A systems science perspective on the capacity for change in public hospitals.

Many types of organisation are difficult to change, mainly due to structural, cultural and contextual barriers. Change in public hospitals is arguably even more problematic than in other types of hospitals, due to features such as structural dysfunctionalities and bureaucracy stemming from being publicly-run institutions. The main goals of this commentary are to bring into focus and highlight the "3 + 3 Decision Framework" proposed by Edwards and Saltman. This aims to help guide policymakers and managers implementing productive change in public hospitals. However, while change from the top is popular, there are powerful front-line clinicians, especially doctors, who can act to counterbalance top-down efforts. Front-line clinicians have cultural characteristics and power that allows them to influence or reject managerial decisions. Clinicians in various lower-level roles can also influence other clinicians to resist or ignore management requirements. The context is further complicated by multi-stakeholder agendas, differing goals, and accumulated inertia. The special status of clinicians, along with other system features of public hospitals, should be factored into efforts to realise major system improvements and progressive change.

Surgical site infection-a population-based study in Australian adults measuring the compliance with and correct timing of appropriate antibiotic prophylaxis.

Prophylaxis for surgical site infection (SSI) is often at variance with guidelines, despite the prevalence of SSI and its associated cost, morbidity, and mortality. The CareTrack Australia study, undertaken by a number of the authors, demonstrated that appropriate care (in line with evidence- or consensus-based guidelines) was provided at 38% of eligible SSI healthcare encounters. Here, we report the indicator-level CareTrack Australia findings for SSI prophylaxis. Indicators were extracted from Australian and international clinical guidelines and ratified by clinical experts. A sample designed to be representative of the Australian population was recruited (n=1154). Participants' medical records were reviewed and analysed for compliance with the five SSI indicators. The main outcome measure was the percentage of eligible healthcare encounters with documented compliance with indicators for appropriate SSI prophylaxis. Of the 35,145 CareTrack Australia encounters, 702 (2%) were eligible for scoring against the SSI indicators. Where antibiotics were recommended, compliance was 49% for contaminated surgery, 57% for clean-contaminated surgery and 85% for surgery involving a prosthesis: these fell to 8%, 10% and 14%, respectively (an average of 11%), when currently recommended timing of antibiotic administration was included. Where antibiotics were not indicated, 72% of patients still received them. SSI prophylaxis in our sample was poor; over two-thirds of patients were given antibiotics, whether indicated or not, mainly at the wrong time. There is a need for national agreement on clinical standards, indicators and tools to guide, document and monitor SSI prophylaxis, with both local and national measures to increase and monitor their uptake.

Lessons from the Australian Patient Safety Foundation: setting up a national patient safety surveillance system--is this the right model?

The evolution of the concepts and processes underpinning the Australian Patient Safety Foundation's systems over the last 15 years are traced. An ideal system should have the following attributes: an independent organisation to coordinate patient safety surveillance; agreed frameworks for patient safety and surveillance systems; common, agreed standards and terminology; a single, clinically useful classification for things that go wrong in health care; a national repository for information covering all of health care from all available sources; mechanisms for setting priorities at local, national and international levels; a just system which caters for the rights of patients, society, and healthcare practitioners and facilities; separate processes for accountability and "systems learnings"; the right to anonymity and legal privilege for reporters; systems for rapid feedback and evidence of action; mechanisms for involving and informing all stakeholders. There are powerful reasons for establishing national systems, for aligning terminology, tools and classification systems internationally, and for rapid dissemination of successful strategies.

Setting priorities for patient safety.

BACKGROUND: Current "flags" for adverse events (AEs) are biased towards those with serious outcomes, potentially leading to failure to address mundane common problems. AIM: To provide a basis for setting priorities to improve patient safety by ranking adverse events by resource consumption as well as by outcome. This was done by classifying a set of AEs, according to how they may be prevented, into "Principal Natural Categories" (PNCs). SETTING: AEs associated with a representative sample of admissions to Australian acute care hospitals. DESIGN: AEs were classified into PNCs which were ranked by overall frequency, an index of resource consumption (a function of mean extended hospital stay and the number of cases in each PNC), and severity of outcome. RESULTS: The 1712 AEs analysed fell into 581 PNCs; only 28% had more than two cases. Most resource use (60%) was by AEs which led to minor disabilities, 36% was by those which led to major disabilities, and 4% by those associated with death. Most of the events with serious outcomes fell into fewer than 50 PNCs; only seven of these PNCs had more than six cases resulting in serious outcomes. CONCLUSIONS: If interventions for AEs are triggered only by serious outcomes by, for example, using recommended risk scoring methods, most problems would not be addressed, particularly the large number of mundane problems which consume the majority of resources. Both serious and mundane problems should be addressed. Most types of events occur too infrequently to be characterised at a hospital level and require large scale (preferably national) collections of incidents and events.

Monitoring in emergency medicine.

Clinical observation is the most valuable monitoring technique we have. Complexity and invasiveness of monitoring increases from prehospital care to Emergency Department, to Anaesthesia and Intensive Care. Many methods of monitoring have specific applications. Non-invasive blood pressure monitoring has no advantages over conventional cuff methods, other than freeing the hands of the operator. Non-invasive cardiac output measurement, transcutaneous oxygen and carbon dioxide measurement are unlikely to play a major role in the foreseeable future in the emergency setting. The most exciting development in recent years has been the widespread availability of pulse oximetry, which allows beat by beat analysis of haemoglobin oxygen saturation.

Uptake and elution of chlormethiazole, meperidine, and minaxolone in the hindquarters of sheep: implications for clearance calculations.

Mass balance principles were used to describe the uptake and elution of chlormethiazole, meperidine, and minaxolone in the hindquarters of sheep. Sheep received a right atrial infusion of either chlormethiazole (3.71 mg/min) or meperidine (2.70 mg/min) for 180 min, or minaxolone (0.37 mg/min) for 120 min. Paired arterial and inferior vena cava (draining the hindquarters) blood samples were taken during and after the infusion. The mean and SD (n = 4) of the time-averaged extraction ratios across the hindquarters (determined from the relevant arterio-venous area under blood concentration--time curves) were 0.12 (0.10), 0.36 (0.13), and 0.27 (0.05) for chlormethiazole, meperidine, and minaxolone, respectively. The rank order of the rate of uptake of the drugs into the hindquarters was the same as the rank order of their lipophilicity, and uptake still continued when both the arterial and inferior vena cava drug concentrations were essentially constant. For chlormethiazole, meperidine, and minaxolone, 48% (44), 4% (6), and 35% (17), respectively, of the drug taken into the hindquarters eluted from the hindquarters after the infusion. Drug uptake and retention in extravisceral tissues, represented here by the hindquarters, can result in the mean total body drug clearance being overestimated when determined by traditional systemic pharmacokinetic methods.

An assessment of methods for sampling blood to characterize rapidly changing blood drug concentrations.

The accuracy of different blood sampling methods used to characterize rapidly changing blood drug concentrations was examined both in vitro and in vivo. It was shown in vitro that blood sampling methods based on the fraction collection principle failed to characterize a "square wave" change in drug concentration, and there was a 9-16-s delay before achieving 95% of the expected drug concentration. Varying the catheter size and length did not improve the response. This observation is consistent with laminar and/or turbulent flow producing dispersion and mixing of blood of different drug concentrations in the catheter. A sampling method (flush and withdrawal) was developed to minimize these effects. In vivo studies showed that peak blood drug concentrations obtained using this method after an iv bolus of a drug were approximately 25-28% higher than those simultaneously obtained by methods based on fraction collection principles. It is concluded that blood sampling methods based on fraction collection principles can produce significant errors in measured blood drug concentrations. The error is greater the greater the rate of change of the blood drug concentrations.

The influence of drug sorption on pharmacokinetic studies of chlormethiazole and lignocaine.

The influence of drug sorption on the measurement of dose and blood concentrations during pharmacokinetic studies of chlormethiazole and lignocaine in a chronically catheterized sheep preparation has been examined. There was no sorption to soda glass tubes, borosilicate glass volumetric flasks or soda glass microlitre syringes but minor sorption to polypropylene syringes, polypropylene pipette tips and rubber bottle stoppers after 240 min contact. During infusions through administration sets including either polyvinyl chloride or polyethylene catheters, no significant loss of lignocaine occurred, but only 41.7-63.9% of the chlormethiazole dose was delivered. No significant decreases in either drug occurred from blood sampled through an intravascular catheter and stopcock system. There was negligible degradation of the samples over 4 h. Sorption of chlormethiazole or lignocaine to the laboratory equipment used was not a significant source of error but polyvinyl chloride infusion catheters could result in significant reductions in chlormethiazole dose.

Physiological and biochemical consequences of electroimobilisation in conscious sheep.

An electroimmobilisation device has been developed to facilitate the automated shearing of sheep, but there is little information on its effects on the body. We have studied its effects on the cardiovascular system and on intermediary metabolism in sheep. Electroimmobilisation caused statistically significant increases in mean arterial pressure, heart rate, cardiac output, renal and hepatic and hindquarter glucose and lactate flux, organ and whole body oxygen flux, hindquarter blood flow and core temperature and decreases in arterial and posterior vena cava blood pH, renal and hepatic blood flow and PaCO2. Notably, no change occurred in PaO2. The metabolic changes demonstrated the capacity of sheep to respond to the increased muscular and cardiovascular work induced by electroimmobilisation. Pulmonary function was not compromised during electroimmobilisation as judged from blood gas changes, and the acid/base changes were rapidly reversed after electroimmobilisation. The recovery to control conditions for all perturbations generally took no longer than 30 min, consistent with a rapid and physiologically adequate reversal by the animal's homeostatic mechanisms.

Equipment to manage a difficult airway during anaesthesia.

Airway complications are a leading cause of morbidity and mortality in anaesthesia. Effective management of a difficult airway requires the timely availability of suitable airway equipment. The Australian and New Zealand College of Anaesthetists has recently developed guidelines for the minimum set of equipment needed for the effective management of an unexpected difficult airway (TG4 [2010] www.anzca.edu.au/resources/professionaldocuments). TG4 [2010] is based on expert consensus, underpinned by wide consultation and an extensive review of the available evidence, which is summarised in a Background Paper (TG4 BP [2010] www.anzca.edu.au/ resources/professional-documents). TG4 [2010] will be reviewed at the end of one year and thereafter every five years or more frequently if necessary. The current paper is reproduced directly from the Background Paper (TG4 BP [2010]).

Measures of patient safety in developing and emerging countries: a review of the literature.

CONTEXT: The World Alliance for Patient Safety was formed to accelerate worldwide research progress towards measurably improving patient safety. Although rates of adverse events have been studied in industrialised countries, little is known about the rates of adverse events in developing and emerging countries. PURPOSE: To review the literature on patient safety issues in developing and emerging countries, to identify patient safety measures presently used in these countries and to propose a method of measurably improving patient safety measurement in these countries. METHODS: Using the Medline database for 1998 to 2007, we identified and reviewed 23 English-language articles that examined patient safety measurement in developing and emerging countries. Results Our review included 12 studies that prospectively measured patient safety and 11 studies that retrospectively measured safety. Two studies used measures of structure and the remaining used process measures, outcome measures or both. Whereas a few studies used surveys or direct observation, most studies used chart audits to measure patient safety. Most studies addressed safety at a single facility. CONCLUSIONS: Investigation of patient safety in developing and emerging countries has been infrequent and limited in scope. Establishing fundamental safe patient practices, integrating those processes into routine health services delivery and developing patients' expectations that such processes be present are necessary prerequisites to measuring and monitoring progress towards safe patient care in emerging and developing countries.

Towards safer, better healthcare: harnessing the natural properties of complex sociotechnical systems.

OBJECTIVES: To sustain an argument that harnessing the natural properties of sociotechnical systems is necessary to promote safer, better healthcare. METHODS: Triangulated analyses of discrete literature sources, particularly drawing on those from mathematics, sociology, marketing science and psychology. RESULTS: Progress involves the use of natural networks and exploiting features such as their scale-free and small world nature, as well as characteristics of group dynamics like natural appeal (stickiness) and propagation (tipping points). The agenda for change should be set by prioritising problems in natural categories, addressed by groups who self select on the basis of their natural interest in the areas in question, and who set clinical standards and develop tools, the use of which should be monitored by peers. This approach will facilitate the evidence-based practice that most agree is now overdue, but which has not yet been realised by the application of conventional methods. CONCLUSION: A key to health system transformation may lie under-recognised under our noses, and involves exploiting the naturally-occurring characteristics of complex systems. Current strategies to address healthcare problems are insufficient. Clinicians work best when their expertise is mobilised, and they flourish in groupings of their own interests and preference. Being invited, empowered and nurtured rather than directed, micro-managed and controlled through a hierarchy is preferable.

Incidents during out-of-hospital patient transportation.

Out-of-hospital patient transportation (retrieval) of critically ill patients occurs within highly complex environments. Adverse events are not uncommon. Incident monitoring provides a means to better understand such events. The aim of this study was to characterize incidents occurring during retrieval to provide a basis for developing corrective strategies. Four organizations contributed 125 reports, documenting 272 incidents; 91% of forms documented incidents as preventable. Incidents related to equipment (37%), patient care (26%), transport operations (11%), interpersonal communication (9%), planning or preparation (9%), retrieval staff (7%) and tasking (2%). Incidents occurred during patient transport to the receiving facility (26%), at patient origin (26%), during patient loading (20%), at the retrieval service base (18%) and receiving facility (9%). Contributing factors were system-based for 54% and human-based for 42%. Haste (7.5%), equipment malfunctioning (7.2%) or missing (5.5%), failure to check (5.8%) and pressure to proceed (5.2%) were the most frequent contributing factors. Harm was documented in 59% of incidents with one death. Minimizing factors were good crew skills/teamwork (42%), checking equipment (17%) and patient (8%), patient monitors (15%), good luck (14%) and good interpersonal communication (4%). Incident monitoring provides sufficient insight into retrieval incidents to be a useful quality improvement tool for retrieval services. Information gathered suggested improvements in retrieval equipment design and use of alternative power sources, the use of pro formae for equipment checking, patient assessment, preparation for transportation and information transfer Lessons from incidents in other areas applicable to retrieval should be linked for analysis with retrieval incidents.

An integrated framework for safety, quality and risk management: an information and incident management system based on a universal patient safety classification.

More needs to be done to improve safety and quality and to manage risks in health care. Existing processes are fragmented and there is no single comprehensive source of information about what goes wrong. An integrated framework for the management of safety, quality and risk is needed, with an information and incident management system based on a universal patient safety classification. The World Alliance for Patient Safety provides a platform for the development of a coherent approach; 43 desirable attributes for such an approach are discussed. An example of an incident management and information system serving a patient safety classification is presented, with a brief account of how and where it is currently used. Any such system is valueless unless it improves safety and quality. Quadruple-loop learning (personal, local, national and international) is proposed with examples of how an exemplar system has been successfully used at the various levels. There is currently an opportunity to "get it right" by international cooperation via the World Health Organization to develop an integrated framework incorporating systems that can accommodate information from all sources, manage and monitor things that go wrong, and allow the worldwide sharing of information and the dissemination of tools for the implementation of strategies which have been shown to work.

Crises in clinical care: an approach to management.

A "crisis" in health care is "the point in the course of a disease at which a decisive change occurs, leading either to recovery or to death". The daunting challenges faced by clinicians when confronted with a crisis are illustrated by a tragic case in which a teenage boy died after a minor surgical procedure. Crises are challenging for reasons which include: presentation with non-specific signs or symptoms, interaction of complex factors, progressive evolution, new situations, "revenge effects", inadequate assistance, and time constraints. In crises, clinicians often experience anxiety- and overload-induced performance degradation, tend to use "frequency gambling", run out of "rules" and have to work from first principles, and are prone to "confirmation bias". The effective management of crises requires formal training, usually simulator-based, and ideally in the inter-professional groups who will need to function as a team. "COVER ABCD-A SWIFT CHECK" is a pre-compiled algorithm which can be applied quickly and effectively to facilitate a systematic and effective response to the wide range of potentially lethal problems which may occur suddenly in anaesthesia. A set of 25 articles describing additional pre-compiled responses collated into a manual for the management of any crisis under anaesthesia has been published electronically as companion papers to this article. This approach to crisis management should be applied to other areas of clinical medicine as well as anaesthesia.

Crisis management during anaesthesia: difficult intubation.

BACKGROUND: Anaesthetists may experience difficulty with intubation unexpectedly which may be associated with difficulty in ventilating the patient. If not well managed, there may be serious consequences for the patient. A simple structured approach to this problem was developed to assist the anaesthetist in this difficult situation. OBJECTIVES: To examine the role of a specific sub-algorithm for the management of difficult intubation. METHODS: The potential performance of a structured approach developed by review of the literature and analysis of each of the relevant incidents among the first 4000 reported to the Australian Incident Monitoring Study (AIMS) was compared with the actual management as reported by the anaesthetists involved. RESULTS: There were 147 reports of difficult intubation capable of analysis among the first 4000 incidents reported to AIMS. The difficulty was unexpected in 52% of cases; major physiological changes occurred in 37% of these cases. Saturation fell below 90% in 22% of cases, oesophageal intubation was reported in 19%, and an emergency transtracheal airway was required in 4% of cases. Obesity and limited neck mobility and mouth opening were the most common anatomical contributing factors. CONCLUSION: The data confirm previously reported failures to predict difficult intubation with existing preoperative clinical tests and suggest an ongoing need to teach a pre-learned strategy to deal with difficult intubation and any associated problem with ventilation. An easy-to-follow structured approach to these problems is outlined. It is recommended that skilled assistance be obtained (preferably another anaesthetist) when difficulty is expected or the patient's cardiorespiratory reserve is low. Patients should be assessed postoperatively to exclude any sequelae and to inform them of the difficulties encountered. These should be clearly documented and appropriate steps taken to warn future anaesthetists.