Personal v. Professional

Personal v. Professional

( Thoughts from Godfrey... )

Although it’s 15 years or more since Carol & I were NHS managers, the managerial perspective becomes an old habitual pattern of thinking after 20 years. They say that police officers after a similar period, will always have their “copper’s radar” on, always on the lookout for a dodgy geezer. And so it is with Carol & I. At the same time as going through a very personal and anxious time before major surgery, we nevertheless couldn’t help looking at the quality, efficiency and effectiveness of the various systems and processes that were in place. There is huge room for improvement.

Let me take you through the events as they unfolded.

The Surgical Admissions Unit is a room with 3 beds in it at the end of the corridor on the 3^rd floor of the Heart Hospital. The letter Carol had received said arrive at 7.00am, and that you can only drink water up to 6.00am. 

Staring Out of the Window ...waiting

 

6.50am Emerging from the lift we asked a passing nurse about where to go for admission. She pointed down the corridor saying the “SAU” was the door at the end on the right.

6.55 The room was deserted. There were 3 beds one of which had dirty linen lying on it. We waited.

7.00 Carol went to the patient loo. It was a mess, paper towels thrown everywhere.

We waited.

7.30 A few nurses walked up and down the corridor but no one came in to see who we were and what we were doing. We waited.

8.00 More activity. A nurse came in and shuffled through casenotes, wandered in and out without even acknowledging our existence. Later a man came and sat at the desktop computer, similarly ignoring us. Nurse returned and sat beside him. They spoke in hushed tones, but we did overhear him describe himself as “a floater”.

Still ignored

8.20 A nurse came in asked if Carol was “Carol Hardings” [sic] and gave her a gown to put on, saying take off all underwear and put it on. She then left, never to be seen again. The bed curtains were left completely open. Not wishing to expose herself to the un-introduced male “floater”, or the various people you could see in the kitchen windows and the nearby roof garden outside, Carol struggled to draw the sticky curtains.

8.25 As I returned from the loo, Carol was trying to draw back the curtains which refused to go around the bend. Meanwhile the nurse had silently stood up from the workstation and walked straight past the patient struggling in vain with the curtains. Nothing to to do with her.

8.35 A different nurse came in to take blood samples and put an ID bracelet on. When asked, no-one knew when Carol would be taken to theatre. Various other people wandered in and out chatting.

8.45 An anaesthetic registrar came in to read Carol’s notes, spending a considerable time chatting about her personal stuff to the colleague perusing the computer. Carol remarked quietly, “It seems rude to eavesdrop on a private conversation, do you think we should leave the room for a bit?”

8.55 The anaesthetist went through the patient history with Carol. Symptoms, when scans were done, including asking how long Carol had been a heavy smoker. “I’ve never smoked”. “Oh, I though I’d read in the notes that you were a smoker” was the response. Strange, we thought. (but more of that later).

9.10. Yet another nurse we hadn’t seen before asked about Carol’s “prephyorrty”

What? So she repeated the question. Oh “PROPERTY” Clearly not a level 7 IELTS then. Then she asked if Carol’s red leather handbag was her “Wiizhe-berg”. No, it’s a handbag. The nurse seemed satisfied with this answer and left. We never saw her again either.

Then there was a long period of waiting including a new more mature person saying to me her name and that she would be booking me through the system. "I hope not, I'm the patient's partner". Another member of staff I never saw again. Then a sister(?) from Floor 4 apologising that the person who was supposed to be there hadn’t turned up, and would Carol like a pillow? (”No I want to know what’s happening. Are they going to operate on me or not?”)

She went off somewhere, and returned to say Carol was on the list for 12.00. An urgent case had been brought in previous night to go first in theatre.

Carol’s response was "Then why have I been sitting here like a lemon all morning waiting around half naked, and why, if hydration is so important pre-op, didn’t someone tell me at 8.00AM that my slot had been cancelled so I could have some water?" (A gap of 2 hours before anaesthetic is required:http://www.rcn.org.uk/__data/assets/pdf_file/0009/78678/002800.pdf )

10.30 Thirst intensified. Nurse from 4^th floor suggest I/V fluids.

The Clinical Nurse Specialist comes in. Carol complains of raging thirst, and says that a I/V line to rehydrate her has been mentioned. The CNS says says "No, we don't do that here - it's not our policy to give pre-op I/V fluids. Try dipping your fingers in cold water and rubbing your gums". She disappears.

Yet another nurse turns up to fit cannula for I/V fluid. Carol says:"Your CNS says it not the policy to give I/V" Nurse goes away to ask. Comes back and inserts a cannula into Carol's wrist..

11.30 Still no saline drip set up, while the 4th floor nurse sits there writing. "How’s that virtual I/V working for you then Carol?" , I say, in a voice meant to be overheard, It’s already been a long frustrating day. If the op is at 12.00 it doesn’t leave much time for rehydration. The nurse carries on writing.

12.10. Nurse stands up, let’s organise that I/V fluid then she says. And does so.

More waiting including an interesting debate on casenote management, record-keeping, subject access rights under the Data Protection Act and the NHS Constitution. More on that debacle in a later blog post....Record Keeping

1.30 Two east European nursing auxiliaries came in to strip and remake the used bed and talked loudly to each other in a language we didn’t understand, Occasionally, one of them looked at me with a serious expression. I was reminded of the Harry Enfield sketch where haughty Polish shopgirls in a newsagent say things about him in their native tongue that he is unable to understand.

Abandoned SAU Desk

2.00 What the hell is happening? Wasn't it supposed to be a12 o'clock op? Everyone has disappeared. We wait. Find the nurse call button as Carol attached to I/V. Back from lunch, the Nurse rings theatre. Apparently the department organising the correct blood type transfusion didn’t get the blood samples early enough. “That’s a lie. They were sent up at 8.30 this morning”. So the surgeon is doing a lung op while they sort it out. More waiting.

2.30 At this point I’m seriously wondering whether the operation will be cancelled. How long before another theatre slot can be found. We had to wait a fortnight for this. Our adrenaline and cortisol levels are red-lining. The tumour is growing, maybe invading….

2.39 Without warning, the theatre porter turns up with a trolley and Carol is wheeled off to Theatre.

It’s been a long and stressful day already. Carol is in tears. Good job neither of us has a “dicky ticker”.

That was the subjective experience from a patient and their next-of-kin's perspective.

From an NHS managerial perspective, the way these interactions unfolded demonstrate deficient processes which fail on grounds of quality, efficiency, and clinical effectiveness.

1. Out of an elapsed time of 7.5 hours (07.00hrs - 14.30hrs), the actual patient- staff contact time was about 45 minutes. And yet much of that contact time consisted in innumerable and mostly fruitless interactions with at least 12 different individuals spread over the entire morning. There was absolutely no need for a fraught moblie patient to be isolated in an empty unlit room dressed only in a skimpy nightgown the entire morning and lunchtime.

a) It is not efficient, to have so many different members of nursing staff walking to the room at the end of the corridor to engage with a patient in order to simply disappear.

b) It is not effective, given that so many of the interactions seemed to require identifying the name of the patient, but resulted in no further intervention.

c) It is of sub-optimal quality in terms of nursing care. The whole principle of the "named-nurse" initiative, is to provide a single familiar point of contact that is reassuring to the patient, avoids overlap of duties, and reduces unnecessary duplication and repetition in communications.

2. There was a lack of managerial oversight. If a member of staff fails to turn up for work, then a designated replacement, fully conversant with the required pre-op clerking and assessment procedures should take their place. It was clear that the variety of staff involved were uncoordinated. No manager was seen on the SAU taking charge to cover for staff absence. As each staff member appeared at various and apparently random times, they had to ask the patient what had happened prior to that, what had been done or not done. There was no "plan" that anyone was working to. Managers should formulate a clear procedure which all relevant staff are familar with and trained to enact. They should not have to "wing-it" just because the person who normally attends SAU is absent.

3. Communication was abysmal. Airport management have recently learnt the hard way, that what makes delayed passengers angry, is not so much the fact that their flight is delayed, but the fact that they are kept waiting without being given any information as to what is happening. It was a question that Carol frequently made to various staff "What is happening?". No-one knew, or at least we assume they didn't, because as often as not, they'd walk out of the room without answering. Clearly, theatre knew when the planned operations were to take place, and they knew when there had been a delay due to a cross-matching foul-up. Why is there not a procedure in place whereby the surgical admissions unit has immediate access to the same information? 

The absence of communication has a clinical component too. Patients who feel heard and informed, form the impression that all is going smoothly. In a cardiothoracic centre, allaying the anxieties of patient's facing major surgery is likely to be of benefit clinically, as well as a matter of human respect and courtesy.

 

4. Staff attitude.

Being asked to strip in front of an open window on a level with residential windows and roof gardens without drawing the curtain is hardly consistent with maintaining the patient's dignity and privacy.

Being asked to do the same in front of a man looking at a PC monitor on the desk directly opposite is also wrong. He had not identified himself, he was not in any nursing uniform, white coat or theatre scrubs.

A nurse ignoring a patient struggling with patient equipment (bed curtains) should seek to assist, not walk aimlessly and casually past as if the patient was invisible.

Walking away, or turning your back, on a patient who has just asked "What's happening, I thought my operation was due to start 3 hours ago..." is unacceptable. The appropriate answer, is "Give me a minute and I'll find out for you".

5. Confused Clinical Protocols.

The previous week, the Clinical Nurse Specialist had emphasized in a phone-call, the importance of being well hydrated before the operation, up to the cut-off point of 6.00 am. (ie 2 hours prior to earliest likely anaesthetic). If staff had known, or bothered to find out that the operation had been rescheduled for 12.00 and again, 14.45, Carol could have safely sipped water up to 2 hours prior to the scheduled time. Yet throughout, it seemed that staff were sticking slavishly to the 6.00am "rule" on oral water, without any understanding that thiis could be altered depending on the later time of the operation. Requiring a patient to start surgery when  insufficiently hydrated is contrary to good nursing practice.

And yet the same Clinical Nurse Specialist, who emphasized the need for pre-op hydration on the phone, was adamant that no more clear fluids could be taken orally and it was not their policy to set up I/V fluids for pre-op hydration. It would appear that if this was an official policy, other less senior nurses were happy to ignore it, which in these (wholly avoidable) circumstances was the clinically correct thing to do.

 

SUMMARY

On the 13th June 2012, the Surgical Admissions Unit was largely unstaffed, and the presenting patient was treated casually, in a chaotic and unplanned way, involving a succession of nursing staff who clearly were reacting in the moment, but not taking any overall responsibility for the swift and thorough preparation of the patient for surgery. Management systems to co-ordinate pre-operative processes were apparently non-existent, as were senior nursing/clerical management themselves.

I noted that the Heart Hospital online feedback from "Gregory A. Dec 2011" seems to have formed a similar opinion about the pre-admission process. He complained about the "Communication between staff (nurses, admin)/doctors...The chaotic, uncaring administration.

I was left in a bed without food, water or any information for more than 17 hours waiting for an operation that was postponed."

The hospital staff worked well together…hardly at all

I was treated with dignity and respect by the hospital staff…not at all

I was involved with decisions about my care…never

On 24 February 2011 the administrators responded to his feedback on his experiences at the Heart Hospital: "I'm very sorry that we did not meet your expectations on this occasion. We always strive to offer excellent care to our patients and your experience clearly falls far short of that."

Clearly, that's just automated P.R. guff. Four months later and another patient's experience draws the same conclusion. These shortcomings can be remedied. Elective surgical admissions can be organised with a much more patient-centric and patient-friendly procedure, as they are in other hospitals up and down the country. 

 

In my experience of under-performing hospitals,and under-performing hospital departments, it is very rare that failure can be attributed to the ordinary individual staff-members. It is a failure of management that causes complaints like this. Indeed even poor staff attitudes can be attributed to poor management where morale is low, guidance is absent, and where managers fail to take remedial steps when warned of a problem.