To grow into the future, we can start by looking at the past.
It’s an exciting time in medicine.
Treatments and diagnostics that we could only dream of a generation or two ago are now a reality.
Historically, for example, ongoing neurological deficit after an ischaemic stroke was considered inevitable. Now, interventional radiology allows us to physically remove the clot, and patients can make a complete recovery. The brain used to be a complete mystery, but with functional MRI we can see exactly which parts are active when someone completes a task, looks at an image, or even just recalls a memory. And these technologies bring great healing and hope to millions of people across the globe.
But all this innovation can have a downside.
We end up developing a habit of thought that says: “we need the most exciting things in our hospital to be the best.” But maybe we’re overlooking the simple things.
Let’s go back to the mid nineteenth century, to the obstetrics ward of a hospital in Vienna. There we will find a Hungarian doctor named Ignaz Semmelweis. Semmelweis worked in a training hospital that provided free maternity care to underprivileged women. There were two delivery wards. One for the training of medical students, and one for the training of midwives.
The clinic with medical students had an incredibly high rate of maternal mortality caused by “childbed fever”, now known as maternal sepsis. Pregnant women knew this and begged to be allowed into the midwives’ clinic. Semmelweis was distressed by the high mortality rate in the medical students’ clinic and set about finding out why. Around a similar time, a close friend of his died after being cut with a scalpel during an autopsy. Semmelweis postulated that particles from the cadavers caused both his friend’s death and “childbed fever”. This would explain the midwives’ much lower mortality rate, as they didn’t participate in autopsies.
Semmelweis began washing his hands in chlorinated lime and instructing the medical students to do the same. And he had extraordinary results. The mortality rate dropped drastically and matched that of the midwives’ clinic.
Unfortunately, the germ theory of disease had not yet taken hold, and Semmelweis couldn’t offer a clear explanation for his results. His ideas were largely ignored and mocked in the medical community, resulting in him losing his job. Distressed by women continuing to have preventable deaths, his behaviour became more erratic, and he wrote offensive letters to the leading medical journals of the day.
His wife had him admitted to an asylum, where he was beaten by the guards. In a tragic irony, he died later of a blood infection caused by wounds from the beating.
It is only after his death that his revolutionary work has been appreciated. We now know that hand hygiene is the single most important way of preventing iatrogenic harm.
It’s a sad story, so why bring it up? What can we learn from the story of Semmelweis?
Firstly, that it may be something that seems simple that makes the biggest impact. One criticism of Semmelweis was that it was too simple an explanation. Medical belief at the time held that the causes of childbed fever were different for each woman. The thought that they could ALL be caused by the same thing was considered farcical. But there can be the same reaction to Clinical Documentation Improvement.
Clinical documentation is common to ALL patient care, so universal that it seems simple, intuitive, and not needing change. But we know that up to 70% of all adverse events in health can be attributed to breakdowns in communication. And what is the primary way that clinicians communicate with each other?
The medical record.
When documentation is unclear, incomplete, or conflicting, it poses a major patient safety risk. How can we safely care for our patients when, at best, we don’t have the full story, and, at worst, we’re missing vital information? By encouraging clinicians to clearly document diagnoses, and link diagnoses to the appropriate treatment, CDI programs make the record a safe and complete communication tool for providers.
We might want the latest and best things, but the simplest – clear communication and good documentation – could have the biggest impact on our patients.
Secondly, new ideas can be resisted. We can see examples in much more recent history than Semmelweis. In the 1980s, the medical community was sceptical of the claim that peptic ulcer disease could be caused by bacteria. To prove his theory, Australian gastroenterologist Barry Marshall deliberately consumed a broth containing Helicobacter pylori. He demonstrated on gastroscopy he had gastritis then cured himself with antibiotics.
If only Semmelweis had such an elegant experiment to prove himself right!
If you’ve ever tried to educate on CDI, you’re probably not surprised to hear that people tend to resist new ideas. You might be familiar with such phrases as “We’ve always done it this way” and “I don’t need to be taught how to write notes”. But to continue to improve for our patients, we have to innovate, and embrace new ideas. And, after a little pushback, we often find that clinicians are glad that they’re involved in CDI. They see the benefits to the patients, the hospital, and themselves.
Even when they’re on board with CDI, some might still think it’s far-fetched to suggest that, one day, every hospital in Australia will have a CDI program. But really, given the massive impact on patient safety, funding, and data, the real far-fetched idea is that we can keep going with our clinical documentation as it is!
We all want to make an impact, and perhaps our next big impact will be improving our clinical documentation.
CDI is here to stay, and we need to get with the program.
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