How Marginal Gains Make the Difference in Intensive Care

Dr Justin Kirk-Bayley and Jonathan Males 

Marginal gains in sport has turned losers into winners how this practise can work in intensive care will be the subject of the Sintetica symposium at our SOA conference in Birmingham. The panel will include top sports psychologist Dr Jonathan Males.

Football is not a matter of life and death... it's much more important than that.

That quote from Bill Shankly, former manager of Liverpool Football Club, sums up just how passionate sports fans are about their team and winning. When you work in the intensive care his words can sound trite as it’s a matter of life and death every day for everyone involved. Its about multidisciplinary teamwork where the stakes are a lot higher than winning the Premiership

Jonathan Males: When I begin working with an athlete I ask them to break down their sport into stages: preparation, playing, or reviewing their performance.  What are the mental demands facing them at each of those stages, and during the transition from one to another? They need to consider the state of mind required at each stage to excel?.

Justin Kirk-Bayley: In identifying a target for marginal gain we ask ourselves three things: what does the evidence say?, what would be a good thing and what is reasonably achievable?

Once the issue is identified we use the Delphi consensus method to distil it into five components where we see a potential to make a one per cent improvement. We then walk through the process for each component to uncover the patients and multidisciplinary teams priorities on the pathway to recovery.

We decided to call this a pathway as it implies a journey; ‘protocol’ is too rigid as it suggests something which must be done, a ‘guideline’ can be ignored. A pathway is something everyone follows to success.

Jonathan Males: When an athlete is standing on the starting line they have to be confident they have done everything they can to have an edge over their competitors. Sometimes this means in their practise they have tried to do things differently to find that edge. Sometimes it works and sometimes it doesnt. We call this a safe to failexperiment.

The athlete makes an incremental change and evaluates its efficacy. If there is an improvement, do it for a week and, if that goes well, embed the change. But if it isnt working they mustn’t be afraid to drop it.

It is the one per cent which counts. They have to know they have left no stone unturned in their pursuit of a gold medal.

Justin Kirk-Bayley: We all need to avoid becoming wedded to a certain way of doing things. Defaulting to the automatic when we are under pressure is naturalafter all we are in life and death situations. But don’t take anything for granted. Assess the response to the intervention. Believe in dogmalysis.

Medicine is an ever-changing discipline. What is law one year is ancient history the next. The upshot of this is that we are duty bound to question what we do. The utility or harm of intervention, or lack of must constantly be addressed.

Jonathan Males: Living in the moment is vital in sport, which is why having the right mindset is so important. All the practice, the hours, days, weeks and months wont help if the athlete loses focus, not just on the day, but on the next shot.

Things go wrong because people start to think too far ahead particularly when the stakes are high. In some situations, like weightlifting or a penalty shot in football, it’s over in seconds. The pressure is on. There is a need to focus on the moment and not what might happen if they do or dont succeed. If they put their thoughts into each part of their sport their focus will remain unhindered and the final goal wont feel like such a burden.

Justin Kirk-Bayley: When you make changes that one per cent in any area of the patients pathway then changes occur in other areas too. Consequently the multidisciplinary teams input is vital if we are to shave off, and we do, half days, and whole days in making the patients journey and outcome better.

Problems occur when individuals are given too many simultaneous complex tasks. To keep someone in the here and now you need to reduce the cognitive burden by breaking their workload into small tasks.

Question: How would you eat an elephant? Answer: One bite at a time. This is where pathways work because you can follow the line and refer back to what has worked and what hasnt and where that fits into the journey.

Marginal Gains Sporting Success

Former Team GB British Cycling performance director, Sir Dave Brailsford, believed it was possible to make marginal gains – a 1% improvement - by uncovering the team’s weaknesses and working out how to improve on them.

By using a wind tunnel he noted the bikes were not sufficiently aerodynamic. He looked at the mechanics area in the team truck and found dust on the floor which hampered maintenance. Hand gel cut down on infections.

All small things which added up to a whole.

The result? Team GB achieved more Olympic golds than ever before and more British riders winning the Tour de France.

Marginal Gains – Recovery Success

By taking into account the patients pathway Justins team have been able to reduce ITU and hospital length of stay.

Marginal gains included rationalising drug information, reducing memory burden and facilitating assessment of therapeutic efficacy. Simple things, like ensuring a patient has their non-slip socks on at the top of the day, prepare them mentally and physically for the physiotherapist and their daily exercise.

Patients weren’t able to continually exercise their core muscles as tubes and lines confined them to bed – the answer was an intensive care bed which converted into a chair.

Accurate information can spur change. An audit at the Royal Surrey showed a high mortality rate for emergency laparotomies. Those facts immediately engaged the team to find a solution, involving small, incremental change which led to a dramatic improvement in outcomes.

Justin Kirk-Bayley: “ Clinicians need to take time to examine the pathway from major surgery or illness to recovery and ask whether it ought to happen that way. Each step of the process should be questioned for its utility. Could it be done better? Nothing should be sacrosanct. Multidisciplinary teams need to get together, look at the things they can measure, constantly make small changes and re-measure, and not be afraid to make positive improvements. That way everyone stands to win.


Dr Jonathan Males is a sport psychologist and executive coach. He has helped athletes and coaches prepare for every Olympic Games since 1992, working with Team GB and Paralympics GB. His focus now is on humanising performance in the workplace, to enable people and teams to thrive, not simply survive.

Dr Justin Kirk-Bayley, MRCP, FRCA, EDIC, FFICM is a Consultant Intensivist & Anaesthetist at the Royal Surrey Hospital in Guildford. Whilst better known for advancing education in point of care ultrasound (POCUS), on the Intensive Care Society FUSIC committee, closer to home he works with surgeons, pharmacists, nurses, physiotherapists to improve patient outcomes after high-risk surgery

Dr Oliver Tweedie Consultant Anaesthetist & Medical Director, Sintetica (m) 07768 981899

Sintetica Ltd 0203 6932740

The Sintetica symposium, “Using marginal gains to improve safety in intensive care”, is on Monday 9th December at 12:30 in Room Birmingham.