Thursday, March 11, 2010

More Chaos at Maidstone Hospital

My friend Tracey Crouch is hopefully the next MP for Chatham & Aylesford. On her excellent blog today, she carries a horrifying tale of the experience of one of her (future) constituents at the local Maidstone hospital. This, remember, is the hospital which hit the headlines for the wrong reasons last year over Cdiff. Over to the constituent...

Tuesday (early hours of the morning) -The response to my 999 call was first class. After an hour or so in A & E my wife was transferred from a bed to a chair because of a shortage of beds and was subsequently moved to the Medical Decision Unit. At one point patients on ambulance trolleys were queuing in the corridors!

My wife remained in the chair for 7 to 8 hours before a bed was made available. During this time the portable oxygen cylinder ran out and as there was no replacement she was crammed between to hospital beds to get access to the ‘piped’ oxygen supply. This resembled a corridor the width of a chair and frankly bordered on a shambles. Once settled in bed a drip was rigged up, a length of bandage being threaded through the loop of the plastic container and hooked over the end of the curtain rail - No drip stand!

The following morning (Wednesday) I was asked by a nurse if I could bring in two of the items on my wife’s prescription because they were not available from the hospital pharmacy. When I returned to the hospital I gave the tablets to the nurse who taped them to the Medication Chart. That morning I learned my wife was to have an Ultrasound and when I asked, when, was told ‘when a porter turns up’. At this point I decided to talk to Pals (Patient Advice & Liaison Services) who subsequently put me in touch with the A & E Matron. I explained my concern at the apparent haphazard way things were in the Department. What appeared to an outsider as being chaos was typical of what happens in A & E it seems. Many of the problems stem from the fact that you cannot close the doors to A & E which means unless you can maintain a steady flow of patients through the system and out the other end chaos will ensue. To get patients out the other end, in many cases, you need beds and they are simply not there.

That afternoon the Matron, on checking, assured me the Ultrasound would take place at 10am the following morning – in less than half an hour of making that statement a porter arrived to take my wife to have her scan - perhaps there was a cancellation! After the Ultrasound my wife was seen by a doctor who said it would be about 2 hours before the scan results were available. 43 hours later I was advised the results were NAD (Nothing Abnormal Denoted).

On Wednesday evening my wife was transferred to the Medical Assessment Unit (MAU) and later
that night she was transferred to XXX Ward. My daughter visited the hospital at 9.30am on Thursday and when I arrived at approximately 10.15am she was walking the corridors looking for her mother! She had reported to the MAU and told that Mrs X was not in the area. It transpired that no one seemed to know my wife had been transferred to XXX Ward and that in effect she was temporarily lost! A number of staff was involved in tracking down my wife’s whereabouts and soon my daughter and I were reunited with Mrs X.

During the afternoon I asked the nurse dispensing medication whether she had the tablets that had been taped to the Medication Chart. She said no and that she had ordered the necessary medication from the hospital pharmacy. I responded by saying ‘this morning you lost the patient and now you have lost the medication I had specifically been asked to bring in’. Before leaving the hospital that evening I checked for the results of the Ultrasound and they were still not available.

I arrived at the hospital at 9am on Friday and requested to see a doctor who hopefully could give me the results of the Ultrasound. Two and a half hours later I met a doctor who was debating whether he should take responsibility for my wife or whether another chest specialist (who my wife had seen as an out-patient some 9 months previously) should be involved. This doctor said if my wife came under his care he could tell me anything from this point onwards but could not comment on any matters arising before this time. That afternoon my wife had a CT chest and abdomen Scan and I was told the results would not be known for 24 hours. I telephoned the hospital at 12 noon the following Monday and was told the results of the CT Scan were still not known. Five minutes after that call my wife telephoned to say she could come home. I went to collect her and again enquired about the CT Scan results. When I was told they were not known I asked whether it was right for my wife to be discharged without knowing the outcome of the Scan. The nurse said Mrs X had not been discharged and then queried it with her. My wife explained that a doctor, who she had not seen before, had said ‘Would you like to go home’ to which she said ‘yes’. The nurse went away and on returning said yes it was alright to go home and that the CT Scan was NAD!

Between my wife and I we survived the week but it certainly was not without incident! I have total admiration for many of the staff but there are fundamental issues that need to be addressed and in my view a starting point would be to listen to the Matrons etc who I am sure can see ways for improvement and who are doing their best with the resources provided.

It appears to an outsider that:

- The records held on a patient in a variety of handwriting and umpteen pieces of paper could lead to inefficiencies
- It is easy to mislay a patient
- It is easy to lose a patient’s medication
- The hand over procedures from one medical team to another is inadequate.
- Full time Staff dedication is difficult to maintain when Agency staff are paid substantially more for similar work.
- The cost of Agency staff could be diluting the available funding for necessary expenditure in the hospital.

There's a lot to think about here for the politicians who will be in charge of the NHS over the next few years. This is one anecdote, but we've all heard others. Are they representative of what hapoens in hospitals each day? I'd like to think not, but if they are, there isn't a politician in the land who can truthfully say they can turn this round quickly.

National targets have a lot to answer for. But in the end, this chaotic situation is the responsibility of local NHS managers to sort out.


Bird said...

Horrifying tale, but I'm not too surprised. I could relate a couple of similar tales following a heart attack in '95 (yes, I know - the Tories were still in) and bladder cancer '09.
I could add further horror stories involving friends during the last ten years. Conclusion: The NHS had many faults in the '90s and they remain today despite much money thrown at it.
I've met some terrific, hard-working individuals along the way though. You have to be lucky with the team you get.

gordon-bennett said...

Get rid of all targets and replace them with online reports by PATIENTS (and/or their relatives) about every medical transaction.

Your example, though rather verbose, is what is required. Such reports should not be subject to amendment by hospital staff but such staff should be obliged to comment/explain in response.

Those reports and responses should be accessible to all and sundry (inc. the public and the press) and the medical staff would quickly learn to react to what the reports are telling them about what the patient wants.

In the real world this is known as customer control.

Robbie said...

This won't be popular, but one thing that would go a long way to sorting this out would be a proper computer system.

Ultrasounds, CT scans etc can't be lost or delayed if they are automatically uploaded to a patient's record as soon as they are done. Nurses can't lose a patient if their record tells them where they have been moved to Medication can't (usually) be lost if it is stored in a dedicated facility.

Our hospitals are a mess for many reasons, but our unwillingness to spend money on anything but medicine and salaries makes them even worse.

Cynic said...

It just cant be true. Gordon told us 'I will not let you down' and he put Alan Johnston in charge of the NHS

Lady Finchley said...

I wish this was a rare tale but it is not. How about neglecting to give a patient with Parkinson's his pills so that he actually froze up and has never recovered? Or allowing a patient to sit in their own mess overnight and not changing the linen or the patient because the nurse went home and 'thought she had forgot something'. Or the middle aged woman with cancer who went to the hospital to die - in her last day she suffered even more because the nurses had forgotten to give her her anti-depressants so she was suffering withdrawal, fear and pain? I could go on and on. And this is in a hospital in a prosperous area of one of the Home Counties. And these are articulate, middle class patients. Can you imagine what happens to the timid, the inarticulate and the poor?

Hollow Godric said...

An extremely unsurprising story. This chaos stems from the fact that hospitals run at full capacity, and often beyond, on a daily basis, and have inadequate staffing and resources. Managers generally only add extra pressure on already pressured staff rather than facilitating clinical work. Put simply:

1. Patient flow into the A+E is unpredictable, and often patients present in clusters rather than a steady trickle. The 4 hour target simply means snap decisions have to be made before all the facts are known.
2. Admissions to MAU do allow for fuller assessment, but duplicates A+E assessments. As MAU has to be able to receive patients from A+E before they 'breach', patients are often sent to a ward as soon as the first bed is available, rather than an orderly transfer to the most appropriate ward.
3. Once on the ward, the pace tends to slow. If the patient is on the wrong ward for their problem, care can be substandard. Odd practices are common because ultimately the senior staff are less focussed on inpatient care on specialty wards. End result is delays in care, different specialists muddying the waters, and slowed discharge. Slowed discharge means the hospital runs at capacity.

I've worked at all these levels, and I can assure you everyone knows the problems, it's just that noone is willing to deal with it.

yarnesfromhorsham said...

Only way to deal with this sort of horror is to complain. Perhaps the only way to deal with the NHS is to flood the organisation with complaints - perhaps then somebody will take notice and improve service. Putting patients first - yeah right.

DespairingLiberal said...

I think this is a fairly common set of difficulties. The area I live in is noted for having quite good NHS treatment and both my pensioner parents have had good medical treatment but poor nursing care. A friend of mine in Bristol who recently had an injury was treated with something verging on contempt by the "nursing" staff, who basically refused to assist her with tasks like getting food to her mouth, when she herself was utterly incapable of doing so due to her injury.

However, I do have some sympathy with the nursing staff. Many of the NHS hospitals are flooded out with "self-induced" injuries and illnesses and many patients now are rude, self-absorbed and irrational in their demands and aggressive in their behaviour. Against that background, many trained nurses have simply withdrawn from the caring side of nursing, leaving it to untrained assistants who in many cases are recent immigrants with poor language skills and abilities.

There are areas where targets have had a negative impact, but I think we need to look at the usage of NHS resources (too high and widely abused both from abroad and from people who really need basic education in living skills), the professionalisation of nursing (distorted training ideology and caving in too much to the nursing and doctors unions), management (still much too disconnected from floor level medical staff - nobody who is not medically trained should be running a hospital).

An even bigger crisis is looming - the explosion in the unwell baby boomer generation moving into a diabetic, unexercized, slothful old age, riddled with medical problems that their parents (the wartime generation) did not have in such large amounts.

We probably need to do something like Cuba - cut back drastically on overpaid doctors and consultants, train up lots and lots of part-timers in basic skills, combined with something like a lifelong contribution to old age medical care with higher bills for those who smoke, are fat, drink too much, etc. Bans on treatment for proven heavy drinkers and proven heavy smokers.

Man in a Shed said...

The problem is no one is responsible for the patient's outcome in the NHS ( any more ).

You old GP has been replaced by two or three part time GPs ( who earn the same each as the old one ), but you can't see the same one each time and you'll have to wait if your impertinent enough to insist on it till they're back again. And even then they have to spend a few minutes looking at their computer screens to remember who you are.

In hospital each member of staff you meet has blinkers on. They do their job, in their shift pattern, and that's it.

If the whole thing isn't working - you can be sure that each member of staff has done their job and it isn't their fault - and if anything nasty happens they'll get councilling and more public sector courses ( which are handed out like smarties though out the entire public sector ).

And that without the nurses who don't nurse, but discuss their social life instead ( thanks to the studentification of an old vocation ). ( This isn't universal or I hope even the majority yet - I've seen some very professional nurses in the NHS - even ones who fight against the grain and don't just accept this old lady didn't want her tea or her drink and make sure they've tried to help her ).

Its nobodies fault - everyone does their job - and the patients just suffer from indifference.

If the patients had a real choice it wouldn't happen, and those staff who have done nothing but their job wouldn't have those any more.

Remember Socialism kills, and does so with the heartless brutality of indifference as the NHS demonstrates on so many appalling occasions.

Kingbingo said...

Yet the left have made it a point of political conviction to refuse to consider any change the NHS system devised six decades ago. We have Cancer survival rates around 40% while comparable countries have 60%. The left is perfectly happy to let that lost 20% die horribly for ideological reasons, all the while desperately trying to convince the public through their captured means of communication, i.e. the education system and the BBC that the only alternative to the current system is either no healthcare at all, or super expensive Harley street care for the rich. Despite dozens of comparable countries, none of whom operate the NHS system who provide better healthcare to rich and poor alike than anyone gets here.

Kingbingo said...

Yet the left have made it a point of political conviction to refuse to consider any change the NHS system devised six decades ago. We have Cancer survival rates around 40% while comparable countries have 60%. The left is perfectly happy to let that lost 20% die horribly for ideological reasons, all the while desperately trying to convince the public through their captured means of communication, i.e. the education system and the BBC that the only alternative to the current system is either no healthcare at all, or super expensive Harley street care for the rich. Despite dozens of comparable countries, none of whom operate the NHS system who provide better healthcare to rich and poor alike than anyone gets here.

davidc said...

1. the nhs is about measuring process not outcomes - who notices if the patient dies as long as all the boxes are ticked (stafford hopital)
2. what is measured can be and often is fudged eg a trolley becomes a bed and that box is ticked

the nhs is no longer about care it is now a career path
sadly we have arrived at a point where i suggest anyone accompanying a patient carries a bright red folder and is seen to make notes of what happens and when

this seems to focus attention in a wonderous way

Johnny Norfolk said...

I would order the senior management team to spend a full day a week every week in each department so they can see for themselves what poor managers they are.I would insist that the most senior of all was available to see everyone who complained face to face.

Its just so shocking on how much maoney hasbeen spent and it ends up like this. The NHS is out of control.

Nurse Anne said...

You are very wrong about the notion that RN's are "withdrawing" from bedside care.

In the late 80's and well into the 1990's business orientated management consultants were brought into hospitals in the USA and UK. These are people who do not understand nursing. Their plans involved cutting RN staff from the bedside and replacing them with untrained carers. On paper this looks cost effective but we have now learned that quite the opposite is true.

Nursing care in hospitals has never recovered from this.

The only places who have fixed it are Victoria, Australia and California, USA. They have legislated strict RN to patient ratios on their wards. The hospitals balked at the idea but the bills were passed regardless and have been proven to be the way to forward.

The untrained carers cannot do very much and are not allowed to know a lot about the patients. This leaves the one RN on shift with more patient information than one person can handle, more drugs to give than can be given and total chaos.

The hospitals are not advertising for registered nurses at the bedside and neither older RN's who want to come back into the workforce nor new graduate RN's are able to find employment at the bedside.

This has nothing to do with university training of nurses and everything to do with penny wise pound foolish hospitals.

Nursing students today spend as much time on the wards as the nursing students did in the 1970's. But they are not allowed to do as much due to worries about litigation. So they cannot be used in the same way that nursing students were used in the old days. This again, is not down to university training. It is down to lawyers. And the RN numbers at the bedside have not been increased to deal with this.

In States and Provinces with strict bedside RN to patient ratio laws you never will never hear of patients starving and being left in their own filth. And all of those bedside RN's are degree educated with no more than 4 or 5 patients at a time. The safe ratio on a general hospital ward is 1 nurse to 5 patients maximum regardless of how many untrained carers are running around the place.

Hospitals that have instituted these ratios have found that 1. More nurses entered the workforce as a result of the ratios. Therefore they had no problems meeting the minimum legal staffing numbers 2. they now had lower costs as a result of less patient complications. 3. They were able to retain RN's at the bedside.

The RN to patient ratios in the UK are obscene. The nurse has more patients than she can handle or care for. It is like working on an assembly line moving through everything as fast as you can, and taking major shortcuts to ensure that you can get around to everyone at least once.

I could go on but this is long enough.

Nurse Anne said...
This comment has been removed by the author.
DespairingLiberal said...

Nurse Anne, a very good and useful contribution, thank you.

Would you be prepared to say from your experience when the rot set in, eg, which government first introduced the McKinsey-ite management consulting and time and motion analysis activities into the NHS that have so degraded it? My mother worked for many years as a midwife in a busy ante-natal clinic and she identifies this as happening under the later Thatcher administrations.

Nurse Anne said...

do think it is unrealistic to expect an exact time for the Ultrasound to occur as an inpatient. The system is chaotic with new patients coming in and being triaged around and over inpatients who are waiting for scans.

The porters are extremely busy. They are of course, unable to keep us informed of where they are going to be and when. They cannot be 10 places at once. It would just slow them down even more (and me) if I kept phoning them to ask when they are going to come to take Mrs. so and so to her scan.

When you come on duty after days off you obviously will not be aware of the patients who transferred in and out on your days off nor where they went. The ward clerk should keep a book with this information in it. But if it wasn't logged then we have no way of knowing where they went.

I am loathe to leave a dying critically ill patient whose meds I am searching for to run to the station and play "let's see where the patients who were here on my days off transferred out to".

Nor will I spend the day ringing porters to see how long they will be or harassing ultrasound to see exactly when someone is going there. It just slows everyone down and makes the patient wait longer.

Demetrius said...

One man I know went into the A&E at Maidstone having been in Acute Urine Retention for 12 hours and it took 14 hours before they found a doctor to look at him. It seems that it can be between 12 and 36 hours when AUR results in major organ failures. Another got a full blown anaphylactic shock at Maidstone from treatment and the PCT refused to pay for allergy testing.

Alexandra said...

Robbie's comments about uploading radiological investigations already happens. This is one (the only?) area where the NHS computer programme has worked. As a hospital doctor in training I can search on PACS systems for the reports and actual images that a pt has had on this and previous visits. I may glance through the images but doctors have differing degrees of confidence in their interpration skills and so I would generally wait for formal reporting by a radiologist before communicating the results to a pt and their family.

Not a sheep said...

Every time I ore Mrs NotaSheep have had to enter a NHS hospital we have met with a lack of systems and lack of care that we have found unbelievable. It is not enough for politicians to repeat the mantras: 'envy of the world', 'free at the point of use' etc. The NHS is both massively over and massively undermanned - the under manning is on the clinical, patient focussed side, the over manning is on the administration side.

Boy on a bike said...

All they need to do is kill some more patients - that will free up beds.

Oh - they're doing that already?

In that case, a higher patient/kill target needs to be set.