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You're coming from today. Thanks very much for joining us October's Grand round uh that we have uh today and just some quick housekeeping. If you could, please make sure your uh your uh microphones are on mute. Um If you are not presenting just to try to avoid any feedback. Um And then if you have any questions during the, the um the talk you into the chat. Um also save them for the end. We have a couple of questions at the end. So, first of all, today, we are, are very, very fortunate to have uh Doctor Becky Thorpe and doctor uh who are both medicine consultants uh at OL and doctor is an associate medical director and doctor is the deputy medical director for NHS England Southwest. Um And they're gonna be doing a talk on uh an introduction to patient safety. Um So I'll probably give you uh a bit of a heads up about 15 minutes if that's ok. Do just another five minutes off. That, that's all right. Um And then a couple of questions at the end. So please. Uh thank you very much. Ok, thanks. I I'm going to uh share the slides. Ok. Yeah. Right. You should be able to see that now. Yeah, I can see that. Um Well, thanks very much for having us. Firstly, we're delighted to be here today and doing the gram round. This is the same talk that we gave to the team at ki hospital on the day before we left. So it was, had some interesting chat after it. So it was um, it was good to have those questions. Um, we'll just go with the first slide if that's ok. Can you move it on, Becky? Oh, I thought I had moved it on. Can you not see it? I can only see the first one. Oh, hang on. Let me try showering again. Let me just shut the, all my dogs off. It's all going well, so far I can't see any slide now. Hang on. Yeah, brilliant. So, um, in our introduction to safety, it would be remiss of us you, uh, start with the sort of safer care part of it because really we're all there to first do no harm. And that is surprisingly difficult in healthcare for a variety of reasons. Next slide, please. Becky. So, healthcare is really quite hazardous when you compare it to other encounters that we do every day. So regulated ones such as driving chartered flights. There is about one fatality for every 10,000 encounters that you have and ultra safe. Things like scheduled airlines are very safe. But for healthcare. We're right up there with about one in 1000 patients who have an encounter with the health service or with healthcare providers will come to harm. Not all of it is serious, but that's about the level that we're dealing with. Next slide, please. So when we look at the error rates in, in hospitals, about one in 10 patients are actually harmed, but most of that harm is trivial. Um But when we look at the system as a whole, we see that there are about 1000 avoidable deaths per month in England and that's due to medical error and omission. Next slide, please. So why do these errors occur so very, very frequently. Uh There are multiple reasons why these errors occur and it's not just one thing that causes the error. Of course, there are errors in clinical judgment. We are all human and we can make mistakes and we can get things wrong. Most commonly, there is system failure. So the system has been designed for us to easily do the wrong thing and make it difficult for us to do the hard thing. And very, very uncommonly, there's carelessness and people have, have made a mistake because they have been careless. Next slide, please. So this is a chap called Henry Henry Laie. And er, he had described clinical judgment in a, in a surgeon's world where he has a famous quote that I can't quite see. Um I don't know if I can put it on the full screen. Oh, yeah. Sorry the next bit. So this is something my, my surgical husband, uh, sort of thinks when he's made an error in the operating theater. So every surgeon carries about him. A little cemetery in which from time to time he goes to pray, a cemetery of bitterness and regret of which he seeks the reason for certain of his failures and unfortunately, whatever branch of medicine we are in, we will all make mistakes and they can be made much, much more easily when we're tired and with human factors that are affecting our judgment. Next slide. And this is a really good quote from a US surgeon, Chris Lia. Good judgment comes from experience and experience comes from bad judgment. And the human brain is really not very good at deciding the level of risk and the balance of probability. You're always at the every time you practice being affected by biases of what you've done before. And the Swi the Swiss Cheese model was first described by James Reen in the early nineties. And this is where he described most medical error as a series of failures that end up uh ending with the patient coming to harm. There's an example here where the patient is allergic to a medication. And uh the first failure point is that the patient's allergy history is not obtained, the prescriber then orders a medication to be administered which the patient is allergic. The pharmacist fails to check the patient's allergy on the, on the drug chart when they're speaking to the patient and the nurse then administers the medication which we know the patient is allergic to and the patient arrests and dies. And that's a very, very extreme, uh, Swiss Cheese model. But you can see how the holes in the Swiss Cheese have all lined up. Um, all those failure points have led to a medical error and I'm going to hand over to Becky now. Thanks Emma. Um, I'll see if I can speak and move the slides at the same time. So, so I'm going to talk to you a bit more about our systems for dealing with, with error and patient safety. So, um, this is just a screenshot of our system, which is called S but the name isn't important. It's essentially a massive database of, um, of patient safety incidents that happen within our trust and everything on there. So it, it might be as simple as, um, someone, um, having a fall on the ward and having a, an injury or it might be much more complex cases that end in, um, that, that end in serious harm or death. We try to record everything and I'll talk a bit about a bit about why that is useful later. But, but the important message is that this is really just a database. So it doesn't need a sophisticated computer system behind it. Um it's just a way for us to collect information about our safety, safety issues and really for us to see where they happen, where they occur as in the geographical location and what are the common themes. So there's a real spectrum of what we see, we can um we can see what we call near misses. So that's when um when something was caught in time. So if that incident had progressed without it being caught, then it could have, then it could have, um, had a, had a safety implication, they particularly get flagged up when the nearness has been something catastrophic. So it might be that somebody very nearly was given a drug that they were allergic to or a drug by the wrong route, which would have been extremely harmful or, um, occasionally from theater. It might be that for example, a wrong site surgery nearly took place because of confusion beforehand. Um But, but, but when we've averted the incident from actually happening, we call it a near miss. And then the other ones, look at the other definitions, look at the actual harm that has occurred. So that can be anything from very trivial. Um, right, the way through to catastrophic and the reason that, that we categorize them is because it helps us decide what the response should be. So what should our organizational response into one of these incidents be if it's something very trivial, then generally we don't need to make any major actions, we just collect that information and that can be really useful. So, if we're having lots of trivial, er, er, er, trivial events of harm, but in very high volumes, then clearly there's just as much of a problem as if we have one catastrophic event every few years. Um, so, so I'll talk you through now what we actually do when an incident is reported. So, um, and we've recently changed this so that we, we're moving towards a more kind of open culture where we're hoping that people will be um encouraged to report incidents even more. And the reason we want to do that is because we want to learn from those incidents as much as possible as much as possible. So actually, we're encouraging the team to try and report anything that they think is a patient safety incident no matter how trivial, because that really allows us to pull together themes across our organization. So we might start to see the first information that, that we might get that there is a problem with something might come from lots of small kind of no harm, events being reported in different areas around the trust rather than relying on just one area to flag something up. So what happens is that after each incident is reported, it's looked at within the next 24 hours um by a member of the clinical team. And that will usually be somebody like a ward manager, um, or a department manager. And at that point, they'll decide what does that, what's, what's their first impression of the level of harm? And that would determine what they do. So, um, so if it's, if it is a moderate harm or above, so that's moderate harm, major harm or catastrophic start off investigation and that will be teams in the place that it happens. So the local teams, um, and, and that, um and that's really important because we know that as time as time goes on after an incident has happened, people's memory degrades people become less interested in it. What we find is really helpful is if we can go back to the team immediately after it's happened and use a number of tools to try and find out exactly what happened. So to work out a timeline to see what went wrong if there's any immediate learning and the other thing that we're looking for that is, is um and this, this is an important question that we always ask ourselves when an instant comes in is is there any immediate risk to patient safety? So for example, if um if a machine had a piece of medical equipment had failed, the question would be, do we need to take that piece of medical equipment out of service? So do we need to remove that in case it happens again? Or it could be that we think a batch of drugs has been contaminated? For example, or mislabeled. The question for us is is there, is there an immediate patient safety risk in that case, the answer might be yes. In which case, we would remove that batch of medication from circulation. And what we do next is based on that investigation, we would determine some actions. So these are non negotiable actions they're recorded on our database every month we go through those actions and that's done locally in the teams, but also a record is held centrally so that we have a record of what improvement has been put in place and what's actually changed to prevent that from happening again, any incident of major harm is seen by the medical director and the chief nurse of the hospital and we would request a more detailed investigation and we used to call those root cause analysis investigations. And that was because we were interested interested in finding out the root cause of the problem. So what had actually happened that caused this event to happen? And we've now changed the name of those to be called patient safety investigations. And that reflects that we recognize much more now that there often isn't a root cause to these investigations of, to these incidents. Often it's a combination of, er, events exactly as Emma described in the Swiss Cheese model. So it might be, it might be 11 thing, one small thing goes wrong after another. And that, that eventually accumulates in a significant incident. Um And then each of these incidents of major harm is reviewed at what we call a rapid incident review panel. And that really allows us to take the system learning. So we might see one of these events happening in maternity, for example. And we might think there are some common themes that we need to share with, for example, another area like critic care or the emergency department or a specialist ward. And that allows us to share that information rather than just waiting for the other areas to have a similar incident. We can share it before it happens and we do some uh we do that in different ways. So we talk about it, our M and M meeting. So that sounds for a morbidity, some uh learning from incidents, er information, er posters and infographics that we send around to staff. Um and we have safety briefings that go out to staff as well. So this is the model that we look at when we're doing our patient safety investigations and, and this is, this is what allows us to take a system view of the and as you can see. So this is called for obvious reasons, this is called a fishbone diagram and it allows us to consider each of those areas. So rather than saying, um rather than jumping to a conclusion and saying this incident happened because of a human factors error, the doctor picked up the wrong bottle of drugs and injected the wrong, the wrong drug into the patient and the patient happened to be allergic to it. We can look at the other factors. So it might be that the doctor has never done this before that, that they would have benefited from more supervision. It might be, there might be some communication factors where someone else said, oh, no, give that one. And actually the, the instructions weren't clear. It might, I think we've lost some connection there if it's not just me, I think, and we try and find sorry be to interrupt, we lost you for a couple of seconds. All right. Have you? Am I back? Yeah, you back and the screen is back as well now. Oh, I carry on. OK. So, um so you can see here in the fish bain diagram, you can see all different factors that come into a patient safety investigation and this really prompts us to, to move away from trying to find one thing to blame the incident on and looking at a more systems based approach. Um and this is helpful because then we can er, take what we've learned from each incident and apply it to different areas. There we go. So, um so this is, this is a, another quote from Leia Donaldson. So to er, is human to cover up is to, is inexcusable. So, so this really reflects that um that what we found even with our very robust patient safety systems is that it's very easy to gather information and collect this information about our, about our risk and our harms. But what's, and, and if you think of all the different ways as an organization, we promote learning. Um, it, even though we've got, we've got, we've plenty of resources. We've got teaching teams, got education teams, we've got simulation, we've got all sorts of ways to disseminate that learning. It's actually very difficult to do that at an organizational level and make a significant difference. But that's the whole, that's our whole aim when we, when we're gathering this information. So um this is, this is just to illustrate. So I don't know if anybody grande's book. So they, they're all good. They're all fascinating. They're kind of essential reading for anyone who works in healthcare. I'll give you some recommendations at the end. But um he, so one of the areas that he's interested in particularly is risk and he has a really a really useful er fact about introduction of a probe. So a very straightforward and relatively cheap intervention. Um When before the introduction, before SATS pros were routinely used in general anesthesia, then the risk of death, death was one in 10,000. After A TS pros were introduced for monitoring, then the risk of death, death dropped to one in 250,000. So a really simple solution that had an enormous impact and that is really reflected in what we see in, in in safety practice now that generally the most simple solutions are the most effective. Say, for example, things like adding a sticker with a checklist to a set of medical notes that gives you a prompt for sepsis, for example, is a very simple solution, but is generally much more effective than more complex solutions. And what we find when we're looking for solutions is that the best solutions come from the people who are doing the job every day. So if the, if the medical directors and chief nurses try to think of solutions and impose them on their, on their clinical teams, they generally aren't fit for purpose. Whereas if the solutions come from within the clinic or like, sorry, Becky, I think we've lost you again for a second. I think she's almost at the end there. I think she's just saying that, you know, teams, the teams make the best recommendations, not trying to be told what to do by other teams. And I think that's also true across system. So people will say, er, checklist that checklists are like toothbrushes, everybody wants one but nobody wants to use anyone else's. And so you've got to be mindful if I'm frozen now, er, of introducing recommendations, er, that you think work at your place before you introduce them somewhere else. And I think the last slide is just a couple of books. There's one by Henry Marsh. He's a neurosurgeon. Um and one by one day, I think the last slide is there, which we can put, we can either send the slides or put them up. Great, thanks. Yeah. Um That's perfect. Bang on time. So, thank you very much. Um Yeah, if you could, you can send me the slides and I can distribute the book or if you wanna stick them into the chat. That would be great. Um The floor. Now, do you have any questions? Thank you both very much for that uh talk. Um Does anyone have any questions? You can either just unm mute yourself and ask a question or stick in the chat and I can read it out for you. Um I've got, I've got one kind of uh us off if that's OK. Um I just wanted to uh to get your um your thoughts on how important the culture is with regards to um you know, data thing and learning from safety incidents because, you know, it could very much be a system that is abused um for the wrong reasons. And I just wanted your thoughts about how important the culture around that and learning from the rather than blame the blaming individuals and any experiences from that either. Yeah, I think you've hit the nail on the head there, Nick. So the culture is the only way that you will be able to drive positive change. And we've learned this from other high risk industries or industries that have got had problems. So, in the airline industry, for example, it's considered to be absolutely normal to flag and raise any mistake or any issue with any staff member. And there's no, it's not seen as punitive, it's not seen as, um you know, people are going to be blamed for things, it's just seen as the safe thing to do. And so they've really been able to drive that ultra safe industry to become even more safe. And I think we're still um struggling with that a little bit in healthcare because I think that people do feel worried that there is a little bit of a clash between the legal system for how things are pursued legally for claims about negligence and the investigation of patient safety incidents. And the two need to be kept as separate as they can so that you can allow learning and transparency and people feel comfortable and safe with, with raising a data and also being involved in, in sorting out the problems um that have led to. Thank you. Any other questions? Can I ask a question there quickly? Is that? Ok, Chris? Hi guys. Thanks very much for the talk. Um I think my, my question really revolves around um sort of buy in, er, and then longevity. So just I think with every change you have in any system trying to get buy in is really important within your way you're working. But um I always find that initially, the uptake of these changes are really positive and then people take it on with a lot of enthusiasm. Um, I'm just wondering what your experience is or any, um, answers to kind of keeping that in the system for the long term because I know that a lot of these things kind of wax and wane. Yeah. Good question, Chris. Shall I take that one? Emma, I'll start em and chip in. So, really, really good question and observation, Chris. I think that's true of any sort of quality improvement or continuous improvement project. You're right that there's lots of enthusiasm and then it kind of disappears. I think it's, I think it's when you're looking at new solutions, you need to make those solutions easy for people. So if the old, the old way of doing things is easier and quicker for an individual, then people will lapse back into doing that. So, I think, um, and that's certainly true of anything really. So, the, um, the new approach to safety has born in mind, I think so. Instead of so what used to happen a couple of years ago is that every time there was a significant patient safety incident, we would ask for an RCA to happen, a root cause analysis to happen. And that would take people hours and I don't know if anyone on the audience has ever written one but it takes hours. It takes, you know, several days worth of work. Um, and, er, and we'd often find the same conclusion. So, you know, if someone had a full ward manager might spend eight hours writing the root cause analysis report and there would be some learning and they would identify exactly the same learning as the person who fell and broke the hip on a different ward down the corridor. But both teams had spent a lot of time doing that. So instead of asking the teams to investigate significant incidents locally, what we've now put in place in our trust is a team of what we call expert investigators. So they're three members of staff who are very experienced in safety, but also have a clinical background and they do er, thematic reviews instead of root cause analyses. So that means that they might take four or five falls that have happened this year, they'll use one of those incidents as the index case and they'll investigate the other incidents in relation to the first index case. So that will allow them to say in our organization, the themes about falls, are you wet bathroom floors or people not wearing shoes in the ward or people not being supervised to the level that we would recommend. Um, and it's taken it away from the, from the actual, the actual clinical teams trying to do the work. So we used the connection used to be, oh God, if I write a DEX, I'll be given an RC A to write I don't want to do that. I haven't got time whereas now you will write a date and there won't be any suggestion of being punished by getting, you know that coming back to you and writing an RC, it will be taken away from you and the learning will come back to you in six months time with some helpful suggestions. So, so, so making, making the alternative solution easier is a sort of essential approach to quality improvement. I think, I think with safety, it's much bigger than that though. It's about the safety culture and the desire to learn and genuinely to make it, make it safer for people. We've had some success with using um patient partners. So in our trust wide patient safety group and some of the other work that we do, we have two patient representatives who come along. And it's interesting how that change how that changes clinicians um behavior in meeting. So when people can be quite territorial or quite colloquial in what they're doing and be quite defensive, people generally tend to be very well behaved in front of patient representatives because, you know, because it's a reminder to us all that, that's the reason we're there. You know, we're doing things to make it better and safer for people like that. So, so that has also been a successful tactic to make it really, really transparent and clear that we're whatever we're doing is not about making our individual lives easier or doing less work. It's about improving things for patients. That's great. Thank you very much. Great. Um, and if anyone's got any other burning questions, uh, in the, uh, just the time, I think we should probably, uh, crack on to the next part of the talk if that's ok. And if there are any questions, please put them in chat, we can certainly, um, distribute that afterwards or, or get to the end. Um But thank you both very much for that. Um Fascinating talk. Uh Really interesting good questions as well. Um And uh yeah, really, really having you. So thank you very much for taking time out of your schedule for us today. Um Next, we got Doctor Duffy who's a uh um uh medicine clinical fellow at Bristol and one of the uh GF went in last year and she's gonna do a case report for us today. Um You can you hear me? Are you hi if anyone who hasn't met me? My name is Olivia, as Nick says I was a global health fellow last year and I was out in the ki from early June to mid July today. I'm going to be talking a bit about health in people experiencing homelessness and we use a case study um that I saw when I was in the UKI to illustrate a couple of points. Um This is mainly quite interactive and done through many meter. So I'm going to post the link on the chat. And if people have their phones ready after a couple of sizes and powerpoint, there'll be a QR code that you can scan that should get you on me, me to allow you to kind of interact a bit more. So I won't be able to see you because I'll be um sharing my slides. But if you have any questions, you can put them on the chat. I'm sure Nick will be able to pick them up or I can answer them at the end. Yeah, thank you. Uh All right, give me two secs whilst I right. So, uh this is again just a little bit about the impact on living on the streets on health in the emergency department in both the UK and Kenya at case and point. So I'm going to start with a case study. Um, it was my first day and I vividly remember a very unwell looking man being carried into the apartment, he was working really hard to breathe and looked really unwell and he was pretty drowsy on his initial observations. He was really hypoxic with sat to 55% and he was breathing really fast with a respirator 35 but he was relatively hemodynamically stable. I was kind of shadowing the doctor at the time and we kind of went through an A T assessment. He had a patent airway, he had audible secretions from the end of the bed and had widespread co crafts bilaterally across both lungs. He was cool properly, um, but had a regular pulse, normal heart sounds and on initial temps or cannulation. And he bled quite a lot in response to the venipuncture and developed quite big hematoma. Kind of hinting that maybe something wasn't quite right with his, um, clotting. His pupils were reactive. They were on the small side but they weren't pinpoint. Um, he was too drowsy to be compliant with the neuro exam but was seem to be spontaneously moving all of his limbs and no rash, a benign abdomen and he had no peripheral edema. So then we got the history from a friend who's coming in with him. He was a street boy. So that's a time for people, um, who are homeless and rough sleeping in Kenya. And apparently he started feeling weak several days ago and subsequently became unable to walk. Apparently today, he had become short of breath, had no cough. Um, he was supposedly well before, but sometimes picked up an unknown medication from the dispensary. His friend did not think that he used any recreational drugs. His friend shortly disappeared. Um, due to the situation of this guy kind of living in the street, there was no family to get any further collateral and he remained GCS nine. So we weren't able to get really any more of a story from him and moving then on to first line investigations, he is not his chest x-ray, but an example of a normal looking chest x-ray and his bloods were particularly remarkable for being severely anemic. He was nomo had mildly elevated inflammatory markers, but otherwise the investigations were fairly unremarkable. So I'm going to ask you to begin to think of a couple of differentials in your head. I'm gonna move over now onto men meter right then. So if you either give me a thumbs up when you're on it. Um And if you can just take a picture of the barcode and scan it, that should allow you to get on to it. Um Any questions, just let me know if there's any issues going on. I'm just gonna give a bit longer. I stuck the code into the chat. So um if you have a struggle with the barcode, just the QR code, just go dot com and then you can stick the, the code in and then it'll go that way. All right, any interest of time will begin to move on and people and just catch up as we go. So I kind of question for the room. What differentials would you be thinking about with this particular patient at this stage? You just go for one for box and press. We'll kind of work from there. Chest infection. Definitely. That was something that we were quite worried about and we did start him on antibiotics, fluids, that kind of stuff. But his chest x-ray kind of throughout his submission actually remained fairly unremarkable. Um, D IC. Yes, that was something I was quite worried about, especially given the picture when we tried to cannulate him some kind of weird bleeding going on. G I bleed again. Yeah, that was something we were considering. Um, yeah, hemolytic anemia and, and associated pneumonia. There was all things kind of considered in the context of this quite unusual picture and quite a young man. Um HIV, he was actually negative, he was negative for TB, he was negative for malaria. Um but there are lots a very wide differential on this quite complex clinical case and he ended up being admitted to the critical care unit. He was on 15 liters of oxygen. Um he wasn't intubated, um but was only able to receive about one unit of blood a day because it was kind of a one in one out system. You really needed a family member or friend to donate a unit of blood to be able to get one out of the blood bank. There were lots of tests that can be done. So there's no cross sectional iag he didn't have the money to pay upfront and there's no family to pay upfront for any CTS and he couldn't have any scopes to look into whether or not this was a G I bleed. So sadly, this man passed away after several days in the critical care unit with no firm diagnosis. Just go back. Yeah, organophosphate poisoning. Again, was something that was considered, especially in the context of all the secretions. Um But again, with the lack of history, it made it really difficult to know exactly what had gone on um with this poor man. So the next question to ask all of you, at what point did you think being homeless impacted on this patient's care? Yeah, definitely. So time to presentation slash delay, he came in when he was very, very, very unwell and likely it would have been easier. Certainly to get a history from the patient himself if they come in a bit sooner, collect history. Absolutely. There was no one really there to give us any more information about his general health. Again, with history gathering all coming into the same kind of picture, it was really hard. Um, when someone in this situation as we see in the UK just pitches up off the street, low G CS, you don't really know what's going on, no money yet. That was a really big thing. He didn't have the finances to access lots of tests and things that could be really helpful in his healthcare. Had seen medical professionals before. Exactly. These are the kind of people who often aren't in the system. They aren't known to healthcare providers, they don't regularly have contact. So it's unsure exactly what their background might be. Mal nourish, again, really important thing. You probably had a really low physiology desire to be able to deal whatever with whatever this acute kind of insult on his body was. And the other thing to kind of think about was that he couldn't even get um much blood transfused because he didn't have anyone around to be able to support him by donating blood into the blood bank. So I'm now splitting the crowd um because I thought it would be interesting to see the differences between what my Kenyan colleagues say and the UK team. Um So my Kenyan colleagues specifically, what kind of proportion would you guess of the patients you see in your services are homeless? There are still any attending colleagues on the call? Ok. So one answer for 1% it's quite interesting. I just give another minute, see if anyone else has any ideas. OK. Well, I now ask the same question of my UK colleagues again, same numbers. What proportion would you estimate of patients using your service? Are people experiencing homelessness? Ok. Got a variety of answers so far. Kind of a real big range here, kind of guess all the way from naught 0.1 all the way up to 5%. OK. Interesting to see that kind of different. So now we go on to numbers. So homelessness is a worldwide phenomenon with 2% of the global population being defined as experiencing homelessness. The definition can vary country to country and often as well as involving people living and sleeping on the street. It will involve people in subpar housing, people in temporary accommodation, people living in slums go to the UK kind of with a broader definition. It's estimate about 0.5% of the population are living with some form of homelessness. But actually if you look at those who are rough sleeping, sleeping on the street, it's a much smaller number. It's naught point naught, not 5% of the population in Kenya, their data is much more scarce and these numbers are likely a underestimate. But there's a couple of sources suggesting that maybe 0.73% of the population um fit a broader term of homelessness. But of these in the 2019 census, uh 20,000, 100 adults were living on the street and actually all the way up to 300,000 Children um were thought to be living on the streets. The background to this slide is a map of the density of people experiencing homelessness. It's actually interesting to see that Kenya and the UK fall into the same bracket of approximately 30 to 99 per 10,000. So that's something about pregnant of homelessness. Now, how do they use the healthcare services? So there's been no specific research in Kenya, but there's been some reviews across Sub Saharan Africa, which suggests across the board that people experiencing homelessness under utilize all healthcare services. But when they do present, they tend to present very late and that therefore results in more frequent emergency department attendances. Similarly, in the UK, people experiencing homelessness are 60 times more likely to use the emergency department. And on the flip side of that, they are 40 times less likely to be registered with a GP and access primary care. There's been an increase in recent years. That's actually tripled the number of attendances to ed by people experiencing homelessness, but it still represents quite a small proportion. So the average across England is in 2019 was 0.18% of attendances. However, there will be massive variation between rural and urban trusts and I'm sure the br I we saw a bigger proportion than that. So my next question now to my UK colleagues, um do you think that you treat these pe patients any differently to other patients? Ok. So far we've got exclusively. Yes, just to give it a bit more time to see if anyone disagrees. Ok. It seems to be a unanimous vote and that's completely right. There's been lots of research to show that as healthcare providers, we do treat these patients differently. I'll ask my question now over to my Kenyan colleagues. Ok. Um may not be able. Ok. Yes, similar answer. And yet there's been research all across the globe to suggest that in both our attitudes but also on institutional levels, there's a lot of stigma and discrimination against these patients um which changes the way that we treat them. So now to delve into this in a bit more detail. I just to look at these factors and see which of those you think influence the way that you manage these patients in your clinical practice. And this question is addressed at um my UK colleagues. OK. So far, we're getting quite a lot on the complex social needs and complex health needs. I completely relate to that myself. Often these patients take a lot of time and when you're kind of working in a busy setting such as the emergency department, it's hard to give them this time. Um And you know, you're not meeting all their needs, intoxication. Yeah, challenging behavior is a really big one. It's something that's focused on quite a lot by the Royal College of Emergency Medicine that can make these, these patients very difficult to manage and it can distract you from what likely is a medical need as you're more focused on trying to manage the behavior, discharge for assessment treatment, completion, incredibly common. Um and you know, can be really difficult. So it's often due to things such as hunger withdrawing, but it means they often end up coming back and never really receiving a full assessment because they don't wait um for a number of factors and then noncompliance again, really difficult to know how to make safe follow up for these patients because you're not quite sure with their chaotic lifestyles, how best they can adhere to advice and medications. Ok. And I'm gonna ask the same question over to my Kenyan colleagues just to see if that, that art is different too from arts. Just give it a minute. Yeah. And this is interesting. So finances is probably a much more significant, it is a much more significant factor in a healthcare service such that in Kenya where there's out of pocket costs, these patients are very, very unlikely to have health insurance and they're very unlikely to have the money or to have nearby to provide the money to enable them to access care. So that's a really important factor which maybe is more. So in Kenya, again, noncompliance complex health needs discharge for assessment. These are kind of common themes that seem to be coming out across both our cohorts of patients. So why does it matter? So this is a population that has a really high morbidity and really high mortality and to achieve universal health coverage in any country, you need to be able to address this population's health and the challenges that that brings. So this is kind of comparing some studies on the morbidity in people experiencing homelessness. Again, there's no Kenya specific research. Um but lots of papers looking across Sub Saharan Africa, which shows actually the pathology is quite similar, there's a lot of injuries, there's lots of intoxication as well as kind of cardiovascular respiratory illnesses. Um infection seemed to come up more in the UK attendances, but both of them showed a lot of mental health, particularly depression, substance abuse, deliberate, self-harm, suicidal behaviors, and substance abuse, violence and mal malnourishment is overrepresented in this population across the globe. So now if we look at mortality, so these are statistics from the UK, which I think are quite shocking. So if you compare the average life expectancy of your average man in the UK at 76 if that man is homeless is 44 your average women, their life expectancy is 81. If she is experiencing homelessness, it is almost half at 42 the big contributors to mortality are cardiovascular disease, overdoses and accidents. And these deaths are often from causes that are amenable to timely effective healthcare. And therefore these are preventable deaths being homeless makes you sicker. But there's lots of good evidence to suggest that those who become homeless are already experiencing significant physical and mental health needs. So you end up in this kind of vicious cycle when those who are sick, become homeless and being homeless makes them even sicker. In the UK. We consider the health of the people experiencing homeless to an example of extreme inequality. This is probably also true of Kenya but applies to a much broader section of the population living in extreme poverty. Whether or not they have a structure over their head, they're likely facing similar inequalities. So another question now for everyone, um what do you think some of the barriers are to homeless people accessing healthcare services a couple more minutes while we're waiting. Sure. Mistrust. Yeah, that's a really important thing. And that often comes from this idea that they feel judged and they don't feel like they get respect and this kind of institutional discrimination of this kind of, um, system failed by the system. Yet previous bad experiences. That's a really important point to kind of bring across. And that's often because it's difficult to address their medical needs when they have so many social needs that are difficult to meet in the emergency department. Um And the stuff that comes up a lot in kind of research in sub-saharan Africa is income, lack of health insurance, transport, not being able to get to where they need to go to access health care services. Um staff strategies, stigma 100% difficulty receiving communication. Yeah, it's a really good one with their kind of care to lifestyles. It's difficult to arrange follow up and get them back into the system. So these are some approaches that have been suggested as being important if you just vote for the ones that you think are important. Um The royal hygiene emergency medicine has promoted um approaching with empathy and addressing causes before they leave. Um for assessment and treatment as kind of ways to better engage this population and make sure that when they come for a medical reason, they get seen towards the end and I can really relate to the empathy um, approach. I recently saw someone in the emergency department, um, who had a history of being very violent, very aggressive. Um, and when I asked them about recreational drug use, they did become quite fairly aggressive. You know, their body language became quite aggressive conversation on talk about family history and they mentioned their mum was unwell, um, kind of chatted him a bit about what was wrong with her, what treatment she was having where she was and just by sharing interest, it completely changed the tone of the conversation. He was calm. He's very civil and actually very grateful for the care that he received. So lot of votes here also for improving primary care access. So if I bring this back to the initial case, um which ones of these that even have made a difference? Oh really? It would have been if you, the patient had presented earlier, had prior engagement with healthcare services. If there were less financial barriers and that's probably applicable to much of the Kenyan population living in poverty, they come late and they come sick. And so in an ideal world, there would be less financial barriers and easier access to primary care to enable there to be more preventive medicine to hopefully prevent cases such as the one I described. However, if we look at the UK, where the UK, where we have less financial barriers and a very well established primary care system, there's still many other barriers which are affecting the way that homeless people are able to access healthcare. So we look at the similarities, you know, morbidity seems to be quite similar. The prevalence seems to be quite similar and likely there's probably similar mortalities in the Kenyan people experiencing homeless. And those in the UK, you know, who we count as homeless, we probably is quite differently. The barriers are probably quite different. But again, the overall themes are fairly similar. If we see them sooner, we can treat them better. And something that we can all do for free is to treat people experiencing homelessness with respect and empathy. Um So I'm just going to open it to discussion questions. I'll be just really interested to hear any similar stories or affections experiences that anyone um either from the Kenya side or the UK side wanted to share. I love you. Um still got a good few minutes uh to go. So if anyone does have any questions, please feel free to use the time poor experiences. I mean, I only saw a few cases in Kenya. So if anyone has kind of equivalent stories, I'd be very interested to hear what their thoughts were. Olivia, I can't even work out how to put, I'm so old. I can't even work out how to put my hand up. So I'm just going to start talking just to say, well, just to say, um really well done, really interesting, um really good. Um A sort of comparison of, of the issues over the two places and great to hear the similarities in many senses. Um, Emma and I were talking this morning about health inequalities and how in, certainly in Bristol, you know, there's, there's a, um, there's such a large population of people who are homeless or who have, um, you know, like the high impact us population who have drug and alcohol, mental health problems and how a lot of the sort of perceived problems that we have them is more, is more about staff's misconceptions and how they're treated with stigma. So I think, I think just even having an awareness and looking into the problem is a great start. So, um you, I mean, you, and you'll just, especially working in the br you'll just get a lot of exposure to this. So if it's something that, um you know, if it's something that, you know, if people think that patients like this shouldn't be in emergency departments or they don't somehow don't deserve the care that, that they're being provided, then it, it, it will just sort of eat you up really, you know, this is really, it's really a key part of what we do. And for lots of these patients, we're the only people that provide them with healthcare sort of points of crisis in their lives. So I think we have, you know, for no other reason other than our own well being and mental health we have, we have to learn how to manage them and cope with them and we have to do it as best we can just like we would for any, you know, for a patient having a heart attack or a stroke. Yeah, I think it's very easy for these patients to be heart sync patients because, you know, they take up a lot of time they can be difficult. There's definitely been times that I've been secretly a bit relieved when I call the name of someone and it actually turns out that they've self discharged. Um But this is the group even within people experiencing homelessness who are at the most risk of premature death and have the greatest amount of morbidity. So actually, these are the people that should really should actively be trying to keep in the department as opposed to being like bit of a relief, don't have to kind of engage with all the work that's going to go into this consultation. Um So I think that's been one of my big kind of takeaways. Uh I think Emma uh playing in the chapter. Um what's the best way to teach empathy and e is could lead by example and challenge every non empathetic interaction. I think it's definitely something we could have teaching on an induction, especially in our hospital where we have such a high homeless population. I think it's something that just kind of like seeps into clinical practice, but I think it's good to be reminded. I think it's really easy to run low on empathy and become a bit kind of deconditioned. I think to be reminded of the importance of treating people with empathy and also the healthcare statistics behind them is quite a good way. Um But yeah, I think leading by example is always like an amazing way to do it because when you see an interaction that goes well, it can be so motivating for you to try and replicate that in your own practice. I've just got a really quick, if that's alright. A funny my PH phone. Um, so one of the most humbling experiences I've had in the br I was, when one of our, er, lead nurses, I was in, I was in minors and there was a homeless lady and she'd come in because she'd had sort of awful diarrhea and she was, you know, she was quite old for a homeless person, but she was an ex IVDU really thin and she was really filthy and sort of in a right mess. And it would have just been, you know, it's, it would have been a difficult consultation because she was a really rubbish historian. Um, and we'd seen her many times before and the nurse who was down there just took pity on this woman and she took her to the shower, she, you know, gave her some food, gave her some, got to get some hot food gave her a cup of tea and she basically had a whip round in minor and just said, look, I'm going to go to Primark, which is about 200 m away from our hospital and buy this lady some new clothes. So we don't discharge her with hospital pajamas. And, and so we all, you know, chipped in a couple of quid and, and then the patients who were in the other cubicles started overhearing what was happening and came out saying, look, you know, we've sat in the waiting and this poor woman, we can see she's in such a mess, really struggling. You know, we will give you some money to go and buy her some clothes. And so she ended up with, I think, sort of 40 quid and managed to go and buy a whole outfit and some shoes and a coat and, you know, at the end, I just thought would I have done that? And I think I wouldn't and I felt a bit embarrassed that I wouldn't have done that. I think I'd have just, you know, treated her medical condition and got her out as quickly as possible. And I think sometimes other people shining the light on how to behave and what you can achieve and including the patients. Every, you know, everybody was just chip it in for this, for this lady cos they could see she was, she was struggling and I think sometimes you can just leading by example, from all team members can be a really humbling experience. And I think she, someone, someone filled in a form, didn't they? Becky? And she won the Chairman's Prize basically for her, just for her actions with, with the deprived population that we see, not just that one but lots of similar ones. And, you know, she's a real force for positive, er, culture and positive change for the rest of us. Oh, I think it makes such a difference, you know, if you haven't been able to wash, if you don't have the right clothes that's always going to be a tricky consultation. And if it, you know, in that situation you would like to be offered a shower, you'd like to be, I mean, what that is, sounds amazing but it makes such a difference to, I guess, you know, their perception of health care. Um, and then what you can kind of the conversations you can have with them on that day. Great. Um, I think in a, uh, time, I think that probably be a really great, uh, time to round this stuff. Um, really, really nice and kind of jump of humanitarian or, you know, humanity really. Um, at the last, at the end there and I think that's something personal I'll take into my, um, clinical practice as well. Um, so thank you Olivia for that. Um, that case. I think it was really interesting and really important topic to talk about. And thanks again to and, uh, Becky for your, um, introduction, patient safety that you had previously. And we've stuck a couple of, uh, links to social media on um, the, um, the chat and the email address if you want to be part of the, um, the, um, the mating list. And there's just a link to the Facebook, um, group for the, and charity and where a lot of this stuff will be, um advertised. Uh There's just an Instagram and Twitter or is called now, if you'd like to give us a follow on there, um All platforms are available. Um Please can you uh fill out the feedback form that will be emailed across to you and just really useful for us to kind of keep developing this uh ground round. Um And then you also get, if you fill in the, the feedback form, you'll get a um attendance as well for your portfolios. Um So thank you so much for everyone who attended. Um And please uh keep an eye for the next session which will be the second Friday in November. Um Thanks again to our speakers today and hope everyone has a good weekend. Thanks very much. Thanks. Bye bye. Thank you.