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The Clinical Communiqué is an electronic publication containing narrative case reports about lessons learned from Coroners’ investigations into preventable deaths in acute hospital and community settings. The Clinical Communiqué is written by clinicians, for clinicians.
Associate Professor Nicola Cunningham
Welcome to our fourth and final edition of the Clinical Communiqué for 2023. In this edition we feature a specific event and diagnosis that led to the tragic loss of ten lives. A cascade of moments that occurred over a short space of time, with an outcome that will be forever etched in the memories of patients, families, first responders, clinicians, and entire communities.
That event was the thunderstorm asthma phenomenon that took place in Melbourne, Australia on 21 November 2016. An unprecedented and catastrophic convergence of factors that triggered severe asthma symptoms in susceptible individuals on a level that overwhelmed emergency and health services.
Many Melbourne-based clinicians can recall the precise moment they learnt that something terrible was unfolding. I was overseas at an emergency medicine conference, along with many of my colleagues from Melbourne, and we woke on 22 November 2016 to hear that overnight our hospitals and friends back home had faced mass presentations unlike anything we had ever experienced before. As the coroner later noted, the twelve hour period from 6.00pm on 21 November to 6.00am on 22 November 2016 saw the single greatest volume of calls for ambulance assistance received by the local Emergency Services Telecommunications Authority in its history. We felt helpless so many miles away, adding to the collective sense of dismay by those who had been ‘on the ground’ and contending with critical resource limitations as they responded to multiple calls for help.
There were many lessons to be learned from that single event. Government organisations and healthcare services looked at their state-wide responses. Clinicians reviewed their asthma management processes and researchers and meteorologists audited all the available data. The Coroners Court of Victoria continued this important work by acknowledging each of the patients that lost their lives in the event and highlighting the areas where there was potential for further improvement in public health and safety.
In this edition we present only one of those ten coroner’s findings as a case précis in order to reflect on the key learnings from the coroner’s inquest that was held to examine the ten deaths from the thunderstorm asthma event. We have also described the other nine patients’ presentations as vignettes, in recognition of every person that lost their life in that event, and to demonstrate the critical aspect that was common to all of them – the terrifying rapidity with which their condition changed from being mildly short of breath to being in extremis. We must remember that it is a matter of minutes between life and death in thunderstorm asthma, and ensure we continue to build our frontline systems in a way that delivers the right care at the right time, every time.
We welcome a new author, Dr Kristin Boyle, an emergency physician, who skilfully articulates the chain of events and learnings as well as her own reflections in the case précis. Our expert commentary has been written by respiratory physicians Associate Professor Matthew Conron and Associate Professor Eve Denton. They brought their clinical expertise and research wisdom to our understanding of the event at the time,
more recently in an article about the weather patterns experienced this Spring, and now with their illuminating contribution to this edition of the Clinical Communiqué.
Click on the image to access the December 2023 Clinical Communique
In this episode we feature two cases of worsening upper airway swelling leading to fatal airway obstruction following routine extubation of patients after surgery. Despite many advances in airway management, extubation-related incidents have not reduced. The cases highlight the actions leading to the loss of airway protection, a failure to recognise the severity of the situation, and an inability to salvage the situation.
- 01:48 Editorial by Associate Professor Nicola Cunningham
- 06:15 Case #1: A fatal toothache by Suzanne Doherty
- 19:54 Case #2: Pulling teeth and tubes – a cautionary tale by Dr Jack D’Arcy
- 36:28 Expert Commentary by Dr Louise Ellard: Extubation: An assessment of risk and strategy
Click here to access the Clinical Communique Podcast Episode #12
Welcome to the first edition of the bulletin on our new ‘Live Best Care’ site.
The key focus of the bulletin is Advancing Best Care Week, running from 7-13 November. This event is an opportunity to reflect and celebrate the amazing contributions of our people delivering Best Care to our community. The week contains events and some great launches that will help everyone to continue to improve the quality and safety of the care delivered at Western Health.
Over the course of Advancing Best Care week, the newly-named Best Care Governance and Support (BCGS) Division (formerly Quality, Safety and Patient Experience) is re-launching and showcasing its range of services through events and information stalls.
During the week we will be recommencing our Auditing Best Care program, where we audit our practice via a series of questions directly to the patient (or carer), bedside checks and reviewing documentation entered into the EMR/medical record.
A number of new initiatives will also be launched during Advancing Best Care week, including PROMPT, our new policy, procedure and guideline system.
The week culminates with the announcement of 2022 Best Care Awards designed to recognise and celebrate examples of the high-quality care we provide at Western Health. Award recipients will be announced at the online Best Care Awards at 2pm Friday 11 November.
Click here to learn more about the activities planned for Best Care week.
The relaunch of the Division of Quality, Safety and Patient Experience as the Best Care Governance and Support (BCGS) Division has involved significant stakeholder consultation, benchmarking and reviewing best practice to develop an exciting and innovative way to support Best Care at Western Health.
The BCGS team are on board to support Western Health and its staff to lead, drive, create and achieve Best Care – care that is person-centred, coordinated, right and safe. The division has oversight of Best Care quality systems including health service accreditation, patient experience, consumer feedback, clinical risk management and improvement.
Click here to read more about the BCGS team’s vision, purpose and structure.
There is a new home for all Western Health Policy, Procedures and Guidelines (PPG) documents.
The new system is called PROMPT.
Prompt will be familiar to our Bacchus Marsh and Melton colleagues as this is currently in use. Prompt was developed by Barwon Health and supports a number of health services across the state. It has a well-developed search function and is known for being a user-friendly platform. We encourage you to take a look and see for yourself!
The PROMPT system for policies, procedures and guidelines (PPGs) goes live for all WH staff on Monday 7th November. Click here to find out more about PROMPT.
To support Western Health’s vision of best care, the Auditing Best Care (ABC) audit is a tool used to monitor our delivery of Best Care and provides us with an opportunity to identify areas for improvement on how we deliver that care.
ABC Audit day will be held across most inpatient areas across Western Health on Tuesday 8 November 2022.
The audit is to be completed at the following locations:
- All inpatient areas at Footscray, Sunshine, Williamstown and Bacchus Marsh Hospitals
- Emergency Observation Units (EOUs) at Footscray and Sunshine Hospitals
The following areas DO NOT need to complete the audit on the day:
- Sunbury Day Hospital
- Day Procedure Units/Treatments/Surgery departments
- Outpatient Clinics
- Emergency Departments
Click here for more information and resources on the ABC audit.
There have been a number of changes and updates made to RiskMan in recent months and ongoing reviews to both the feedback and incident management procedures.
Day 3 of Live Best Care Week (Wednesday 9 November) focuses on RiskMan.
As well as Best Care Stalls at all sites, a Zoom Q&A Session with BCGS Team members from 1-2pm includes our RiskMan Coordinator. This is a great time to have any of your RiskMan questions answered (zoom link: https://westernhealth.zoom.us/j/95737561932?pwd=Z0tXRHVrN21yS2pWbUVMNjk2eS83dz09)
The BCGS team will also be roaming around all sites so please welcome them to your areas and ask any questions you may have.
Improvement is about giving the people closest to issues affecting care the time, permission, skills and resources they need to solve them. It involves a systematic and coordinated approach to solving a problem using specific methods and tools with the aim of bringing about a measurable improvement.
Our team aims to embed the Institute for Healthcare Improvement (IHI) Model for Improvement. Life QI is an online platform based on the IHI model we are currently piloting to bring improvement tools, people and data together to support improvement projects to succeed.
Day 4 of Live Best Care Week (Thursday 10 November) focuses on Improvement.
There will be Drop in Zoom Sessions to ‘Ask an Improvement Coordinator about your project’ sessions at 10am & 1pm (zoom link: https://westernhealth.zoom.us/j/95737561932?pwd=Z0tXRHVrN21yS2pWbUVMNjk2eS83dz09)
The 2022 Best Care Awards recognise and celebrate examples of the high-quality care we provide at Western Health. Award recipients will be announced at the online Best Care Awards at 2pm Friday 11 November.
Prizes in the form of departmental funding and keepsake trophies are available from our corporate sponsors Maxxia and HESTA for the following categories:
- Person-centred care – involves seeing the person in every patient and providing care that is welcoming, respectful and designed to engage the patient in their health care decisions.
- Coordinated care – entails prompt access to patient services, resulting in an effortless patient journey that is designed to optimise time to care through efficient services provisions.
- Right care – involves providing appropriate, equitable and effective care for each person.
- Safe care – supports the design and delivery of care and services to patients to minimise the risk of patient harm.
Accreditation surveys against National Safety and Quality Health Service (NSQHS Standards) are a mandatory requirement for Western Health but also provide a wonderful opportunity to present how we deliver Best Care.
The next NSQHS Standard Accreditation survey is scheduled for 21 to 23 November 2023.
As an exciting new concept, WH are introducing ‘Fab 5’ Teams to enable a business as usual model for compliance with NSQHS Standards across Western Health. Nursing, Quality, Medical, Allied Health & Education Leads have been identified for each NSQHS Standard aligned Fab 5 Team, with Nursing Leads (DONMs) delegated as team leaders.
The Fab 5 teams will support aligned WH Committees and front-line staff to effectively use, monitor and improve quality systems and clinical practices supporting Standard compliance on an ongoing basis.