KEN HILLMAN. Patient safety, a new perspective.

Patient safety in acute hospitals is often described in limited terms such as infection rates and pressure areas without considering that many people gain little or no benefit from being admitted there in the first place. We also ignore the impact on patient safety when management make decisions such as closing hospital wards, prolonging waiting lists and reducing front line health care delivery.

It is nearly 30 years since the first major publications on the high incidence of potentially avoidable complications in acute hospitals.  Since then, there has been a rapid growth in the patient safety industry.  Every hospital has staff devoted to ensuring patient safety.  Much research has been conducted; conferences are held all around the world; organisations have been established; countries have their own systems of accreditation and many books have been written by gurus in the field.  While there have been countless articles describing the problem, there is little evidence that any interventions have been rigorously shown to reduce serious adverse events.

We have tended to concentrate on complications in acute hospitals without examining possible causes. There is now rigorous testing of new drugs and interventions to ensure their safety before they are approved for use in patient care. This is part of the movement to ensure that whatever we do to improve and maintain safe patient care has a sound basis – so-called Evidence Based Medicine. At the same time, sweeping changes can be imposed by government and health managers without any evidence on the harm it may cause, nor any evidence on how patient safety will be improved. For example, front line staff can be reduced while the layers of bureaucracy are increased; wards can be closed; operating times reduced; expensive IT systems can be introduced without any evidence that patients will be safer; and the latest business models introduced at great cost with little or no evidence and no evaluation after they have been introduced. Is it safe to reduce front line staff? What effect has delaying elective surgery on the suffering of patients? What happens to patient care when the IT system goes down or when the system is inappropriate for use by clinicians delivering care?

And how safe is it for patients to be admitted to acute hospitals when they offer little or no benefit to patients? The population of patients has changed radically over the last 30 years.  They are now older with multiple chronic conditions.  And yet our medical system still assumes that the patient population has remained young with a single, potentially treatable illness which can be managed by a specialist in that area. The elderly frail population collect chronic health conditions as they age.  While these conditions may lend themselves to modifications by various interventions, they are also progressive, largely irreversible and a normal part of ageing. What complications do patients suffer in hospitals when it is not explained that the admission will have little or no impact on their health?

It is the increasing impact of the age-related deterioration that makes the elderly prone to admission to hospital with conditions such as infections and falls.  It is also the sum of the underlying chronic conditions and increasing frailty that determine the outcome of the patient, both in the hospital and after discharge.  The underlying chronic conditions become markers of an elderly frail person’s state of health, rather than diseases that can be cured.

Can these people be safely managed in acute hospitals?  There is abundant data to suggest that hospitals are dangerous and inappropriate for elderly patients and, indeed, for other patients having unnecessary and unproven interventions. The normal and anticipated age-related deterioration in the elderly has become medicalised. They are rarely identified as people where the miracles of modern medicine will have little impact on their overall health.  Surprisingly, it is rare that the system has an honest and empathetic discussion with them about the limitations of medicine and the potential dangers of hospital admissions. Most elderly Australians will spend their last few days of life in acute hospitals even though the hospital has little or nothing to offer.  In fact, many are discharged from the hospital in worse health. Ironically, given the choice and a clear explanation, most elderly people would rather stay at home.

There are now ways of determining prognosis and trajectories of illness in the elderly as a basis for conducting these conversations. So why don’t we use them? To ensure that patients are safe and not inappropriately admitted to acute hospitals, we need to know whether information about their clinical state and future health is discussed with them. We need to know how many were empowered to determine their own goals of care and whether they wished to be continually admitted to acute hospitals, when they have little to offer.  If they choose to be managed in the community, we need to know whether there were appropriate resources to ensure they were safely cared for. For those who were admitted to an acute hospital, we need to know not just whether they were discharged alive but what was the long-term impact of the hospital admission on their quality of life and whether they would have chosen, in retrospect, not to have undergone hospitalisation.

To ensure maximum patient safety, the information on all aspects of patient safety needs to be available to those who can effect change. This currently does not happen. The managers of health care are largely driven by the imperatives of cost and avoiding adverse publicity. Many of the resources in running health care are devoted to these imperatives. Decisions based on cost cutting need to be based on evidence of risks and benefits. Evidence Based Management is currently not part of the health business. It may be that, by putting patient care and safety first, costs would be reduced and adverse publicity avoided.

Information which puts hospitals in a bad light is currently censored. And yet, in order to drive change and improve the safety of patients, those working in the system need to be aware of the weak points and be empowered to effect change. For example, we need to know which people are being admitted inappropriately to acute hospitals without discussing the high risks and the limited benefit with them. The risks and benefits need to be measured as an important patient safety indicator and shared with those who can effect change. Most importantly, society needs to be empowered to make its own choices and how people can be better informed in order to make those choices.

Ken Hillman  AO is an actively practising intensive care clinician who is also a researcher employed by the UNSW. He has published widely in areas such as patient safety and more appropriate end of life care He has recently published a book, A Good Life to the End, covering areas such as ageing, how to choose a good doctor, advance care planning and more appropriate care for the elderly.

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2 Responses to KEN HILLMAN. Patient safety, a new perspective.

  1. Ian Webster says:

    Ken, a great paper as usual from your real experience at the front-line in public hospitals.

    Add to the litany of management decisions and practices which need to be evaluated for their impact on patient outcomes – time spent by front-line clinicians (20% to 50% of their time) filling in forms and codifying events to protect the organisation rather than provide patient care, cuts in cleaning staff, cuts in hospital porters and cuts in the clinical and support staff who deal with the problems no-one else wants to deal with – alcohol and drug addiction, chronic disabling conditions such as pain and dementia, troublesome young people and the homeless.

    The ‘safety industry’, which you describe so well, picks off the ‘low lying fruit’ that captures the headlines but does not deal with the bedrock which keep the system working.

  2. Mary Tehan says:

    Thank you for highlighting some of the shortfalls of the “managed care” system we currently have here in Australia. The choice between acute hospital and home care and which setting is better for elderly patients is a worthy conversation to have. The issue of safety, even if it is implemented through the lens of EBM, can fall (pardon the pun!) between the cracks of community expectations and constraints in the healthcare system as a whole (across settings). Some things like whether that person lives alone or not, if there is family, neighbour or carer support available or not, denial or awareness of increasing inter-dependency or dependency on others, financial considerations, geographical distance from ANY available healthcare clinicians, and unrealistic patient and/or family expectations can all contribute to admission to hospital as part of the process of increasing awareness of morbidity and/or mortality … regardless of the healthcare need attempting to be addressed on any particular hospital admission/s. My unmarried aunt was admitted to hospital 11 times before she came to realise that the community healthcare system couldn’t meet her expectations of continuing to be cared for at home. Just prior to her last admission to hospital she was having up to 14 visits per day by a plethora of healthcare professionals and local council support services (e.g. RNs x 4 times per day to administer eye drops; ADL support services x 2 etc etc)! Part of the struggle for family and carers at home is when to draw the line in offering and providing support in order for the ageing or ill person to become aware of their reality within everyone’s limitations as part of the human condition, whilst at the same time not being negligent. Safety is front of mind for everyone but it needs to be within realistic limits.

    The questions that healthcare professionals ask people in their homes in order to assess their capacity to continue to live there also needs updating … but that’s another part of the story for another time.

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