AUGUST, 2015

‘Unacceptable variations in practice’
Different nurse to patient ratios
Lack of after hours Doctors

Unnecessary variations in practice can lead to errors.

Some Clinical Guidelines are only available in medical, pharmacy and nursing associations. Others are kept in public hospitals and only available to staff who work there. Patients are not able to access this information (unless they lodge a freedom of information application). There is wide variation in actual practice across different hospitals and clinics.

There is also wide spread variation in nurse to patient ratios. Some hospitals have fixed ratio’s and 24 hour medical staff on the premises. Other hospitals have a minimal number of nurses, prefer to use agency staff and have no doctors available after hours and at weekends.

Due to lack of public information about these issues, patients have no way of checking hospital practices or their staffing levels before they undergo treatments.

As a result, issues that impact directly on patient care are not discussed publicly, and are not available to individual patients undergoing treatments.

An overweight man in his fifties called Tom went into a small private hospital to have a knee replacement. Tom had been a competitive athlete and now suffered from severe arthritis in both knees. He now worked in a sedentary job, did little exercise and was constantly in pain. Tom elected to pay upfront, because of the speed of surgery.

The surgery went well. He was taken to the ward. There a machine with intravenous painkiller medication was set up, and Tom was given a button to press, delivering small amounts of morphine.

At first the button did not relieve his pain, and Tom buzzed continuously, demanding more morphine. The nurses gave the man what oral tablets they could, then called the surgeon. There was no junior doctor in the hospital to assess patients or write up extra medications. The surgeon gave a phone order of intravenous morphine. This settled Tom’s pain.

But then his pain levels rose again, and Tom started buzzing the nurses. They rang the surgeon again, and he gave another phone order for morphine. After several orders of intravenous morphine, plus the continuous small doses of morphine using his button, Tom finally settled down.

The nurses did not use the hospital checklist for intravenous morphine pumps, called ‘Patient Controlled Analgesia’ or PCA’s.

Nursing staff were always very busy in this small private hospital. There were set no nurse to patient ratios and busy wards often ran on a small amount of staff, who were pushed to the limit to mange post operative patients. The hospital ran on agency staff and has very few permanent nurses.

The patients were all in small single rooms, branching off a long corridor. With the hospital’s plush carpet and pay TV in every room it was sold to patients as a nice place to recover from theatre. In reality it meant that patients were difficult to monitor. They could not be seen from the nurse’s station. It also took nurses a long time to get in and out of all the private rooms, to check their patients.

Evening nurses noticed that Tom had became more drowsy. They checked oxygen saturation and were concerned it had dropped. One nurse rang the surgeon at home to ask for advice. He told her to put oxygen on the patient and not to call him again at home for something trivial. The nurse put an oxygen mask on Tom, dialled it up to 5 litres then let the man sleep.

Overnight the man became difficult to rouse. After being back from theatre for 6 hours, he had received three sets of vital signs, no sedation score, no respiratory rate assessment. No one tallied up how much morphine he had received. He remained difficult to rouse. The nurse rang the doctor at home again. He told her to remove the morphine pump control and turn up the oxygen to 8 litres. The man still did not wake.

There was no junior doctor in the hospital to do a simple test called arterial blood gases. This test would have shown how high the carbon dioxide levels was in Tom’s blood. The nurses only options were to call the consultant at home and wake him up.

The night nurse went in to do one last set of obs on Tom at 6am. She found him dead.

The autopsy subsequently showed Tom had died from respiratory, then cardiac arrest. The Coroner later criticised the hospital for having failed to provide adequate supervision of the patient. The hospital was not fined.

No nurse or doctor was charged. The hospital was not fined.

© Wikihospitals 2014