Cutting back on nursing education can lead to an increase in hospital errors

Managing the huge variety of patients that come through the doors of Emergency Departments is not easy.

The way people’s bodies react to both illness and treatments can be surprising.

This is why ensuring that time is put aside for continuous nursing education is so important.

An elderly man called Battista was brought in to the Emergency Department by his relatives. Battista was coughing, anxious and complaining that he couldn't breath.

The family told the Doctors he’d had a cold for several weeks.

“The doctor gave Dad some antibiotic tables, but they didn’t work” explained his daughter. “We didn’t know what else to do, so we brought him to the Emergency Department.”

When the doctor listened to Battista’s chest with a stethoscope, he could hear coarse crackles in the bottom of both lungs.

Battista was also coughing up thick green sputum.

The Doctor diagnosed a severe chest infection.

He prescribed Battista intravenous antibiotics and told him he would be admitted to hospital for a couple of days.

The family was relieved. At least Battista was getting some attention. Their father came to Australia from Italy in his twenties, worked in the building industry and despite being a smoker, had always been fit and strong.

A couple of days in hospital is all he needs” the daughter assured her mother.

The ward clark tried to find his medical history. But there was very little information available. Battista spoke little English. His family were obviously close, but only concerned that his shortness of breath was managed.

The nurse checked his saturations and were concerned that his oxygen levels were quite low.

She wanted to quickly get Battista's oxygen levels up to a normal range and reduce his work of breathing. So she gave him 4 litres of oxygen via a mask.

Battista was also given inhalers to open his airways, and saline nebs to break down the thick sputum.

With the oxygen and medications, his shortness of breath seemed to subside. Battista appeared more comfortable. His breathing was not as laboured.

He seemed calmer.

A specimen of sputum sent off for testing, to see what type of chest infection he had.

And a bed was found for him on a general medical ward.

The ward nurse who admitted Battista checked his oxygen levels. His oxygen levels were still low. So she turned the oxygen mask up to 6 litres a minute. She helped him undress and get into the hospital bed. By now Battista was slow moving and seemed a little confused.

The nurse made sure he got his antibiotics on time and checked to see that the sputum specimen had been sent off to pathology.

Nursing staff were busy overnight, and only checked Battista intermittently.

Battista slept soundly.

At 6 am the night nurse had difficulty raising Battista. She thought that was odd.

However at that time of the morning, patients were waking up and wanting to go to the toilet and nurses were busy running around doing obs and giving out medications.

Battista's oxygen saturations were still low. His nurse made a note to let the medical team know when they did their morning rounds.

Then she turned the oxygen up to 8 litres a minute and rushed off to see her other patients.

As usual the early morning nurses shift was chaotic.

Patients had to be sat up for breakfast, given tablets and taken to the toilet. By 9.30 am the doctors were starting their round.

They found Battista lying in his bed his blood pressure was so low it didn’t’ register. His face was extremely pale and he was unresponsive.

A code blue, or emergency call was made.

The crash team, or resuscitation team rushed in. A  junior doctor took a sample of blood from an artery in Battista’s wrist and sent off for an  arterial blood gas test.

The results showed that Battista had low levels of oxygen, high levels of carbon dioxide and his blood ph was in the acidic range. Type 2 respiratory failure was diagnosed.

Battista was rushed by ambulance to a more advanced hospital, with an Intensive Care Unit.

He subsequently died.

Nurses in this hospital all worked short shifts, seven and a half hours, instead of the normal eight hours.

This saved the hospital from paying for an extra half an hour per nurse, per shift. The hospital management thought this was economical.

However it also meant there was no time available for any formal nursing education to take place.

As a consequence, nurses did not revise essential education, like understanding the difference between type 1 and type 2 respiratory failure.

Wikihospitals 2014