NEWSLETTER - DAY 03 WEDNESDAY 20th FEBRUARY
Hospitals learn about efficiency from F1 I
n a world of severe hospital budget cuts and ever-increasing calls for higher levels of efficiency and safety, hospitals must start working differently – and they can learn a lot from the corporate world. So said Allan Goldman, Clinical Unit Chair for Critical Care at London’s Great Ormond Street Hospital at the 6th World Congress of Paediatric Cardiology and Cardiac Surgery, currently on in Cape Town. “In terms of how we process patients, we need to learn how industries process things and get rid of waste in systems. We need to look at how they efficiently manage flow,” he said. “In terms of safety we have to learn from high reliability organisations,” Goldman told a plenary entitled Heart Surgery is a Risky Business: Doing it Better, Safer for Less. Hospitals must shift their focus towards “from physician-, surgeon- and nurse-centred care to patient-centred care, said Goldman, who trained in South Africa. “We have the opportunity, with fantastic data, to improve outcomes,” he
By SUE SEGAR said, adding that such data was often to be found in the examples and experiences of industry. In an inspired move, following a “small cluster of failures” around an operation in the late 1990s, Goldman’s hospital consulted a Formula 1 Team in a bid to learn about systems of efficiency. “We wanted to learn how they did a pit stop – and how we could relate that to how we handed over patients from a theatre team to an intensive care unit,” he said. “At a pit stop, the racing cars come in and their tyres are changed and they are filled with fuel in a matter of seconds. We wanted to learn from this efficiency.” In a further bid to learn from industry, the hospital’s head of the Cardiac Unit, contacted a human factors expert who had transformed the airline industry. “From that time on we have had this ethos of having human factors experts in our department to look at factors affecting the performance of operations using human factors.
Surgeons learn a thing or two about efficiency from Formula 1 teams
Allan Goldman
“The Formula 1 Team helped us to look at team interfaces. “We realized we have a huge amount to learn from other industries.” Goldman said another great challenge for hospitals, moving forward, was how teams work together. “We need to move away from a focus on individuals. “Of course we need fantastic surgeons. There’s no question of that. But it is really the big teams and how functional they are that will determine outcomes.” Goldman said decreasing availability of money, coupled with higher expectations and a new shift on patient safety, placed a heavy responsibility on hospitals to learn to “do the same with less money”. “We have been through the first phase of getting children with high mortality rates in the 1960s, 70s and 80s to mortality rates of one to two percent. “The next challenge is about quality of life and long term outcomes.” Goldman said the knowledge he gained from working with - and learning from - industry had led to his joining up with a retired pilot and a retired surgeon to start a series of conferences called Risky Business: Learning from other industries. They have run 10 conferences since 2006,” he said. “It is possible, if we change the way we think and work, to learn from other industries and from each other.”
new mindset for surgeon training T
he ‘good old days’ of training surgeons in public hospitals are over, according to a leading American expert in cardiothoracic surgery. D r J i m Tw e d d e l l , w h o w o r k s at the Children’s Hospital of Wisconsin, was speaking on day three of the Sixth Wo r l d C o n g r e s s o f Pa e d i a t r i c Cardiology and Cardiac Surgery i n C a p e To w n . “ To d a y , due to growing medical liability exposure, cardiothoracic surgery is becoming a decreasingly glamorous profession,” said Tw e d d e l l , a d d i n g t h a t t h e r e were 93 applications for 116 cardiothoracic surgeon p o s i t i o n s i n 2 0 0 9 i n t h e U S, a n indication of the dire need for more skilled surgeons. I n t h e past, doctors did their t ra i n i n g at large public hospitals a n d t re a ted low-income pat ients w h o h a d no medical aid, he said. T h i s w as a time when young d o c t o rs were allowed to make m i s t a k e s, which William Nolen d e s c ri b e d so well in his 1980 m e m o i r The Making of a Surgeon . T h a t era ended in 1989 when t h e L i b b y Zion Law was passed, re s t ri c t i ng the number of hours t h a t m e dical interns are allowed t o w o rk . The law was named in h o n o u r of a New York teenager w h o s e death was attributed to a l l e g e d mistakes by overworked h o s p i t a l interns.
Jim Tweddell
By KATHERINE GRAHAM “The challenge remains: How do we achieve surgery practice without endangering patients’ lives?” Tw e d d e l l asked. He suggested the example of training airline pilots should be followed, using simulation to master skills on the operating table. In the US very good results were being seen in the integrated sixyear residency which reduces the time that surgeons are required to train, he said. Some of the simulations being used in this residency include sewing up rubber tubes and animal hearts. “ We are confident that we can develop a valid grading system for technical training. Although the fidelity is low, the students are working with real tissue and there are no human lives on the line.” Likening the skill of a surgeon to that of a musician, Tw e d d e l l said that medical students need time to hone their abilities in order to become trustworthy cardiothoracic surgeons. This was a metaphor t h a t R o d o l f o N e i r o t t i , o f D e Vo s Children’s Hospital in Michigan, said he approved of. Earlier in the congress, Neirotti spoke about the disparity between the first and third world regarding cardiac s u r g e r y . “ Wo r l d w i d e , 9 0 % o f more than one million children born with congenital heart disease every year have suboptimal medical care,” he said. Discussing the importance of human capital, Neirotti said that the quantity and quality of skilled workers hadf a direct effect on the economic development of a society. “Cardiac surgery has much in common with any other complex structure in which performance and outcomes depend on sophisticated individual, technical and organisational
factors and their interaction.” Referring to a 2010 Health Harvard publication,
Professionals for a New Century, Neirotti said that existing health systems were under enormous pressure, with challenges like hyperspecialisation, population demands and technological innovation demanding that the current educational model be reformed. “The existing health needs should determine the core competencies of medical staff, which in turn should determine the curriculum,” he said. “At the moment, it is the other way around.” “ Ta i l o r i n g t h e c u r r i c u l u m according to health needs allows for an individual learning process rather than a one-size-fits-all approach,” N e i r o t t i s a i d . “ We n e e d t o m o v e away from fact memorisation to searching, analysis and synthesis of information for decision making. In this way, we will not only be training people seeking professional credentials, but actually be imparting real skills.”
Nursing experience impacts mortality By SUE SEGAR N
ursing experience in paediatrics has a significant impact on patient mortality for cardiac surgery patients. This was the message from Patricia Hickey, vice president: Cardiovascular and Critical Care Services at the Boston Children’s Hospital during the plenary session on February 20. In an address entitled Skill Retention: Experience Counts in the ICU, Hickey shared her latest data on nursing and organizational factors that impact mortality for cardiac surgery patients. “For the first time we have shown that, in those intensive care units where there are more nurses with less than two years experience, the odds of dying, for those children, are higher,” Hickey told delegates. “For every ten percent increase in nurses with less than two years experience, the odds ratios for death significantly increase for those patients.” She continued: “The message is not that we shouldn’t hire new graduates. We should hire them. “But we need to support them for two years as they are learning and it is important to ensure that they are in an environment where they are mentored and supported.” Hickey’s data, based on research conducted in 2012, also showed, for the first time, that in those units with increasing numbers of nurses with over ten years of experience, the odds of dying are significantly less.
“That’s a message that we need to retain our experienced nurses.” Hickey said she and her team embarked on their research when they found that while there was data on nurses relating to adult hospitals, such research had not been conducted in paediatric hospitals. “So our team began a journey of looking at and examining what are the nursing and organisational factors that impact mortality and morbidity, focusing on congenital heart surgery patients. “The research objective was to describe and understand nursing and organisational characteristics of cardio-vascular care in children’s hospitals and to examine the nursing organisational and unit level factors associated with risk adjusted mortality.” Hickey said there was a “spectacular” 100 percent response. A cross-sectional survey was designed to elicit data about nursing and unit characteristics of 43 freestanding children’s hospitals providing cardiac surgical care. Hickey said her research had led to two key findings applicable to paediatric cardiovascular and critical care services: “There are two messages. For the future we need to hire new graduates and support them for at least two years in intensive care units and, secondly, we have to
Nurses need experience to avoid future mistakes
Patricia Hickey
ensure that we have a retention strategies to retain our nurses as they do have significant influence on patient outcomes and survival. “For the first time we now have data about nursing education and experience and its association with outcomes in our patient population. “So we have gone ahead and made recommendations that over 20 percent of registered nurses with less than two years experience significantly increases the odds of dying and for those units with over 25 percent it is even more dramatic.”
Advice I’d give the 25-year-old me F
amily comes first. This was the first and most important tip passed on by Allison Cabalka, associate professor at the Mayo Clinic in Rochester, Minnesota during the Meet Your Mentors Session. In an address titled Advice I’d give myself age 25, Cabalka urged medical practitioners never to take their precious families for granted. “Time is precious and it’s easy to take things for granted as you move along in life. “We think because we are physicians and healthcare professionals, we are invincible, and always in control. But we have a lot to learn. “Career demands are placed on us at an early age and medicine can be an isolating environment. It is common to become overworked and to start underrelating to our family. “While we are trying to get ahead, we must never forget we are part of a team and that team includes our family.” Cabalka, who joked that “I have no corner on the advice market as it’s been a while since I was 25”, said she had gleaned her tips from older and wiser mentors in her life. In her second tip, warning that “Something’s gotta give,” Cabalka stressed the impossibility of having it all. “So, set priorities and be flexible. Re-evaluate things. Flexibility is key to
By SUE SEGAR many of the things we do in medicine. “Tackle projects that are finite. If you take on something, try let it be something that goes on in perpetuity. Know when to say no.” Thirdly, said Cabalka, she would tell her 25-year-old self to find an older mentor – a sentiment expressed by several speakers during the moving session. “Spend time with your mentor. Watch, listen, learn and discuss. It is not nice to work in a vacuum,” she said. Further tips – which were welcomed by younger practitioners in the session – were: • Know Your Limitations: “We are humans, and not God. To be a jack-of-all-trades and master of none is not an option. Develop a skill and master it.” • Live Within Your Means: “It’s not a popular idea as we want to get ahead in a materialistic society, but it is possible.”; • Be Generous: “We are blessed. We should give to others - not just money, but time and skills. And cultivate an attitude of gratefulness.” • Volunteer: “Offer help next door or in your local clinic and even somewhere outside medicine. You have many skills and can offer them to others. Use them wisely and
Spending quality time with those close to you helps to relieve professional pressure
Allison Cabalka
generously. This keeps you humlble and you will learn so much from the people you interact with.” • Exercise Regularly: “Start early and go often. Develop good habits. You really cannot afford not to. Go for the natural endorphins.”; • Read: “And not just the pile of journals next to your bed. Read for fun. Expand your horisons.”; • Travel: “It broadens your horisons and allows you to interact with people with different experiences. Do it with your family. Do it for work.” Lastly, said Cabalka, find a “Sabbath” rhythm in life. “Take time to rest, relax, ponder and pray. Take time away from the all-consuming world of medicines. We owe it to our families and to our patients to be the best physicians possible.”
Sudden athletic death on the rise By KATHERINE GRAHAM
S
udden cardiac death is becoming an increasing worry for athletes, a leading sports scientist has said. Speaking on the third day of the Sixth World Congress of Paediatric Cardiology and Cardiac Surgery, Professor Wayne Derman of the South African Medical Research Council said the condition could be defined as natural death resulting from sudden cardiac arrest occurring unexpectedly within six hours of the onset of symptoms. Last year saw the deaths of several top athletes due to sudden cardiac arrest, including London Marathon runner Claire Squires, Italian soccer star Piermario Morosini and Norwegian Olympic swimmer Alexander Dale Oen, drawing fresh attention to the tragedy of young, fit sports people who are felled in the prime of life. Perhaps most dramatically, Fabrice Muamba suffered a cardiac arrest in March 2012 during a televised FA Cup match between Bolton and Tottenham Hotspur, from which he recovered even though his heart stopped for more than an hour. “The risk of sudden cardiac death for people younger than 35 is 0.3 to 3.6 per 100 000 people per year,” said Derman. “In athletes, this figure is much higher – one to three people per 100 000 per year.” But he was at pains to point out that exercising remains good for you and that this event is very rare. “Exercise is potent at reducing your overall risk of a heart attack,” he said. “An obese diabetic smoker has a lower chance of a heart attack than someone who doesn’t exercise.” Derman said that although exercising is beneficial to your heart, when the intensity of the exercise is too high
Fabrice Muamba luckily survived his on-field heart attack
and the recovery period too low, this raises the risk of sudden cardiac arrest. He said better screening was needed to prevent deaths. “Of the two athletes who died in the Ironman race in East London last month, both had recently tweeted that they were suffering from upper respiratory tract infections,” he said. As the debate rages between the US and Europe on the benefit and harm of screening, Derman said the focus should be on what screening protocols should be medically recommended and scientifically justified.
Wh o says I can ’ t P l a y ?
T
he question of screening athletes’ hearts was one of the hot topics of discussion at the Sixth World Congress of Paediatric Cardiology and Cardiac Surgery, currently being held in Cape Town. In a provocative talk, Professor Michael Ackerman of the Mayo Clinic asked whether the physician’s role was as a disqualifier or an educating informer. He said the message of many cardiologists was “unless your heart is perfect, you can’t play”. Ackerman said a positive development was that the 36th Bethesda conference in the US, which determines the eligibility recommendations for competitive athletes with cardiovascular abnormalities, had opened up some room for manoeuvre. “Now the message from the US medical fraternity has been modified to ‘unless your heart is perfect or the syndrome is confined to just your genome, no sports’.” The so-called “safe six” sports for people with genetic heart problems are billiards, bowling, cricket, curling, golf and riflery, said Ackerman. “Of course, cricket players are livid that their sport is considered low risk while ping pong
By KATHERINE GRAHAM isn’t!” he quipped. He said the conventional wisdom of physicians of “when in doubt, kick them out” was not the Mayo Clinic’s philosophy. “We have a number of patients with Long QT Syndrome (a disorder of the heart’s electrical activity) who know that exercise can be harmful to them, but who choose to remain athletes,” he said. “It’s unfair to impose genetic discrimination on sports people.” Dr Bongani Mayosi of Groote Schuur Hospital, who was part of the team responsible for the pre-competition medical assessment for the FIFA under 20 World Cup, said it was important to learn players’ personal and family history, as well as to perform clinical examinations, 12-lead ECG and echocardiography. “Our conclusion was that there are big ethnic variations among different soccer teams and their cardiac risk profiles,” he said. “Clearly Africans are not a homogenous group.”
From space technology to virtual surgeries C
omputer-aided design technology developed by the automotive and aerospace industries in the 1960s, is today being used to develop virtual pre-operative models that allow cardiac surgeons to investigate a variety of different procedures to find the one that will deliver the best results. A pioneer in this relatively new field is thoracic surgeon Dr Tain-Yen Hsias, who yesterday presented a paper entitled Virtual Surgeries in CHD (chronic heart disease) at the 6th World Congress of the Paediatric Cardiology and Cardiac Surgery currently underway in Cape Town. A relatively new innovation, computer modelling is today widely used for a wide variety of applications, ranging from architectural designing, to new cars and tools. “CAD and CAM (Computer Aided Design and Computer Aided Modelling) is ubiquitous in everything we use and wear,” says Dr Hsias. “The power of the computer has allowed us to dream bigger, to use it for virtual surgery.” Although its use was at an early stage in cardiac surgery, it is already being used in oral surgery and for orthopaedics, where it is
By RAY JOSEPH being used to help custom design prosthetics, he says. “It gives us the ability to see form and function, but what we do with it must not only look good, it must also work.” Dr Hsias described the work of a cardiac surgeon as similar to that of a plumber, “making sure the blood flows the right way”. Computer modelling also helped surgeons understand the possible effects of surgery and illustrating multiple variables, and so helping to improve operative and patient outcomes. Using a variety of slides to show different scenarios, he illustrated how powerful a tool computer modelling could become in cardiac surgery by helping surgeons to explore various surgical options to find the best outcomes before a patient goes under the knife. The “big breakthrough” in the use of computer modelling in medicine happened in 1996, says Dr Hsia. It had evolved to where it was now possible to investigate different solutions for complicated total cavopulmonary connection (TCPC) procedures for congenital heart malformations virtually, in order to find the best
Tain-Yen Hsias
solutions before operating. “It helps tremendously with clinical decision making ... a lot of expertise had emerged through this. “We can plug in what we know and we can now compare predictive and real life aspects of surgery,” making modelling a powerful training tool. It was also a powerful training tool that allowed surgeons to be trained in new and complicated procedures. “Making a valve repair look good is easy, making sure it works is trickier. This helps us find the best solutions.”
Medical professionals are using Computer Aided Design (CAD) to help with their procedures
This newsletter was produced by the team at HIPPO. www.hippocommunications.com