loss
• critical incident: an event that has caused harm or loss.
Critical incidents
Critical incidents may be ‘clinical’ and occur in the course of treating a patient such that the patient is directly affected. They may, however, be ‘non-clinical’ and relate to service personnel or system functionality and not directly affect patients, e.g. a needle-stick injury or computer failure. A near-miss is an event in either category that has the potential to cause a critical incident, but for whatever reason does not.
Steps in the risk management process
• identify the hazard
• determine who may be harmed by the hazard in future and how it might happen
• evaluate the risk related to the hazard, in terms of the likelihood of it causing harm or loss and the seriousness of the consequences if it happened
• determine the actions that are necessary to prevent the hazard from causing harm or loss and those to be taken in the event of it occurring
• formulate a plan that places the above actions within a practical clinical context
• communicate the plan to the staff who may cause or be affected by the hazard
• audit the implementation of the plan and update it if necessary.
Contributing to risk management
Most hospitals use a designated incident reporting form. This may be in paper or electronic form and you have a responsibility to know how to access them, where to send them and how to use them routinely. If possible, attend risk management meetings: they offer a valuable opportunity to learn from your mistakes and those of others.
HEALTHCARE-ASSOCIATED INFECTION
Healthcare-associated infection (HAI) affects an estimated 1 in 10 patients in the NHS every year. Intravenous and urinary catheters, surgical wounds and other breaches to host defences are important risk factors for HAI in these patients. The high incidence of HAI is a major source of concern for patients and their relatives and, as a result, hospital cleanliness and the control of HAI have become major political issues in the UK.
Prevention of HAI
All healthcare workers, with the support and direction of local ‘infection control’ teams, have a responsibility to ensure that standard (or universal) infection control precautions (SICP) are followed. This includes careful attention to environmental hygiene:
• high standards of hygiene in clinical practice, including handwashing care in the use of medical devices, e.g. urinary catheters, CVP lines and peripheral IV cannulae
• use of personal protective equipment
• prudent use of antibiotics
• active surveillance and audit of HAI.
Good hand hygiene is exceptionally important and all clinical staff should use effective handwashing techniques. Detailed guidance on SICP is provided in Table 16.1; this advice provides adequate protection for the majority of patients. However, a brief risk assessment should be performed in all patients admitted to hospital, as more comprehensive precautions may be necessary in some, e.g. contact and/or air-borne transmission precautions.
| Hospital environmental hygiene | |
| Hospital cleaning | Hospitals should be clean and acceptable to patients, visitors and staff |
| Instrument decontamination | Shared clinical equipment must be decontaminated appropriately after each use |
| Hand hygiene | |
| Indication | Hands should be decontaminated before and after every direct patient contact |
| Alcohol hand-rub | Preferable to washing unless hands are visibly soiled |
| Handwashing with liquid soap and water | Indicated if hands are visibly soiled or potentially grossly contaminated and after several applications of alcohol gel |
| Personal protective equipment | |
| Gloves | All invasive procedures, contact with sterile sites, non-intact skin, mucous membranes, and during all activities that carry a risk of exposure to blood, body fluids, secretions and excretions |
| Plastic aprons | When close contact is anticipated and there is a risk of clothing becoming contaminated |
| Full-body gowns | Should be worn where there is a risk of splashing of blood, body fluids, secretions or excretions |
| Facemasks and eye protection | Where there is a risk of blood, body fluids, secretions or excretions splashing into the face |
| Respiratory protective equipment | Particulate filter masks must be correctly fitted and used for the care of patients with respiratory infections transmitted by air-borne particles |
| Sharps disposal | |
| Handling of sharps | Needles should not be recapped or disassembled after use and sharps should be handled as little as possible and not passed directly from hand to hand |
| Sharps bins | Sharps must be discarded into an appropriate sharps container which must not be overfilled |
Contact transmission precautions
These should be used in addition to SICP when there is particular concern about transmission of infection by direct or indirect contact. Typical clinical examples include certain gastrointestinal infections, including C. difficile, and MRSA. To reduce environmental contamination, infected patients should be isolated and gloves and aprons should be used by all staff during patient contact.
Air-borne transmission precautions
These are used in addition to SICP for infections that are readily transmitted by air-borne droplets, such as tuberculosis and chickenpox. Patients should be nursed in a side-room and further specific precautions depend on the known or suspected infective agent. Stringent respiratory isolation procedures are required for infections such as multi-drug-resistant tuberculosis (MDRTB), including the use of a negative pressure cubicle and personal respiratory protection for staff.
Management of HAI
It is important to distinguish between simple colonization and clinical infection. This is a frequent clinical dilemma in patients with MRSA, particularly in intensive care or chronic disease settings.
Colonization
Management should include SICP and contact transmission precautions. Where possible, topical rather than systemic therapy should be used since complete eradication of colonizing organisms is often difficult. Any attempt at complete eradication should be directed by infection control teams.
Clinical infection
HAIs, e.g. hospital acquired pneumonia, UTI related to catheterization and wound infections should be anticipated in patients with known risk factors. These include antibiotic use, prolonged hospital stay, chronic lung disease, tracheal intubation or other instrumentation, heavy sedation or a depressed conscious level. Antibiotics should be started promptly and the choice of empirical agent should reflect the increased frequency of drug resistance in HAIs, e.g. MRSA, vancomycin-resistant enterococcus (VRE) and various multi-resistant Gram-negative organisms. Follow your local guidelines and seek senior microbiological advice at an early stage.
C. difficile-associated diarrhoea (CDAD) is an increasing problem in UK hospitals. Prevention should be the primary goal: avoid the unnecessary use of broad-spectrum antibiotics (e.g. third-generation cephalosporins), particularly in the elderly, and pay careful attention to SICP. Follow your local protocols for the diagnosis and treatment of C. difficile (see p. 171).
AUDIT
Throughout your career you will be involved in clinical audit: ‘a quality improvement process that seeks to improve patient care and outcomes through systematic review of care against explicit criteria and the implementation of change’. Regular audit is a central component of the wider ‘clinical governance’ framework that underpins good reflective medical practice (see ‘Clinical governance’, p. 440).
Why and how
Audit improves patient care and your understanding of it. In addition, a clinical audit project is an opportunity to enhance your CV and become more involved in any specialty that interests you. Most units you work in will be continually involved in local and national audit programmes. Take the opportunity to discuss potential audit projects with your supervisors.
In contrast to a piece of research with a defined end-point, audit projects are self-perpetuating. Each single audit is undertaken as part of a continuous ‘audit cycle’ (see below) driving ongoing improvement in patient care, through analysis, action and further evaluation.
The audit cycle
Stage 1: choosing a topic
Identify a problem or area of particular interest. If the problem spans across speci-alties or departments consider organizing a joint audit; this makes implementing changes more feasible and avoids uninvolved parties feeling ‘blamed’.
Stage 2: identifying an audit standard
Identify a relevant standard of care or baseline data set that can be used for comparison. This could be a clinical guideline, e.g. NICE or SIGN, published clinical research, a previous audit or other standard of care, e.g. a patient’s charter.
Stage 3: planning
Pose a specific question, or set of questions, to be addressed by the audit, e.g. are national targets for secondary prevention following acute MI being met? It helps if the question can be measured numerically.
• choose the variables you will use to answer the audit question; they should be valid (the variable is able to measure what it is intended to measure), reliable (consistent), applicable to all relevant cases and simple to collect
• identify what resources are available to you, e.g. access to case-records, clerical support
• secure a ‘sponsoring’ consultant to advise you and support your approval and record access requests
• determine the size of the sample you will need to answer the question posed, e.g. perform a power calculation; statistical power may have to weighed against practical issues and the time available for data collection
• ensure you have enough time in your current post to complete the audit
• consider what you will do with the results: if you hope to present them at a meeting, check the submission deadline for abstracts.
Stage 4: data collection and analysis
This may be time-consuming and it is often useful to seek some guidance from senior colleagues and your local clinical audit department regarding the most efficient method, e.g. if a questionnaire is being used, some audit departments may be willing to advise on its construction. Where possible, consult multiple sources since individual clinical records (e.g. case-notes) are often incomplete. Ensure the data are stored securely and consider how you will analyse the data; with prior consultation your audit department may be willing to help (see also ‘Reporting results’, p. 446).
Stage 5: reviewing your findings
Once data analysis is complete you should compare your findings with the audit standard. Identify key messages, targets for improvement and potential objectives for further audit. Consider presenting your findings to your unit or hospital department; this will facilitate the next stage in the process.
Stage 6: implementing change
Stage 7: closing the audit loop
An audit is not complete until you have ‘closed the loop’ by re-auditing after implementing any action points identified in the first audit, to evaluate the impact of the actions undertaken.
EVIDENCE-BASED MEDICINE, STATISTICS AND GUIDELINES
The practice of evidence-based medicine links information derived from research to clinical practice. Its application requires an understanding of research methodology and its clinical relevance.
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