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PHARM Podcast 38 – Clinical logistics :the science that turns strategy into reality with Dr James French and Dr Scott Weingart

Dr James French and Dr Scott Weingart discuss MAKING THINGS HAPPEN in  ED and PREHOSPITAL CRITICAL CARE

Hi folks! Today’s episode brings together three doctors in EM and CC from UK, USA and Australia : Dr James French, Dr Scott Weingart and yours truly!

You are going to enjoy this one as we talk about the science of clinical logistics and making things happen , safer, better, in a resilient manner. I met James last year in Brighton at an Air MED meeting with Cliff Reid , Karel Habig, Brian Burns and other consultants from GSA HEMS. Cliff , James and I share a common love of KUNG FU TRAINING. More on that at a future podcast!

To begin with here is James setting the scene for the podcast : QUOTE BEGINS NOW

Hey Minh,

I thought I should summarise my thoughts regarding our podcast.

Essentially I was given the task about a year ago of choosing, procuring and embedding all the new clinical equipment and associated procedures for use in our new emergency room. You may recall that UK trauma systems have been extensively reformed (finally – Injury; the Epidemic of Modern Society published in 1966 I believe). Our hospital has been designated as a trauma centre which required significant redevelopment. This was a fantastic opportunity, a blank canvas, that I wanted to be a an organised process diagram rather than a Jackson Pollock!

I started wondering why I found it easier to manage a seriously injured trauma patient in the Prehospital phase, which is a resource limited, time pressured, safety critical and sometimes hazardous operational environment, than in a resuscitation bay. I think some of the features that make such PHEM scenarios “slick” are as follows:

1. The practitioners are relatively senior.

2. All of the practitioners are educated using a competency based curriculum, delivered using full immersion simulator based training. They therefore are competent, but also their competency is context specific.

3. The equipment used is packaged logically in sections, so “what plays together stays together”.

4. Each equipment section for example in a Thomas Pack, is mainly kitted for a single procedure on a single patient. Once the bag is “trashed” it is labelled not safe to use and is restocked. The response platform therefore contains additional complete trauma bags, which can be used immediately in other patients.

5. Where necessary our practice is supported by a procedural aide memoir (PAM); a simple, accessible, process driven document that helps us do the procedure.

6. And you know your kit backwards, because you’ve packed it a thousand times!

7. You also usually only have one or two patients to deal with at a time.

8. Care is transitional. We transition from the car wreck to our trolley, we then stabilise, splint, anaesthetise and package, and then transition to the transport platform where we transition to the receiving hospital. We don’t notice these transitions, because that’s our job, and we don’t see being mobile as abnormal. In fact PHEM practitioners get uncomfortable when we stay in one place for too long.

9. On the roadside space is not a problem! (usually, well unless you’re trapped, well you know what I mean!)

Let’s just contrast that to the reality of a busy Emergency Department:

1. There are more juniors than seniors. And supervising doctors are frequently tied up looking after one of the fifty other patients.

2. The practitioners may be competent, in terms of strategy, for example they’ve been taught to put in a chest drain and have done ATLS, but it is highly unlikely they will have context specific competency to your individual ER operational environment. Their induction will have covered fire lectures, infection control, and where to take a dump, but actually sweet naff all when it comes to actually looking after a crashing patient in your totally individual operational environment. More than that no two trauma teams are ever the same. Add into that three new intakes of doctors per year and residency rotations And the only safe and logical thing to assume is that although they may know what to do (strategy) they may have little or no idea how to actually deliver this competency in your operational environment (clinical logistics).

3. Equipment is often scattered, seemingly at random, all over your department. I’m sure we can all recall taking longer to find the right bits of kit, than it actually takes to do the procedure. This time is wasted and one thing none of us have is time to waste in a busy ED. A manager that practices using lean management principles would call this “non value adding time”; I call it, exasperating, frustrating and a total ball ache.

4. Because each bay is used continuously ,often you have no idea which bay is safe, what resources you have, and the redundancy is in a store room, down the corridor, usually near the toilets or the staff room.

5. We have policies and sops, usually more than we are aware of, but these are often relatively inaccessible and too long to actually support practice in real time.

6. Doctors in an ED seldom contribute to equipment checking and stocking. Why? Because we have 300-600 patients a day, and we don’t have enough resources to look after them, let alone do a job that could be done by a nursing aide. Some docs will also believe that such activities are beneath them.

7. We have departments bursting at the seems with patients, surging excessive inflow, exit block and resulting overcrowding.

8. Care in an ED is seldom considered to be transitional. It’s all about the resus moulage, or the procedure, etc etc. We don’t routinely drill, analyse or refine our transitions to CT, theatre, and IR. however how many times have you been on even a short transfer, in the hospital, and the monitor has failed, or the infusion pump battery has gone dead, or you’ve dropped a highly expensive item of equipment ? Think about the courses we do ATLS, APLS; none of these courses consider these transitions, however you could argue that a patient is at more risk when transitioning between healthcare geography in a hospital than at any other time during their journey.

So how do we manage these risks, and try to emulate our PHEM practice? Well given we are all almost by definition pragmatists in EM let’s consider the following example. Mr Smith needs a chest drain.

1. Everything you need for a chest drain insertion is on one place. All major procedures are stored in single use trays that contains everything you need. These trays are stored in mobile equipment stacks that can be wheeled if necessary from on bay to another. There is a separate stack for medicine, trauma and Paeds. This makes each bay completely patient adaptable. You dept have to hunt around for anything. This is truly lean and efficient.

2. The chest drain procedure tray contains in its base an A3 PAM that helps you decide on drain sizes in kids, the volume of lidocaine you need by age/mass band, a simple how to guide and team support information (how to get hold of senior support in a hurry).

3. The tray slots into a generic procedure trolley. The procedure trolley contains any items you may need that are not in the procedure tray that are individual to the user, for example sterile gloves. each tray also contains the relevant paperwork you need to fill in.

4. The trays are labelled with high levels of conspicuity. You can identify a tray from 12 feet away.

5. Once used, the tray is transferred to a used rack. Each morning the trays are barcode scanned, which tells me about frequency of procedure use (and infers the currency of our users), updates our stock requirements, and tells our clinical logistics team what trays they need to make that day. Because stock control is so closely monitored and uses a pull system, or Kanban system, we need less space for storing disposables. We don’t rely on massive stock in out department, rather a rapid logistics chain. This means, in theory at least, you could turn some of your many stick areas into clinical areas (if your logistic chain is up to it).

6. Each bay has a medical and trauma tower and we have two Paeds towers. They are all identical. This results in massive shop floor redundancy.

7. The only elements of the systems that are not single use are the airway trolleys. These are checked every day using two person challenge response checklists. The docs also do this. To maintain awareness we also do rolling functional checking. For example Thursday might be chest drain day. The daily diary will read ” Daily functional check. Using a PAM talk though chest drain insertion and lay out the circuit necessary using the silhouette.” Checking is therefore an educational functional activity, rather than a nominative one.

8. We have started the Transitions Project. Each transitions team guides rapid, safe and effective transitions and is composed of staff members that are involved in each interface. For example the CT transitions group contains ED and Radiology staff. This work is ongoing but I will keep you posted regarding the results.

When I get to work, I will take some photos of all this so it makes more sense.

Hope this is helpful,

James

Dr James French BSc BM Dip IMC RCS (Ed) FCEM

Consultant in Emergency Medicine and Prehospital Emergency Medicine, Cambridge University NHS Trust.

Honorary Injury Control Research Fellow, Emergency Medicine Academic Group, University of Leicester.

QUOTE ENDS NOW

SHOW NOTES REFERENCES:

ISOBAR CLinical handover tool

ATMIST checklist slide 61

Stay safe and enjoy the interview! I certainly did!

Minh

Now on to the Podcast

Right Click and Choose Save-as to Download the Podcast.

9 Comments Post a comment
  1. Ed Valentine #

    Just read through James’ comments and found myself nodding in agreement to every single point he makes. Fantastic degree of insight into the problems faced in the ED (I’ve often had exactly the same thought – ‘why is it that I can manage a major trauma patient better and more efficiently at 2am on the side of the road with just myself and a paramedic than happens in an ED Resus bay with loads of members of staff present?’) and James presents some very interesting potential solutions! Nice one! Will go and listen to the podcast now.

    September 9, 2012
  2. Minh, Scott & James,

    Fantastic discussion. The clarity with which James approaches the scenario is inspiring and something to aspire to. There is so much in this that resonates with me in my work with motor sports medicine, from the scene survey and on-site resource utilisation to the AT.MIST.ER mnemonic and planning for both clinical and logistics needs.

    The logistics discussion was particularly helpful, especially the recognition that the majority of practitioners are clinically knowledgeable, skilled and enthusiastic, but may not be fully aware of the context-specific logistics of the situation they are in – a common aspect of hospital based doctors & nurses volunteering for motor sport (and probably other sporting) events.

    Thanks for the show note links; I’m sure they can be put to good use in preparing event teams at future races.

    Great work

    Matthew

    September 9, 2012
  3. Great podcast! I found it very helpful, especially the distinction between algorithms and checklists. As a resident I found checklists to be very helpful and practical (www.emupdates.com). I think senior doctors have developed some type of mental checklists when they run the emergency department. It seems to be a challenging concept to teach especially when our education focuses more on facts knowledge rather than the process of analyzing information (http://en.wikipedia.org/wiki/Fluid_and_crystallized_intelligence). I love logistics and posted (http://academiclifeinem.blogspot.com/2012/09/do-you-know-your-resuscitation-room.html) an list, not all inclusive, about the equipment in the resuscitation room because being prepared makes a big difference (“If I had eight hours to chop down a tree, I’d spend six sharpening my axe.”— Abraham Lincoln) Thanks for posting James’ notes here, they are invaluable.

    The literature shows that lots of mistakes happen during handover and that’s an important area that needs to be brought up forward. Thanks for addressing it along with the human factor.

    I really liked the clinical scenario since it involved two patients. I would love to hear more on how to manage multiple patients at the same time. I am really interested in learning how people reason their way of changing priorities on a constant basis.

    I also want to mention, that just like James, I have found all of your works on podcasts, blogs, videos very inspirational.

    September 9, 2012
  4. Brilliant. Haven’t (yet) downloaded the podcast but the points made in the written intro above gel exactly with mine. Inspired by the ‘logistics over tactics’ discussion on em-crit and resus.me a year ago, I’ve been trying to apply these principles to small rural EDs in Australia – not least because although the vast majority of the work we do is low-acuity stuff, when the shit does hit the fan the team is suddenly in a situation of having to perform critical procedures with no backup and often lack of recent experience. ANYTHING that we can do to make it easier is worthwhile…PAMs and simple gear set up is one, regular drills in set up is another.

    And the point about what works well in the PHEM vs ED environment is well made, as others have commented. No good taking the shit hot ED reg and dropping them into a paddock along with a flight nurse, unless they’ve drilled and drilled. Why we don;t take the PHEM approach to our resus bays is beyond me…

    September 10, 2012
  5. Great podcast/discussion. Stripping the way we work and what we use back to the basics. High visibility trolleys, regular checking and a system for restocking. Discipline and accountability!
    The other reason the prehospital environment is often easier is the absence of extra people with egos that don’t add anything!
    Everyone knows their role, is focused and part of the team!

    September 11, 2012
  6. Effing brilliant, gentlemen! “The science that turns strategy into reality”… love that description. Also the science that brings critical care transport medicine into the forefront as a specialty that has much to teach the rest of the house of medicine. Rock on.

    September 12, 2012

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  2. Keep it simple - KI Doc
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