Critical thinking Matt Morgan: Fixing our broken wards BMJ 2019; 366 doi:

As I reach the top of the staircase a faded sign reads, “Block A, Tower 3, Wards 7F and 6G.” Nobody really knows what these characters mean or how they help to navigate the twists of an ever changing, expanding hospital. A patient looks up and down at a clutched paper letter, wondering if they’re going the right way. A hospital porter senses their disorientation and points them back towards the way they’ve already come.

As I approach the door of the ward, I see a line of relatives huddled around a buzzer with “ONLY PRESS ONCE” taped over its scratched buttons. Once a minute, once an hour, once a day? A busy nurse, looking after patients and supporting families, hears the buzzer’s call but can’t answer it. As I open the door with my access card, the opportunity is seized and families flow in. Through that one door come meals, x ray machines, dirty linen, nurses, doctors, patients, and dead bodies.

On the ward the relatives peer into different wings, looking for “bed 9 in the 4 bedder,” without knowing what that means. As an overflowing catheter bag is quickly carried to the sluice, the dinner trolley is manoeuvred to make room. The height of the desk at the nurses’ station is an awkward compromise—too low for my knees to fit underneath and too narrow to house a set of paper notes. As I squeeze in, the computer mouse falls to the floor, hanging helplessly by the wire and swinging like a pendulum. I feel the same.

I want to speak to the patient and her family. I think that the patient is going to die. The cloth curtains around the bed are too thin to contain this news from the well wishers next door, so I look for a more private area. (“Just use the office, it should be empty.”) I don’t want to use the office. This is a hospital ward. It should be the perfect environment to do all of this—for conversations to be spoken, for food to be eaten, for patient care to happen, and for medicine to work.

Yet the many hospital wards I’ve visited all over the world have a design that’s changed little since the late 18th century. It’s time to reimagine it. The general ward should have as much consideration as a shiny new operating theatre or boardroom.

Wards need separate entrances for utilities and families—even a circular design with dividing walls. Natural light and noise reduction technology would aid sleep, and communal areas would encourage socialising, rather than eating in a chair next to the bed. We need separate areas where intimate examinations, treatments, and even difficult conversations can happen. These should be large enough to house a hospital bed and a supportive family. We should replace faded signs and use floor maps, with directions to toilets and exits, that are shown to nudge human behaviour.

Think too about staff. Central workspaces should encourage thoughtful work with additional areas close to patients, for individualised care. Zoned areas could indicate different levels of need and safe “wander paths,” allowing movement even when patients are unwell. And ageing posters that fail to change behaviour could be replaced with art that encourages reflection and has been shown to aid recovery. Hospital needs to be a place that promotes healing, not one that simply delivers it.

Read the full article here.

Expanding neverland —applying never events management to hospital infrastructure

It had been a tough weekend for our colleagues. They had to deal with a complex patient in cardiac arrest. Yet the response team took days to get to them. This decline was hardly a surprise, the warning signs were there in the notes months before. Chronic ill health, previous missed opportunities to intervene with a failure to engage with difficult palliative care conversations. Had the case been examined in detail, a DNAR decision would probably have been in their best interests. Yet instead, there was a mad scramble to treat all reversible causes while the team tried to keep blood flowing through the system at short notice.

This may sound a sadly familiar story, but we are not talking about a patient. We are not even talking about a human. We are talking about a sudden break in the critical physical infrastructure of a hospital that was predictable, should have been prevented and responded to without the necessary skills nor urgency. As the NHS creaks into its 71st year, hospitals up and down the country will echo these events. Cables will break, pipes will burst, and lifts will stop. These are all predictable events. The important thing is that prevention can work and a rapid response should be rehearsed. The day of the week, the time of night or the hospital manager on duty should not matter just as it does not for patients when they are sick. A sick hospital means that all patients are at risk and a proportionate response should be elicited.

In 2009 the NHS implemented a “never events” policy to improve patient safety. The list of never events included wrong site surgery, in-patient suicide, and wrong route medications. It was hoped that this list would allow focus on detection, investigation and action with reports shared with care commissioners. It has long been taught that before offering help, you should first “check the scene is safe”. The physical structure of a system is a core component of safety for both patients and staff. It is about time that never events are extended to organisational events and non-clinical staff. 

We propose that the never events list should include:

  • Malfunctioning safety systems during an event such as fire detectors, sprinklers and circuit breakers.
  • An inadequate or untimely response to critical infrastructure systems failure including water, electricity and transport.
  • Serious injury to staff from known, predictable risks including asbestos exposure, non-compliant building regulations or structural damage.
  • Failure to address staffing gaps that are known about that result in patient or staffing harm.

If it is right to call proximal patient harms events that should never happen, then surely it is right to apply these same standards to the wider hospital structures that endanger the many as well as the few.

Tom HolmesConsultant in Intensive Care Medicine.

Matt Morgan, Honorary Senior Research Fellow at Cardiff University, Consultant in Intensive Care Medicine and Research and Development lead in Critical Care at University Hospital of Wales, and an editor of BMJ OnExamination. He is on twitter: @dr_mattmorganMatt’s first book, Critical—science and stories from the brink of life is available to order now www.drmattmorgan.com.

Competing interests: None declared

If you missed it, have a listen to this BBC Radio London interview with the lovely Jo Good https://www.bbc.co.uk/sounds/play/p07bhgym.

Whose choice is equipoise in clinical trials

Doctors constantly strive towards what is best for patients. Good doctors try to make accountable decisions based on integration of clinical experience, medical evidence and patient preferences – a stable three legged stool that is safe to sit on. Great doctors do the same but realise that such decisions can only ever be based on the best evidence at that time. Ultimately such decisions may in the future be shown to have been wrong.

With less than one in ten interventions in critical care being based upon high quality evidence(1), we must be honest with ourselves and our patients. Although public awareness programs and quality improvement initiatives are common, these should be based upon best evidence driving knowledge translation for patient benefit. It may come as a surprise that these uncertain treatments include even simple concepts such as how much oxygen we should use when people are critically ill(2). Admitting this uncertainty about fundamental treatments can be hard.

In order to improve the care of our patients, we need to advance the evidential basis for our own practice. This involves addressing the remaining nine out of ten interventions that lack evidence head-on, challenging assumed, potentially outdated, or frankly wrong knowledge. This comes from a position of equipoise.

Even when trials are based on acknowledged evidence gaps, then funded, designed and delivered, we stumble against a new barrier – equipoise. Whilst the trial committees, funders, ethical committees and collaborators all maintain equipoise, individual treating doctors will sometimes prevent trials from being conducted in their own institutions. Their reasons are noble – they want to do what they feel is right for patients and be early adopters. The problem is that feelings do not save lives

Things that we have felt to be right in the past have a regular habit of actually causing harm(3-5). Some people feel best in the safe, understandable and predictable world of demonstrable physiology at the bedside as an end in itself. Understand and correct the physiology and you can deliver treatments that feel right. However, whilst physiology is important, adaptive physiology in critical illness is complex and instead we need to strive towards meaningful patient outcomes as the stick by which to judge our feelings.

Getting the right balance is hard. How should “equipoise” be decided (5)? Should it be by country, by hospital, by department or by an individual? We worry that an individual’s feelings about what works and what doesn’t may negatively impact on clinical trials. They may restrict sites from contributing towards important research, reduce recruitment rates, increases the costs of research, waste public money and ultimately be bad for patients. More than 30 years ago Benjamin Freedman writing on ‘equipoise and the ethics of clinical research’ suggested that the concept of ‘clinical equipoise’ should refer to genuine uncertainty in the expert medical community rather than on the part of individual investigators(5). Despite the passage of time researchers still find themselves encountering the same issues today.

As most trials in critical care are funded from the public purse, we need an agreed solution. There should be a social responsibility for equipoise as we strive to create new evidence for patient benefit. Too often the lack of generalisable medical evidence means that complex decisions are based only on clinical experience and patient preference. The original stable, three legged stool becomes too unsteady to safely sit upon. The development of clinical research networks both in the UK and internationally can help, outsourcing difficult evidential challenges to those best placed to balance them. This allows individual clinicians to focus on the job of integrating their outputs with clinical experience and patient preference whilst allowing equipoise to answer the questions for which uncertainty presides.

Matt Morgan is an Honorary Senior Research Fellow at Cardiff University, Consultant in Intensive Care Medicine and Research and Development lead for critical care at University Hospital of Wales, and an editor of BMJ OnExamination. He is on twitter: @dr_mattmorgan. His first book “Critical – Science and stories from the brink of life” published in May 2019.

Matt Wise is a Consultant in Intensive Care Medicine and Research and Development lead for Specialist Services at University Hospital of Wales.

Paul Dark,Consultant in Critical Care Medicine, NIHR Clinical Research Network National Specialty Lead for Critical Care and Chair in Critical Care Medicine, University of Manchester. He is on twitter: @DarkNatter

Disclosures/conflicts: none. This work is original.

  1. Zhang Z, Hong Y, Liu N. Scientific evidence underlying the recommendations of critical care clinical practice guidelines: a lack of high level evidence. Intensive Care Med. Springer Berlin Heidelberg; 2018 Jul;44(7):1189–91.
  2. Schjørring OL, Perner A, Wetterslev J, Lange T, Keus F, Laake JH, et al. Handling Oxygenation Targets in the Intensive Care Unit (HOT-ICU)-Protocol for a randomised clinical trial comparing a lower vs a higher oxygenation target in adults with acute hypoxaemic respiratory failure. Acta Anaesthesiologica Scandinavica. 2019 Mar 18;18(15):711.
  3. Chohan SS, McArdle F, McClelland DBL, Mackenzie SJ, Walsh TS. Red cell transfusion practice following the transfusion requirements in critical care (TRICC) study: prospective observational cohort study in a large UK intensive care unit. Vox Sang. 2003 Apr;84(3):211–8.
  4. Cooper DJ, Rosenfeld JV, Murray L, Arabi YM, Davies AR, D’Urso P, et al. Decompressive Craniectomy in Diffuse Traumatic Brain Injury. N Engl J Med. 2011 Apr 21;364(16):1493–502.
  5. Freedman B. Equipoise and the ethics of clinical research. N Engl J Med. 1987 Jul 16;317(3):141–5.

The car seat of life

While stuck in an angry snarl of traffic during another grey morning commute, I had time to contemplate the view from the car’s rear-view mirror. If this was the “family car” then the back seat would be decorated with children’s toys and crayons. It might be messy, but would reflect adventure and discovery and excitement. Instead, my commuter vehicle had two neglected child seats. In contrast, on the front passenger seat there was a horror show of adult mess and misgivings. I couldn’t help but think the universe was trying to tell me something. Welcome to lessons from the car seat of life. 

I had ricocheted through a busy run of clinical shifts. The faces of the many patients I had cared for still occupying my mind. Over the past week I felt I had done my bit for humanity. However, while you can largely leave the patients at the hospital, it is the “curse of extra tasks” that follows you home. We want to help the greater mission and therefore we volunteer left and right. However, every “sorry to bother you but…” and “can you just help out for a sec” adds up and takes away. So I covered a locum shift here, attended a meeting there, tried to co-write a paper, delivered extra teaching, and squeezed in a conference call or two, or three. The resulting early arrivals and late departures could be tallied in the lines under my eyes. We might recognize the toll of overwork in our morning mirror, but this time it was writ large in the passenger seat to my right. 

Instead of a lovely conversant human sitting next to me on my drive, let me describe the detritus of my week and the self-recrimination that followed:

–      Fast food wrappers: one for every meal and beverage shoved or guzzled. Was I reduced to such low-grade fuel just to keep my engine going?  

–      A mobile phone charger and cable: my lifeline to the world which I scrambled to recharge after my phone died. How long had I lived with the spectre of being called back at all hours and never really getting away.

–      A mouldy apple core: a vain attempt to reach my five-a-month let alone five-a-day. What does it say when you don’t eat right and don’t clean up compost? 

–      A chocolate bar wrapper: a “pick me up” because of missed meals and lousy sleep. Can you really make up for lost sleep and time?

Some of your car seats may look like this all the time—and perhaps that is fine. I am not here to moralize only to reflect. The point is that mine is normally empty and clean and as uncluttered as my mind. This state of affairs was not normal. It could just as easily have been a blinking light on the dash. I really shouldn’t ignore this, but who has the time? Perhaps it is more accurate to admit that I had temporarily forgotten my priorities.

There may be other areas of your own life screaming out a warning. My polite suggestion is that you dedicate time and space to listen. For example, does your refrigerator routinely contain food well past its sell by date? Are you wardrobe hangers empty because your clothes are conducting a protest on the bedroom floor? Do you climb over unopened mail by your front door? Do you routinely forward yourself emails because you can’t bring yourself to deal with them now. This is not piety, and I am not suggesting that cleanliness is next to godliness. Instead the issue is that modern life may leave you feeling that you no longer have time for general maintenance or self-care. When you get so distracted that you fail to do what is now known as “adulting”. These routine chores used to be the cornerstone of everyday life. Clean your shoes, brush your hair, and tidy your room. Get the little things right and the rest will follow. 

The following week, I tidied up my car seat of shame. I also tried to hit reroute. I cancelled a meeting, I turned down a locum shift, I excused myself from a conference call, and I got a half decent sleep. Small steps but at least I felt a little more in control. My car seat was clean and my life was a little manageable. I then borrowed the family car and threw the kids in the back seats. We headed out for a quick adventure that coincided with the route that I cover on my morning commute. The kids made a shocking mess of the back of the car. In contrast to feeling distress, it felt like a clean start and a fresh perspective. I have a way to go but am getting better at enjoying the journey.   

Matt Morgan, Honorary Senior Research Fellow at Cardiff University, Consultant in Intensive Care Medicine and Research and Development lead in Critical Care at University Hospital of Wales, and an editor of BMJ OnExamination. He is on twitter: @dr_mattmorganMatt’s first book, Critical—science and stories from the brink of life is available to order now www.drmattmorgan.com.

Peter Brindley, Professor of Critical Care Medicine, Medical Ethics, Anesthesiology at University of Alberta, Canada. He is on twitter @docpgb

Disclosures/conflicts: none. This work is original