Patient care is being compromised by poor communication within healthcare teams and with patients, according to the National Confidential Enquiry into Patient Outcome and Death.
Poor communication in hospitals within healthcare teams and with patients and their carers is a serious and recurring problem that is compromising the care of patients, particularly people nearing the end of their life, according to a survey from the National Confidential Enquiry into Patient Outcome and Death (NCEPOD). Deaths in Acute Hospitals: Caring to the End? reviewed the care of over 3,000 patients of all ages who died within four days of admission to hospital. According to the report, over 60% received good medical care but a third of patients did not. The reviewers found that half of the patients in the survey were not expected to survive, and also found evidence that healthcare professionals fail to make the judgement that patients are approaching the end of their life. This means that they fail to implement appropriate end of life care,” report author, Dr David Mason, pointed out. The report found that, following the admission of patients in an emergency or urgent setting, there is often no formal assessment of co-morbidities. Many, otherwise remediable, medical conditions go uncorrected, problems are overlooked, surgical complication rates are high and deaths occur despite the best anaesthetic, surgical and medical expertise available. The authors pointed out that much can be done to pre-empt such problems but this requires good planning and service, as well as a team that functions in a coordinated manner. They emphasised that continuity of care and an understanding of the case throughout the patient’s hospital stay must be assured. According to NCEPOD, change in the hospital team structure over recent years has seen individual clinicians become “transient acquaintances during a patient’s illness” rather than having responsibility for continuity of care. In its opening statement, the enquiry team was particularly critical of staffing arrangements and shift working, which it described as “disruptive” and predicted that, with the implementation of the European Working Time Directive, this disruption is likely to continue and to impact on the training of tomorrow’s doctors. Advisors undertaking the peer review of cases identified a number of recurring themes:
• Poor communication and team working. • Lack of multidisciplinary care. • Poor end of life care planning. • Lack of involvement of palliative care teams. • Inadequate consent. • Deficiencies in diagnosis. • Delay in assessment and treatment. • Poor fluid and electrolyte management. • Failure to recognise or manage malnourishment. • Poor documentation. • Failure to adapt level of care to health status of the patient. • Failure of audit and critical incident reporting. • Neglect of deep vein thrombosis and antibiotic prophylaxis.
Some of the report’s main findings are outlined below.
Process of care following admission
NCEPOD found that consultant involvement in assessment and diagnosis became less frequent in the evenings and at night time, when the diagnosis was made by foundation doctors and SHOs in 25% of cases. NCEPOD advisors acknowledged that in some specialties this may be appropriate, but pointed out that many of the emergency patients had complex conditions requiring urgent senior input. In a quarter of cases there was, in the view of the advisors, a clinically important delay in the first review by a consultant. Poor communication between and within clinical teams was identified by the advisors as an important issue in 13.5% of cases and poor documentation was commonplace. The authors said that this hinders effective communication between team members and makes the subsequent assessment and audit of care difficult. They added that the seniority of clinical staff assessing a patient and making a diagnosis should be determined by the clinical needs of the patient, and not the time of day. Services should be organised to ensure that patients have access to consultants whenever they are required. They added that organisation of services will vary from specialty to specialty, but the benefits and risks to patient safety of reduced working hours should be fully assessed, and clinical teams must be organised to ensure that there is continuity of care.
The NCEPOD authors expressed concern that a total of 182 patients did not have all the essential investigations performed. Some 5% of patients encountered a delay. However, 96% of patients who underwent a radiological investigation had all the appropriate radiological investigations performed, although access to CT scanning and MRI scanning remains a substantial problem – with many sites having no or limited (<24hours) on-site provision. Only 150/297 hospitals have on-site angiography (noncardiac) and of these only 76 have 24-hour access. NCEPOD said that hospitals which admit patients as an emergency must have access to plain radiology and CT scanning 24 hours per day, with immediate reporting. There should be robust mechanisms to ensure communication of critical, urgent or unexpected radiological findings in line with guidance issued by the Royal College of Radiologists. In addition, diagnostic and interventional radiology services should be adequately resourced to support the 24-hour needs of their clinicians and patients.
The NCEPOD advisors found there was lack of involvement of trainees in emergency surgery in a supervised learning environment. In addition, there was a lack of communication both between different grades of doctors within clinical teams, and between different clinical teams and other healthcare professionals. There was a poor standard of record keeping and the authors of the report pointed out that good legible records, and co-ordinated handovers are essential if good communication between team members is to be established. Once again, out of hours was identified as a problem area. There were instances of poor decision making and lack of senior input, particularly in the evenings and night time. Of particular concern was the fact some of the basic aspects of clinical care continue to be neglected – such as the monitoring, recording and management of fluid balance in the elderly and those with multiple co-morbidities. In the specialty of cardiothoracic surgery, for example, the NCEPOD team highlighted the case of a middle aged patient who presented with an acute dissection of the thoracic aorta. Discussion took place between a cardiothoracic and a cardiology specialist registrar without direct consultant input. A decision was taken to deny surgery but admit to a coronary care unit for medical management despite the fact that any prospect of survival without surgery was remote and despite the fact that there were no particular co-morbidities to contra-indicate surgery. The patient deteriorated over the next 12 hours with more pain despite reasonable blood pressure control. There was no re-referral to the surgeons. The patient had a cardiac arrest and died. The advisors questioned whether there was optimal team working between cardiology and cardiothoracic surgery and stated that there should have been involvement by consultants in the decision making process.
Positive findings of the report in relation to anaesthesia included:
• 68.8% of patients had documented pre-operative assessment. • 91.5% of cases had co-morbidities that were managed adequately in the pre-operative period. • 95.8% of these sick patients were anaesthetised by an anaesthetist of the appropriate grade for their condition. • 89% of patients had their temperature managed actively during the operative period.
However, the report also highlighted room for improvement. In particular, trainees and associate specialist anaesthetists frequently did not record the consultant to whom they were responsible. NCEPOD made the following recommendations:
• Anaesthetic charts should routinely have a section that allows the recording of anaesthetic information (leaflets received, risks etc.) given to patients. • Anaesthetic charts should record the named consultant and the grade of the anaesthetist anaesthetising the patient. • All trainees and staff and associate specialist grades should record the name and location of a supervising consultant and whether they have discussed the case with that consultant.
Patients admitted under a surgeon appeared to be more likely to receive venous thromboembolism prophylaxis. Nevertheless, only 55% of patients admitted under a surgeon and 38% of patients admitted under a physician did so. NCEPOD commented that the use of venous thromboembolism prophylaxis in medical patients included in the study was unacceptably low and said that national guidelines for prophylaxis (which are currently being developed) are urgently required.
NCEPOD called for the training of nurses and doctors to place greater emphasis on basic skills such as the monitoring of vital functions, recognising deterioration, and acting appropriately. All trainees should be exposed in an appropriate learning environment to the management of emergency patients and clinical services must be organised to allow appropriately supervised trainee involvement.
In the 77 cases where advisor assessment was possible, the overall quality of care was judged to be good in 55. However, there were 11 cases where there was believed to be room for improvement in clinical care, four cases where there could be improvements in organisational aspects of care, and three cases where there could be improvements in both. In three cases, care was felt to be less than satisfactory. Contrary to the findings made in relation to the initial diagnosis of adults, the authors found that in paediatric cases initial diagnosis was more likely to be made by a consultant. NCEPOD acknowledged that recognition of serious illness in children can be relatively difficult and requires the input of senior clinicians at the onset. District hospitals may have particular problems delivering a high standard of care when dealing with very sick children and NCEPOD said that a well co-ordinated team approach is required.
End of life care
NCEPOD found examples of where healthcare professionals were judged not to have the skills required to care for patients nearing the end of their lives. This was particularly evident in relation to a lack of ability to identify patients approaching the end of life, inadequate implementation of end of life care and poor communication with patients, relatives and other healthcare professions. Nearly 50% of patients, who died with 96 hours of admission to acute hospitals, were not expected to survive and over 68% of these were considered to have received good practice. The advisors considered that nearly 6% of patients had an unnecessary admission to hospital and this was due to a deficiency of social and medical support in the community. In over 16% of patients who were not expected to survive on admission there was no evidence of any discussion between the healthcare team and either the patient or relatives on treatment limitation. Of those patients not expected to survive on admission in only a third were end of life care pathways used and 30% did not have “do not attempt resuscitation” (DNAR) orders. In around 22% of cases, DNAR orders were signed by very junior trainee doctors and NCEPOD found that palliative care teams were rarely involved in the care of patients who died in the study. NCEPOD chairman, Professor Tom Treasure, said that more patients are dying in hospital, and the report highlights the challenge medical teams face in making the transition between saving life and allowing natural death: “It should be ensured that patients achieve the best quality of life until they die. Effective team working and communication with patients, relatives and carers are fundamental to getting this right.”
Responding to the report, John Black, president of the Royal College of Surgeons, added: “This hard hitting report highlights the loss of proper team working in UK hospitals, resulting in dangerous failures of communication which make it harder and harder for clinicians to provide safe care for patients. The Royal College of Surgeons has been warning for some time about the dangers of multiple handovers. “The problems revealed in this report date from 2006 and 2007, when the NHS was already struggling to meet the demands of a 56-hour working week. Now that, in theory, everyone in the NHS is working for only 48 hours the situation in the country’s hospitals can only have worsened. Previously, the College published a survey into the early effects of the 48-hour European Working Time limit on surgeons and found that these new rotas had almost entirely removed adequate time for handover of sick patients.” • Copies of the report can be downloaded from the website: www.ncepod.org.uk
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