1328 and some

On the 22nd of July I posted a blog entitled ‘1328’ – this was the number of days we had been recording (since the opening of Mallard Ward) until the first person experiencing Clostridium difficile was detected amongst our patients.

I had lots of response to that blog, which focused on the impact ‘going back to zero’ had on me and the team.

I thought it appropriate to update those of you who read this blog as to what has happened since then.

Our patient received treatment for the infection, recovered and is now back home.

In the hospital, as part of the assessment to determine why something has gone wrong, we conduct a root-cause analysis (RCA) – specifically for hospital acquired infections within this category – that is usually, C. difficile and MRSA infections, we conduct a more specific investigation called a Post-infection review (PIR).

Our PIR was attended by me, our ward manager, nurse practitioners, matron, the head of infection control and a several others from hospital management and service delivery teams – the focus of the exercise being to determine whether the infection could have been avoided, and, in particular whether there were lapses in treatment or care from which we could learn.

Examples of these lapses could be the doctor prescribing the wrong antibiotic, staff not washing their hands or ensuring a clean environment, not reviewing the antibiotics or other drugs, such as anti-acid treatments which can contribute to increasing the likelihood of infection and other general aspects of care.

Our PIR showed that we did everything that was expected of us – hand washing, prescribing, diagnosing, treating. In other words, there was nothing humanly possible that we the team could have done to avoid our patient contracting the infection – our care was safe, timely, person-centred and consistent with best-practice guidelines.

The outcome of the review was that our patient’s case of C. difficile was ‘unavoidable’.

Within healthcare (at least in the NHS), there is a major focus on avoidable and unavoidable harm. Sure, to the patient who has been harmed, there isn’t much difference – they have a pressure ulcer, fall or infection, but, to the team, to the organisation and likely to the patient and relatives beyond the immediate event, there is a significant difference.

‘Did my dad die because someone didn’t follow policy, didn’t pay attention or, was the outcome inevitable?’ ‘Might my mum have survived the operation if she had a different surgeon or she was at a different hospital?’

It is these heart-breaking questions that relatives sometimes pose the doctors and nurses after something terrible has happened.

In the case of ‘avoidable harm,’ the answer is a possibly maybe, in the case of an ‘unavoidable harm,’ the response is probably not. This can, in some circumstances offer succour, in others not.

It is well established that every day in every hospital patients experience ‘harms’ – it is also very true that virtually all staff go to work with the sole intention of helping, supporting and caring. Things don’t always go that way – for a variety of reasons – some avoidable – whether relating to ‘human factors’ – that is the fallibility that comes with being a human or some other factor such as lack of knowledge, fear of challenging poor practise, limited resources, and so on.

With time and hard work, the amount of harm should reduce, and with this there should be a fall in avoidable harm and any harm that does happen should be unavoidable.

Reflecting on our 1328 days and the impact this had on me, the staff and our patient – going back to zero; on our ‘days since’ sign on the ward we dutifully started counting from zero – it was about 20 days until the review meeting. With the each day, people gained more understanding and acceptance of the new reality and things moved-on; possibly I gained more humility.

After the PIR however some of the staff discussed whether the reversion to zero was necessarily the best thing for our patients and our team. After all, a peer-reviewed meeting had determined that all the care we had provided was excellent, there were no failings or short-comings in the treatment, environment or approach to care.

What was the benefit of going back to zero?

We discussed the semantics of the wording – could we word the sign differently – would this suggest that we were cheating the system, playing games with numbers and data?

We discussed this as a team and this week we raised the issue at our clinical governance meeting – today we even debated the validity of displaying ‘days since’ signs altogether – whether there was a risk of such a reversion to ‘zero’ having a negative impact on staff moral or patient and relative confidence.

The evidence from patient safety literature is clear that the more transparent an organisation, the more it is prepared to bare-all, show the good and the bad, the successes and the failures, the more likely people are to have confidence in the system.

We concluded that a change in the wording from ‘days since’ to ‘days since avoidable’ was reasonable (this is something I have seen used at hospitals across the country), therefore we could come back from zero.

Today, we are therefore at 1374 days since there was a case of avoidable C difficile on Mallard Ward.

What do people think?

To me, the point is, why are we doing this? Why do the staff update the figures daily, consistently; why has safety become a central part of the culture on our ward? Staff connection with patients and their experience of care is fundamental to positive outcomes – when John Donne’s sentiment, ‘no man is an island’ is central to the function of our ward, with each patient and relative and member of staff being part of something bigger than the individual.

When you harm my patient you harm me. Working to protect patients is protecting and maintaining your own wellbeing.

This is the point of the signs, this is the point of sharing the information, this is the point of allowing ourselves to be vulnerable. This is person-centred care – the care I provide is the care I would want provided to me, the experiences of my patients are also mine, the journey we travel is one we share.

This is when care is more than just numbers.

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