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NEWS: Henry Creagh More than 10% of hospital deaths could be avoided, conference is told BMJ 2008; 336: 852-a [Full text]

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25000 Deaths

Alan Fowler   (19 April 2008)

Re: 25000 Deaths

Phillip J. Colquitt   (20 April 2008)

VTE teams may help

Goran P. Koracevic, Svetlana Pavlovic, Dragan Milic   (21 April 2008)

25000 Deaths 19 April 2008
Alan Fowler, retired home CF31 1QJ Send response to journal: Re: 25000 Deaths	25000 hospital deaths a year in England from thrombosis after surgery is tragic1 because most of the deaths are preventable. The solution lies in a change in our hospital bed and chair culture. At home most people sleep on their sides with only one or two pillows. In hospital patients are usually given several pillows and the head of the bed is elevated, so they spend most of the time on their backs, slumped in a half sitting position and with the calves compressed. As early as possible they are helped out of bed to sit in a chair. This means that the legs are even further below the heart, impeding venous return. Moreover since the chair usually has a horizontal seat they tend to slump forwards, thus reducing chest expansion. The solutions involve radical but simple changes: 1.All hospital beds to have a regular upward tilt of the foot end. 2. Except in orthopnoea, only two pillows allowed, but the patient is sat up for meals. 3. Encourage patients to lie on their sides, however unsociable this may seem. 4. No patient who cannot walk to be put in a chair, unless it is a full ‘Recliner’. 5. All bedside chairs to have tilted seats to prevent slumping, cantilevered arms to assist rising and footstools to elevate the legs. 6.All beds to be fitted with poles to aid mobility and all rational patients to be instructed on how to operate electrically driven profiling beds. These mechanical measures are suggested as additional to current medicinal prophylaxis and pre-operative physiotherapy training such as ‘foot-pumps’ and ‘closed glottis breathing’ ie chest expansion without allowing air to enter the lungs. News Item BMJ 2008; 336:852 Competing interests: None declared
Re: 25000 Deaths 20 April 2008
Phillip J. Colquitt, Technician/RN Independent Comment Send response to journal: Re: Re: 25000 Deaths	Surgeons(registrars) and physiotherapists are the main protagonists in the "sit in a chair" culture. The legs are dependent, as you say, and the patient is used as boasting material for nurses who attempt to implement these questionable directives which are duplicated in what is optimistically titled "the care plan". In ten years, I've not seen anyone but nurses write in, or read, said care plan. So it's a real "team effort". Handover, that other idol of nursing worship, thus includes "she's(90 year old) been sitting out all day", followed by a massive chest expansion on the part of the reporting nurse. Meanwhile, the elderly patient is often slumped through sheer exhaustion and drug related CNS depression, and the first thing the oncoming shift hears from them is "can I please go back to bed?". When patients are left out by physiotherapists in a chair, and they happen to begin to look seriously unwell, it becomes an occupational health and safety issue to lift them back to bed. Beds in our facility(colon surgery) are about 50% four function electric, allowing elevation of the head, the bed itself as a whole, tilting of the whole bed either up or down, and elevation of the area behind the knees. The other 50% are odds and sods with a foot pump pedal for elevation. Our chairs seats are tilted backwards, and a spring loaded pin mechanism allows some personal seat height adjustment. Not that it matters much, because people who've had major colon surgery cannot tolerate being "bent in the middle", especially when their inevitable post -op ilieus distends their abdomen. Neither can they tolerate lying flat. So the well intended chair design produces the "cross lying" position often seen. Allocated space around the bed is minimal, and certainly well below that needed, and the massive bulk of the bedside chair impedes all access to the patient and their attachments on the relevant side, further compromising smooth delivery of care. I wouldn't have any trouble implementing a plan wherein the bedside chair did not exist, and the patient outcomes were equal to or greater than those with said chair. Competing interests: None declared
VTE teams may help 21 April 2008
Goran P. Koracevic, Head for VTE 18000 Nis Serbia, Svetlana Pavlovic, Dragan Milic Send response to journal: Re: VTE teams may help	The statements that “More than 10% of hospital deaths could be avoided” [1] and that “venous thromboembolism caused more than 25 000 potentially preventable deaths a year in UK” [2] are alarming and call for action at the same time. The chameleon among the diseases, VTE, has been world medical problem, i.e. worldwide more than half of all hospitalized patients are at risk for VTE [3]. As thoughtful, initiative to decrease “unnecessary mortality” should be widely accepted trough out the world. One of the best ways to go is to follow the recommendation form the UK expert group: on admission to hospital, all adults should have a mandatory documented risk assessment for venous thromboembolism [2] To our shame, such suggestions have been published as long as in 1992 and the response in practice was far from adequate! [4] Also, recent discussion in BMJ about VTE has been one of the most informative and thus valuable, because it gave portrait of current knowledge about the particular disease [5,6]. Namely, “mainstream” trends have been presented through the prism of different personal experiences of doctors, gifted in describing their opinions and feelings. For example, guidelines were bravely confronted with respectable personal experience [7]. (Audietur et altera pars!) Essentially, in decision making process, the way we generally act is probably synthesis of our medical education- based knowledge plus guidelines, plus personal experience and logic. As for debated numbers of patients dying from VTE in the hospital, most of studies are old decade or two, but even relatively recent one has not much better figures (5.2% of adult cases, published in 2004) [8]. In addition, old number (10%) came from best centers and it may reflect current situation in many regions in the world. In practice, we commonly do not think about VTE, as shown by the data that clinical suspicion (premortem) was raised in only 18% of the cases [9]. Even if we think, we usually miss, because of all patients presenting with symptoms suggestive of VTE, only 15–25% actually have the disease [10]. VTE remains the most common preventable cause of in-hospital death [11]. As distribution of risk factors for VTE, clinical presentation, modes of prevention may vary substantially from one department to another, and diagnostic possibilities have not been the same even in the neighboring cities / institutions, diagnostic VTE algorithms should be tailored according to the local situation. Optimization of the VTE prevention and management understand coordinated action of local experts from different departments. With this idea in mind, we formed The VTE team of Clinical Centre Nis 2.5 years ago. The Team has 16 members and 4 advisors, and we have paid much attention to education about VTE (Every good clinical action starts with education!), as well as to improve “diagnostic habits” for VTE and to shorten time needed for diagnostic procedures. One of our basic perceptions has been the following: doctors overlook VTE more commonly due to lack of including VTE as a diagnostic possibility then due to absence of basic knowledge about it. Thus, we made visual reminder- flyer that hangs in every emergency room in the Clinical Center. It contains list of risk factors for VTE; which symptoms and signs should arise suspicion on DVT and which are important for PTE; Wells score for PTE, photo of a swollen red leg, as well as typical X-ray of PTE; and finally what any doctor from any department should do before consultation of cardiologist or vascular surgeon. To conclude: 1. VTE team of motivated and educated doctors may help tailoring best guidelines to the local diagnostic and therapeutic possibilities. 2. An illustrative (and provocative) flier with crucial information and protocol for VTE should hang in emergency rooms to remind doctors on the most important preventable cause of death in the hospitals around the globe today. References: 1. Creagh H. More than 10% of hospital deaths could be avoided, conference is told. BMJ 2008; 336: 852. 2. Fitzmaurice DA, Murray E. Thromboprophylaxis for adults in hospital. BMJ 2007; 334: 1017-8. 3. Cohen AT, et al; ENDORSE Investigators. Venous thromboembolism risk and prophylaxis in the acute hospital care setting (ENDORSE study): a multinational cross-sectional study. Lancet 2008; 371(9610): 387-94. 4. Lowe GDO, et al. (THRIFT Consensus Group). Risk of and prophylaxis for venous thromboembolism in hospital patients. BMJ 1992; 305: 567-74. 5. D'Costa D. F. Prophylaxis for medical inpatients is not entirely proven. BMJ 2007; 334: 1127. 6. Atkins R. Thromboprophylaxis in orthopaedic surgery, a question of balance. Rapid Response, bmj.com, 25 May 2007. 7. Macdonald D. Modern Orthopaedic Surgery is not a "high risk" for thromboembolic disease. Rapid Response, bmj.com, 25 May 2007. 8. Alikhan R, et al. Fatal pulmonary embolism in hospitalised patients: a necropsy review. J Clin Pathol 2004; 57:1254-7. 9. Pulido T, et al. Pulmonary embolism as a cause of death in patients with heart disease: an autopsy study. Chest 2006;129:1282-7. 10. Ljungqvist M, et al. Evaluation of Wells score and repeated D- dimer in diagnosing venous thromboembolism. Eur J Internal Med, Corrected Proof. 11. Ageno W, Dentali F. Prevention of in-hospital VTE: why can't we do better? Lancet 2008; 371(9610): 361-2. Competing interests: None declared