Regular readers of this blog will be in no doubt that I love the work of a rural doctor – but am not shy to express my frustration with some of the systems within which we are constrained.
Not least is the never-ending onslaught of safety directives from Country Health SA – kind of ironic that barely a week goes by without an email reminder not to inject chlorhexidine into the intrathecal space, to be careful with shoddy Chinese-knock off titanium hip screws and not to mix noxious chemotherapy agents in my consulting room.
But when it comes to meaningful issues, like the complete disinterest of CHSA in tangible risks such as the lack of difficult airway equipment in rural hospitals, the paucity of functioning cardiac monitors locally and the lack of enthusiasm for team-training and use of checklists, there seems to be no direction from top down.
A recent proposal to audit ED intubation in SA rural hospitals – perhaps the most high risk procedure that a rural doctor will do (by default an occasional intubator), has been knocked back as ‘not necessary’.
Meanwhile in-house compulsory ‘morbidity & mortality’ audit by the CHSA-appointed Principal Medical Officer (a non-rural GP who operates out of metro Adelaide) was focussed on – no, not retrieval cases, not near-misses on the wards – but on the proper completion of paperwork for deceased nursing home residents.
The mind boggles. So much for meaningful quality improvement. Yes I know that paperwork is important – but to focus on this area and not the issue of improving quality in how critical illness is managed in rural EDs seems somewhat lacking in vision.
I believe that this is symptomatic of a system that is prepared to measure everything but knows the value of nothing.
So what about the stapler?
Well, I reckon it was about three years ago that the stapler was removed from the doctor’s office at the local hospital.
The reason? Apparently because staples are a safety risk – someone might cut themselves!
Now the only reason I use a stapler is to bind together a wedge of transfer paperwork when sending patients off the Island, either as a rotary-wing retrieval or as a fixed-wing transfer. Bundling together my letter, copies of the in-patient notes and nursing obs plus relevant letters/ECGs/X-rays etc as one parcel should make it easier for this information to be read and retained by the receiving team.
Now there is no stapler. So bits of paper get lost…and patient care suffers if vital information is mislaid.
Yes, I know that I could use a paperclip – but somehow there is never one around. But never mind – we are 100% compliant with a 0% stapler-induced-major haemorrhage death rate amongst the staff. We should be proud…
I find it hard to believe that I can be trusted with sharp scalpels, mind-altering drugs, laryngoscopes and other sharp/pointy/dangerous things – but not a desk stapler.
Somehow I bet there is a stapler in the CHSA CEO’s office…
Tim, I hear you brother.
It is often frustrating to work in a mindless bureaucracy. Tough to change from within. There seem to be endless people employed to do stuff that just doesn’t make any sense.
A good example: We recently had a “VTE risk assessment tool” [a form with boxes to tick] introduced to our place. Good idea, VTE is an important, preventible contributor to M&M.
But – the form is purely a risk tick form, no clear direction as to how to use the data once collected. Who to clexanate etc….
Then the clincher – we were audited. Good, are we using this tool and making a difference…. ah, no the audit only looked at wether or not the form was completed correctly. No mention of if appropriate therapy utilised or if there were any patient-oriented outcomes we achieved or did not!
We need to have an Atul Gawande to pull our socks up and show how simple interventions can save lives
But efforts seemed to be fixated on stationery and outcomes that just don’t matter to our patients.
FYI _ I did get a nasty paper cut from one of the forms I was incorrectly completing.
C
Casey are you making up new words again??
“clexanate”
why not clexanise, clexanation, clexaning, clexaned
It does flow better than enoxaparinate – sounds fatal!!!
Mark Raines
Paper cut?
I hope you are dosed up on TXA…
Haha I loved it Tim! In Camperdown (2000 people, 1.5hrs from big hosp) I fought the ENTIRE YEAR to buy a slightly different iSTAT (4+ instead of 3+) so we could do a lactate on our abdominal pain patients.
Simple enough request you think? I think I’d do better pulling teeth (and my patients often seem to think I’m a dentist anyway…).
Anyways, love the stapler metaphor – somewhere, sometime, something went wrong with managing risk? Removing a stapler is as easy as emailing all docs to remove them… training us in proper intubation technique, creating transfer protocols, streamlining our access to tertiary specialists and not having to talk to registrars who think we are idiots… these are too complicated.
Back to emailing about removing pencils from ED, the lead might poison a child who eats 50 of them…
PS. I know lead pencils are graphite – just thought I’d get in there before someone pedantic pulled me on it 😉
So it’s not just me then!
Any more examples?
More importantly, how to fix these mind-numbing bureaucratic impediments to bringing ‘quality care, out there’?
I feel your pain!
As a student in a small urban hospital in NSW I remember being deeply ashamed that the geriatric ward was unable to supply a box of tissues to a weeping patient as it was “too expensive” yet someone in OH&S had been able to spend the time and effort to produce a multi-page document delineating the proper usage and safety risks associated with using the fax machine.
… And the big risk that needed time, effort and printing costs to make sure all who used the fax were well warned?… Getting one’s finger caught in the paper feed!
That is shameful.
No tissues for a teary patient? But a multipage document to state the bleedin’ obvious?
Shameful, just shameful