[HSF] ICU Management Systems

Fri Apr 11 12:01:29 EDT 2008

okay we all know the system sucks....but what are the answers or ideas
or fixes.... that is my question.

On 4/11/08, Ani Anyanwu <anianyanwu at hotmail.com> wrote:
> > 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> > > >
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