The Health and Disabilty Commisioner’s report on the tragic death of a 50 year old man in Wellington Hospital makes interesting reading for Liaison Psychiatrists. The report focuses on the behaviour of the doctors and nurses concerned and the systemic problems that allowed them to happen. What is interesting is that the family were far more concerned about the attitude of staff to their brother who had a bipolar disorder and had recently been treated with risperidone for hypomania.

[Mr A] was an unassuming and gentle person, painfully aware of the views generally held by society towards mental-health consumers and the treatment that often resulted. The injustice and unfairness of this situation made him very sad, and after more than thirty years in the mental health system it was something he had become resigned to. During his stay in Wellington Hospital, [Mr A] told us on several occasions not to get a nurse or make a fuss as it would ‘just make them angry’. ...”

Our belief, based on own experience at this time and strengthened by your report, is that [Mr A’s] inability to co-operate, due to his deteriorating condition, led to him being labelled as a ‘non-compliant’ patient. That label, along with his history of mental health issues, led to a situation where many of the medical professionals involved in [Mr A’s] case seem to have down-graded the level of care they provided, based on their own prejudice and as a punitive measure against him for being ‘non-complaint’.

They felt that this was a reason why his agitation was minimised and he received a low priority. This doesn’t really come across in the expert comments which really just focus on what was recorded in the notes rather than interviews with the people concerned. This is a weakness in the report in that the way it is done makes it hard to say anything about attitudes.

Support for the culture of stigmatising patients with a mental health history comes from the DHB internal review, which comments on the need to “review smoke free policy to consider the needs of mental health patients in general inpatient areas”. Presumably this review won’t include patients who are not “mental health” patients (whoever they are). As one of the experts writes “this is to miss the point, it is not only ‘mental health’ patients who suffer while in hospital but any heavily addicted patient needs to have their needs addressed”.

The discussion on smoking is interesting. The issue was that the man was going through acute nicotine withdrawal for which he didn’t receive any effective treatment. (Presumably this wouldn’t be allowed to happen if he’d been withdrawing from alcohol). He wasn’t allowed to smoke on hospital premises and only received nicotine patches. His family brought in a nicotine inhaler in an attempt to control his withdrawal. The evidence appears to be that nicotine gum and inhalers are equally good at controlling acute withdrawal symptoms (DARE review).

According to the nurse expert there is an exemption in the 1990 Smoke Free Environment Act that allows hospitals to permit smoking in incapacitated patients. I couldn’t find it in the Act – anyone know where it is? Clearly according to this report there needs to be some flexibility in the management of incapacitated patients with a nicotine addiction in hospital.

On using electronic notes in medicine

This week I saw a patient with a complicated medical history. To find out what this was I spent part of the consultation turned towards a computer trying to find the most recent electronic discharge summary from the surgical team. I managed to do this and then spent 30 minutes after the one hour appointment typing the notes into the computer.

This illustrates some of the advantages and disadvantages of using electronic notes. First they improve communication – there is no doubt about this and I would never want to go back to pen and paper notes. It is so much easier to find out what is happening to people – just log onto the nearest computer and there are all the notes. Clinically I work in an organisation which provides mental health care to 450,000 people - so the provision of care is complex involving different clinical teams and many different people. Having the narrative notes from all these people in one place available from any computer is great. However there are significant downsides.

Firstly you need to find a computer to log onto. They are not always available at places where patients are seen. Secondly there is the additional time spent typing in notes. With pen and paper notes I used to make notes when I was talking to patients. The advantage was that they were instantaneous and it was easy to capture verbatim comments. Now I have to set aside time to type in notes – usually about one hour per clinic which translates into one less new patient each week. For the organisation I work in this represents terrible value for money, I must be one of the best paid yet least efficient typists in the organisation. Then there are the physical effects of all this extra typing – I have for the first time developed an overuse syndrome in my wrist and several other colleagues are nursing sore backs. Another problem with electronic notes is that not all parts of the health service use them – I still need to track down paper notes on people seeing other physicians. This doesn’t exactly encourage joined up health care and emphasises the split between mind and body.

Lastly there is the effect electronic notes have on “dumbing down” health care. The problem is that the electronic notes are not blank screens. There are numerous forms to complete from assessment forms to risk and hazard forms. What this does is that it encourages a checklist approach to assessment so that the emphasis is on completing the forms rather than finding out what is important for the patient. Every assessment is the same no matter what the patient needs and it is a “good” assessment if all the boxes on the electronic forms are completed. The ability of health workers to prioritise needs and to understand why this person has this problem at this particular time is damaged. Also there is an emphasis on risk and “hazard” rather than needs. This is often simplistic so that assessment of risk emphasises predicting whether people are at high, medium or low risk of violence/self harm. Unfortunately it is clear that clinicians prediction of who is going to kill themselves is no better than chance and probably not worth doing, after all most people who commit suicide are low risk. The purpose of risk assessment is identifying modifiable risk factors rather than some vague prediction of the future. So health care is dumbed down – just fill in the forms and that is fine no matter what they mean.

So would I return to pen and paper notes – no. Can electronic notes be improved. Yes – find another way of entering the data rather then getting expensively trained clinicians to be typists; decrease the number of forms and make them more flexible as well as training in how to keep notes; and get the whole organisation to use the same system. Then the goal of joined up health care and better communication in a complex system will be one step closer.