Sosena Kebede, MD, MPH
“The physician must … have two special objects in view with regard to disease, namely, to do good or to do no harm”
(Adopted from Hippocratic corpus- a collection of medical works associated with Hippocrates and his teaching)
Addis Abeba, May 29/2020 – This simple statement that describes the fundamentals of healthcare is as ancient as the practice of medicine itself and timeless in value. The principle is taught to many medical students in Latin as “Primum non nocere” or translated as “First Do No Harm”. The science of patient safety and quality is a reiteration of that precept and a recognition that sometimes, despite our best efforts and good intentions harm can be done to our patients while they are in our care. In 2016, a study by Makary and colleagues reported that in the United States an estimated 250,000 people die each year due to medical errors making it the third leading cause of death after coronary disease and cancer. Medical error has been defined as “an unintended act (either of omission or commission) or one that does not achieve its intended outcome”.
What makes healthcare especially hospitals a potentially dangerous place for patients if we don’t adhere to quality standards? And, what are those quality standards? An accepted definition of quality standards from the Institute of Medicine (IOM) describes the concept as one that is “safe, timely, effective, efficient, equitable and patient-centered”. Each of the six components of quality deserves a discussion of its own but that is beyond the scope of this commentary. Instead, here are some common patient safety considerations to remind us what is at stake in the time of Covid-19 when there is an anticipation of increased demand for healthcare services including for intensive care unit (ICU) in resource constrained countries like Ethiopia.
* Barotrauma: Some patients who are unable to breath effectively on their own may need to be hooked to a machine temporarily that can breathe for them while they continue to receive treatment. This can be lifesaving. However, lung intubation (the process of inserting a breathing tube inside the wind pipe of a patient that is then attached to an external machine, a ventilator, that will do the breathing work for the patient who is unable to breath effectively on his/her own) even when done by highly skilled critical care personnel can result in lung punctures that can be fatal.
*Neuropsychiatric/delirium: up to 1 in 3 patients who spend more than 5 days in ICU will experience some form of neuropsychiatric side effects including psychotic reactions. This is much worse if patients are intubated which requires them to be on medications to paralyze and sedate them that put patients in sensory deprivation and immobilization while their body may concomitantly be undergoing high stress conditions including pain. The elderly are particularly at the highest risk for this outcome and the symptoms may persist months after hospital discharge. COVID-19 patients tend to require prolonged intubation which puts patients at even higher risk for these complications.
*Venous thromboembolism: blood clot formation in the extremities (Deep Venous Thrombosis or DVT) and blood clots in the lungs (Pulmonary Embolism or PE) can happen in up to 30% of ICU patients. COVID-19 patients are at even higher risk for blood clot formation and require regular blood thinner administration.
*Hospital Acquired Infections (HAI): patients who stay in the ICU often need intravenous (IV) catheter insertions into one of their main veins (called central lines), urinary catheters for voiding, and feeding tubes to get their nutrition. Unless meticulous sterile procedure is used, each of these insertions, in addition to the breathing tube in their windpipes can be a source of Infection. The Centers for Disease Control (CDC) estimates close to 99,000 Americans die every year due to HAIs. It is hard to imagine what the prevalence of HAI would be in health facilities where there is poor access to water and sanitation facilities.
*Gastro-intestinal Bleeding: the high risk of gastro-intestinal bleeds in prolonged intubation requires routine use of gastric acid suppressants.
*Motor deficits: due to a combination of immobility and medication side effects critical illness polyneuropathy/myopathy which manifests as muscle weakness and nerve damages can be seen in ICU patients and requires early mobilization to mitigate it.
*Hemodynamic derangement: because of rapid fluid and electrolyte changes and multi-organ system involvement seen in most ICU patients, they need close monitoring of their vital signs and checks on their heart, kidney, liver, and central nervous system functions to intervene in a timely fashion.
*skin ulcers: skin ulcers can form from prolonged bed confinement and poor nutrition as well as traumatic ulcers from skin puncture for injections and these skin breakdowns in turn could be additional portals for infections.
Hospital care including ICU care can be life-saving and important for the management of some Covid-19 patients. However, the inherent risk of healthcare associated complications must be discussed openly so that healthcare providers and patients can work together to reduce this risk to the absolute minimum. Harm reduction to our patients should start by reducing unnecessary medical contacts-contacts with hospitals, medications or procedures as well as by carefully analyzing the risk/benefit ratio of every procedure in relation to each individual patient.
Championing the principle of disease and disability prevention and the empowerment of patients to maximize their health outside of the healthsystem will always be the best we can do for patients. If and when healthcare services are needed the success of patient safety is achieved by a collaboration between a vigilant healthcare system and a well-informed public that jointly make judicious use of services that avoid excess harm in the line of care. AS
Editor’s Note: Sosena Kebede, MD, MPH, is the founder and Executive Consultant of HealthCare Engagement, LLC that provides quality improvement services to health systems and patient engagement trainings to community members. She is an internal medicine physician who worked for the Johns Hopkins Health System (JHHS) for several years on various capacities including as an Assistant Professor of Medicine at the School of Medicine, as Health Policy Instructor at the Bloomberg School of Public Health, as Patient Safety and Quality Consultant at the Armstrong Institute for Patient Safety and Quality and as a Primary Care Physician at one of JHHS’ community physician sites.
She can be reached at firstname.lastname@example.org