Issue 13 / 14 April 2014

COMPARISONS are frequently made between health care and aviation in terms of safety and there is no doubt medicine has learned a lot from the airline industry.

Safety systems in medicine that developed from aviation include staff factors like training and seniority and the effects of fatigue, and procedural issues like checklists, drills and simulation training. The practice of anaesthesia, in particular, has incorporated many lessons from aviation. “Time-out” procedures and cross-checking have reduced patient identification mistakes, drug errors and procedure errors.

Of course, no system is perfect, as the ongoing media coverage about the missing Malaysian Airlines plane makes clear.

Even so, it remains a mystery to me why a health system staffed by smart, motivated people can’t eliminate mistakes. What does aviation have that we don’t? Don’t we value health care more than travel?

The key difference is that health care is an often unpredictable necessity and air travel is a discretionary luxury.

Imagine if commercial airlines operated like emergency departments (EDs). You could turn up at any airport at any time, unannounced, expecting to travel. You would join the queue and demand to board. If all seats were full but people were still waiting, they could queue in the aisle.

A tired pilot would still have to fly a double-shift if a colleague called in sick. And what if no pilots were available? The flight steward would take over the plane — there would be no option to cancel the flight.

While quality and safety have improved markedly in emergency medicine during my career — with better staffing, skills and equipment than ever before — the systematic limitations to safety remain. On top of that, the ED is now more than ever the safety valve for the whole hospital.

Sick patients denied access to the intensive care unit remain in the ED. Patients considered too sick to go to the wards remain in the ED. Inpatient units expect patients referred to them from the ED to be investigated, stabilised and have a provisional diagnosis, while performance requirements expect this to be done in a limited time.

Is it any surprise that ED care generates complaints and errors — especially when seen in retrospect? Not only is the ED providing the community with the right to access unscheduled health care, it is also protecting the rest of the hospital by carrying the greatest load of risk.

This doesn’t mean that EDs should be exempt from continuously learning about and trying to improve safety and performance, but it does mean that expectations should be both realistic and explicit.

The demands of the community and of the rest of the hospital concentrate risk in the ED. It is therefore inevitable that the service provided to each patient will be a compromise, depending on competing demands.

Once this has been acknowledged, it can be managed in various ways. It can be accepted as an inevitable consequence of the way our services are currently designed. It can be improved by spreading the risk across the hospital. Or it can be mitigated by significantly improving ED resources.

Whatever approach is chosen, it is no longer acceptable to blame the ED for its circumstances. We need to be explicit about both expectations and constraints.

A system can’t be safe unless it’s not only designed but is also allowed to be safe.
 

Dr Sue Ieraci is a specialist emergency physician with 30 years’ experience in the public hospital system. Her particular interests include policy development and health system design, and she has held roles in medical regulation and management.

19 thoughts on “Sue Ieraci: ED risks take off

  1. Diane Campbell says:

    All very true.  With the addition that the airline has the absolute right to refuse to carry drunk or beligerant passengers,  or to fly at all if there is a perception of safety problems.

  2. Edward Brentnall says:

    Thank you, Dr Ieraci.  What a marvellous analogy!  Forty years ago the old “Casualty” was the greatest source of medico-legal problems, and it is still for the reasons given.  We have made huge progress but there is such a lot more to do.  Perhaps persuading the system to allow GPs to provide better procedural services on a 24/7 basis might help.  Opening more hospital beds might take some of the pressure, but would be expensive.

  3. Ian Hargreaves says:

    Although medical and lay commentators use the airline analogy, it is grossly inappropriate. Pilots are certified for one plane – a Qantas 747 captain cannot fly a 767, nor an Airbus. There are 2 or 3 qualified pilots for every trip. The plane goes to one destination, along a pre-appoved flight corridor. The passengers pay a couple of hundred dollars for a short hop and a couple of thousand for a long one. If they are fussy, like Bob Carr, they pay (or get some other sucker like the taxpayer to pay) $1,000/hr. The fundamental interaction is human-machine, ie the brakes and the bomb-bay doors are always in the same position, never mis-located, never mis-labelled.

    If you had an ED doctor who was certified to diagnose only appendicitis, who had two colleagues wih her at all times to assist, and only saw patients with appendicitis, you would have the safety record of airlines. 

    Because our fundamental interaction is human-human, with all the biological variables that entails; and our costing/staffing models require versatility, there are obligate errors. Using sub-specialists can help, eg a hand surgeon to look at a hand injury or a neurosurgeon to look at a head injury, but the doctor at the coal face is nowhere near as specialised as a commercial pilot.

    If anyone uses the airline analogy, give them 100mg of suxamethonium IMI. 

    Then tell them the intubation-certified doctor is on her compulsory 12 hour between-shift break.

     

  4. Luis Gallur says:

    Why do ED doctors with minimal training in Anaesthesia give anaesthetics in the ED on emergent patients ? That is concentrating the risk in ED is it not . Risk averse Anaesthetists and comprehensive Specialty Anaesthetic training  has made anaesthesia an extremely low risk event with litigation and insurance premiums tumbling for Anaesthetists despite an increase in patient age and co-morbidities . Standard Anaesthesia principles are often not adhered to in the ED . Proceedural sedation ( never defined ) as applied in EDs  is not sedation it is total intravenous general anaesthesia ( TIVA) usually with an unprotected airway .

  5. Monash University Publisher Packages says:

    Remember the comment – I think from Paul Nisselle.  When aircraft get old they are parked in a Nevada desert. When people get old they go to ED.  So although the safety systems of flying are important and give us many lessons  (Eg James Reason’s Swiss Cheese Model) there are important differences and thank you Dr Ieraci for expanding our understanding of that.

  6. Sue Ieraci says:

    Luis Gallur said ”Risk averse Anaesthetists and comprehensive Specialty Anaesthetic training  has made anaesthesia an extremely low risk event with litigation and insurance premiums tumbling for Anaesthetists despite an increase in patient age and co-morbidities”. That is my point exactly. The ED is not a controlled environment where cases can be booked, selected or cancelled. Apply the anaesthesia conditions to the ED work environment: a specialist and their team for each case, scheduling, the right to refuse care – and see how safe ED could be. But who would treat the rest of the patients?

  7. Anne Leversha says:

    Safety requires management leadership and a team approach. One aspect of safety where a few hospitals have ‘dipped their toes in the waters’ involves including a pharmacist in the ED team. The ED pharmacist can make a valuable contribution to the ED safety net for patients and staff.

  8. David Long says:

    Thunderstorm up ahead?  The aeroplane doesn’t go.

    Sick patient or difficult airway for an elective anaesthetic?  Put off the case.

    Your mother or the Police wont have you?  You can still come to the ED.

    Unlikely to be any pharmacists in an ED over this long weekend.

    Those of us in the front line of Emergency Medicine will still keep doing the best job we can, caring for everyone who turns up at any time of day, regardless of the thunderstorms.

  9. Diane Campbell says:

    Thank you Luis  Gallur for bringing attention to a very large elephant  present in a lot of emergency departments.   Emergency physicians and the ACEM have brought about  this situation where too many “sedations”  which are GAs  given in surroundings unacceptable to anaesthetists. 

    I do understand that in resource poor areas,  particularly in rural areas,   that this is sometimes done to avoid a 3 day wait for a procedure.  

    The hospital encourages it because opening theatre  means having consultant anaesthetists and surgeons present,  a “quick sedation” in ED saves the cost of an anaesthetist, theatre nurse, anaesthetic assistant,  supervising consultant etc.   The anaesthetists who deplore the practice don’t allow ED staff to attend theatre to maintain airway skills,  and we no longer have public spirited citizens overdosing on barbiturates and TCAs to practice on!  The ED may be housing the elephant but it’s being fed apples  by numerous interests.

    D Campbell

     

  10. Werner JANSE VAN RENSBURG says:

    Thank you Sue, thought provoking as always.  Being summoned to the cockpit of a nose diving plane may seem exciting and noble in the beginning, however most people start asking questions after a number of encounters.  Trouble is, as you mentioned things are about to “take off” given the burden of preventable illness impacting on our productive members of society in the context of an ageing population and fewer resources to foot the bill. Don’t expect politicians to initiate a coversation about the setting of expectations, until it is too late.  Buckle up, we are in for a bumpy ride …

  11. Bryan Walpole says:

    Well said Sue, but look at the errors now, and 30 years ago.

    It was usually inadvertent discharge with…

    Missed myocardial infarct (discovered at at autopsy)

    Missed intraocular foriegn body ( very expensive, that one)

    Missed exradural haemorrhage ( mostly died or badly disabled) 

    Missed injuries ( intraabdominal haemorrhage, pelvic/spinal/limb fractures) catastrophes all.

     

    Now

    Given wrong drug, oops ( rarely bad outcome)

    Missed obscure diagnosis ( cancer, immunological disease,) No effect on outcome , 

    Grossly delayed attendance/ admission. (hardly EDs fault)  “Not seen for “x” hours”

    Failed discharge (unscheduled readmission) Occasional bad outcome, usually done for reasonable reasons.

    Senoir staff, better diagnostics,quality timely referrals have changed the problem entirely, so although the number of complaints may not have fallen; the goal posts have got closer together.

    Who remembers the  bad old days with “White mouth sign”    Answer ..watch this space in a few days. Retrospectoscope for the first correct reply!

     

  12. Health Directorate Library Canberra Hospital says:

    Luis Gallur and Saint From Elsewhere … You might benefit from spending some time in the resus area of a modern tertiary, well-staffed, consultant-led ED and observing the conditions under which we perform procedural sedations, and RSIs/DSIs.

     

    As Dr Leraci mentioned, EDs are no longer “casualty departments” staffed by random juniors “having a go”.

  13. Sue Ieraci says:

    Thanks for all the comments. Bryan Walpole has hit the nail on the head: health care in general is safer and more effective than ever before, but expectations and risk aversion keep increasing ahead of us, creating a cycle of apparent ”failure” as our ”stretch targets” keep stretching and stretching. No other area of health care is as scrutinised, regulated and ”stretched” as ED care. Meanwhile, the ED contains many lessons for other specialties in adapting to new models of care, providing for the greater good, and getting the best value for resources in a risk-averse but cash-strapped environment. ED clinicians are held to account for the outcomes of all those who seek care – especially for delays in care.There is no cancelling cases – because the ”sins of ommission” count, as well as the ”sins of commission”.

  14. Bryan Walpole says:

    White mouth sign…..used to see it every year till- 1975 ,in  middle aged males (mostly)

    A discharged ED patient, found dead in the car park/at bus stop, with white material dribbling from their lips.

    Mylanta, given for the epigastric/retrosternal pain was vomited prior to/ with cardiac arrest.

    Atypical chest pain was not an admittable condition. NSTEMI was unknown.

    2nd year residents were in charge of ED . No concept of risk stratification in chest pain.

    ACEM changed everything.

    Bryan.

     

     

  15. Bryan Walpole says:

    Twenty five years ago, I visited Tokyo and saw a major receiving hospital.

    They had no ED. There was no way into hospital expect via the clinics, or ambulance. 

    If the patient rang an ambulance, one central bureau for the city took all calls, had onsite medical assistance, and the patient was only sent a nescessary ambulance,( otherwise patient told to see GP) and it was directed to the approprite hospital, where each dept had a roller-door that opened onto the ambulace tail. Thus the patient was delivered to an appropriate ( mostly) resus/receiving room, in medicine, surgery, O&G, paeds, as required. All wards had a groung floor secure reception room. Anaesthesia attended as required.

    Worked very well, occasional misdirected patient ferried between departments,rare use of ICU ( complex ventilated patients) but workload was controlled, bedstate locally regulated, and staff kept up resus skills, no need for emergency medicine.

    But then, the japanese are respectful, orderly,tolerant and accept regulation without complaint. ( Or did then)

     

  16. Philip Hoyle says:

    Thanks Sue

    A big difference with aviation is that when there is a disaster, airline management is accountable e.g. out of job. In health care in every jurisdiction there have been massive efforts to bottle the blame up at an operational level e.g. incident investigation that almost always fails to sheet home system failures to the system managers. RCAs are a meaningless routine that usually just pre-load responsibility for the next failure back to the clinicians by recommending new, impossible or irrelevant system changes, that completely miss the point of what is driving the system failures in the first place.

    Aviation (perhaps not Qantas!) shows us that to have a safe, sustainable system management needs to partner with emergency medicine, instead of treating it like a handmaiden 

     

  17. Steve Walker says:

    The old airline comparison. People compare unsceduled critical care with scheduled airline operations.

    Airline travel is very safe. This is due to the skill & dedication of many aviation professionals over the years, and the result of many hard learned lessons. It is also safe because it is a discretionary luxury – safety costs, and is one reason air travel is out of reach of many. But for those who can afford it, be assured it is the safest form of transport yet devised. In fact, it is often said the most dangerous part is the drive to the airport.

    So catching a commercial flight is perhaps similar to….. having botox. This procedure is very safe, and the most dangerous part is probably the shock of the bill.

    So how did ED get compared to airlines? It’s apples and oranges. 

    Lets compare apples with apples. Lets look at the helicopter EMS industry, which performs unscheduled emergency work, often operates despite poor weather, and there is pressure to get the job done.

    In USA in 2008, there were 668 EMS helicopters. 12 of these crashed (ie 2% of the national fleet) with 29 fatalities (1 for every 23 helicopters). 2008 was a bad year, and 1% of the national fleet is more typical. 

    2% of the fleet. That is far worse than the fatality rate for P-platers (140,000 P1 licence holders in NSW, 2% = 2800 deaths).

    2% of patients “crashing” = 2 deaths due to error each day in a busy ED.

    Maybe ED isn’t doing so bad after all.

  18. Flinders University of South Australia says:

    The procedural sedation issue is a distraction but I prefer evidence rather than opinion.  A brief review of the literature suggests the concern may be excessive:

    http://www.ncbi.nlm.nih.gov/pubmed/16365337

    The analogy between aviation and medicine is correct if you were to to consider that the situation is more akin to flying a sortie during wartime finished by a night carrier landing.

     

  19. Steve Walker says:

    Last Saturday night. 3 males presenting with a STEMI within 90 minutes. Two of these presented within 10 minutes. All were big STEMIs with lots of ST elevation.

    One cath lab.

    An extreme example of a common situation where demand exceeds supply. But you can’t artifically turn off the demand and so you have to cope.

    If these STEMIs were airline flights, they would not be accepted until they had filed a flight plan. And the flight plan would not be accepted without an available landing slot. At major airports, there is intense demand for these slots. No slot, no flight. Does this sound anything like emergency care? Nope, I didn’t think so either. 

    The question of “sedation” is interesting. There was an anaesthesia conference in Singapore 2 weeks ago. A big theme was cognitive decline following general anaesthesia drugs – whether a formal GA in theatre, or PSA in ED. There increasing evidence this is a real issue, especially in the elderly. There is data that ketamine causes neuronal apoptosis, Much of this data is animal data and in vitro work on human cell lines. The in vivo applicability? We don’t know yet.

    But it does make me wonder about things like Colles fractures in the elderly. 20 years ago, these were managed by local block in the ED. Now they are a GA in theatre using image intensifier. Yes I am sure this approach produces a slightly better looking post-reduction XR. Whether this approach (admission, fasting, delays for theatre, and then a GA) is really better for the 80 year old connected to the Colles fracture is questionable however. 

    Propofol and ketamine are great drugs. But there may be an important end point we have not fully understood. 

     

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