Fiona Moss

Neurological aspects of hyponatraemia

Hyponatraemia is a common biochemical finding, but clinical features due to it are infrequent. They are most likely to occur when the plasma sodium concentration has fallen quickly to below 120 mmol/litre. In a study of 73 hyponatraemic individuals, it was possible to identify four categories of patient, the clinical features becoming more severe as the sodium level fell. In 25 instances there were no effects (mean plasma sodium 118·3 mmol/litre), in a further 25 cases there was confusion only (mean plasma sodium 117·1 mmol/litre), in 13 there were focal neurological signs and in 10 there were convulsions (mean plasma sodium 110·8 mmol/litre). In the group with convulsions there were six deaths, the four survivors all being young women. The 13 cases of ‘focal’ neurological signs included three instances each of hemiparesis and monoparesis, seven of extra-pyramidal disturbance and six of cerebellar ataxia. All these abnormalities resolved when the plasma sodium concentration rose to 125 mmol/litre. Active measures to raise the plasma sodium level are only needed when there have been convulsions and the aim should be to achieve a value no higher than 120 mmol/litre. In other cases, the only treatment required is to restrict fluid intake.

Alternative models of organisation are needed.

Anyone considering a fundamental rethink of the role of consultants risks exposing tensions in the medical profession that have characterised the development of medical practice since the 18th century. That tense story was one of beds and money, power and domination. Rethinking the role of consultants must now take into account the relationship between consultants and their specialist colleagues and general practitioners; examine the distribution of work between consultants and junior doctors; and relate the contribution of the consultant as specialist to that of other health professionals. After half a century of a national health service characterised by equity of access to care, we urgently need to debate the roles of those who work in it and in doing so to focus primarily on the needs of patients.

Severe hypernatraemia in adults.

In a prospective study of abnormalities of plasma sodium concentration carried out over one year 20 patients were identified who had a concentration exceeding 154 mmol(mEq)/1. Of these, eight patients had diabetes mellitus, eight had primary intracranial disorder, and four had become dehydrated. Five of the eight diabetics presented with hyperosmolar, non-ketotic precoma, and in all eight hypernatraemia developed despite treatment with hypotonic (0.45%) saline. There was a good correlation (r = -0.93) between the rates of change of plasma sodium and blood glucose concentrations, and thus a rise in plasma sodium concentration appeared to be a consequence of the treatment. In the early phase of treatment urinary sodium loss was extremely low despite a brisk diuresis, the infused sodium then predisposing the patients to hypernatraemia. All of the eight patients with intracranial disorders showed evidence of abnormal production of the antidiuretic hormone, six having frank diabetes insipidus. Severe hypernatraemia in this group was associated with a high mortality, fluid balance being difficult to maintain. Two of the four patients who had become dehydrated had had a recent gastrointestinal haemorrhage. In these patients infusion of 0.9% saline contributed to the hypernatraemia since urinary sodium loss was low. Severe hypernatraemia in adults is uncommon, but in established cases plasma and urinary biochemical indices should be measured frequently. Monitoring of the central venous pressure is usually necessary, and patients are best managed in an intensive care unit.

The importance of quality: sharing responsibility for improving patient care.

In health care quality is usually understood in the context of “clinical quality” and an implicit distinction is drawn between managerial and clinical activity. The separate introduction and development of quality initiatives within the NHS has contrived to accentuate the different notions of quality that follow traditional “tribal” divisions within hospitals. Nurses often led quality assurance programmes, while doctors took up medical audit, and managers found that risk management programmes had something to offer their professional concerns. The recent directives to develop clinical audit go some way to addressing these divisions. But the onus of meeting the patients charter initiatives has provided yet another separate focus for quality improvement within hospitals.nnIn other organisations quality improvement is often linked to the concept that quality should be a characteristic of the whole organisation. The process of quality improvement and quality control in the industrial and business world is dominated by the theory and application of total quality management (TQM). This approach to management developed after the second world war when Japanese industrialists, keen to compete with other economies, engaged American experts to advise on the application of statistical techniques to the production process. These advisers, who included W Edwards Deming and Joseph Juran, understood that documenting the technical quality or the specifications of components on a production line would not in itself produce lasting improvement in the quality of production. Instead, by introducing principles and techniques drawn from a wide range of disciplines, they advocated the development of an internal approach to quality improvement, where everyone in the organisation is part of a continual drive to do better. Together, these principles and techniques are described as TQM. The successful results of the application of this approach to manufacturing by the Japanese are well known.nnMuch has since been written on TQM …

Learning from failings in healthcare: a challenge for all healthcare systems

Might Mid Staffs be a turning point? The most important single change in the NHS in response to this report would be for it to become more than ever before a system devoted to continual learning and improvement of patient care, top to bottom, end to end. 1nnReactions to significant and public failures in healthcare in the UK, and no doubt elsewhere in the world, trigger forensic inquiries. The aim, after finding out what went wrong, is to draw out lessons with the aim of ‘ it’ never happening again. Each inquiry, whether small and internal or large and statutory, publishes a report with recommendations. These reports make difficult reading for anyone working in healthcare. For although the context and clinical details are never quite the same, they point to similar and familiar failures. The latest public failing in the UK has triggered not one but two inquiries and three reports: a report followed each inquiry with a third from an expert group, chaired by Professor Don Berwick, charged with taking the lessons from this latest failing and specifying what changes are needed to make the National Health Service (NHS) a safer health system. Will this third report, written to, and for, everyone in the NHS, make a lasting difference?nnThe context for the Berwick report is the care provided at Mid Staffordshire Trust, a district hospital in the English West Midlands. Concerns about standards and the safety of care, and a higher than expected death rate, alerted the regulator, the Health Care Commission, which in 2009 investigated this hospital and published a report very critical of standards of care. There followed reports by the Department of Health and, later in 2009, the Secretary of State for Health commissioned an independent inquiry chaired by Robert Francis QC, which reported …

Writing is an essential communication skill: let's start teaching it

Its none of their business that you have to learn how to write. Let them think you were born that way. - Ernest Hemingway nnEveryone knows that good communication skills are crucial for the delivery of high quality patient care. Breakdown in communication between patient and professional is a frequent element of those episodes of care that result in disaster.1 Although not formally taught as an explicit specific set of skills until the latter part of the 20th century, communication skills are now included in all undergraduate and many postgraduate health care training programmes. Such teaching is mostly concerned with the skills need to listen to and talk with patients: to help them articulate what is wrong and explain what might be the cause; to express what is troubling them and to help them make informed decisions. In simulated teaching, the interactions between health care professionals—what they say and how they say it—receive the attention of those observing how a team works as a unit. But very few health professionals are taught how to write, though a paper in this issue of PMJ suggests that they can be.2nnClear and accurate writing is also important for good patient care. Writing that lacks clarity, is ambiguous, or is simply unfathomable can also hinder important communication within teams …

Looking after the staff who care for patients: an essential investment for good quality care

Evidence from many sources relates the quality of team work and team functioning to the quality of care. In short, being cared for by teams that function well, rather than those that do not, improves the quality of care and reduces the risk of both complications and death. If team working were a ‘drug’ it would be prescribed prophylactically to all patients on entry to any healthcare system. The characteristics of both good and poorly functioning teams have been defined. We know what is needed, but the process of changing teams behaviours or developing those that function well seems difficult and takes even longer than introducing an effective intervention into everyday practice. A recently published report provides interesting details about the characteristics of the working environments and cultures in those organisations found to deliver better and safer care than average and suggests that good staff engagement is an important distinguishing feature.nnHealthcare is complex and team working is therefore not straightforward. Patients with a single condition may depend on several teams for their care—sometimes all at the same time. Take, for example, someone being diagnosed with lung cancer. Care starts with their primary care team followed, perhaps, by referral to a respiratory team and then onto a surgical or oncology team. But within each of those stages there will be others involved this persons care: the phlebotomy team; the endoscopy team; the pathology team. And, within each of the clinical teams, there may be defined sub-teams including nursing teams and medical firms.nnComplexity cannot be used as an excuse for tolerating …

On the recording of notes: information from patients is of little use if not recorded

Learning about “the consultation” and developing from novice to expert starts early as medical students get to grips with the parallel tasks of understanding the first steps in clinical decision-making, learning the questions prompted by particular symptoms, and setting out to become good communicators. First attempts are invariably awkward, but as experience and knowledge accrue, it all comes together and a consultation that would take a first-year student hours can be accomplished in a third of the time by a Foundation doctor.nnThe outcome of that process is a note in the record that describes all the key findings and either then or later includes a record of the management plan. Over time the record is extended and includes notes about progress, response to treatment, and all events up to discharge from care. The record is thus a key document in communicating findings, discussions, decisions, plans and actions to everyone concerned in the care of that patient. Yet how much attention is paid to the quality of these notes?nnMuch emphasis is, correctly, paid to the …