WELFARE Flashcards
PERSONAL HEALTH ISSUES - ANAESTHESIA
- Supports
- mentor, maintain networks
- avoid professional isolation
- ensure continuing PPD - ensures contact
- Recognise times of high stress - ensure sufficient support - SELF-Care
ABC - ACTIVE(physical, social, mental)
BELONG - join in socialise
COMMIT - hobbies, acquire skills, volunteer
HALT - Dont be Hungry, Angry, Late Tired ( arrival)
I’M SAFE Illness, Medication, Stress, Alcohol, Fatigue Eating
Take stock of life once a year
HEALTH CARE Formal consults ( no corridor) Dont self diagnose or medicate Have a GP - use them as POC - dont self refer specialist Health screen - dental, opthalmic Consider family history
WORK ORGANISATION Ensure breaks Recognise yourself as an expert not slave Take sick leave/ leave when neccessary Take rec leave regularly Upskill yourself
HOME ORGANISATION
Ensure home help
Children - child care, date night
WHO YA GONNA CALL?
Colleague, Mentor, GP, SOT, Psych, Lifeline
FINANCIAL ISSUES
Seeking Advice - consider registered financial planner - have a plan for professional and personal life -review regularly - Private Practice vs Public
TAX INSURANCE - personal, housing SUPERANNUATION - LEGAL DOCUMENTS - EPOA, estate plan FINANCIAL CHECKLIST
DEPRESSION AND ANXIETY
ISSUES:
Doctors tend to deny issues, poor help seekers.
mental health stigma
inertia of severe depression
SUSPECT dep:
Sad face, performance, mood, motivation, interest, withdrawl, weight up/down, deterioration self care, sleep problems, absenteeism
suspect anx
increased apprehension about mundane tasks
increased resistance to new or difficult tasks
absenteeism
Suggestions:
Share concerns. Discuss trusted colleague, consult psychiatrist if necessary
May be able to approach a spouse or partner with concerns.
Someone must take responsibility to make the approach. Someone who has the capacity to affect the subject’s career path MAY not be the best person
RUOK?
May take several attempts for the individual to accept help.
Devise plan , rehearse fall back strategies. eg recontact 48hrs until person has “heard you”
Intervention is best done with person’s GP
IF ITS AFFECTING PATIENT CARE
discuss issues with trusted colleague or employer
if affecting performance and they refuse help they need to be reported to registration authority.
CRITICAL INCIDENT SUPPORT
PATIENT / RELATIVES
- breaking bad news
- open disclosure
INDIVIDUALS
Debriefing process
retain confidentiality
support must be customised to individual and situation
- process must all individuals to discuss individual and team-level performances, identify errors made and develop a plan to improve performance.
- approach relevant department (legal) to receive guidance before appraoching patient (if required)
- Record FACTS of case, contact MDO
ADVERSE EVENT
RCA conducted and any findings addressed.
anaesthetic department to deal with results of mishap(RD11)
INDIVIDUAL SUPPORT
Private room
professional directly involved = second victim
may need intensive support - support should be offered ASAP after incident.
BE empathetic . Professional psych may be neccessary
Their response to incident is variable depending on level of training, resilence, past experience, personal support networks, coping skills
Debriefing and support should be offered on individual basis and reinforce an individuals natural recuperative process. May need to be offered more than once.
Debriefing should be customised to their needs.
Distress should be acknowledged (response varies over time). Potential for PTSD or Adjustment disorder
Formal counselling should be provided by recognised and trained psychologist.
Peer support
consider time off work
relief from further duties until feel able to return
single session debriefing ineffective in preventing PTSD, may have negative effect on pre existing psych disorders. so formal / mandatory process may be harmful
Neccessary non clinical downtime - paperwork , legal, unofficial debriefing.
MDO notified
Colleague chosen as a mentor may assist with compiling the necessary documents.
debriefing should be documented
Root cause analysis - may help second victim
Departmental education to break perceived stigma or accessing support services.
Legal action = greater need for long term support
GROUP SUPPORT
group debriefing may be worthwhile better in regular rather than ad hoc teams.
support personnel need specific training
groups deal better with group issues
a psychologist could be introducted to the group
HOSPITALS
Provide adaquate training for CIS issues
all members need to know who department support person is/are
Careful consideration will need to be given as to whether or not individual should interact with family. Family may need closure
anxiety to debriefing may be alleviated by regular exposure (eg sims)
CONFIDENTIALITY - must not jeopardise future career prospects
Sexual misconduct
Notifiable - engaged in sexual misconduct in connection with practice of the practitioner’s profession
Misconduct: power or age differential, accessing pornography, current patient.
degree of dependence, evidence of exportation
length of relationship
Community expectations
Unique relationship, power imbalance, vulnerable pateint
Breaking Bad News
Plan and rehearse strategy
Do the job well - maximise acceptance of bad news
apologise but not to admit fault” i regret that this has happened”
Open disclosure
STEPS
Private room - no distractions
Support person - for family and for you if needed
Junior doctor to learn
Establish identity of person youre tlaking to
Sitting same level - body language is appropriate
Check knowledge of person ; consistent story from treating team
Fire a warning shot - “im afraid i have bad news””
Do not use Jargon
Allow pauses
Express sympathy without accepting any blame
Acknowledge and verbalise - youre upset
Check understanding - would you like me to repeat
Elicit and address concerns
Support services
Further contact may be necessary
Document
SPIKE EM
Setting Patient Perception Invite Information Knowledge transmission Emotions and Empathy Summary and Strategise
After a major mishap
Anaesthetic Environment/List/Equipment
Other Anaesthetist/DA arrange for equipment and anaesthesia systems/drugs/equipment to be isolated if applicable.
Arrange for a relief anaesthetist to carry on with immediate duties. Consideration should be given to all staff involved.
The other anaesthetist should inform ward staff, hospital admin, referring doctors.
Where incident may lead to medico legal process. Follow hospital policy notify management and relevant insurers.
An account of facts of the mishap as known at the time of writing should be drafted as soon as possible - should not speculate.
Very important - if medicolegal
Discuss account in draft form with mentor/MDO
DO NOT ALTER ANY EXISTING NOTES MADE DURING CASE
Patient/Relatives
other anaesthetist arrange for NOK to come to the hospital
structured team interview should be arranged ( proceduralist and anaesthetist should be present.)
TEAM DEBRIEF/SECOND VICTIM
Immediately after event may be a need for informal defusing of emotions’; this may include all staff involved in the incident. Potential for distress much be acknowledged.
Counselling and organisations providing professional support after a critical incident may include GP++
Contact a senior colleague/friend and notify duty anaesthetist
Recognise second victim potential for ongoing personal stress following a major mishap.
ISOLATED ANAESTHETIST
Regular Leave - Every 3 months - rec leave, sick leave PPD
LOCUM - employ to cover leave, give handover, orientation, must have contract outlining duties and responsibilities
CPD / CME Peer Support Group (online) Professional Organisations (Rural SIG) Colleagues (Local/Rosters group) Mentor Liason - facilitate leave Regional referral centre - make links ICU - establish link with nearest regional centre Privacy- set personal/professional limits Health and GP - stay fit active
IMPAIRMENT IN A COLLEAGUE
can be said to occur when a colleague’s behaviour consistently departs from the expected behaviour set out in these codes of conduct, and impacts on his or
her performance, and thus the safety of his or her patients
Physical/Mental ….. acute/chronic, temporary, permanent
DIFFICULT ISSUES
Anaesthetists work in isolation.
Recognition of impairment is difficult, even when the colleague is well known to you.
Confidentiality must be maintained, although mandatory reporting laws (see Australian
law below) may require you to breach confidentiality where patient safety may be
jeopardised.
“Mandatory reporting” has the potential to cause concern in doctors treating other
doctors, because of confidentiality issues. If patient safety is thought to be jeopardised,
then reporting takes precedence.
The practice of a colleague whom you suspect to be impaired may deviate minimally or
significantly from accepted standards.
Intervention and management may be complicated.
You may wish to give support, but you must avoid condoning poor behaviours or
practice.
As an anaesthetist, you cannot become a “treating” doctor, (ie creating a situation of
“Duty of Care”), by engaging in clinical advice to a potentially impaired colleague.
However you can give advice as to which avenue(s) of professional help might be
appropriate.
HOW DO YOU RECOGNISE IMPAIRMENT?
Nursing or anaesthetic assistant staff may report unacceptable behaviour, or incidents of
concern, or may complain about the colleague’s work. (Personality clashes must be
distinguished from impairment).
You may observe unacceptable practices.
Peer review, QA and accreditation systems may help in the early identification of
impairment.
Family members may report concern about the colleague’s health.
CONSDIERATION Early INtervention CONFIRM REPORTS (difficult) Privacy Discuss concerns with seniors Potential medico-legal problems consult MDO Do not take on a duty of care All concerns documented Criminal activites should always be reported Support person Time to listen Sick leave/retirement options
PROACTIVE MEASURES
Buddy/Mentor systems
GP!!! avoid self diagnosis etc etc
ERGONOMICS
moral and legal obligation promote safe work place
aware of OHS check lists
scanning environment, check risks incl fire
get patient to move, use pat slide, hover mat
Bend knees blah blah stay healthy.
SUBSTANCE ABUSE
Raising Awareness and Being Prepared -proactive program in departments - education and recognition ?sustance misuse committee health and ethical issue - therapeutic strategies rather than employment'/criminal
SUSPICION AND RECOGNITION
DIRECT EVIDENCE - IV needle/cannula in doctor or observating his/her use of injectable agents
Critcal Call MET if neccessary Do not leave doctor alone Relieve doctor of clinical duties Notify HOD Notify duty psychiatrist - immediate escorted admission to in patient detox centre
IF AGREES to stop work and be admitted, notify regulatory authority APHRA, when convenient - next day
If refuses - then an immediate notification to regulatory authority must be made.
MAJOR SIGNS
- gathering information and require reporting, planned intervention
Injection marks on body
Observation pill, syringes, IV equipment in non-workspace environment
Direct evidence of diversion, self administration, misuse, false records (illegible, inaccurate)
Inconsistencies in recording drug use in patients.
CONSISTENT pattern of complaints regarding excessive pain by recovery or ward staff, pain out of proportion to given drugs
Reports of change in attitudes or behaviour
Observed withdrawal symptoms (tremors)
Observed intoxicated or bizarre behaviour
CIRCUMSTANTIAL
AT WORK
Long sleeve gowns - conceal arms (IV) sensitivity to temperature
Spots of blood on clothing
Increased sick leave/absenteeism
Unavailability, irregular hours, poor punctuality
Working alone, refusing breaks, relieving others
volunteering more cases
leaving patients unattended
carrying syringes or ampoules in clothing
being in hospital out of hours when not on duty
increasing time in toilet or bathroom
intoxicated behaviour, pin point pupils, weight loss
increased accidents or mistakes
frequent moving/changing jobs
unexplained absences while at work
AT home/work
overspending
deterioration in relationships
elaborate rationalisations/biazarre conduct
deterioration in personal hygiene
health concerns expressed by family memeber
social withdrawl
wide mood swings. / significant changes in behaviour
Collection of evidence possibility of reports being true - challenging situation maintaining confidentiality patients potentially at risk anaesthetist is significantly at risk Discretion should be required
PREPERATION AND RESPONSE
may be achieved by overview by senior colleague or delegate
If possible talk to a colleague who has had previous experience of a team member misusing substances
reports will need confirmation by internal investigation
Protection of patients and suspect
If event suspicions are not confirmed case should be dismissed but a report filed with records of HOD
Verification of Abuse
retrospective audit may confirm suspects escalating drug usage.
Careful observation for signs and symptoms is essentials to produce definitive evidence
all evidence documented
process may take some time
IF there is definitive evidence relevant authority bodies must be informed.
INTERVENTION
Denial is frequent, intervention should not be attempted on insufficient evidence
More rapid intervention should be considered if major signs of this illness have been observed or documented eg self injection
INTERVENTION PLANNING
HOD Psych, senior colleague
Medical board must be informed of the circumstances of abuse and abuser
Decided in advance the plan, including post intervention stratergy options
MEETING
Normal operating day , when anaesthetist is on duty
informed on their arrival to work, can appoint an advocate.
Should then be accompanied at all times for his/her protection against self harm
if no advocate appoint a mentor
firmly and sensitively aware of the need to take into account the interests of the anaesthetist
introduce members and explain reason for meeting
state the evidence and allow response
control dialogue to avoid getting side tracked.
denial is common often repeated
Outline options - substance misuse committe. voluntary engagement in treatment. Reassure doctor of continued support,
Usually ends with anaesthetist being accompanied to voluntary detoxification unit.
SUICIDE risk is high
Early psych assessment in recommended esp if discharge to community.
record results of intervention meeting and subsequent treatment in the confidential file.
OPTIONS
Voluntary treatment - psych assessment.
Transfer to detox facility
Participation in AA, NA , Doctors in recovery
INvoluntary treatment
Mandatory reporting
Following assessment commital under mental health act.
Report may be made to the police( but consider this carefully)
Return to work
Assessment by MBA
Cooperation of anaesthetic departments - monitoring program
Limitations by MBA / hours, place worked, mentoring, professional supervisions, access random drug screening etc
ETOH
Inappropriate (time/place) for the smell of alcohol on breath.
Impaired performance and personality changes.
Interpersonal difficulties with family, friends, or co-workers.
Drinking excessive amounts of alcohol frequently.
Drinking when it is dangerous to do so (such as during or before driving).
Binge drinking - frequent excessive drinking.
Legal problems related to drinking.
Craving and loss of control.
Physical Dependance
Tolerance
Treament
MEDICOLEGAL RISK
Subject to a range of medicolegal risks
- maintain good records timely, accurate, detailed
- do not publicly criticise colleagues
- be careful with delegation
- communication with patients/relatives is vital
- maintain Medical defence insurance
Informed Consent! "material risk" "reality risks" Good record keeping Empathic approach "good bedside manner OPEN DISCLOSURE Good professional relationships with peers
IMPAIRED COLLEAGUES
all health professionals are required to report to relevant regulatory authority “notifiable conduct”
-substance, sexual, impairment
In the event of a claim
Consult MDO - facts only
Compose a document (with help if needeD)
oPEN Disclosure can sometimes prevent this
Employer/Hospital can sometimes help
Explore feelings about case personally (dont write these down)
recognise stress associated with claims -
recognise anxiety/depression
active intellectual interest can give you some control over case
Ongoing stress management is essential
Wellbeing issues
Orientation
- detailed for new members / senior and junior
- personnel, equipment, hospital communication
- expectations, rosters, leave
- outline ANZCA trainee assessment
Trainees selection criteria for appointing trainees safe rosters diverse educational activities career advice SOT Support
Assessment
welfare assessment
have a GP, importance of psych support, ANZCA doc support program, welfare advocate rather than SOT to avoid conflict of interest
Follow ANZCA processes
MENTORS AND BUDDIES
2 colleagues who agree to look out for each other - personal and professional issues
Well-being strategies
know how to access each department have a welfare advocate - online toolkit
regular education sessions
substance abuse recognition
FATIGUE
Anaesthetic job entails out-of hours - complex OT, emergencies, obstetrics
Fatigue is the subjective feeling of the need for sleep, an increased physiological drive to fall asleep and a decreased state of alertness.
Vigilance is a critical component of anaesthesia
Need 6-10hrs/night - will build sleep debt cumulitive
restore sleep 7-8hrs uninterrupted
sleep debt - after restriceted sleep for 2 or more night
wakefulness impaired 16-18 hrs
dangerous driving >17hrs = 0.05%
Age - sleep patterns are altered and ability to recover is reduced by age
Microsleeps - induced by fatigue
Recovery ( 2 nights of restoarative sleep)
INDIVIDUAL
Planning - knowning roster, good sleep hygiene, recognise fatigue, self monitor - someone else do list ! LOL
Awareness
OVernight - be prepared to ask for assistance
Prevent risk to patients
Risk Mitigation
Afternoon nap prior to night shift 60-90 min
20-30min nap during shift
eating proper meals
Sleeping as soon as shift over
Avoid caffeine - prior to post shift sleep
Sleep loss induced deterioration in performance is mitigated by naps 30-45mins and caffiene 100-600 in first 24 hrs
Naps are followed by sleep inertia - dissipates over 15-30mins
caffiene just before short nap may mitigate sleep inertia but combats rather than prevents
Controlled exposure to bright lights during extended overnight shifts
recovery
1-2hr short nap normal day then sleep the next night
long term
time for leisure,rest and sleep
adequate breaks at work
regular recreation leave
DEPARTMENTS
health and safety legistlation to provide safe working environment to minimise risks that cannot be eliminated
Surgery daytime / life or limb after 10pm-8am
If elective list goes past 5-6 should finish by 10pm avoid late d/c to recovery
anaesthetists working time should not exceed 12hrs.
planned shift duration below 16hrs with 8 hrs rest before next shift
Departments/Hospitals should have management plans for short term consequences of anaesthetists being unavailable
Leave should be encouraged and accessable
rosters for shoft and weekends have enough lead time for life planning
Forward planning roster day-even-night , enough time for handover
Rest facilities , taxi reimbursement scheme
Hospital should monitor fatigue and its consequences. incl unrostered overtime.
SLEEP
Unchallenge your brain - eye mask = melatonin - VOUD ELECTRONIC DEVICES 30-60mins eliminate unwanted sounds - consider podcast/hypnosis low volume to help sleep
HOT BATH
- vasodilation = sleep
socks = vasodilation = sleep
Sleep in a way tht works for you
Be prepared
IM SAFE (fatigue and fitness tool) Illness, Medication, Stress, Alcohol, Fatigue, Eating
Fatigue TOOL SLEPT Sleepy? Long Shift Relying on ENERGY drinks to stay awake? do you need Power nap do they look Tired?
Nap before driving home
Are there other ways to get home?
Driving tired is dangerous
NIGHT
Sleep rountine - afternoon nap
Plan how to get home
need to rest before driving?
During NIghts Well hydrated and eat healthy snack breaks are essential 15-20min nap can improve alertness be vigilant for 4am dip work as a team
Between nights
dont drive if tired
have a snack before sleeping
go to bed ASAP
dont do things between shifts, tell housemates you need sleep
Recovery
Short nap and get up
aim to goto bed at usual time need 2 nights to restet
