Helen Salisbury: Protocols and plastic aprons

Having a particular, set way of doing things can be useful. Following a protocol means that the whole team knows in advance what’s meant to happen. The steps will already have been thought through and laid down, and if we adhere to them the likelihood of a safe outcome is increased.1

This is the ideal. In general practice, however, protocols seem to have multiplied without any obvious commensurate increase in patient safety. Checking our shared drive this week, I discovered that we have (among others) an assistance dog protocol, a panic alarm protocol, and one about how to respond to sudden illness in the practice. No one would argue against having a well thought out strategy for any of those, but the problem with many written protocols is that they remain just words on a page. I’ve probably read all of my surgery’s protocols, but they clearly haven’t stuck in my brain. It’s also possible that they were created merely to satisfy the Care Quality Commission so that, if it asked whether we had a policy on assistance dogs, we could say “yes.”

This isn’t an argument against protocols in themselves—more an objection to accumulating vast numbers that are written and forgotten. All staff may be required to tick a box to say that they’ve read them, but unless these procedures are rehearsed, discussed, and owned by everyone in the practice they serve little purpose. The vital ones must be revisited regularly so that when you need the panic alarm, or a patient collapses, you don’t have to stop and look up the protocol.

When a protocol languishes in cyberspace it looks as if we’re just covering our backs: a fig leaf, contributing as little to patient safety in the surgery as the original ones added to modesty in the Garden of Eden. It always puzzles me when we, as doctors and people of science, continue to do things with no useful purpose. We now know that the SARS-CoV-2 virus is airborne, yet we persist in wearing flimsy plastic aprons over our scrubs. I’ve yet to meet a single primary care doctor who believes that these provide any protection, yet we continue to don them obediently before each patient contact and add them to the toll of plastic waste each day.2

Perhaps there’s little active harm in writing protocols that are immediately forgotten, or wearing pointless plastic pinnies, but there is an opportunity cost. Could the time spent writing the protocol have been better used? If we weren’t faffing about with plastic aprons, might we be more focused on opening the windows? We could also consider the deeper impact: what effect does repeatedly doing something that we know to be pointless have on our self-image as rational humans and scientists?