Sepsis
discuss the relationship between clinicians, caregivers, and children, which creates a complex decision-making environment and adds to psychological pressures. “There are a lot of things that caregivers bring
to a particular consultation – their anxiety since COVID has gone through the roof. Ten years ago, I wouldn’t see children presenting with only one day of fever every day in our emergency department. We regularly see children now who have had 12 hours of
fever.Add the pressure from parents to the limited information that healthcare staff have, and you can see how this becomes really challenging,” he commented. While tools and testing guidance are important, they alone won’t solve the problem of overprescribing of antibiotics. Social, systemic, psychological factors and cognitive bias must be addressed, he asserted. Prof. Roland outlined some key
recommendations for addressing key decision- making challenges across different stakeholders (see Table 1), pointing out that a comprehensive approach is needed, in order to have an impact. Technological solutions must consider the human factors in medical decision-making, therefore. “If you ignore the social or psychological
challenges that staff and caregivers face, we are not going to win on this, because it’s not going to be a number alone that is going to save patients’ lives,” he concluded.
Importance of flow The discussion continued with a presentation by Dr. Ed James, a Consultant in Emergency Medicine, at NHS Lothian. Dr. James is also a National Clinical Advisor for Unscheduled care, working for the Centre for Sustainable Delivery – focusing on Pre-Hospital and Front Door delivery
– and is currently supporting on redeveloping the Flow Navigation Service for NHS Lothian. During his presentation, he discussed how
system flow problems in the NHS impact critical care processes like sepsis identification. He pointed out that the NHS in England, Scotland, and Northern Ireland is not currently functioning effectively and this dysfunction undermines the systems and protocols that were designed for efficient environments. He introduced the audience to the concept
of ‘Little’s Law’ and a mathematical approach to hospital flow. (Little’s Law is a metric for seeing the velocity of a process and allows you to see how many items are in the queue of a production. It can be applied to any industry.)5 Presenting some occupancy data for a ward
in Edinburgh, he explained that, on average, a general medical unit had around 60 patients, with only 52 beds. This led to patients being
located “all over the place” – referred to as “borders”. Doctors have to undertake ‘jungle ward rounds’ – so called because clinicians have to seek out the patients. He revealed that they are aiming to reduce and maintain length of stay in Medicine of the Elderly (MoE) to 14.9 days. “Lord Darzi said that we need to drop occupancy rates to 80% and that occupancy in the NHS is coming in at 100% in some areas... Pretty much every hospital manager and senior clinician will say that 80% is not going happen. But we can be more subtle than that. We should be more subtle than that…and we can be a lot more specific. “We can say ‘all you need to do is reduce your length of stay by 1.5 days’ – then it seems achievable. You can give a local team, a local challenge, with a local quality improvement project to attempt to do that. Alternatively, you can say: can you reduce your admissions by one patient per day? That was the approach that we took in Edinburgh – we reduced our admissions by 2.3 patients per day and saved 30 beds,” he continued. So, why does this matter? Overcrowding
creates a “Where’s Wally” phenomenon, Dr. James explained. It creates significant difficulties in identifying critical patients. Sepsis identification relies on regular observation measurements (for NEWS2 scores), and each set of observations takes 215 seconds per patient. At 100% capacity (for example, in a department with 45 beds), 2.7 nurses are required for hourly observations. At 200% capacity (a daily occurrence), it requires 5.4 nurses. With record overcrowding of 155 patients, it would require 9.1 nurses (half the nursing staff) just for observations. Dr. James concluded that current sepsis identification systems were designed for
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