When doing your 'best' isn't enough

Summary

Blog by critical care outreach sister, Claire Cox, on a typical night shift and how it led her to the Darzi Fellowship.

Content

I am a critical care outreach sister. I have spent much of my time caring for the sickest patients in the hospital – usually in crisis.

I was on a night shift when I was asked to review a patient.  A 93-year-old lady with beautiful red nails. I shall always remember that. As we are not allowed nail polish for work, I always admire others’ nails when mine are thin and brittle from constant hand washing.

She was admitted with a chest infection following a fall at home. The nurses asked me to review her as they were unclear of the plan (escalation plan). I called the registrar on call, who suggested we wait until morning for the ward round and her consultant could decide. The registrars reasoning for this was that ‘he didn’t know her’.  He did know that she was frail, had multiple co-morbidities and had a CURB score of 2 – but that is another story! She was unable to articulate what she wanted, which begs the question... is this really the right time to be asking her what her wishes are?

The registrar’s actual words to me were: “just keep her alive until the ward round”.

She was a very chatty woman, disorientated – but you would be at midnight, in the dark in a place you didn’t know. We had a giggle about each other’s nails, and I left.

She was having hourly observations and a trickle of fluid.

4am I attended a cardiac arrest call.  It’s the lady I saw earlier.  My heart sank. I knew that resuscitating her was futile. Not only that, but I felt uncomfortable doing CPR, the nurses around me feel uncomfortable doing CPR, this feels wrong. So very wrong.

CPR is performed. I have tears in my eyes. The nurses doing CPR have tears in their eyes. Her tiny frame being pushed, ‘assaulted’ in such a violent way, was distressing.

After 30 minutes of CPR my patient with the beautiful red nails was declared dead.

The doctor calls the next of kin, her daughter. The daughter arrived on the ward at 5am.  The doctor and myself escort her into a tiny, hot windowless room.  The doctor explains what has happened.  His final words to the daughter were: “we did the best we could”. 

What?!

I’m sorry. No that was certainly not the best ‘we’ could have done. That was the final straw.  I needed to do something that was meaningful and could change, even just a tiny part of this monstrous system we have created. Hence, I embarked on the Darzi fellowship.

The pied piper of system change

So, I found myself in a position where I could make a difference. During my time on the Darzi fellowship I went through the systems within systems of learning from deaths and avoidable harm. Complex is a too simple a term to describe it.

I organised a ‘systems change day’ in January 2019. All parts of the system, including patients and relatives, CEOs , commissioners, you name it, came. The aim of the day was to find out the bottlenecks in this system and attempt to stop these events happening over and over and over again. It is not just the ‘bad’ deaths, but the near misses, the ‘one off incidents’, the ‘it won’t happen here’ incidents. I know, you have heard these phrases before. I have heard them countless times.

The recommendations from the day were:

● To involve clinicians in uncovering good and bad practices and find innovative solutions to reduce risk.

● Involve patients, citizens and families, not only with the investigation process, but find innovative solutions to reduce the risk of it reoccuring.

● Ensure standardised, competency based training to anyone conducting a clinical investigation.

● Involve the investigation team on the ‘shop floor’.

● Improve the relationship between citizens and families within the Trust.

● Reconsider the way we measure safety – are we measuring the right things?

● Use a standardised approach to investigations nationally.

● Consider a new model of care to allow governance of large hospital Trusts to be shared to allow improved access to information.

What I can be sure of is my strong belief that this is the right thing to do.  If it is not a success – we tried.  It may be the wrong time to try, but we tried.  Everyone coming to that meeting had guts. Guts to say, “we are not doing our best – but what can we do to change?”

About the Author

Claire is an experienced nurse of over 20 years. She has worked in numerous specialities in the NHS and in different places around the world, from being a repatriation nurse to volunteering in refugee camps and striking up collaborations with nurses in the USA. Since 2011, Claire has worked as a Critical Care Outreach Sister where her desire for patient safety was ignited.

After winning the Kent Surrey and Sussex Patient Safety Prize in 2016 for her work in cardiac arrest and medical emergency teams, Claire went on to complete the Darzi fellowship in April 2019. During Claire's Darzi year, she met Helen Hughes from the ‘systems change day’.  It was here that Claire and Helen recognised that they both shared the same passion for patient safety.  It was a natural progression into Patient Safety Learning that has allowed Claire to pursue her passion alongside a like-minded group of passionate people.