Monday, June 19, 2017

Good habits, clear communication, core networks.

A useful case study of decision-making in complex, dynamic multi-causal systems. From A dog bite sent him to the ER. A cascade of missteps nearly killed him. by Sandra G. Boodman.

A dog bite leads to an uncommon infection which in turn leads to a near death outcome along with hearing loss and toe amputations.

The couple are just 50, they are educated professionals, he an industrial engineer and she a university STEM professor.

Other than lacking a spleen (from a car accident in his twenties), he was in good health until bitten by a dog. From that point, his health collapsed over a period of several days. Personal health and healthcare systems are both complex, dynamic multi-causal systems. This occurred in the UK where healthcare is nationalized with the pros (free) and cons (rationed and overburdened) attendant to such a system.

A straight-forward dog bite leading to near death. Here were the things that went wrong, and indeed, most had to go wrong for this multi-causal chain to lead to the outcome that it did. If only one or a few of these things had not happened, the catastrophic outcome would have been avoided.
Patient had no spleen (critical to the immune system and therefore making him especially susceptible to infection).

Patient and spouse were unaware of needing to take special health precautions owing to absence of a spleen.

Patient did not advise doctors that he did not have a spleen in the first few days.

Patient had no routine doctor.

Patient had not had a check-up in years.

Patient did not have any routine immunizations.

Patient was infected with a rare bacterium, not routinely experienced by healthcare practitioners.

Patient waited a day before visiting an urgent care clinic.

Patient declined antibiotic recommended by the clinic.

Clinic did not make clear that the probability of infection was 20% rather than 5% as communicated.

Patient returned to the clinic 24 hours later to be referred to a nearby hospital.

Patient and Clinic did not communicate clearly with one another as to which local hospital he was to go to.

Patient arrived at the emergency room which was overcrowded and had to wait. While waiting, patient's spouse left to take of their dogs. Important as it is often important to have a clear thinking advocate in a hospital environment.

Patient gave an incomplete description of condition to the triage nurse, omitting that he had no spleen, that he had been recently bitten by a dog or that he had been administered a tetanus shot.

Contextual circumstances masked some of the diagnostic clues. Specifically, patient mentioned he was a runner who often have low blood pressure, masking what would have otherwise been a diagnostically significant condition.

Emergency room was so over-crowded that the wait to see a doctor was several hours long without a clear time commitment.

Spouse called another hospital emergency room but their wait down was also several hours.

Patient and spouse did not know patients' normal blood pressure and ignored advice from a paramedic to stay in the emergency room because of the low blood pressure.

Patient and spouse left after several hours without having seen the doctor and without knowing the seriousness of patients' condition.

Patient and spouse waited several more hours before returning to the emergency room.

It was six-days after hospitalization before a specialist with the necessary experience (he had seen a case of the rare bacterium several years before) saw the patient.
By my count, at least 21 things had to go wrong for this outcome.

It is easy to fall into a legalistic or moralistic effort to adjudge whose fault this was. Was it the patient for failing to follow routine basic health maintenance actions (primary care doctor, routine check-ups, up-to-date vaccinations)? Was it poor communication between healthcare providers and patient? Was it disregard for the gravity of the situation by patient and spouse? Was it poor National Health Service administration for underfunding emergency room capacity? Was it poor emergency room diagnostic practices? Was it bad luck that contextual circumstances (running) masked the health conditions?

Yes, all these contributed and more. It is a dynamic, complex, multi-causal system.

The interesting question when dealing with a dynamic, complex, multi-causal system is not so much whose fault it is as what are the changes that could have been made to avoid the bad outcome. Whatever those changes, they might or might not be feasible or affordable in a resource constrained environment, but that is a choice.

It is, I think, important to acknowledge that the patient and spouse did at least one thing right, given the probabilities involved. There is no inherent reason to assume that a routine dog bite is a serious matter. They did exactly the right thing in terms of waiting an amount of time before they could see that there were complications, they were right to start at a clinic. They were right to attend the emergency room. The escalation protocol makes sense.

What is especially alarming about this case is that the patient and spouse, given their professions, are almost certainly from the upper quintile in terms of intelligence, competence, experience, capability, etc. If the system can fail this catastrophically for them, what does that bode for the other 80%?

Of course, this is an extreme example and says nothing about the overall healthcare system effectiveness (that's a different discussion.) But it is striking that at least 21 process failures not only had to occur but did occur. Nearly every one of the failures was not unreasonable in its context. It is nearly impossible to design a human system with zero quality defects.

There is not enough information in the article to do a detailed process analysis but the reality, I suspect, is that there are few improvements that are feasible, affordable and would make a material difference in aggregate. Perhaps it is not process improvements where we ought to focus but rather more strategic issues.

Three things stand out from this case to me. The first is that the couple might have avoided much of this complication had they followed basic routine health practices (primary-doctor, routine check-ups and up-to-date vaccinations). Had they done that, patient likely would have been more alert to the risk represented by not having a spleen and would have communicated that more clearly and earlier.

The second is the importance of clear, accurate, and timely communication. Had this occurred at various stages, again the outcome might have been circumvented.

The third is the importance of advocacy within an emergency room or hospital environment. Constrained, high tension, dynamic, complex, multi-causal systems are difficult to navigate at the best of times. If you are in ill-health, you really need someone else to manage that for you. Your social network (usually anchored in your family) needs to be robust enough that someone is there as your advocate when you need them.

Strategically that suggests that process deficiencies can be mitigated by good habits, clear communication, core networks.

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