Sick hospitals—Is there a cure?
Article Outline
Across the Western hemisphere it has become increasingly apparent that hospitals are potentially dangerous places to be in. As Julian Bion President of the European Society of Intensive Care Medicine, asked at a recent conference ‘if your hospital was an aeroplane would you fly in it?’ Over the past two decades it has been the policy of most Governments to achieve economies of scale in order to reduce the cost of healthcare. As a result many services were ‘contracted out’. These included catering, cleaning, portering, supplies and maintenance. Nursing was emasculated and control over these elements, which supported and maintained an acceptable environment for care, was removed. The coordination of care ceased to be the responsibility of experienced nurses in whom power and authority were vested and nursing itself was viewed as an expendable commodity. As a result we have seen an exponential rise in the incidence of adverse events. Adverse events have been defined as ‘an unintended injury that results in temporary or permanent disability, including increased length of stay, which is caused by health care management rather than the disease process’ (Wilson et al., 1995, p. 461). The frequency of these events ranges from 16.6% (Wilson et al., 1995) in Australia, 10.8% in the UK (Vincent et al., 2001), 7.5% in Canada (Baker et al., 2004) and 2.9–3.7% in the USA (Thomas et al., 2000). It is unlikely that there is any great difference in the incidence across countries rather that reporting mechanisms are more sensitive and specific in some countries than others.
Adverse events include medication errors, falls and incidences of failure to rescue. Failure to rescue implies patients sustain complications which, if they had been acted upon earlier, could have been avoided. They include myocardial infarction (MI), cardiac arrest, re-intubation, acute pulmonary oedema, pulmonary embolus, stroke, sepsis and acute renal failure. The result of which is often an unplanned intensive care unit admission.
Commensurate with these findings is research which demonstrates the effectiveness of nursing if staffing levels are appropriate. Examples of this are in MI patients where an increase in nursing hours per patient day resulted directly in improved survival (Schulz et al., 1998). A higher proportion of hours and a higher number of care days by registered nurses resulted in lower rates of urinary tract infections, upper gastrointestinal bleeding, pneumonia, shock and cardiac arrest (Needleman et al., 2002). These are precisely the factors associated with the adverse events identified earlier. In surgical patients each additional patient in excess of a four patient workload resulted in a 7% increase in mortality and a 7% increase in the odds of failure to rescue (Aiken et al., 2002). Failure to rescue is a term used to denote an outcome whereby the patient demonstrated signs of deterioration but these were not acted on appropriately and in a timely manner. This has often been associated with a lack of knowledge, failure to appreciate clinical urgency and a failure to communicate effectively (McQuillan et al., 1998). Might it not also be an effect of decreased staffing levels and the replacement of nursing staff with support staff as demonstrated by the research outlined above?
In response to this some states have legislated for safe staffing ratios, namely in California, USA and more recently in Victoria, Australia (ICN, 2006). The ratios indicate the maximum number of patients to be assigned to a nurse during one shift and vary according to levels of acuity. At first reading this can appear to be a positive innovation potentially resulting in the improved recruitment and retention of nurses and enhanced well being, with the concomitant effect of improved quality of care and outcomes for patients and increased confidence in the public health system. However, established ratios may not accurately reflect the needs of patients or the complexity of care required. For example if the number of patients assigned to a nurse is dependent on ‘acuity’ how is acuity defined? Usually it directly relates to the consumption of resources, i.e. increased technological requirements by which a hospital can measure the cost of care. It would not determine the time needed to support the relatives of a brain dead patient or the waking head injury patient who is restless and has made clear his abhorrence of technology by pulling out all intravenous cannulae and removing monitoring systems. Established ratios are a very blunt measure of staffing requirements which also fail to account for the lay-out of particular ward or unit areas, the presence of non-RN staff and specific workplace issues characteristic of a particular hospital. Therefore it is not just an issue of numbers but also of the risk presented by particular patients in specific environments which needs to be assessed in determining appropriate nurse patient ratios, issues which have been raised by this journal in the past (Ball and McElligott, 2003, Ball et al., 2004).
Hospitals will always be required for the care of the acutely ill and injured and nurses are the key to efficient and effective care (Black, 2005). The cure for the current sickness in hospitals is therefore to recognise the unique contribution made by nurses and empower the profession to establish the effect it so clearly had and still has the potential to achieve. The answer is not to reduce the number of nurses yet further only to reap the results in increased adverse events, clinical incidents and higher mortality rates which, whilst these are disappointing in terms of hospital league tables and sources of irritation to policy makers can represent real tragedy to individual patients and their families.
References
- . Hospital nurse staffing and patient mortality, nurse burnout and job dissatisfaction. J Am Med Assoc. 2002;288:1987–1993
- The Canadian adverse events study: the incidence of adverse events among hospital patients in Canada. Can Med Assoc J. 2004;170:1678–1686
- . Realising the potential of critical care nurses. Intens Crit Care Nurs. 2003;19:226–238
- . Moving on from patient dependency and nursing workload to managing risk in critical care. Intens Crit Care Nurs. 2004;20:62–68
- . Rise and demise of the hospital: a reappraisal of nursing. Br Med J. 2005;331:1394–1396
- International Council of Nurses. Advancing nursing and health worldwide www.icn.ch; 2006.
- Confidential inquiry into quality of care before admission to intensive care. Br Med J. 1998;316:1853–1858
- . Nurse staffing levels and the quality of care in hospitals. N Eng J Med. 2002;346:1715–1722
- . The relationship of hospital structural and financial characteristics to mortality and length of stay in acute myocardial infarction patients. Outcomes Manage Nurs Pract. 1998;2:130–136
- Incidence and types of adverse events and negligent care in Utah and Colorado. Med Care. 2000;38:261–271
- Adverse events in British hospitals: preliminary retrospective record review. Br Med J. 2001;322:517–519
- . The quality in Australian Health Care Study. Med J Aust. 1995;163:458–471
PII: S0964-3397(06)00070-X
doi:10.1016/j.iccn.2006.05.002
© 2006 Published by Elsevier Inc.
