The editor of the MJA, Dr Annette Katelaris, has described it as the most important study published in the MJA in the last 10 years.The reasons for the study were twofold: an earlier American study suggested only 50-60% of GP's followed known Best Practice and with the explosion in Medical technology, drugs, treatment and published research, and GP's are finding it increasingly hard to stay abreast of all current research.
The essential steps of the study were:
- Identify the most important conditions to follow: 22 selected with 522 indicators.
- Create Best Practice Treatment Guidelines for each condition from the published evidence.
- Data Collection and Analysis from selected GP's and patients.
This simple 2 page document arose from a Quality Improvement (QI) project for Brent James' ATP course and they've calculated lives saved and reduced treatment costs.
It was refined over time through use, it also served as a Data Collection tool and met the prime requirement for QI projects: Can you prove you've improved things, not just changed them?
Donald Berwick asserted in 1996: Not all change is improvement, but all improvement is change.[8]
The reasons for the success of the IMHC CAP Treatment Guidelines are linked to Caretrack:
- A central, specialist organisation researched Best Practices then refined them into a practical, usable document.
- The CAP Care Instrument a) included Data Collection b) invited feedback and c) allowed physicians to deviate for individual treatment plans and document their deviations.
- The Guidelines were refined and extended over time through the feedback and analysis of the deviations.
- The integrated Data Collection allowed whole region care and outcomes to be centrally monitored and reported. Just as in a Hospital, the primary care physicians had the backing and support of experts in many fields.
Since this CAP Treatment Guideline is over 10 years old, I think we have to ask: Why aren't expert-prepared Treatment Guidelines for GP's the norm?
The essential strengths of well designed Treatment Guidelines are:
- Continuity and correctness (no steps skipped/duplicated) of care, regardless of changes in physician.
- Delegation of appropriate duties: nursing and other staff can deliver routine care according to the prescribed protocol. Physicians are freed for more demanding and important tasks.
- Automatic exception reporting to the physician responsible for a patient allows better treatment and earlier detection of complications and other conditions.
I agree with a comment from Dr Brent James that no GP can now stay current and have time to practice. Reading all research and reducing it to procedural guidelines and protocols is now a separate, specialist activity. This is a systemic problem that will only worsen, at a gathering pace.
Healthcare is far more than Medical Treatment and Surgery. This approach of Standardised Treatment with Data Acquisition, Monitoring and Reporting is as valid for drug use in Hospitals, Primary Care Clinics and Healthcare-in-the-Home as the ICU.
Good friends of mine suffered a medical misadventure 20 years ago when an ear specialist, not a GP, prescribed multiple courses of gentamicin, without any blood tests, to treat an ear infection without result. A subsequent specialist found it was a fungal infection acquired from garden compost and cleared it with topical treatments.
The patient now has moderate to severe hearing loss as a side-effect of the gentamicin.
They would've been spared this outcome from a dangerous drug with known side-effects if their community pharmacist had been issued with a standard Treatment and Reporting form.
In a private communication, I've had described to me a Pharmaceuticals Treatment and Reporting system that was instituted and used in a public hospital for around 5 years. While the project was running, the medical and nursing staff were extremely happy with it and the Clinical Pharmacist staff, at only 50% strength, were able to easily handle the work load whilst producing better results, more consistently.
[1] UNSW, Australian Institute of Health Innovation, Caretrack Project
http://www.aihi.unsw.edu.au/project/caretrack-australia
[2] MJA: CareTrack: assessing the appropriateness of health care delivery in Australia
https://www.mja.com.au/journal/2012/197/2/caretrack-assessing-appropriateness-health-care-delivery-australia
[3] ABC Radio National, Health Report: Caretrack Study - The standard of health care in Australia
http://www.abc.net.au/radionational/programs/healthreport/care-track-study/4133230
The researchers took 22 medical and surgical conditions and lined them up with the best evidence informed care. They screened 35,000 people and ended up with just over 1,000 with one or more of these conditions and then examined the notes. Jeffrey Braithwaite again.[4] Brent James of Intermountain Healthcare. [PDF]
... had to go through 225 Ethics Committees in order to be able to do this study?
We found that 57% of care against our 22 conditions and 522 indicators was in line with best practice. What we’re calling appropriate care, evidence based
Last 5 pages of this presentation are the clinical forms for Community-Acquired Pneumonia (CAP).
http://www.mdanderson.org/education-and-research/resources-for-professionals/clinical-tools-and-resources/clinical-safety-and-effectiveness-educational-program/selected-lectures/csetraining-modeling-processes.pdf
[5] Intermountain Healthcare ATP (Advanced Training Program):
http://intermountainhealthcare.org/qualityandresearch/institute/students/Pages/atp.aspx
[6] ATP Quality Improvement projects:
http://intermountainhealthcare.org/qualityandresearch/institute/alumniresources/Pages/home.aspx
[7] CAP project presentation [PDF's]
http://intermountainhealthcare.org/qualityandresearch/institute/alumniresources/Documents/2005-002.pdf
http://intermountainhealthcare.org/qualityandresearch/institute/alumniresources/Documents/2003-035.pdf
[8] BMJ: A primer on leading the improvement of systems, Donald M Berwick
http://www.bmj.com/content/312/7031/619
[9] "The Checklist Manifesto", Atul Gawande
http://www.amazon.com/Checklist-Manifesto-How-Things-Right/dp/0312430000/
Further Reading
Prof. Chirs Del Mar comments on Caretrack. Unread, behind a paywall.
https://www.mja.com.au/journal/2012/197/2/dog-walking-its-hind-legs-implications-caretrack-study
Despite its limitations, this important study highlights a genuine need for systematised performance monitoring.
An unrelated, though major, study soon after Caretrack. Supports more competence testing and training.
MJA: The effect of clinical history on accuracy of electrocardiograph interpretation among doctors working in emergency departments. 06-Aug-2012.
https://www.mja.com.au/journal/2012/197/3/effect-clinical-history-accuracy-electrocardiograph-interpretation-among-doctors
Related projects at Uni of NSW, Australian Institute of Health Innovation (AIHI):
Building quality,governance, performance and sustainability in Primary Health Care through the Clinical Microsystem Approach
http://www.aihi.unsw.edu.au/project/building-qualitygovernance-performance-and-sustainability-primary-health-care-through
Uni QLD: Clinical microsystems
http://aphcricremicrosystems.org.au/research
Patient Safety: enabling and supporting change for a safer and more effective health system
http://www.aihi.unsw.edu.au/project/patient-safety-enabling-and-supporting-change-safer-and-more-effective-health-system-0
IHI citations on Community-Acquired Pneumonia. Not read. Source an IHI paper:
Dean N.C., et al.: Decreased mortality after implementation of a treatment guideline for community-acquired pneumonia. Am J Med 110:451–457, Apr. 15, 2001.
Dean N.C., et al.: Improved clinical outcomes with utilization of a community-acquired pneumonia guideline. Chest 130:794–799, Sep. 2006.
Patient Safety and Aviation arguing "it's not the same"...
A standard excuse for not persuing Quality Improvement.
Patient safety is harder than aviation safety, And five practices to borrow from aviation.
http://nextlevel.gehealthcare.com/quality-safety/medical-errors/patient-safety-is-harder-than-aviation-safety.php
Patient safety: What can medicine learn from aviation?
http://www.ama-assn.org/amednews/2010/06/14/prsa0614.htm
The article lists under "Aviation's methods, medicine's applications"
- Checklists [standard Operating procedures]
- Teamwork Training
- Briefings, Debriefings and timeouts
- Incident reporting
- Simulator training
- Standardisation [equipment and controls]
Another thought provoking post Steve, and an interesting insight into the mind of a professional at Systems Design and Administration.
ReplyDeleteA few quick thoughts:-
Given the litigious nature of the USA, I'd be expecting an uptick in malpractice suits, even without injury, for hospitals and practitioners not using proven Checklists for standard procedures where they exist.
It's my limited observation that most doctors don't use checklists - particularly on ward duties. Put that down to lack of time perhaps. Given the percentage of the health care budget spent on administration perhaps that's where the problem/solution lies. i.e. building the checklists into prescription/notes system (whether it be an application or a paper form). And - in theory doctors in hospitals would implement the checklists - in pratise it tends to be nursing staff.
Again - failure to implement checklists is possibly a problem at the administration level, not doctors or nurses.
When the recording system is provided by a pharmaceutical company, as is often the case with GPs, then the checklist is going to be outside of the administration system (practise secretary, nurse/s).
...an ear specialist, not a GP, prescribed multiple courses of gentamicin, without any blood tests, to treat an ear infection without result. A subsequent specialist found it was a fungal infection acquired from garden compost and cleared it with topical treatments.
The patient now has moderate to severe hearing loss as a side-effect of the gentamicin.
They would've been spared this outcome from a dangerous drug with known side-effects if their community pharmacist had been issued with a standard Treatment and Reporting form.
Same dog, different leg action?
Wouldn't the checklist at the pharmacist simply be a last-ditch defence which might catch the problem, but not solve it. The pharmacist is not usually the best place for a second diagnosis, but is the best place to *double-check* for potential problems with the medication (over-prescribing, potential side effects effecting existing problems, contraindications etc). I suspect the checklist would have been best employed at the specialist.