Saturday, 23 January 2010

Ward doctors

Ward nurses are busy. Medical and surgical wards I visit don't have the staff to do the work that's needed. It's manifestly evident to everyone, but since it costs to pay for more nurses, wards are chronically under-resourced. Our mental health wards are not, thankfully, with a 2:1 patient:staff ratio at the moment.

We staff wards sufficiently 'cause that's what we need to get the work done. Any less and we have worse outcomes.

Our neighbouring acute Trust seems to enjoy collecting data from their medical and surgical directorates. Almost as much as it enjoys documenting events, or non-events. Curiously, it thinks the best people to do this aren't clerical staff or IT staff or medical informatics folk, they reckon it's best to get the nurses to do it. One perk of having nurses on the wards is that they can provide nursing care. On the acute hospital site, I don't see nurses doing a whole heap of nursing now ('cept for the neuro rehab site where they're delightfully anarchic and simply crack on and sort patients, huzzah!) since they're mired in process and paperwork. The Productive Ward has sought to reduce this, but largely hasn't worked on their wards, instead it's generated more process. Ho hum. Maybe it'll get better. They've got less front line nurses and even more Modern Matron managers to sort this out.

Yesterday I saw a lady presenting with confusion, on a medical ward. She had a chest infection, against a background of worsening chronic obstructive pulmonary disease. She had dementia. She had no idea where she was, who was around her, why she was there, how long she'd been there, what was happening, what the different kit around her and the other 3 ladies in her bay was. She had no notion of what day it was, or what time of day.

Ward staff found her difficult to manage, since every 15 to 20 minutes or so she'd anxiously walk to the nursing station, loiter until a nurse passed by, then ask them what she should be doing. It took them time to talk with her. Time they did not have, since their Trust mires them with process that's seemingly more valued than the direct clinical care. They wanted to, but were rushed, they knew they weren't giving her the time she needed and deserved. Much frustration.

But when I saw her, she was settled. She wasn't wandering around the ward, seeking reassaurance any more. She wasn't even sat out in her chair, she was still in her bed. Because the nursing staff had been frazzled, so moaned to the junior doctor. The ward doctor is very young and very inexperienced and has no notion of person centred dementia care. The ward doctor is a doctor and she can prescribe. Haloperidol 10mg had been given, which had flattened her. Spectacularly. Well it would, being about x10 the dose we'd normally give, but ho hum. She was then lying in bed, keeping her nasal cannula on, causing no problems what so ever.

The junior doctor knows no better and can't. She's still too junior.

I get that the junior doctor has to support her nursing colleagues when they're fraught and frazzled. Yet, treating the staff's agenda to the detriment of the patient seems a step too far.


DrPolitico said...

We staff wards sufficiently 'cause that's what we need to get the work done. Any less and we have worse outcomes.
_ _ _ _ _

It is very good of you to point out the pressure those on the acute wards are under. Unfortunately it must be the case that those of us in acute medicine also have worse outcomes because of the staff shortages. Your example is a case in point. Your patient will now be at much greater risk because of her sedation.

I now rarely have a nurse with me on my acute medicine ward round because the nurses are so busy - often, as you have found out, doing less important things such as handing out questionnaires demanded by the management.

I am sure my Trust would not take kindly to my making these observations so I have set up a new account to conceal my identity.

DeeDee said...

Medicine is not the only field where there is endless process and bureaucracy. IT is almost as bad. Each time something goes wrong, the immediate answer is to add another form to fill out, another set of signoffs to obtain, and another meeting. Sitting down and having a think about how to actually do things better doesn't get a look in.

The reason for this is that nobody in management is going to get in trouble if they suggest more process, as this is the expected response. If they suggest something different, and that goes badly, they WILL be in deep shit.

Of course, "when things go wrong" for us = "software crash, some bankers are inconvenienced", rather than suffering or death.

That may be the crucial difference.

Nikita said...

Until I discovered the wonderful world of blogging, I was pretty disgusted with the NHS in regards to the care of the elderly. I still am, but now know the reasons behind it.

Our residents, in the majority of cases, are returned to us drugged up to the eyeballs and catheterised. If they were continent when they were admitted, once catheterised - we remove it, they never are again.

We did not realise medical wards were seriously understaffed. We do now.

We cater for those with behavioural problems. We are often asked via the telephone how we manage Fred or Betty. We do. If the reason for their admittence can be treated with meds, we suggest that they be sent home.

I am saddened that a hospital admission is detrimental to the well being of the elderly, demented person. They deserve better.

Socrates said...

10 times?

On a similar theme of shut you up medication Boobies (Not Funny) - Neuroleptics and Autistic kids in America.

cb said...

I have to say this mirrors quite closely more than a few interactions our team has with the general hospital next door.

Nurse Anne said...

I would not have given her that much haldol.

But what else can they do. These patients get hurt and they fall. They need someone who can sit with them. Management won't provide it.

Granted they do want us to hand out questionairres and spend the shift doing audits. We refuse to do it, or half ass do it. And we still cannot get any time with the patients. Every 4-6 hours I have to spend nearly two hours just mixing, preparing and giving iv anitbiotics. 30 minutes out of every hour is spent answering phone calls. It's not on.

Eileen said...

My daughter works on such a ward - as a chest ward they have hi-dependency beds, and lots of elderly demented patients who often terrorise the rest of their bay. One standing near the nurses station wouldn't be noticed - the 2 staff for 20 patients (on a REALLY good day)never get to spend long enough there. Last time she tried halperidol as a last resort it had no effect at all. No wonder mega doses may be given.
BTW - a heartfelt welcome back! Happy New Year!

Doctor Kirsten said...

I'm an FY1. My first ever shift was the night shift. An elderly gentleman with dementia had come in that day for an inguinal hernia repair. I was asked to se him as he had wandered off of the ward onto a neighbouring ward and was refusing to come back. Security had been called to 'assist' him back. After 15 minutes of talking the gentleman "Mr B" shall we call him decided he didn't trust myself or the nursing staff but trusted one of the security guards and came back to thw ward with us. We got his soon on the phone to try and provide a friendly recognsable voice to reassure him he was safe, and hopefully feel less lost and frieghtened in the hospital. He was in an open bay so we put his light on, kept reminding him where he was, giving him jobs to do in the general area so as not to disturb the other patients. Having never met Mr B prior to anaesthetic I had no idea of his usual level of functioning so had to assume this was delerium due to anaesthetic. I was bleeped away multiple times during the evening but kept returning to the ward to keep this gentleman company so the nurses could get on with their work. Eventually he grew bored of me, started walking into the ladys bays and the nurses were very tired of having to 'be with' this gentleman as they were really busy, its an acute surgical ward after all. In the end 2mg of haloperidol syrup was tried, no effect. 2mg Haloperidol IM had the effect of Mr B stitting by the nurses station listening to the nurses talking as they wrote their notes. By the morning Mr B was still awake but more weary. I left the hospital and returned after the weekend to find him lying in bed. Haloperidol 10mg BD had been prescribed for the weekend, my first job would be to cross this off the chart. I asked an OA Psychiatrist how I could have managed that night better, was like talking to a wet fish, no real advice. Any ideas?

Milk and Two Sugars said...

Oh, dear. As a brand new hospital doctor, the pressure from nursing staff to prescribe sedation is immense, bordering at times such as these on ridiculous. My collegues and I developed a single hard-and-fast rule during the first few days: Only If It's Necessary For The Patient's Care. So if the person is on an insulin infusion, for example, and it is absolutely necessary that they be on it and that they have BGLs done hourly, and they are absolutely unapproachable due to agression, then we're probably at the point where sedation has become medically indicated. We evaluate each patient individually, because that is what they deserve. And most of the time, ward measures have worked a charm. Once all I had to do was turn on a light, and the very eloquent elderly lady who was "agitated" became settled and happy.

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The Shrink said...

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Varan said...

Bannerjee report anyone? But seriously, I don't feel that there is enough culpability levelled at iatrogenic deaths in the NHS at the moment and probably, ever. Only been nursing for 20 years so I dunno really.
@Doctor Kirsten: There is actually specialist delerium units dotted around the country, such as Elm B at Cumberland Infirmary (01228 814480) but I don't feel the condition is given the recognition it deserves at the moment. I mean, what is the point of keeping the elderly/powerless alive if they are only going to keep coming back to fill beds?