Dr Robyn Holgate, Chief Medical Officer of ER24 Global Assist in South Africa, explains what it takes to guarantee patient safety in aeromedical transfers, and asks if there is more still to be done
Patient safety forms the basis of any clinical quality performance review nowadays. Since the 1999 report by the Institute of Medicine (USA), titled To Err Is Human, which estimated that as many as 98,000 patients die annually from preventable medical errors, many hospital-based healthcare providers are focusing on improving patient safety efforts. Growing financial pressures globally are forcing us to re-examine how we can better provide improved value in aviation medicine. These trends of more affordable service delivery are becoming the new norm. In light of these cost constraints and affordable healthcare solutions, are we doing enough to promote patient safety and clinical quality in the aeromedical environment? A small error in judgement could change the health of a country, hence it is critical that we implement systems within our aeromedical environment to keep our borders, healthcare providers and our patients safe.
checklists have been instrumental and invaluable in assisting us to achieve our patient safety goal
The healthcare sector initially looked towards the aviation industry to assist and implement checklists for our patient safety initiatives. No doubt checklists have been instrumental and invaluable in assisting us to achieve our patient safety goal of preventing human error in healthcare. Examples include Emergency Medical Care and Resuscitation checklists and the recent surgical safety checklist by the World Health Organization. In our own aeromedical environment, we have implemented checklists to manage equipment, pre-flight, in-flight and post-flight checks, and these checks have decreased the incidence of near misses. I recall a flight many years ago where I forgot the monitor, forgivable at 02:00 hrs? Fortunately, the flight was without incident. Checklists, discipline and teamwork that we have adapted have formed a critical part of all our patient safety initiatives at ER24 Global Assist. In order to ensure patients received the safest, most reliable care, we needed to move beyond a mechanical type environment with checklists to an integrated Quality Improvement programme which embraced the opportunity to provide compassion, dignity, discussion and empathy for our client base. Our programme thus includes a culture of safety, adverse event management, medication safety, teamwork and communication, trigger tools, and much more. For example, weekly safety meetings / team interactions, combined safety training and attending crew resource management sessions.
emphasis during our reviews has shifted from a traditional model of blame to that of a just culture
We have a confidential reporting system for adverse events, and the emphasis during our reviews has shifted from a traditional model of blame to that of a just culture. Following adverse events where a trend is identified, we have taken to releasing patient safety alerts internally. The very nature of our emergency business lends itself to adverse events, the human factor ever present. Examples of recent adverse events include dispatch delay and medication error. Although we receive less than one per cent of call volume as adverse events, less than international trends, we take every reported incident seriously, with the ultimate goal being to conclude our investigation and implement improvements to avoid a recurrence of such events. One such example is a recent adverse event where an opioid analgesic was used in place of adrenaline (Epinephrine) in an infusion; fortunately without any adverse effect for the patient. As a result thereof, all schedule analgesics are now kept in a separate pouch inside our drug bags, and resuscitation drugs are readily accessible. A small change as a result of patient safety reporting systems being implemented.
We have developed trigger tools to further support our passion for patient safety. These are our red flag incidents as well as prospective triggers to evaluate the health within our environment and these are reported monthly.
all schedule analgesics are now kept in a separate pouch inside our drug bags, and resuscitation drugs are readily accessible
Cost and clinical outcomes
Clinical cost efficiency is critical to sustain our business. We must strive to provide the best possible care while managing costs in order to keep our exceptional clinical reputation in a cost-sensitive environment. Clinical indicators such as response times (a two-hour activation time for international air ambulance cases subject to clearances and other logistical challenges), intubation (>80-per-cent first pass intubation success) and intravenous insertion success (99 per cent inserted in less than three attempts) are proudly equivocal to the best in the world. We have researched and acknowledge that mechanical ventilation is the gold standard for all our intubated and ventilated patients, hence we have invested in the best equipment to empower our team to do their best clinically, examples include the Hamilton T1® ventilator, Draeger®Oxylog 3000 plus and Zoll/Phillips ECG monitors with invasive pressure transducing and 12 lead ECG capability for cardiac/ haemodynamic monitoring, and point of care arterial blood gas monitoring. Our neonatal successes should be celebrated: our smallest baby transported by our speciality neonatal team weighed just 500g and we were able to initiate high flow ventilation. We re-intubated six per cent of our babies due to blocked or inappropriately sized tubes, and subsequently began weaning high percentages of oxygen (which is toxic in premature neonates) in the majority of our babies.
Where to next for patient safety initiatives?
Our goal is always to achieve and then to maintain or exceed our standards. We have international accreditation via NAAMTA, an achievement we are proud of, that will take significant effort to maintain. We have installed state-of-the-art software in our contact centre to ensure a faster, more accurate dispatch to any emergency with additional clinical resources to ensure our staff understand patients’ emergencies. The foundation for reviewing quality clinical performance has been achieved at ER24 Global Assist, our next step is to automate our reports, research and present our findings internationally.
About the author
Dr Robyn Holgate is the Chief Medical Officer of ER24. She started her medical career as an ICU and trauma nurse, and later completed her Bachelor of Medicine and Surgery (MBBCh) at the University of Witwatersrand in Johannesburg, South Africa. She's also obtained her MSc in Medicine (in Emergency Medicine). After gaining clinical and emergency medicine experience within the state sector, she moved to ER24 in 2009.
This article appears in the March 2019 print edition.