Making prudent healthcare happen

Turning everyday medical decisions into prudent practice

  • Dr Graham Shortland, Medical director and Consultant Paediatrician, Cardiff and Vale University Health Board

Summary

This essay provides an initial reflection to engage physicians and patients in conversations about preventing harm, ending unnecessary tests, and evaluating treatments and procedures.

There are many tools to help physicians and patients make effective choices, using evidence, to ensure high-quality care. Each patient situation is unique and in each case physicians and patients should determine an appropriate treatment plan together. This section includes examples already being used in Cardiff & Vale University Health Board.

Medicine

The practice of medicine

The topic of medicine is large. It creates the challenge of which areas we need to concentrate and reflect on when thinking about how to put prudent principles into practice.  Its scope gives us an opportunity to draw on ideas from a wide range of initiatives and innovation. Medicine cuts across many of the themes in prudent healthcare, particularly prescribing, primary care, allied healthcare, diagnostics and surgery.

Medicine continues, in many ways, to be practiced in a very traditional way. A patient progresses through levels of service, relying on communication between the primary care physician, hospital physician, tertiary specialist to reach review in outpatients.

Imprudent healthcare

The figures regarding imprudent healthcare are staggering.

Many healthcare professionals are probably aware that an estimated 10 per cent of all healthcare interventions are associated with some form of harm.[1]

But how many of us are aware that approximately 20 per cent of all work done by the health service has no impact on patient outcomes?[2]

Or that some studies suggest that only 18 per cent of the time patients spend in clinical environments offers immediate value? The rest – as much as 82 per cent of a patient’s time – is spent waiting for the next step in the process?[3]

Taking our three prudent principles and exploring these startling facts, it’s possible to start to develop changes in practice which could lead to improved care in our health systems, right across the vast area of medicine.

How can we improve our health systems?

By questioning everyday things and reviewing our practice, there are many ways in which we can reflect on the prudent healthcare principle of doing no harm.

The following example from Cardiff and Vale University Health Board comes from our questioning of the everyday and changing our practice to reduce the risk of harm.

Reducing harm caused by peripheral venous cannulas

Inserting a peripheral venous cannula (PVC), also known as a venflon, is a common procedure in many healthcare settings. However, using a PVC carries an associated risk of infection. PVCs can cause bloodstream infections by enabling microorganisms to gain direct access to the bloodstream. Microorganisms come from contaminated hubs or connections, the hands of healthcare staff, the patient’s skin at the insertion site and contaminated drugs and infusions.

Even though the incidence of local or bloodstream infections associated with a PVC is low in relation to other invasive devices, complications result in considerable morbidity because of the frequency with which PVCs are used. In the 2011-2012 Europe –wide point prevalence study the Wales report showed about 35% of patients in the acute sector had a PVC.

Phlebitis is the most frequent complication associated with peripheral intra venous (IV) infusions, occurring in up to 96 per cent of all patients.[4] Bloodstream infections are also a major cause of morbidity and mortality.

The most commonly isolated organisms from all types of intravenous cannulas are coagulase-negative staphylococci (35 per cent) with staphylococcus aureus the second most common (25 per cent).[5]  Methicillin-resistant Staphylococcus aureus (MRSA) accounted for 40 to 45 per cent of staphylococcus aureus infections in a 2006 prevalence survey.[6]

Complications often arise because PVCs are left in situ for too long, or because they are inserted when they are not required. The longer a PVC is in place, the greater the risk of complication. Inserting a PVC when it is not needed exposes a patient to unnecessary risk.

Many infection control experts believe that healthcare associated bloodstream infection can be markedly reduced, if not completely eliminated.[7] An Australian study[8] showed a bacteraemia rate of one per 3,000 cannulae, and more recently an infection rate of 0.2 per 1,000 intravenous cannula days has been demonstrated.[9]

The 1000 Lives Plus campaign provides advice on the use of PVCs in its ‘how to’ guide, “Reducing Healthcare Associated Infection – Appropriate and timely use of invasive devices”.

The guide advises that to optimise care:

  • PVCs should only be used if they are needed
  • They should be removed as soon as possible
  • All PVC procedures should be performed aseptically.

Carry out the minimum intervention

Unnecessary tests

Treatments and procedures do not always add value to care. They can take away from care by potentially exposing patients to harm, further testing, false positives and contribute to stress and avoidable costs for patients. Unnecessary tests, treatments and procedures also put increased strain on the resources of our healthcare system.[10]

We know that hospital inpatients may experience repeated blood tests, despite being clinically stable. Repetitive inpatient blood testing occurs frequently and is associated with adverse consequences for the patient, including anaemia and pain. A Canadian study showed significant reduction in haemoglobin as a direct result of phlebotomy. Given that anaemia in hospital patients is associated with increased length of stay, readmission rates and transfusion requirements, reducing unnecessary blood testing may improve patient outcomes.[11-13]

A reduction in the amount of testing can be achieved without negative effects on adverse events, readmission rates, critical care use or mortality. Interventions aimed at reducing laboratory testing also result in significant cost savings.

Further improvements in reducing unnecessary tests, can be achieved by the proper use of samples. To encourage proper use of investigations, a process has been introduced in Cardiff and Vale University Health Board to support staff and to reduce wastage. Phlebotomists now only bleed inpatients when a fully completed specimen request form is provided. Forms not completed properly are handed back to the ward staff and request forms which are amended immediately result in the phlebotomist bleeding the patient. Patients with outstanding or incomplete specimen request forms are either bled by ward staff or wait until the next phlebotomy session.

Where samples are taken by staff other than the phlebotomists, the laboratories hold samples in storage for 24 hours before processing them if the specimen request form is not fully completed. There are exceptions for samples which are not straightforward to retake or where delay may lead to spurious results, this includes tissue samples, cerebrospinal fluid, bone marrow, blood gases, or samples which are clearly urgent from the clinical details.

Improving the requester details has allowed demand to be monitored and the number of rejected samples reduced. We commenced the right first time initiative in March for Inpatients at Cardiff and Vale Hospitals and in April 2013 we rejected 2306 samples, the monthly average rejection rate is now less than 300 per month.

It has also reduced repeat testing of patients as the emphasis is on getting the request right first time.

Reducing unnecessary results – Wales Newborn Screening Laboratory

This affects everyone the NHS cares for. In 2013, the Wales Newborn Screening Laboratory developed and implemented a new testing protocol for the screening of babies for sickle cell disorders. The aim of screening is to identify babies with sickle disorder to ensure early treatment. Before the new screening tool was developed, the test used previously had identified babies with the disorder as well as babies carrying a sickle cell disorder. This approach had the potential to cause harm from further testing as well having significant cost implications.

The new testing protocol was based on tandem mass spectrometry and identifies only those babies who have the disorder. By preventing large numbers of carrier babies from being identified, unnecessary follow-up testing and referral for genetic counselling has been avoided. As well as reducing potential harm, the new protocol has reduced the cost of the screening programme.

The UK National Screening Committee endorsed the use of this new technology and testing protocol. The new protocol for newborn screening for sickle cell disorders was rolled out in Wales in June 2013.

Promote equity between professionals and patients

One of the major challenges for prudent healthcare will be the improvement of the patient pathway across community, primary care and secondary care systems. Decisions can be made at any point in the pathway, giving us the opportunity to prevent unnecessary referrals, encourage agreed practice and reduce unnecessary variation in treatment for our patients.

The importance of educating and engaging patients so they can make informed choices about their care is vital. This includes making sure people have access to patient-friendly materials to help them learn about the tests, treatments or procedures in question, when they are necessary and when they are not, and what people can do themselves to improve their health. Allowing patients to make informed choices also depends on the environment and setting of the interaction between patient and professional. We must recognise that each patient situation is unique – health professionals and the people receiving healthcare need to work out appropriate treatment plans together.

Outpatient clinics can be demanding environments for patients and healthcare professionals. The treatments offered across specialities in outpatients may vary, but the way these clinics serve patients share many steps in common. To provide patients with safe, high-quality care, it is important outpatient clinics run efficiently.

Three examples of recent service improvement and redesign show how outpatient settings can deliver improved outcomes for patients by applying prudent healthcare principles.

Bringing diabetes care closer to home

The Community Diabetes Initiative for Cardiff and Vale aimed to standardise diabetes care across GP practices in Cardiff and the Vale of Glamorgan. The initiative also aimed to move the management of most type 2 diabetes from the hospital into the community.

To move the management of type 2 diabetes into the community and streamline the service, a number of changes were made to working practices, particularly affecting consultants’ working practises:

  • each of 72 GP surgeries in Cardiff and the Vale of Glamorgan were allocated a consultant
  • consultant supports practices with email, with a one working week turnaround
  • consultants commit to two practice visits, for each practice they support each year
  • mentorship for practice nurses put in place with a diabetes nurse facilitator to up-skill in areas of need.

The initiative has been running since September 2012. More practices are engaging with the initiative and there is increasing consultant commitment to the service. It provides care closer to home and offers increased access to care, treatment and education. By acquiring new and updating existing skills, greater confidence in the management of type 2 diabetes patients has been reported by general practices taking part in the initiative.

Through audit of the service we have found there is:

  • an increased ability and willingness for general practice to contact consultants for advice
  • reduced referral rates for diabetes opinion (up to 30 per cent)
  • improved quality of GP referrals to hospital diabetes clinics
  • no waiting list for new patients at diabetes clinics
  • an absolute reduction of type 2 diabetes referrals (zero from some practices)
  • evidence of increased number of patients starting their injectable medicines in the community rather than in hospital settings.

Our experience with remodeling the diabetes service has taught us that having agreed pathways helps us to work more efficiently as our patients do not have to come to hospital clinics so often. They can receive better care locally. Reducing unnecessary variation in diabetes care has also meant we can test and implement national guidelines and local initiatives to keep improving our service. We are now applying this learning to other areas.

Addressing asthma

Inhaled corticosteroids for the treatment of asthma by prescription account for approximately £6.5m a year. This accounts for the majority, 63 per cent of the total respiratory spend by Cardiff and Vale University Health Board. Most of the expenditure is in primary care. Of concern is evidence that even though prescription items are rising, prevalence of asthma and chronic obstructive pulmonary disease (COPD) is static (Quality and Outcomes Framework data 2005).

Reducing variation

National guidelines exist, produced by the British Thoracic Society (BTS), but there are large variations in prescribing practice in both primary and secondary care. Even though 80 per cent of asthma can be controlled with low-dose inhaled corticosteroid, between 31 per cent and 81 per cent are prescribed at high dose.

There is the potential for improved patient care and cost savings by:

  • stepping down a patient’s inhaled corticosteroid dose appropriately
  • establishing correct dosing through improved patient assessment and following BTS guidelines
  • securing a diagnosis.

A number of initiatives were undertaken in Cardiff and Vale UHB in 2012–13 to improve patient care and achieve cost savings. These included

  • prescribing meetings attended by every prescribing lead and respiratory lead nurse in primary care
  • an audit of asthma and COPD care
  • asthma and COPD pathway posters distributed widely.

In addition, Script-Switch software was used to guide clinicians to the BTS guidelines when they attempted to prescribe high-dose inhaled corticosteroids.

This approach has resulted in decreasing prescribing costs and has reduced variation in prescribing and clinical care. There is more appropriate prescribing for patients and better education. Health professionals are better educated leading to better assessment and prescribing. Most importantly the pathway of care is now consistent across the primary and secondary care interface with no mixed messages.

There is also data to suggest that this initiative has resulted in decreased prescribing of high dose corticosteroids in Cardiff and Vale UHB despite increasing trends in other University Health Board’s.

Medicine Graham Shortland graph

Patient partnerships deliver better outcomes in osteoarthritis

Obesity is an established risk factor for the development and progression of knee osteoarthritis and knee pain. A number of trials have shown that combined weight loss and exercise is associated with improved function and mobility in patients with osteoarthritis of the knee. Some studies also report reduction in pain 14 and one suggests that weight loss in those who are overweight and obese may avoid the need for knee replacement operations15. People who are obese have poorer outcomes post-surgery because of wound infection, decreased ambulation and dislocation.

National Institute for Health and Clinical Excellence (NICE) guidance for the care and management of osteoarthritis states that healthcare professionals should offer advice on the following treatments to all individuals with clinical osteoarthritis:

  • Access to appropriate information
  • Activity and exercise
  • Interventions to achieve weight loss if the person is overweight and obese.

An innovative joint care programme at Cardiff and Vale University Health Board has been designed to support patients to use these interventions thereby reducing the need for surgery. This is provided by putting in place single referral access for obese patients to evidence-based diet and exercise support.

The new pathway was open to people with chronic knee pain, thought to be due to osteoarthritis, who were also classed as obese: with a body mass index of 30 and above. The pathway combined two existing services. The first was an eight-week, dietician-led “Eating for Life” weight management programme, held in community venues. The second, the “National Exercise Referral Scheme”, run over 16 weeks from local leisure centres by local authority staff. The new, 24-week, pathway was piloted from April 2012 to February 2013.

The pilot pathway had the following aims:

  • to increase overall and musculoskeletal health and exercise tolerance
  • to reduce pain and increase mobility and so avoid the need for surgery
  • to improve muscle strength and general health status
  • to reduce the morbidity of surgery if this becomes necessary.

The pilot was operated in three phases relating to the source of referrals:

  • Phase one – triage from the orthopaedic department waiting list
  • Phase two – direct referral from secondary care clinicians
  • Phase three – open access to GPs to makes sure lifestyle support was offered as early as possible in the patient pathway.

More than 330 referrals were received during the pilot phases of the new pathway. Approximately two thirds of all referrals accepted the invitation to join the programme.

At the end of the first eight weeks, 69 people accepted the invitation to submit outcome data. Analysis of this showed that most people had lost weight with an average weight loss of 2 per cent. Most had also seen improvement in their knee function, with an average increase in Oxford Knee Score (OKS) of 4.2. Participants also demonstrated an improved quality of life score with an average improvement in EQ-5D (VAS) of 6.5.

Interestingly, although weight loss at eight weeks was less in those with a Body Mass Index of 40 and above, it appeared that this group had better average improvement in their Oxford knee and quality of life scores. At the time of the pilot evaluation, outcome data was only available for six patients from week twenty-four. However, all six had lost weight (average 8.9 per cent) and five recorded both an improved OKS (average 5.5 increase) and quality of life score (average 9.1 increase).

Evaluation of the pilot found the programme had met its aims of reducing pain and increasing function for those who completed the course. Since the pilot, the new approach has been embedded in routine clinical care pathways for osteoarthritis. The pilot has informed the development of the Cardiff and Vale Optimising Outcomes Policy. Ongoing evaluation of the dietetic weight management programmes for 2013 showed that 69 per cent of people starting the programme completed it, and of these, 78 per cent lost weight with an average weight loss over eight weeks of 2.7kg (range 0.1–8.6kg).

Next Steps

Five practical steps can be taken to move from debating prudent healthcare, to putting it into action:

  1. Question all routine practice carrying a risk. Ask if medical devices like cannulae and catheters necessary for your patient? What can we all do to reduce unnecessary use?
  2. Change our relationship with testing. More is not necessarily better with testing. Will your patient benefit from this test? Will the benefit be greater than the risk, inconvenience or cost?
  3. Give patients the time and opportunity to think about treatment options. Before deciding on a course of treatment let patients consider the options that are right for their needs and circumstances.
  4. Use standard pathways for frequently used services. Standardising pathways reduces arbitrary variation, improves efficiency and makes sure patients access the appropriate care. Pathways make sure we only seek specialist help when it is necessary.
  5. Think more widely about how to support patients in meeting lifestyle needs. How can you support them tackling health issues like smoking, obesity and depression which affect their health and experience of healthcare?
Acknowledgements

Aled Roberts, Lindsay George and Helen Lawton – Diabetes

Simon Barry, Ramsey Sabit, Guy Marshall and Fiona Walker – Respiratory

Caroline Hill and Andrew Goringe – Unnecessary tests

Sian Griffiths – Osteoarthritis

Eleri Davies – 1000 Lives Improvement Healthcare Infection

Stuart Moat – Neonatal Screening


References

  1. Vincent C, Neale G, Woloshynowych M. Adverse events in British hospitals: preliminary retrospective record review BMJ 2001;322:517.
  2. MacArthur H, Phillips C, Simpson H. Improving quality reduces costs Cardiff:1000 Lives Improvement; 2012.
  3. The Health Foundation. Learning report ‘Improving Patient Flow. How two Trusts focussed on flow to improve the quality of care and use available capacity effectively’ London: The Health Foundation; 2013.
  4. Weise N, Stijnen T, Van den Broek Should In-line Filters Be Used in Peripheral Intravenous Catheters to Prevent Infusion-Related Phlebitis? A Systematic Review of Randomized Controlled Trials. Anesth Analg 2010;110:1624-9.
  5. Drug and Therapeutics Bulletin (no author given). Managing bloodstream infection associated with intravascular catheters. DTB 2001;39:75-80 [online] [Accessed 2012 January 23] Available at: http://dtb.bmj.com/content/39/10/75.full. pdf+html
  6. Smyth ETM. Healthcare acquired infection prevalence survey [Conference presentation] 6th international conference of the Hospital Infection Society; 2006;Amsterdam; The Netherlands. See also: Hospital Infection Society. Third prevalence survey of healthcare associated infections in acute hospitals in England. 2006 [online] [Accessed 2012 January 23] Available at http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/ PublicationsPolicyAndGuidance/DH_078388
  7. Jarvis Choosing the best design for intravenous needless connectors to prevent bloodstream infections. 2010. [Accessed 2012 January 23] Available at:
    http://www. infectioncontroltoday.com/articles/2010/07/choosing-the-best-design-for-intravenous-needleless-connectors-to-prevent-bloodstream-infections.aspx.
  8. Collignon Intravascular catheter-associated sepsis: a common problem. The Australian study on intravascular catheter-associated sepsis. Med J Australia 1994;161:374-8.
  9. McLaws M L, Taylor The Hospital Infection Standardised Surveillance (HISS) programme: analysis of a two-year pilot. J Hosp Infect 2003;53:259- 67.
  10. Attali M, Barel Y, Somin M, Beilinson N, Shankman M, Ackerman A, Malnick SD. A cost-effective method for reducing the volume of laboratory tests in a university-associated teaching hospital. Mt Sinai J Med 2006 Sep;73(5):787-94.
  11. Lin RJ, Evans AT, Chused AE, Unterbrink ME. Anemia in general medical inpatients prolongs length of stay and increases 30-day unplanned readmission rate. South Med J 2013 May;106(5):316-20.
  12. Smoller BR, Kruskall MS. Phlebotomy for diagnostic laboratory tests in adults. Pattern of use and effect on transfusion requirements. N Engl J Med 1986 May 8;314(19):1233-5.
  13. Thavendiranathan P, Bagai A, Ebidia A, Detsky AS, Choudhry NK. Do blood tests cause anemia in hospitalized patients? The effect of diagnostic phlebotomy on hemoglobin and hematocrit levels. J Gen Intern Med 2005 Jun;20(6):520-4.
  14. Messier SP, et al. Exercise and weight loss in obese older adults with knee osteoarthritis: a preliminary study. J Am Geriatr Soc 2000; 48:1062-1072.
  15. Coggon D, Reading I, Croft P et al. Knee osteoarthritis and obesity. International Journal of Obesity and Related Metabolic Disorders. 2001; 25 (5): 622-7

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One Comment

  1. The statement that ‘1 in 10 healthcare treatments result in harm’ in the graphic is not supported by the reference given

    http://www.bmj.com/content/322/7285/517

    Rather, the paper shows that about 1 in 10 patients experience an adverse event of which about half were preventable. The example of an adverse event they give is that of inadequate care leading to pressure sores, and poor catheter management leading to necrosis of the penis.

    This is quite different from the impression given, which is of treatments given causing harm.

    Good healthcare, which avoids harm, depends on accurate and clear thinking, and careful reading of the evidence. Paying attention to detail is a fundamental necessity if waste and harm are to be avoided.

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Watch Dr Graham Shortland expand on his article by clicking on the video.

“How many of us are aware that approximately 20 per cent of all work done by the health service has no impact on patient outcomes? Or that some studies suggest that only 18 per cent of the time patients spend in clinical environments offers immediate value? The rest – as much as 82 per cent of a patient’s time – is spent waiting for the next step in the process?”

Making it happen

  1. We are probably aware that one out of every ten healthcare interventions causes harm but we may not know that 20 per cent of our work has no impact on patient outcomes and only 18 per cent of the time patients spend in our care offers them any therapeutic value – the rest of the time is spent waiting.
  2. Doing what we have always done will give us the results we have always got. Question everything, stop assuming an intervention delivers benefit and explore the risks. Inserting a peripheral venous cannula is a good example, the individual risk of infection is low but because we insert so many the incidence of complications generates considerable morbidity across Wales.
  3. Look to deliver the minimum appropriate intervention whenever possible. Just because we can do something, doesn’t mean we should do something. We can start with eliminating unnecessary tests and stop generating unnecessary results. The case of sickle cell screening of newborns demonstrates how over testing may create unnecessary harm for patients and unnecessary costs for NHS Wales.
  4. Promoting equity between patients and healthcare professionals may be our biggest challenge. By working across disciplines, settings and by involving patients we can redesign services together to improve services and meet patients’ needs more appropriately.
  5. Prevention is always better than cure, and where we can address the causes of ill health we have the opportunity to reduce the burden of disease, improve quality of life and reduce the need for expensive medical interventions.
No result could be fetched.