[HSF] ICU Management Systems

[Ani Anyanwu]

> before proceeding. The operating surgeon was finished at the end of the day and if > his operation was not finished, the on-call surgeon took over. Imagine my > surprise as I was well along with operation for aortic dissection when the on > call surgeon tapped me on the shoulder and informed me that it was 5 o’clock and > I was finished for the day. 
 
 
As absurd as this account may seem it illustrates the fallacy and inherent unsafety of the 'excellent' surgeon based approach we run now. 
 
Often is the case in institutions that some surgeons are much busier than others and you have one surgeon do four cases in a day and another four the next day, maybe 16 the whole week, make even 25 and another surgeon in same or other institution doing one case every two days. How could that be safe for say the 5th or 6th patient in those series of operations, or the second who starts to bleed when the fourth is being done (michael has already raised the issue of who looks after these patients in the ICU)? Surely performing so many operations in so short a time without rest must increase risk of errors and malperformance due to fatigue or reduced judgement? Of course the argument will be that the busy surgeon is the best surgeon so everyone wants his or her operation done by that surgeon but if patients were informed would they really make this choice? Take parallel from aviation industry - would you want to be flown by a team of pilots who had just flown a jumbo back from Hong-Kong just because they are the best or would you want a fresh team? How many patients are actually told that they will be the fourth case of the day or the surgeon will be operating on them in parallel with another case or that the surgeon will not be available immediately after the case because he will be doing another 3 more? There was a presentation from Papworth once (dont know if it was published) that compared outcomes between patients operated in morning and afternoon by same surgeon and found a mortality benefit if you had surgery in morning.
 
It is indeed a joke the way surgeons deliver surgical care in the United States and some other countries and I suspect as Dr Flege says that the patients in Sweden are far better off and their outcome much less subject to variability that those operated in the USA today.
 
Ani
 
 



> From: Jbflegejr at aol.com> Date: Thu, 10 Apr 2008 14:00:19 -0400> Subject: Re: [HSF] ICU Management Systems> To: OpenHeart-L at lists.hsforum.com> CC: > > Michael, > I had the opportunity to work as a visiting surgeon in Umea, Sweden for three > months in 2001-2002 and participated in a system of care from which we could > derive some ideas. Umea has a tertiary care university medical center. The > heart center had cardiac surgeons, cardiologists, cardiac anesthesiologists, and > support staffs in a single administrative unit which was headed by Torkel > Aberg, the chief of cardiac surgery. About 1000 cardiac operations, all adult, > were done annually and the case mix was similar to ours as to age, diabetes, COPD > and other comorbities. Hospital mortality ranged from 1% to 2% since > inception of the unit in 1988. They have a CT surgical training program. There were > seven or eight attending surgeons which included a visiting surgeon or two. > Physicians in Sweden, trainees and attendings, have observed a mandated 40 hour > work week for thirty years. > The surgeons and anesthesiologists provided the postoperative care until > discharge. The surgeons rotated beween operative duties and postoperative care > every two weeks or so. When a surgeon was on operative duty, that is all that he > did, ordinarily a case or two each day. When he was on postoperative care with > the anesthesiologists he also was responsible for consultations and made the > decisions for operation or not. The operating surgeon reviewed the patient > assigned to him for operation the evening before and made the final decision > before proceeding. The operating surgeon was finished at the end of the day and if > his operation was not finished, the on-call surgeon took over. Imagine my > surprise as I was well along with operation for aortic dissection when the on > call surgeon tapped me on the shoulder and informed me that it was 5 o’clock and > I was finished for the day. > The on-call team composed of surgeons and anesthesiologists took care of the > patients at night and weekends including take-backs for bleeding, emergencies, > etc. > I characterised this as a corporate system and it provided as good care as I > have seen. It depended on a staff that had equivalent capability and trusted > one another and on highly standardized policies and procedures. It functioned > well despite the rather stringent work hour constraints. > I am sure that those of you who read this will put forward plenty of reasons > why such a system could never work in the USA such as the doctors won’t accept > it, the patients won’t accept it, the system for payment won’t work, the > surgeon cannot have all of his individual preferences, etc. > In my view, the way we work now does not work very well and as those of us > who grew up awhile ago when ideals and expectations were considerably different > drift from the scene the way we work now will be untenable. I firmly believe > that within a short time work hour constraints will apply to all physicians and > will be considerably more stringent than now. How are the patients, which > will likely include me, going to receive good care unless we drastically change > the way we work? John Flege> > > > **************Planning your summer road trip? Check out AOL Travel Guides. > (http://travel.aol.com/travel-guide/united-states?ncid=aoltrv00030000000016)> _______________________________________________> OpenHeart-L mailing list> > Send postings to:> OpenHeart-L at lists.hsforum.com> > To UNSUBSCRIBE, to CHANGE email address, or to view archives:> http://mmp.cjp.com/mailman/listinfo/openheart-l> > All messages transmitted by the OpenHeart-L are subject to the policies and > disclaimers posted at:> http://www.hsforum.com/listdisclaim> -----------------------------------------
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