Robust collaborative practice must become the bedrock of modern healthcare

Summary

This blog is part of a series written by Dr Charlie* taking a closer look at some of the patient safety issues affecting people's lives today. 

In this blog, Dr Charlie describes how although digital prescribing can work well it needs all those involved in the system to put their heart and soul into it. Families and patients must be involved, drugs prescribed must be regularly reviewed and care must be joined up.

*Names have been changed in this blog.

Content

My relative Connie* is 93 and was recently discharged from hospital after a stroke. She also has vascular dementia. She was put on the anticoagulant (blood thinning) medication apixaban. Anticoagulants are very useful in stroke prevention when someone has an irregular heartbeat but must always be weighed up against the risks of subsequent bleeding.

Connie has had frequent falls and the paramedics have been called on several occasions to take her to hospital or to get her off the floor. After one such fall, it was noted that she had significant bruising all over one side of her back and that she was in pain. She was reviewed at the local teaching hospital and there were further concerns that there may be an underlying cancer.

Communication problems

Connie was on iron for anaemia. Jane*, a family member, told me that she thought Connie was passing blood. Meanwhile, Connie had another appointment at the hospital which included a CT scan. Jane was told that Connie almost certainly had bowel cancer, but since she was not fit enough for an operation it would not be kind for her to undergo further investigations.

Jane became very worried about Connie who looked pale and was getting much weaker. When I learned that Connie was taking apixaban, I suggested that there should be a review of the multiple medications Connie had been prescribed. After several phone calls, Connie’s drugs were reviewed by a paramedic employed by her GP practice and her dose of apixaban was halved.

However, Connie’s general health continued to deteriorate. She had become very breathless, had no energy and felt very unwell. I know as a doctor that halving the dose of an anticoagulant when someone is potentially bleeding is no solution at all. Jane told me not to worry because Connie had an appointment with her GP.

A few days later, after Connie had seen her GP, I learned that the GP was indeed concerned, had stopped the apixaban and wanted an urgent hospital review. A phone call later that day revealed that Connie was seriously anaemic. Her haemoglobin result was 48 (normal range 120-140). The GP arranged for Connie to attend the hospital for an emergency blood transfusion. Jane and Connie were told that the blood will be ‘ready and waiting’ when they arrive at the hospital.

But after several hours, with Connie very uncomfortable sitting in a hard chair, Jane asked what was happening. Another blood test was required in order to get the transfusion. It took a while for the nurse to take blood successfully. Connie was dehydrated. But at least they had moved her to a bed.

Another couple of hours pass, and then the nurse explained to Jane that there was a problem because Connie had an unusual blood group. Jane was bewildered. She could not understand how this was not known about because she was well aware of this.

By the time the blood was ready for transfusion it was at the end of the day; it had to be given very slowly because Connie was in heart failure. After one unit, Jane was informed that she needed to take Connie home and return the next day because there were no beds in the hospital. Apparently, they were in an area that closed for the night.

Jane had taken a day off work to get Connie to the hospital. Nonetheless, she was given no choice and struggled to get Connie back home, but at least was told that the following day hospital transport would be arranged to fetch Connie for the second transfusion.

No joined up care

Two days later, Connie was less responsive and transferred by ambulance to A&E. In A&E Connie was diagnosed as having a progressive stroke. Jane was told this was because the apixaban had been stopped. Connie’s potassium levels were also very low, so while she was transferred to a ward for terminal care, the medical team had also started intravenous replacement of potassium. A couple of hours later, Connie was much improved and she got herself up and dressed. (Low potassium can mimic stroke by causing weakness.) A senior doctor tells Connie’s immediate family that she MUST have the apixaban reinstated.

Jane explained to the senior doctor that the GP and the consultant had diagnosed Connie with bowel cancer, and that she was deemed to be end of life and had required transfusion to increase her quality of life. The doctor told her that this was wrong. Connie should have attended her appointment at the ‘diverticulitis’ clinic and if she did not have apixaban she might become seriously disabled with a stroke.

Jane is by now upset and confused. Connie almost died because she was so anaemic after bleeding from her bowel and two days ago they were told that Connie had bowel cancer. In fact, Jane had been summoned to pick up the drugs to care for her at home in her last few days of life. Now another consultant had told her that this was incorrect and that Connie needed to go back on this anticoagulant drug. Jane asked me why there was no joined up care? Why were they upsetting her with such difficult choices?

Undoubtedly there are risks and benefits of each course of action, but what made it so difficult in this situation was that the different specialities could not see what had been written in the medical record despite the fact that Connie had only been treated in this one hospital – a major teaching hospital.

The decision to start an anticoagulant must be made when all the risks and benefits are looked at. It must be a holistic decision and informed consent makes sense only when done in collaboration with the patient and their family (in this instance Jane has power of attorney for health). In addition, this decision should be kept under review by a doctor who is able to make decisions. Connie is falling frequently and is at risk of a head injury as well as the fact that she was becoming anaemic to the extent that it was suspected that she was bleeding. The ‘tap is still running’ and so a prescription of iron tablets alone are not going to make the situation better. Despite Jane’s insistence that she could see fresh blood, there was still enormous reluctance to stop the anticoagulant and Connie could very easily have died as a result.

Once Connie was admitted to hospital, the care was not joined up and the non-medical family were then expected to understand the complexity behind the situation and asked to make decisions under less than ideal conditions.

Medications need to be regularly reviewed and risks recognised

How many more families are caught in similar situations? What safety nets are in place to enable people to get urgent reviews of the drugs they take? Although there are many more non-medical prescribers, including those who can start drugs like apixaban, these same prescribers are not qualified to stop them. The burden of illness due to the adverse effects of drugs is recognised and yet still the NHS has not taken the responsibility to make sure that every patient has their drugs reviewed whenever there is any change to their symptoms.

Digital repeat prescriptions make it easier for drugs to be kept on repeat without proper attention being paid to whether that drug is still required or to the dynamic nature of risk. Whenever a person’s health changes, there are new risks and any new prescriptions increase the potential for new drug interactions.

At every health encounter, there should be a mandatory review of the prescribed medication. But this would be inadequate without the accompanying information relating to other healthcare events, including appointments at other hospitals, community facilities or clinics. Patients alongside their representatives need to be involved because good communication remains the most vital component of any medication reviews.

Final thoughts

Surely the most sensible way for digital systems to exchange information must be by using the portal which is identified by the unique NHS number. But patient information must be accurate and the key to ensuring its accuracy is full collaboration with patients themselves.

In my experience the medical profession is still far too reluctant to listen to the voices of concern when they arise from patients and their families. It is time for robust collaborative practice to become the bedrock of modern healthcare.

Patient safety is more than just digital safety. It is also about knowing the people, knowing the patients, and working collaboratively and flexibly while having patients’ interests at heart. 

Read the other blogs in the series:

• Robbie: A homeless patient’s struggles with the system
• Digital-only prescription requests: An elderly woman sent round the houses

About the Author

Dr Charlie is an Emergency Physician with many years of experience working in A&Es in the UK. Dr Charlie also has a family with children and identifies as someone with extensive lived experience as a patient. Knowing what is possible and what is achievable even within imperfect systems, Dr Charlie has a passion to improve patient care.