August 2017
‘my patient needs me’: the traffic is just too busy. Nowadays the on call registrar will have varied experience and competencies and will not necessarily be safe to perform a reopening, especially as they may not have a competent assistant. I suspect we are all very similar - we hate it when our patients are struggling or suffering complications. Part of that is that we take our responsibility very seriously and their struggle may be due to our actions. The extreme example of this is when a post operative patient arrests. First of all you find out who the patient is and whether they are under your care - and when you find out it is indeed your patient your brain rapidly tries to think of the reasons for the arrest and what solutions may be possible. It is a sickening feeling. In my early consultant years a patient following CABG was bleeding on the unit. I was called from home being told that the patient was unstable, was having cardiac massage and was about to be reopened. I couldn’t get to the hospital quick enough. I drove too fast. I pushed my way to the front of the traffic lights. I might have even carefully gone through a red light. I rushed up to the unit. The registrar was doing internal cardiac massage and informed me that he had inadvertently ripped the IMA graft off the LAD. A few weeks later I related this story to my ‘mentor’ Joe McGoldrick, surgeon at Leeds. He stopped me exactly at this point of the story and asked ’So what do you do next?’ I replied - ‘control the bleeding, call the perfusionist, establish bypass’ (this was before off pump surgery was established)
Thankfully the patient went home well a few days later with all grafts intact, having established bypass on the ICU. So fast forward to 2012 and we had a divisional away day at the Boro’s ground (they weren’t playing) - the surgeons had a break out meeting and we thought of our future plans:
“In my surgical training it was a ‘given’ that the operating surgeon took responsibility for their patients post operatively. This made a lot of sense as it was this surgeon who would know the intricacies of the complex cases and therefore was best placed to advise and action any problems.”
Joe said ‘No, none of that! The first thing you do is pretend its your colleague’s patient’.
Out of the blue Steve Hunter suggested that we should consider whether the on-call surgeon should be responsible for all the reopenings.
I laughed because I knew he was right. When you reopen a colleague’s patient you lose most of the emotion and you become more objective, but you still do an equally professional job.
We hadn’t really considered this before, but we agreed it was certainly worth trying. Fundamentally we trusted each other to look after each others patients and the basic agreement was that the on-call surgeon
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should always come in for the reopening and not let the registrar be unsupported. In retrospect this decision was helped in that we had similar practice portfolios and an existing working harmony to build on. We had some anxieties... would we be less meticulous closing the patients if we thought a colleague would be reopening it? Would our colleagues let our patients bleed too much before reopening the patient or... Would our colleagues have too low a threshold for reopening the patients and make our quality markers look worse? May I add that as a unit at this time we were not performing well on our reopening rate and our anaesthetists and theatre team were unimpressed by the number of call outs. Five years on and its fair to say that this model of care has been a great success. First of all, there is even more pressure to make sure the patient is dry at the end of a case as you don’t want your colleague to be disturbed. There is nothing worse to start than the morning text saying that they had to reopen your patient in the night. Secondly, when you go home after an operating day you can truly relax. You know your colleague will do a great job if there are any issues with your patient. Thirdly, and most importantly, this change of culture in association with audit / reflection, has brought a very significant reduction in our reopening rate and also our mortality and length of stay. Another unexpected consequence was that it brought the team further together. No longer was it ‘my patient’ or ‘my results’ but it was more about the overall performance of the unit and the benefit to our patients. In this national survey there are three other units that have adopted this practice. As yet we have not explored the reasons why they perform this way nor whether it works for them and their patients. This model may not suit all units and time will tell if this is a temporary variance from established practice or whether it sets the scene for other units to try. n