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In healthcare, focusing on patients rather than populations is crucial. This review highlights cases from South Tees, showcasing the importance of evaluating care from a patient perspective. Each case reveals challenges and highlights areas for improvement, ranging from the timely administration of thrombolysis in strokes to the management of complex cases such as unruptured AAA. Despite the difficulties encountered, including issues with communication and diagnosis, these real-life scenarios provide insights into the multidimensional aspects of patient care and emphasize the need for continuous improvement and patient advocacy.
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We think about patients, not populations Reviewing from a population view is about what happened Reviewing from a patient view is about what should have happened Hindsight bias Poor care bias – even if it made no difference The Clinicians’ View
Most cases are fairly easy to scoreand in South Tees most are a Hogan grade 1 or 2
Aet 97 • Care Home Resident • Mild CFF due to IHD • PPM
Right sided weakness • Partial Anterior Circulation Stroke • Probably during night - found 0730 • CT at 0900 • Thrombolysis at 0944 - alteplase - direct consultant supervision • On stroke ward by about 1030 • Next day alert, sitting out, but aphasic
Good all round care • Some notes unclear or difficult to read • SALT done early • Good rehab • MDT plans by day 14 for placement
Around day 16 seems to have developed aspiration pneumonia • Appropriate re-review of swallow • Appropriate antibiotics and physio • ABG & DNAR • Drowsy • "Unlikely to survive" • But re-site cannula and vancomycin
Next day antibiotics changed on med micro's suggestion • And truly a good bit of intrusive care • Two more days before "ensure comfortable" • But still physio • Next day EOLCP • But only for hours
I am not wholly proud of this care, but it is a 1 • We plugged on too long with unpleasant treatment, neglect of palliation when we knew how guarded her outlook was • But it is still a 1
Aet 71 • Known AAA under surveillance • IHD • PVD
GP referral • Known AAA - 5.1 cm • Midline pain spreading through to back • A&E ? Leaking AAA
A&E noted AAA • CT aorta within 30 minutes of arrival. Not leaking but now 5.9cm • ? Renal colic, ? Diverticulitis • Admit surgeons • Discuss with vascular • Imaging shows no stone and no clear diverticulitis
Day 3 "pain over AAA ++" • Refer vascular • Seen later on, less tender, but pain is postural and radiates to back • MDT Friday
Several comprehensive reviews • All by FY1 in the night • No clear diagnosis made • All presumptive diagnoses trivial with no supporting evidence
Continued to have low grade reviews, pain but no progress • Day 7 0145 - it burst • In point of fact we didn't do that well with trying to fix it then, but as the presentation was PEA, Hb 5 the disorganised response was probably unimportant.
There were odd features in the presentation • But he wasn’t re-imaged and he doesn’t seem to have any high level reviews that actively questioned the putative trivial diagnoses • Our urgent AAA results mean his risk of death with surgery was very low
A big chap • Aet 76 • # NOF • AF – poorly controlled
Rate control with metoprolol • Operation went well • Back to ward looking OK
AF speeds up and BP falls • Nothing else obviously wrong • Med Reg gives advice on the ‘phone • More metoprolol • Immediate terminal decline • Bloods come back too late - Hb 6
The bleeding was not obvious • AF speeding up is common in these circumstances • Catastrophic bleeding is rare • So in the original team’s shoes…
