Systems engineering in healthcare - a personal UK perspective.

Increasing demand and growing complexity of the delivery of healthcare is associated with worsening performance in safety, delivery, quality and affordability. Systems engineering (SE) is an established body of knowledge that is widely used outside healthcare in domains such as aerospace and communications. Healthcare represents a complex adaptive system (CAS) and a combination of 'hard' and 'soft' systems engineering techniques have been successfully combined and piloted in primary, community and secondary care improvement projects as part of an emergent programme for developing embedded NHS capability in healthcare systems engineering. The current barrier to wider adoption appears to be a gap in awareness, belief and capability but the mounting evidence from a growing number of healthcare systems engineering (HCSE) practitioners is that this capability chasm can be crossed.

Systematic kidney disease management in a population with diabetes mellitus: turning the tide of kidney failure.

PROBLEM: A significant proportion of patients with diabetes mellitus do not get the benefit of treatment that would reduce their risk of progressive kidney disease and reach a nephrologist once significant loss of kidney function has already occurred. DESIGN: Systematic disease management of patients with diabetes and kidney disease. SETTING: Diverse population (approximately 800,000) in and around Birmingham, West Midlands, UK. KEY MEASURES FOR IMPROVEMENT: Number of outpatient appointments, estimated glomerular filtration rate (eGFR) at first contact with nephrologist, number of patients starting kidney replacement therapy (KRT) and mode of KRT at start. STRATEGY FOR CHANGE: Identification of patients with low or deteriorating trend in eGFR from weekly database review, specialist diabetes-kidney clinic, self-management of blood pressure and transfer to multidisciplinary clinic >12 months before end-stage kidney disease. EFFECTS OF CHANGE: New patients increased from 62 in 2003 to 132 in 2010; follow-ups fell from 251 to 174. Median eGFR at first clinic visit increased from 28.8 ml/min/1.73 m(2) (range 6.1-67.0) in 2000/2001 to 35.0 (11.1-147.5) in 2010 (p<0.006). In 2010, the number of patients starting KRT fell 30% below the projected activity using 1993-2003 data as baseline (p<0.003). The proportion starting KRT with either a kidney transplant, peritoneal dialysis or haemodialysis via an arteriovenous fistula increased from 26% in 2000 to 55% in 2010. LESSONS LEARNED: Systematic disease management across a large population significantly improves patient outcomes, increases the productivity of a specialist service and could reduce healthcare costs compared with the current model of care.

Lower limb acute compartment syndrome after colorectal surgery in prolonged lithotomy position.

PURPOSE: Acute compartment syndrome in patients undergoing prolonged colorectal procedures is uncommon but can have catastrophic consequences for the patient with the development of metabolic acidosis, myoglobinuric renal failure, Volkmann's contracture, limb loss, and death. The potential to produce long-term disability in a patient has important medicolegal implications, particularly if the complication is avoidable. Why only some patients develop acute compartment syndrome is not fully understood. The purpose of this study was to highlight current knowledge and suggested prevention strategies. METHODS: A review of the relevant English language articles was performed on the basis of a MEDLINE search of the keywords: acute compartment syndrome, lithotomy position, reperfusion injury, and fasciotomy. RESULTS: Different factors play a role: lithotomy position with or without head down, ankle and knee position, external compression for deep vein thrombosis prophylaxis, method of leg support, duration of surgery, and physiologic factors, such as gender, age, and body mass index. All efforts should be directed to prevent the establishment of acute compartment syndrome and there are accepted suggestions, such as limiting the time of leg elevation, positioning the leg below the atrium level, and monitoring postoperatively patients at risk. There is still debate on the intraoperative use of pulse oximetry to detect hypoperfusion and the appropriate use of sequential compression devices and antithromboembolic stockings. CONCLUSIONS: Acute compartment syndrome is uncommon but cases have been reported after prolonged pelvic procedures in the lithotomy position and it is a preventable condition. More research is required to set clear guidelines on patient positioning during surgery.

Digital photography in wound care.

Many nurses caring for patients with wounds do not have access to a medical photographer and have attempted to capture wound images as an unambiguous record of wound status. This often forms part of an initial wound assessment and is used throughout the treatment programme.

The identification and diagnosis of malignant leg ulcers.

Leg ulcers are predominantly managed by nurses working in primary care. One audit has suggested that 34 per cent of leg ulcer patients receive treatment without a documented diagnosis (Moffatt and Harper, 1997). Malignant leg ulceration is an uncommon condition but several recent reports suggest that its prevalence is increasing (Taylor, 1998; Yang et al, 1996). Tests such as tissue biopsy, which are required to exclude the less common causes of ulceration, are currently outside the role of the primary care nurse who has a vital part to play in referring patients to a specialist for further detailed assessment. This article raises awareness of the types of malignant leg ulcers and the clinical features associated with them.

Telemedicine: a new model of care.

An estimated one per cent of the population will have a leg ulcer and prevalence increases markedly with age (Angle and Bergan, 1997). At any one time it is estimated that 100,000 patients have open leg ulcers that require treatment. This treatment is mainly repeat dressings over extended periods of time, carried out by community nurses. This is estimated to cost 600m Pounds each year in the UK (Logan, 1997). Improving healing time for leg ulcers and reducing recurrence leads to an improved quality of life for patients and their carers in addition to major cost savings for the NHS.

Telemedicine: an innovative way of managing patients with leg ulcers.

The optimal management of patients with leg ulcers requires a multidisciplinary approach, with contributions from both community and hospital specialists to identify, investigate and treat the underlying causes, provide patient education, assess healing and dress the wounds, monitor outcome and prevent recurrence. However, current practice is impaired by the limited communication between community and hospital specialists. There are inconsistencies in methods of transferring and updating patient records between the hospital and the community, and this can lead to confusion over the diagnosis and appropriate management. Telemedicine, the electronic exchange of medical information at a distance, would appear to offer a way to establish an efficient and effective communication link between hospital and community specialists involved in the care of patients with leg ulcers. The authors of this article believe that modern information technology and the existing NHSnet information infrastructure could be employed to create such a link via electronic patient records.