Updates from the BMJ

Preventing Stroke in Atrial Fibrillation

New guidelines have recently been published by the European Society of Cardiology on the management of patients with atrial fibrillation. They are summarised in the article New European Guidelines on Atrial Fibrillation BMJ 2011;342:d897. Two of the most important recommendations are the increased identification of patients at risk of stroke, and wider use of anticoagulants. The original CHADS2 score has now been replaced with the CHA2DS2-VASc system. Patients with each of the following demographics score a point (congestive heart failure, hypertension, diabetes, vascular disease, age >65 and female). Patients with each of the following score an additional 2 points: previous stroke or TIA, age >75. For a patient with a score of zero, no anticoagulant is required. For those with a score of 1 or greater, oral anticoagulants are recommended over aspirin 75mg. Although aspirin is still considered a reasonable option for patients with a risk score of zero to one following initial assessment, it is no longer the preferred option for most patients.

The new guidelines have been created following a wave of evidence of the benefits of oral anticoagulants over aspirin and new evidence has been released which shows that patients on warfarin or aspirin have a similar risk of bleeding. In addition, new oral anticoagulants are beginning to emerge which may replace warfarin in the future because they don't require therapeutic monitoring of levels. Dabigatran is a direct thrombin inhibitor that does not require therapeutic monitoring. Patients who are on warfarin presently and stable on the drug should not be changed to dabigatran but pending approval of the direct thrombin inhibitor, it may replace warfarin in the forthcoming years.

National Patient Safety Agency: NG Tube Placement

On a separate note but carrying on with the national patient safety agency theme, an article appeared in the BMJ this week on the topic of Checking placement of NG feeding tubes in adults. BMJ 2011;342:d2586. NG feeding tubes are frequently used for patients who develop dysphagia or those on ventilators in intensive care for short to medium term use as an alternative to longer term feeding via a PEG tube. Most NG tubes are inserted safely however there is potential for serious patient harm to occur should the tube become displaced from the stomach. Aspiration pneumonia following incorrect NG tube insertion can be potentially fatal. So how do we reduce the risk of this occurring? Testing acidity of stomach contents by using pH litmus paper is the gold standard first line check, with X-ray interpretation as second line. However, since 2005 in England there have been 21 reported deaths resulting from misplaced NG tubes with misinterpretation of xray images the leading contributary factor. This is a serious avoidable event, and in one audit, less than one third of junior doctors had received training on interpreting Xrays for misplaced tubes or were aware of existing guidelines. Ways to stop adverse events from occurring:

• Avoid placing NG tubes outside normal working hours wherever possible.
• Do not give NG tube feeding to patients at high risk of aspiration
• Do not place NG tubes without prior training including how to interpret the xrays
• Use the online website www.trainingngt.co.uk for guidance
• Do not flush the NG tube with anything until pH testing is completed
• pH level of between 1 and 5.5 is acceptable. No more.
• If no aspirate can be obtained or the pH level is >5.5, Xray request asking specifically for interpretation of NG tube placement. Ask a radiologist for interpretation advice if unsure.
• After radiography, clearly document decision and next steps for the patient eg. safe to use.
• Tubes should be checked once daily for correct placement and before giving feed or medication because they may have become displaced.

Scottish election - SNP win an overall majority

The major news in Scotland this week was the Scottish election. The map on the left shows the SNP (yellow) dominance and the Scottish National Party have won an overall majority in the Scottish parliament (Scottish election: SNP majority for second term). Like it or not, the SNP are going to be at the centre of any decision making processes in Scotland over the next five years, but what does this mean for healthcare and the NHS in Scotland? The SNP outlined in their manifesto that they would "ring-fence" NHS spending in their budget, but is this enough? Over the next five years the NHS in Scotland is going to need significant amounts of investment in order to carry on providing a high-quality service to its patients. Continuing with the current level of spending may not be enough. Scotland is facing an ageing population and the government is going to be expected to foot the bill of the countries increasing health burden. But where is this money going to come from? The SNP have said that they will freeze council tax for five years, so not from there. Prescription charges, they were abolished as well. Perhaps the SNP's proposal for minimum-pricing on alcohol will make a return to the forum after it was rejected last year. What will Scotland's reaction be to any proposed NHS reforms in England, will Scotland follow suit? Even the government in Westminster cannot seem to agree on the correct course of action (Clegg fights back with NHS pledge - BBC News). It has been quite widely commented that the SNP defeated Labour in the election due to Labour's 'negative' tactics in contrast to the SNP's 'positive' visions. I just hope that behind the promises and pledges which won the SNP the election there is a sustainable vision for the future of Scotland's economy. And what about the independence referendum? Surely that is something that the country can ill afford at this point in time and could turn out to be a costly waste of time. On the other hand, with the SNP winning such a large majority of seats in the government, perhaps Scotland will become an independent country within my lifetime. I never thought I'd see the day but all of a sudden it becomes quite a realistic, albeit concerning prospect. On one hand, the next five years could either be one of many successes and improvements for Scotland, but on the other it could be a very difficult one if the correct decisions are not made.

Patient Safety in the Undergraduate Curriculum

Furnace, near Inveraray

First photos from the rural GP placement here, one from Furnace with a view of Loch Fyne on the background, and another of Inveraray castle. Don't think it has rained a single day since I got here 3 weeks ago, maybe a first for the west coast of Scotland.

Inveraray Castle, home of the Duke of Argyll

I read the following editorial in the BMJ this week with interest: Paterson-Brown S. Improving patient safety through education. BMJ 2011;342:d214. According to the author "a window of opportunity exists to include training in human factors in undergraduate and postgraduate training". I thought that what we'd done over the past four months was pretty relevant, so submitted this to the BMJ as a 'rapid response'...

" Teaching undergraduate students about human factors and how to investigate adverse events should become part of the curriculum. In some places, teaching on this subject is already attracting the attention it deserves. Here, a small group of medical students undertook a selected study module in patient safety in their final undergraduate year. Clinical supervisors identified areas where patient safety was at risk, including shift handover, venous thromboembolism prophylaxis and oxygen prescribing. Using guidance from the Institute for Health Improvent, the students spent four weeks carrying out improvement projects using ‘plan, do, study, act’ (PDSA) cycles. The “bundles of care” or changes otherwise introduced resulted in improvements in patient outcomes by the end of the project period. The efforts resulted in benefit for the students who learnt about patient safety, and the patients who received better care. One way of teaching this subject is by investigating either incidents where errors have occurred or areas where improvement is required. Patient safety is not currently as high up the educational agenda as it should be. An opportunity exists now to introduce this into the undergraduate curriculum for the benefit of the next generation of doctors and patients."

I'm lucky to have had teaching on this already as an undergraduate but I don't think everyone is being given the opportunity at the moment. It seems to me that this is pretty important for all future doctors to know so I think the emphasis should be placed on teaching students, rather than postgraduates, in order to make improvements from the bottom upwards.