People mistakenly think they will receive the same standard of care, wherever they go
Healthcare is not like the building industry.
There are no national regulations covering how often nursing observations are to be done after major surgery, or the methods that should be used to calculate chemotherapy doses.
A few standards exist but they are kept private, in pharmacy guilds or medical specialty associations.
Major public hospitals tend to write their own in-house policy and procedure manuals.
However small private hospitals only keep government regulations around non health care regulations such as building codes, fire hazards, chemical spills etc.
There is no way the general public can access information on these guidelines.
Even if people were willing to file Freedom of Information applications, they would not know the names of these documents.
And even if these documents were accessable to the average patient, who would responsible for monitor them?
Australian hospitals are funded by a wide variety of different Federal and State government departments, private companies and not for profit organisations.
These different funding groups are all covered by different regulations, and have different lines of accountability.
There is also wide variation in access to qualified nurses and Doctors.
Large public hospitals usually have a fixed nurse to patient ratios and medical staff on the premises at all times.
Small private hospitals may operate on a skeleton of casual nurses and have no doctors available after hours and at weekends.
So the issues affecting clinical standards include -
- Large variations in the availability and quality of clinical guidelines across different hospitals
- Fragmented funding sources across different hospitals, all linked to their own vested interests, data collection sources and bureaucracies
- Large variations in staffing education and ratios across different hospitals
- Lack of public information about any of these issues
Taking all this into account, it is not surprising that there is such widespread variation in clinical practice, from one hospital to another.
One thing is for sure. The majority of time patients spend in hospital, they are directly under the care of nursing staff.
And their chance of going home safely after their hospital treatments, is closely linked to both the quality of those nurses and the nurse to patient ratios.
Everyone reacts differently to pharmacy drugs
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 in his youth, and now suffered from arthritis in both knees. In his fifties and overweight, Tom worked in a sedentary job, did little exercise and was often in pain. Tom elected to pay upfront for private treatment, because of the speed of surgery.
No waiting periods. Tom thought this was great.
Surgery went well.
Afterwards Tom was taken up to the ward. A machine with intravenous morphine was set up beside his bed, and Tom was given a button to press when he had pain. It was explained that each press of the button would deliver small dose of morphine.
At first the morphine button was not enough to relieve his pain. Tom buzzed the nurse repeatedly, demanding extra morphine. The nurses gave the man what oral tablets they could, then called the surgeon at home. They had no choice, there were no junior Doctors in the hospital to review patients or write up different types of medications, as there would have been in a public hospital.
The surgeon gave a phone order of intravenous morphine. This settled Tom’s pain at first.
But several hours later his pain levels rose again, and Tom started buzzing the nurses. They rang the surgeon again, and he gave another phone order for intravenous 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 a checklist for the morphine pump, adding up his cumulative doses, his respiratory rate, pain levels and sedation score.
These checklists are compulsory in public hospitals when ever patients have morphine infusions that they can control. The checklists are time consuming to go through, and the patient needs to be reviewed every hour.
Nursing staff were run off their feet in this small private hospital. There were no set nurse to patient ratios in this hospital, so nursing staff were looking after six post op patients each. The majority of nurses were casual.
There were few blood pressure machines available.
Patients were all placed in small single rooms, branching off the long, plush carpeted corridors.
Because it was not a typical hospital ward, patients could not be seen from the nurse’s station. The long corridors also meant it took nurses a long time to get in and out of the rooms to check their patients.
Overnight nurses noticed that Tom had became more drowsy.
They checked oxygen saturation and were concerned it had dropped. Early in the morning, Tom's nurse rang the surgeon at home to ask for advice.
He told her to put oxygen on the patient and was not happy to have been woken up for something so trivial.
The nurse put an oxygen mask on Tom's face, dialled it up to 5 litres then let the man sleep.
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 overnight 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.
However the hospital was not fined, no individual Doctor or nurse was charged and the public were never made aware of the error and the circumstances causing it.