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We think about patients, not populations Reviewing from a population view is about what happened Reviewing from a patient view is about what should have happened Hindsight bias Poor care bias – even if it made no difference. The Clinicians’ View.

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Presentation Transcript
the clinicians view
We think about patients, not populations

Reviewing from a population view is about what happened

Reviewing from a patient view is about what should have happened

Hindsight bias

Poor care bias – even if it made no difference

The Clinicians’ View
slide5
Aet 97
  • Care Home Resident
  • Mild CFF due to IHD
  • PPM
slide6
Right sided weakness
  • Partial Anterior Circulation Stroke
  • Probably during night - found 0730
  • CT at 0900
  • Thrombolysis at 0944 - alteplase - direct consultant supervision
  • On stroke ward by about 1030
  • Next day alert, sitting out, but aphasic
slide7
Good all round care
  • Some notes unclear or difficult to read
  • SALT done early
  • Good rehab
  • MDT plans by day 14 for placement
slide8
Around day 16 seems to have developed aspiration pneumonia
  • Appropriate re-review of swallow
  • Appropriate antibiotics and physio
  • ABG & DNAR
  • Drowsy
  • "Unlikely to survive"
  • But re-site cannula and vancomycin
slide9
Next day antibiotics changed on med micro\'s suggestion
  • And truly a good bit of intrusive care
  • Two more days before "ensure comfortable"
  • But still physio
  • Next day EOLCP
  • But only for hours
slide10
I am not wholly proud of this care, but it is a 1
  • We plugged on too long with unpleasant treatment, neglect of palliation when we knew how guarded her outlook was
  • But it is still a 1
slide12
Aet 71
  • Known AAA under surveillance
  • IHD
  • PVD
slide13
GP referral
  • Known AAA - 5.1 cm
  • Midline pain spreading through to back
  • A&E ? Leaking AAA
slide14
A&E noted AAA
  • CT aorta within 30 minutes of arrival. Not leaking but now 5.9cm
  • ? Renal colic, ? Diverticulitis
  • Admit surgeons
  • Discuss with vascular
  • Imaging shows no stone and no clear diverticulitis
slide15
Day 3 "pain over AAA ++"
  • Refer vascular
  • Seen later on, less tender, but pain is postural and radiates to back
  • MDT Friday
slide16
Several comprehensive reviews
  • All by FY1 in the night
  • No clear diagnosis made
  • All presumptive diagnoses trivial with no supporting evidence
slide17
Continued to have low grade reviews, pain but no progress
  • Day 7 0145 - it burst
  • In point of fact we didn\'t do that well with trying to fix it then, but as the presentation was PEA, Hb 5 the disorganised response was probably unimportant.
slide18
There were odd features in the presentation
  • But he wasn’t re-imaged and he doesn’t seem to have any high level reviews that actively questioned the putative trivial diagnoses
  • Our urgent AAA results mean his risk of death with surgery was very low
slide20
A big chap
  • Aet 76
  • # NOF
  • AF – poorly controlled
slide21
Rate control with metoprolol
  • Operation went well
  • Back to ward looking OK
slide22
AF speeds up and BP falls
  • Nothing else obviously wrong
  • Med Reg gives advice on the ‘phone
  • More metoprolol
  • Immediate terminal decline
  • Bloods come back too late - Hb 6
slide23
The bleeding was not obvious
  • AF speeding up is common in these circumstances
  • Catastrophic bleeding is rare
  • So in the original team’s shoes…
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