Flying Safely in Hospitals

How safe do you feel when you fly? Are you one of the white knuckle brigade? Do you have a personal sedative regime? Or are you able to kick back, relax and sift through the plethora of movies you’d only burn your retinas with when strapped in an airborne metal tube?

Whatever your personal phobias most passengers can see the efforts taken to ensure a safe flying experience. Which flyer doesn’t know by now that you leave the kids to flail for oxygen for a bit and look after yourself first after witnessing the all-too-familiar safety demo? Behind the choreographed routine that can be put to good use in a nightclub, there’s a really serious attitude to safety. It’s an attitude that people in health often point to as an example that they follow. Well, I work with aviators and next time you hear anyone say they’ve learnt all the lessons from aviation, put your wallet away before they try to sell you a large architectural landmark on the harbour.

Cruise Control on the Wards

Mistakes in hospitals aren’t just fodder for the tragically inept inhabitants of a medical soap. They are a very serious business. This week, NPR covered a recent publication from the Journal of Patient Safety (and thanks to @MelissaLDavey for that one) revising estimates of the number of deaths that mistakes in hospitals contribute to in the US – the study suggests it may be between 210000-440000 each year (previous estimates dating back to 1998 had it at 98000). If accurate, medical mistakes would be the 3rd most common cause of death in the US – behind only heart disease and cancer. It’s the equivalent of more than two Airbus A380 airliners plunging from the skies every day across the US.

It’s a matter for Australian hospitals as well. Improving safety would be one of the most effective ways of improving health outcomes from hospital care. Focus has been placed on this and aviation safety practices all too frequently get trotted out as inspiration. The problem with this isn’t that aviation practice isn’t worth modelling. The thing is that aviation safety is a comprehensive program. All too often, those working on the hospital safety blanket are taking a couple of patches from the flight experience and hoping that’ll cover enough of the old holes and make it just pretty enough.

The Whole System

All too often in my experience in healthcare people refer to lessons from aviation when talking about individual elements. They’ll trumpet simulation “like pilots do”. Or they’ll mention “managing resources” like in an aviation emergency. It plays like someone has decided to “Like” the Air Crash Investigations Facebook page and glean what they can from the conversation.

What we should learn from aviation is that you can’t just do 50% of the job. Aviation as an industry started wrestling with the problem decades ago and has evolved a system that looks across the whole set-up.

Here’s the quick version – initially the assumption was that crashes happened because technology messed up, or individuals made mistakes. Over time it became apparent that you couldn’t address issues in an isolated fashion. You need to look at every step of the chain.

So aviation safety doesn’t just focus on the way the aircraft is built or the maintenance. It doesn’t stop with the crew training and simulation. It looks at skills maintenance, communication patterns between crew members of all levels, personal and interpersonal factors affecting how the crew responds and individual thought processing in crises. And it looks beyond the flight. It looks at control systems and industrial pressures that might influence how crew members respond in any situation. It goes on and on.

The key thing is that it is taken seriously. The time and effort make this clear.

Safety At The Frontline Needs People In The Background

This is where health systems have a long way to go, and where they can’t even be classed as “Aviation-Lite”. Now, clever bloggers include things like graphs with equations and stuff. This blog has been remiss in not providing graphs so I’ve tried to address this flaw.

This graph absolutely doesn't reflect a reality where safety has received steady resources and resulted in increased awesomeness. [via www.gcse.com]

This graph absolutely doesn’t reflect a reality where safety has received steady resources and resulted in increased awesomeness. [via http://www.gcse.com]

Hospital safety has not received steady and unrelenting support. I couldn’t find a graph that properly depicted the concept of “piecemeal”.

All too often what we see is isolated initiatives. So we hear that someone is now doing simulation training. But the simulation training doesn’t incorporate whole teams that actually work together. Or comprehensive communication training so all team members feel free to contribute. Or even repetition of the scenario training on a regular basis.

Or we introduce safer working hours without extra staff to make sure adequate senior cover is part of those hours. Then we forget to train everyone as to how to conduct handover in a fashion that will minimise vital information being missed.

What is most likely the case is that those interested in hospital safety understand how comprehensive the approach should be, but don’t get the backup to do it. Because safety is just another example where the frontline staff, like the aviation crew, need support behind the scenes.

This is not a novel idea and has been eloquently addressed in slightly different settings by Prof Tarun Weeramanthri writing for Croakey and the excellent Julie Leask.  Denigrating anyone who isn’t part of the “frontline” is a popular chant for politicians at the moment. You can see a recent version of this “no frontline cuts” mantra from the new federal health minister here. No doubt some bureaucracy is worthy of review but people with clipboards actually matter. Each time a bureaucrat is axed, it’s just possible a public health fairy loses its wings.

There are people trying to address hospital safety and they’re not just the ones wearing stethoscopes or uniforms. They need proper resources to address this little thing that’s been identified as the 3rd biggest killer in the US. Without taking it seriously enough, the hospital version of aviation is going to look an awful lot like a movie they won’t show on a plane – Flying High. 

The Oh-So-Sleepy Doctor

When you’re meeting a kid you’re about to anaesthetise, the first couple of minutes are a pretty important determinant of how the rest of your interaction will go.  Plenty of those kids are fairly stressed. I suspect more than a few are waiting to meet this guy.

Actually those scrubs would have some advantages

Actually those scrubs would have some advantages

So if you find something that works you tend to stick with it. Which is why I often introduce myself as “the sleepy doctor (because, you know, saying anaesthetist 10 times a day just gets tiring).” Sounds like the lamest of Dad jokes (it is) but trust me, it kills in the under 10 set. Any parents nearby get to fling back an equally inane remark about hoping it’s not me who’ll be doing the sleeping and we’re away.

It came to mind when I was reading another airing of the doctors and fatigue issue in the BMJ the other day (helpfully passed on by the excellent Dr Mel Thomson who mustn’t be busy enough with maggots).  As it’s behind a paywall, the pdf is right here if you want it (Doc Fatigue).

It raises a few well-worn arguments and casts about a few lazy analogies and stereotypes, all while suggesting people don’t take fatigue seriously enough in medicine. It’s fair to say that opening an article with a fiery plane crash and closing with allusions to lessons “bought in blood” provides bookends to a not entirely balanced comment piece.

Fatigue and Sharp Objects

Fatigue is well known to impair your fine motor skills and reasoning abilities, along with a bunch of other quite relevant mental faculties hopefully employed by medicos. Anyone who has pulled an all-nighter for an assignment or tried to reconstruct the superlogical planning you came up with at 4 a.m. when you’re still up at 10 a.m. could attest to that.

So you’d think it’s self evident that anything contributing to fatigue should be stamped out when you’re trusting people to handle pointy things or deal with stuff most people value. Like their life, for example.

Acting on the potential risks of fatigue is not necessarily simple though. Have you seen the evidence that teenagers require different sleeping patterns? Or that they perform better at school if you start a bit later? Or that teens are involved in fewer traffic accidents if school starts later? No one seems to be marching the streets though. Perhaps they’re waiting for more evidence. Perhaps everyone is still wrestling with the changes across society that would be necessary to facilitate a shift in school start times. Either way, it’s another example that wrestling with a response to fatigue is no easy thing.

Note the time efficient use of the commute for sleep AND yoga. [via the chive.com]

Note the time efficient use of the commute for sleep AND yoga. [via the chive.com]

Sleep is Just a Baby

The study of sleep and fatigue is still in its infancy. It’s not that long ago that sleep was thought to be a time when not much happened. This might explain why there is precious little evidence demonstrating directly that patients do suffer ill effects from doctors being fatigued. There is enough out there that various bodies have been trying to modify factors like work hours to produce change, as much as the writer of the above article might like to say it is “on the fringes”.

In Australia, the Australian Medical Association launched the Safe Working Hours campaign in earnest in 2002. Change has been produced, although audits show some of the hours worked are still excessive. The European Working Time Directive aims to produce similar change.  In my experience, most clinicians support this stuff, unlike the article’s Surgeosaurus (the dinosaur famed for its grumpy belittling of junior staff and fondness for white coats I assume). That doesn’t mean there aren’t reasonable concerns to raise with the way changes are implemented.

The Many Sides to Safety

We know that the number of adverse events in hospitals that could have been prevented are horrifying , but not really the specific role of fatigue within that mix. So it would be good to start with more rigorous research in that area. To lampoon anyone raising concerns about the focus on hours alone misses the point entirely.

I’d be happy to dismiss the concern that reducing exposure to the real world of hospital medicine leads to less experienced doctors. It’s not that difficult to see that time spent in the hospital working at the intellectual level of gutter sludge on the 35th hour of a shift is probably not productive clinical experience anyway. The extra duration of training required to offset these changes would be pursued by those working in subspecialties regardless.

The real issue is with adequate resourcing of safe working hours. If you’re going to change a roster so that doctors aren’t working prolonged shifts, you have options. One is to increase your staffing considerably so that a similar experience mix is still in the hospital. This also provides junior staff with vital senior support.

The other option is to bump up your staffing a little (mostly with junior doctors), make shifts shorter (but with more requirement to hand over care between shifts, a known issue in patient safety) and  introduce long weeks of night shifts that last up to 12 hours (a little like trying to impose a sudden reversal in sleeping patterns analogous to jet lag). Which practice would you think is more common in a cash restricted environment?

So it is worth looking closely at whether the way we’ve introduced reduced working hours for doctors has actually achieved its goals. The questions should be whether fatigue has actually been reduced, doctors are still trained well and patients are actually safer.

Captain Safety

Pointing to all things aeronautical is another lazy line to run. There are some archaic attitudes out there in medicine. There is absolutely a need to accept that fatigue matters. It’s also true that aviators can teach us a thing or two.

The writer dodges an essential issue though. The aviation industry hasn’t just addressed the attitude, they’ve addressed the whole system and accepted the cost of solutions.

Hospitals are not resourced to provide long hours of 1:1 tuition for every practitioner. They are not resourced to allow teams to debrief every job. They are not funded to incorporate team-based training and simulation training in the weekly routine. Staff movement and turnover is much higher. Handover of patients and tasks occurs in large teams, not small ones. And the hospital is only a small part of how the whole issue of safety is valued by the administrations running them and overseeing them.

Safety Clickbait

By all means, raise fatigue as an issue. But if all you’re going to do is dirty up  your hands and finger paint caricatures to discuss it, then what’s the point? It turns out that improving safety isn’t as simple as sharing anecdotes and telling doctors to go and have a nap.

The writer could have chosen to talk about the need to look at the whole system, fund safety initiatives properly and monitor results. Or would that have been too much like rational discourse, rather than the clickbait I so clearly fell for?