Blog, nurse, hospital, iv drip

Best practice has no clear legal status

Patient think that they get the same standard of care, no matter where they go

Well, I’m sorry but they don’t.

Healthcare is not like the building industry. There are no national regulations covering the basics of patient care. 

The result is that nursing observations after surgery, even the way chemotherapy doses are calculated, actually varies from hospital to hospital.

And can you find out which hospital follows which procedures?

Very unlikely.

Clinical Guidelines are fragmented and there is wide variation in actual practice.

Large public hospitals usually have a fixed nurse to patient ratios and 24 hour medical staff on the premises. Small private hospitals may operate on a skeleton of causal nurses and no doctors available after hours and at weekends.

One thing that does remain constant, is the importance of quality nursing care to patients safety.

The majority of time patients are in a hospital, they are directly under the care of nursing staff.

And their chance of going home safely after hospital treatments, is closely linked to good ratios and qualified nursing staff.

Everyone reacts differently to drugs. Which is adequate numbers of qualified nursing staff are so important

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.

Surgery went well.

Afterwards he was taken up to the ward. There a machine with intravenous morphine was set up, and Tom was given a button to press, delivering small amounts of the drug.

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 different types of oral medications. The surgeon gave a phone order of intravenous morphine. This settled Tom’s pain at first.

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. Unbeknown to the nurses, he kept pressing the morphine button, to prevent any further episodes of pain recurring.

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

This check lists records how often the patient has pushed the button over the last hour, what their cumulative dose of morphine is and what their sedation score is and what their respiratory rate is.

The hospital did not have specific protocols for managing Patient Controlled Analgesia machines.

Nurses were just told to get through post operative obs as quickly as possible.

Nursing staff were very busy in this small private hospital. There were no nurse to patient ratios in this hospital and busy wards often ran on a small amount of staff.

There were few blood pressure machines available. Patients were all in small single rooms, branching off long plush carpeted corridors.

This meant that patients could not be seen from the nurse’s station. It also meant it took nurses a long time to get around and see all their patients.

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.

If you don't measure, you can't manage

Overnight Tom became difficult to rouse. Despite this, he had only received three sets of vital signs.

Importantly, no one had tallied up how much morphine he had received. A sedation score had  not been completed.

Tom remained difficult to rouse. The night nurse rang the doctor at home again. He told her to remove the morphine pump control and turn up the oxygen to 8 litres.

Tom remained difficult to rouse.

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.

A 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 Doctor or nurse was charged.

Wikihospitals 2014

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