Friday, 28 October 2011

A 0% complication rate procedure. Is it time to try it?

When a patient’s large bowel is brought out through the abdominal wall it is called a colostomy. This colostomy is placed usually on the left side of the abdomen. Many patients develop a bulge/hernia around this colostomy upto 70%. These bulges results in patients’ colostomy bags not fitting them properly, leakage and sometimes bowel obstruction needing emergency surgery. Very expensive, very risky. These hernias can be mended surgically but sadly the results are not so good with upto 77% recurrence of hernias around the colostomy after surgical repair.

But what really fascinated me was that

In 1977 it was published in the journal Disease of Colon and Rectum, American surgeons found that in 106 patients they had 0% parastomal hernia rate - no parastomal hernia - when the colostomy was brought out through the umbilicus (with an overall complication rate of 3.9%). The difficulty for open surgery in current practice would be the non-availability of the umbilicus because of the mid-line incision. That was the meeting's view.

My personal view is that this is mind blowing. Given the anatomical and evolutionary fact that intake and output orifices are in the midline (including the umbilicus before we are born), it now strikes me as strange why surgeons ever thought of placing stomas away from the midline. However, with the advent of laparoscopic surgery, the umbilicus is now available for stoma placement.  With a published 10% to 70% parastomal hernia rate and up to 77% recurrence of repaired parastomal hernias, the resources taken up in dealing with these are enormous; it looks like we could have a winning situation for everyone if we placed end stomas through the umbilicus. We could have dramatically better results.

I am not sure if anyone is willing to take this up but I wish someone would.

0% complication is what Successful Healthcare looks to me. It may not be possible in many areas but where we get a link to such a course we ought to vigorously pursue it


Tuesday, 4 October 2011

Healthcare desparate to spend more

I wonder if the NHS desperate to spend more
Two examples
If you look at old reports the NHS is supposed to save £337million by using Microsoft products. That is not an issue if Microsoft was the only software producer of exclusive products. Let us take the example of common office use software such as writers, spreadsheets, presentations etc. It is no secret that Open Office has been available for a long time now and is completely free; there are others such as Libre. They are all fully compatible with MS word. What prevents the NHS from using it? The arguments we get are usually as follows, the support provided by Microsoft which is crucial will be lost and the office software is only a small component of the services provided by Microsoft and is unlikely to make a difference. 

To be frank I have nothing against Microsoft or their products, I like them and use them. The point I am trying to make is that the NHS seems not too keen to look at every possible saving.

The recent re-organisation
From about 150 Primary Care Trusts the recent changes mean that NHS could end up having 500 commissioning organisations. Which could translate to 500 CEOs, 500 finance directors, 500 new logos and 500 new of everything.  Cannot be sure that it exactly translates like this, but at a superficial level it seems so. I sincerely hope that the improved quality that is aimed for is achieved.

These are surely an over simplification of issues but it is possible that we in the NHS have forgotten that it is small drops together that make an ocean.