Systems approach to patient care

Wednesday, January 4, 2012

The last weekend of the regular season in the NFL presents some games that are meaningful and to the victor, a spot in the playoffs is the reward. Some games are less important and teams who have secured their playoff spot often rest their star players. And of course, there are games where players play for pride because their year will soon come to an end. In the midst of all these scenarios, Matt Flynn, the backup quarterback for the green Bay Packers, stepped into a starting role for one game and set records for passing yards and touchdowns. There are a variety of possible explanations but one that may be most plausible is that Mr. Flynn stepped into a system that increased the chance for success.

Systems have finally made their way into medicine and new generations of students and residents are taught to care for patients in ways that might increase patient outcomes, decrease mistakes and minimize potential complications. While this may sound like an assembly line approach, it tends to work when critical care that needs to be provided crosses many physicians and specialties. The multiple injured patient challenges many hospitals and those that are designated trauma centers tend to provide care in an organized manner. Practice scenarios are repeated so that doctors, nurses and support services like lab and x-ray know their roles, where to stand and in what order tasks must be done.

Ring the initial evaluation and resuscitation, an ideal team has many members including two physicians, two nurses, an assistant and a scribe. The lead physician is stationed at the head of the table and is in charge. There should be only one person giving orders, otherwise it becomes chaotic. He is also responsible for evaluating the upper part of the body including the airway. The second physician is stationed at the side of the patients and looks after the torso and extremities. The nurses split the duties of IV access, medications and monitoring. The assistant often helps with placing tubes into the patient, as well as helping move the patient safely. The scribe is key in documenting the play by play since too many things happen too quickly for everybody to remember. It prevents medications from being given too frequently or being forgotten.

Once the patient is stabilized, lab, x-ray and other tests may be needed and moving the patient is a finely choreographed skill that needs cooperation between many people. Often it is difficult to know if a spinal cord injury is present and the patient is handled carefully to prevent paralysis. Log rolling a patient to check the back for injury or to move them onto a board that will allow transfer to a CT scanner or other treatment area takes many hands, especially if the patient is comatose or combative.

Aside from the staff, there are diagnostic and treatment guidelines used to help with diagnosis. It’s too easy to miss a significant problem if more than one catastrophe is happening to a patient and attention is diverted one and the other ignored. More than just a checklist, it’s a repetition of the physical examination and reviewing the diagnostic test results that help minimize the miss rate. And good diagnostics leads to good therapeutics. Knowing that a problem exists is the first step in beginning to treat it.

In the past, ill patients were surrounded by too many good intentioned people and more than a few gawking bystanders drawn to the scene as they wandered through the ER. Streamlining the system makes a difference and allows parts of the team to be interchangeable. That recognition probably hurts the egos of a few physicians but that is the tradeoff that a well-oiled machine brings to the bedside. Better care tends to occur when physicians fit the role they are supposed to play.

There is always a captain of the ship and that is the physician at the head of the bed. Decisions and responsibility fall come with the job but success depends upon the team. It might be the same mantra that could be attributed to Matt Flynn, a quarterback who stepped into a good system, who was surrounded by a fine supporting cast and who succeeded in his role.

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