Providing courage, balance and humanity in the emergency services

Nacho Vallejo
 

@varelalaf

Urgency is a unique environment in healthcare. It works intending to deal with situations that can put the person's life at risk, but it’s also a "safety net" or, as we have defined it on some occasion in this blog, "a refugee camp of the health system". The care for people in this field of health isn’t only due to pathological and physiological disorders, but sometimes those who go to the emergency room do so as a consequence of dysfunction of our healthcare system that manifests itself with "collateral damage" derived from poor accessibility and, in other cases, from an excess of activity.

Centralisation of complex surgery: clear, obscure and proposals

@varelalaf

A large group of European and North American surgeons have published in Annals of Surgery a review of the difficulties of centralising complex surgery around the world. The complex issue has multiple actors, starting with governments and respective funding models and continuing by the hospitals, the doctors involved and their corresponding scientific societies. It is surprising, however, that patients rarely appear in such discussions.

Medicine based on customs

@varelalaf

The universe of my childhood was full of incontestable rules; most of them had to do with the precepts of religion, although the matter affected all aspects of daily life. I remember that you could not bathe in the sea or in the pool if you had eaten or drank within a minimum period of two hours, a period that the strictest families extended to three. When you were a teenager and you protested, the parents told you all kinds of calamities that could happen to you if you failed to comply with the rule, according to a lot of legends that were passed down from generation to generation.

Surgery and the elderly

@varelalaf

More and more elderly people are being seen in the operating room, especially for large joint replacement interventions, for colorectal cancer resections or for vascular pathologies, to cite the most frequent casuistry. Many of these actions are aggressive and generate risks of postoperative complications, which often require catheters, serum, transfusions, intubations, etc. Therefore, a lot of clinical circumstances are generated that induce immobilization, a situation that adds a new chain of risks, especially thromboembolism, bedsores, infections, disorientation, delusions, malnutrition and dehydration.

The urgencies and the elderly

Reflections (and proposal) in the face of the impending winter emergency crisis

@varelalaf

If nothing is done, vulnerable people will increasingly go to the emergency room because of their multi-pathology, the presence of certain symptoms that are difficult to manage from home or the problems of their environment, they call 061 increasingly often. And that is how hospital emergency services become refugee camps within health systems. A clinical trial conducted in 24 French hospitals, which included more than three thousand people over 75 years of age in a clinically critical situation, showed that the centres most likely to enter older people in critical units, in addition to not reducing their long-term mortality term, neither improved their functional capacity or their quality of life.

Coronary Bypass and Hemodynamics: the amount matters

In the article "Comparing hospital performance within and across countries: an illustrative study of coronary artery bypass graft surgery in England and Spain", signed by a Spanish-English team in which Sandra García Armesto (IACS) and Enrique Bernal (REDISSEC) participated, it was concluded that the Spanish hospitals of the study operated in general with a smaller number of cases than the English (it was coronary bypass). Therefore, it is suggested that the number of cases intervened should be a tracer that could explain why mortality from this process is twice as high in Spain as in England.

European Collaboration for Healthcare Optimization (ECHO) is a European network of administrative databases for the analysis of clinical practice variations. In the following article: "Hospital Surgical Volumes and Mortality after Coronary Artery Bypass Grafting: Using International Comparisons to Determine Safe Threshold", carried out by almost the same authors as the previous one, based on data from the ECHO project, confirms that for interventions of coronary bypass there is a clear relationship between volume and mortality and concludes that the minimum limit of interventions of a cardiac surgery team, if you want to safeguard the safety of patients, should be 415 per year. In the following graph (from the previous article) it is observed how the Spanish hospitals that participated in the study (dark spots), generally underwent fewer coronary bypasses (many did not reach 200) and showed greater mortalities.

The English surgeon, talking about Henry Marsh

Not too long ago, after having read his book "Surgery, the ultimate placebo", I wrote about Ian Harris, an Australian traumatologist. I remember that Harris defends the rigor in the surgical indications after having observed that more than half of the surgery that is practiced does not have enough support of consistent scientific evidence. Now I have finished the book "Do no harm", by Henry Marsh, an English neurosurgeon at the lintel of retirement, and I am inevitably immersed in the comparison between the two texts: first, Harris's, is written by someone who loves surgery and believes that too often is practiced with little rigor, while the second, Marsh’s, is a biography of great literary level, elaborated from the notes that the surgeon has been taking throughout his career, not in vain has he received several recognitions. Marsh, like Harris, is passionate about his work, but his literary contribution comes not from scientific exaltation but from the knowledge he has accumulated from his own mistakes. The veteran English neurosurgeon has not published any revealing research nor has he led any innovative discovery. His honesty and his hands are his strength.

Inappropriate use of large healthcare structures

The healthcare system has many resources that can be used appropriately, or not. Think of the child with fever who leaves the paediatrician’s office with a prescription of antibiotics, the elderly lady who ends her days in an intensive bed, when, in their case, a palliative action would have been more appropriate or the person with a moderate headache, without other neurological manifestations, which, by insistence, ends up undergoing a tomography. George Halvorson, in "Health care will not reform itself", echoes an investigation that, after reviewing 5 million medical records, concluded that waste due to clinical practices that don’t add value could be considered to reach at least 25% of the total health expenditure.

This waste affects practically all areas of healthcare, but now I would like to focus on what happens with the inadequacy of the use of large health structures: operating theaters, emergencies units, intensive care units, wards and primary care.

Experience versus evidence, regarding Ian Harris

Professor Ian Harris, author of the book, "Surgery, the ultimate placebo", is a traumatologist who directs a research unit focused on the results of surgical practice in Sydney. Harris says in the book's introduction: "Lack of evidence allows surgeons to practice techniques for the simple reason that they have always been done, because they learned them from their mentors, because they are convinced that it works or simply because it does everybody. It's easier to have no problems if you behave like most colleagues, my argument, says the author, is that trusting tradition and perceptions often leads, in terms of clinical effectiveness, to unconvincing results."

Fast-track surgery. A new revolution after laparoscopy?

In the 90s, two different groups of surgical professionals developed new strategies aimed at improving the postoperative outcome of colon or rectal surgery patients. On the one hand, a group led by Dr. Kehlet from Scotland proposed different measures pre and post operatory while in Cleveland, another group led by Dr. Delaney focused his studies on postoperative models of introduction of an oral diet and early mobilization. Note that these new guidelines were not based on innovative technologies, but what they wanted was to simply lessen the suffering of the sick taking care to accomplish a combination of essential elements: better informed patients on the overall process, stress reduction, decreased pain, exercise as soon as possible, etc (Kehlet 1997).

In 2001, the same Dr. Kehlet led the group ERAS (Enhanced Recovery After Surgery), which coordinated several units of colo-rectal surgery in the Nordic European countries. ERAS developed 17 strategies, all evidence based with the intent to promote activities ranging from the politics of patient’ preparation to the process’ evaluation and outcomes (Fearon 2005).

Subsequently several systematic reviews and a meta-analysis have demonstrated the success of the ERAS program, also known as fast-track multimodal rehabilitation or (multimodal rehabilitation), which managed to obtain a significant reduction in the average hospital stay without increasing readmissions (Varadhan 2010).

"The Surgical Signature" and how the patients can influence the overtreatment

In his latest book, Tracking Medicine, presented in the first post of this blog, Wennberg says that it’s possible to recognize a hospital by their rates of interventions profile (population-based) from a small handful of surgical procedures. And he demonstrates it with the following graph:

The analysis of the 5 selected areas in this 1975 work shows the profile of five surgical procedures ("The Surgical Signature") of each of them. So you can see that the men of Portland have the highest probability of the series to be undergoing prostatectomy (50% above the average), while citizens of the same Portland, in general, have the lower odds of having haemorrhoidectomy (40% below the average), Lewiston women face the highest rates of hysterectomy (60% above), in Augusta the average varicose extractions doubles, Waterville is the champion in operating haemorrhoids (nearly triples average) and finally the Bangor area is only notable for having the lowest rates of prostatectomy’s series.

The paper concludes that variations in the use of surgical resources are observed not only in comparisons between systems (see previous post) but also, the phenomenon has a land mark that does not correspond with the socio-demographic characteristics (which are adjusted) nor with the prevalence of diseases susceptible to surgical intervention.

Preference sensitive health care: the causes of variations

There is a case-mix part (25% according to Wennberg) such as inguinal hernia, cataracts, metrorrhagia or knee osteoarthritis, for which modern medicine has an effective surgical response, although in the application of the technique there is often a margin for the doctor’s interpretation, another margin for the subjectivity of the patient, such as pain perception or adaptation to the lack of visual acuity, as well as a very important factor: the decision of the patient himself. There are men who prefer to wear a brace to hernia surgery and women who prefer to live with their uterus, provided that the degree of the discomfort and metrorrhagy allows them to.

After this introduction, let’s see the Variations in Health Care, the good, the bad and the inexplicable report by John Appleby and his collaborators, published by King's Fund in 2011, which states that variations in hospitalization rates are pervasive and persistent, and even affect common interventions known to be effective such as hip replacement for advanced osteoarthritis cases.

                Distribution rates of hip replacement in England 2009/10