Thursday, October 11, 2007

Prodicus blames the nurses

Prodicus has been spending a little time in hospitals recently, and he is very angry.
Visiting a sick relative in a large and rather well-regarded general hospital over a period of many months, I noticed that the wards and corridors were plastered with wash-your-hands messages, including dozens of posters of smiling consultants washing their hands and captioned, 'If I can do it, so can you'.

I cottoned on quickly. I made a habit of washing my hands last thing before I went to the hospital and immediately on arriving in the ward. There was a basin by the door, plus alcohol gel. I used soap and water and the gel, and only then greeted Uncle Demosthenes and sat down for a natter.

The ward was full of incontinent, bed-ridden old chaps, completely dependent on nurses and health care assistants for all their bodily needs. Often, one of them would cry out for a bed-pan, and usually, he would have to wait quite a while. There were frequent 'accidents'.

A doctor or two would usually come round during my visit. Almost every doctor I saw used the basin and the gel before approaching Uncle Demosthenes or any of the other patients.

The nursing staff, however, never did. Never. Are you listening? NEVER. The qualified nurses usually wore gloves and some of the health care assistants did, too, but not once did I see either a nurse (including the sisters in navy blue) or a health care assistant wash their hands or use the gel before or after handling a patient. Not once.

This is negligence. The solution is discipline. Any member of clinical staff approaching a patient without having cleaned their hands should be disciplined. And therein lies the rub.
...

It does not matter if a nurse does not wash her hands. The only thing that happens is someone dies, but sick, old people die in hospital anyway, don't they? Of course they do.

No-one will notice that the nurse killed old Ron by being a dirty, negligent nurse. No-one will notice that she didn't wash her hands after handling old Fred's faeces-smeared zimmer frame and before turning old Ron. And if they do happen to notice, no-one will reprimand her (or him). Nurses are 'angels', beyond reproach, and that's an order.

And so the whole thing drifts down to the level of the murderous C.diff. catastrophe we now see in Kent.

I hope there are prosecutions in Kent. I hope individual medical and nurse managers, right down to the nurses, are hung out to dry. Fired. Humiliated and disgraced. And the agencies should get hit badly in their profits, for not enforcing standards among their nurses.

I hope hand-washing police are stationed in every ward, with clipboards and clickers; names should be taken and warnings issued. People fired.

And I don't really give a toss what it costs. It would be money well spent, because the first rule of medicine and nursing is 'First do no harm'. Whatever it costs to make sure that nurses are not killing patients under the noses of supine managers and wicked, bullying union politicos, will be worth it. Not killing the patients deliberately or by negligence is the beginning of health care. You would think.

Before my medico commenters go absolutely, indignantly ballistic, do go and read the whole thing: Prodicus does acknowledge some of the problems inherent in dealing with this negligence, including the lack of management in both hospitals and nursing agencies.

UPDATE: the boss of the hospital has had her severance pay put on hold.
The health secretary has told the trust at the centre of a hospital bug investigation to withhold any severance pay to its former chief executive.

Rose Gibb of Maidstone and Tunbridge Wells NHS Trust resigned on Friday after four years in the post.

Please, do not be too impressed: this is simple government spin again. Seriously, does anyone doubt, once this whole thing has blown over, that Rose Gibb will receive her severence pay in full? Really?

It's pure spin, that is all.

UPDATE 2: it is at this points like this that I like to remind people—especially my medical commenters—that I do know what it is like on the front line.

26 comments:

JuliaM said...

"I hope individual medical and nurse managers, right down to the nurses, are hung out to dry."

I wholeheartedly agree. I'd really like to have seen the CEO of the Trust not allowed to resign, but have to take her lumps too!

Prodicus said...

Just heard on the radio that the govt. has put her severance pay on hold. Good.

Dr De'Ath said...

This kind of vindictive attitude is not productive. I am sure you will flame me for this, but anyway:

On the whole the staff on the ground do a pretty decent job under tricky circumstances; yes, there is a minority who should know better, however lynching them is not the solution.

It's very easy to sit and judge from your ivory towers, however most of you would not believe the sh*t that nurses have to put up with, I certainly would not do their job.

By casting so much blame locally you are missing the point and being sucked in as the politicians like Alan Johnson want you to be. They want to pretend that this is a one off, and that Tunbridge Wells is just a bad apple.

The problems are systematic and they stem from Whitehall. The majority of the blame should be at the door of this government for the way in which their systematically failing policy is inflicted upon the NHS, resulting in these side effects.

A bit of scientific knowledge would also help, as the media is bloody useless as reporting on this issue, meaning that 'superbugs' become an emotive frenzied topic and not something that can be rationally discussed.

A lot of NHS staff are far from perfect, however you are doing a great diservice to the majority of hard working ones who have put up with a hell of a lot of crap forced upon them by this Labour government. A witch hunt will not help prevent this type of thing happening again.

What needs to happen is that Hospital Acquired Infection must be dealth with in an all encompassing manner. All the aspects of policy that have resulted in it getting out of control such as bed cuts, staff cuts, high bed occupancy, no isolation rooms, poor cleaning, endless targets meaning patients moved too fast endangering infection control etc-

these need to be addressed by a government that thinks holistically.

This government does not tackle things holistically, take the recent Darzi interim review, it is a sticky plaster on a gaping wound, it is all about tabloid pleasing gimmicks and not proper policy crafted by experts based on decent fucking scientific evidence.

We need the best microbiologists and public health doctors involved, not fucking Darzi and his bunch of Labour buddies.

This is why you are so wrong to pin all the blame to the staff on the frontline.

Anonymous said...

''you would not believe the sh*t that nurses have to put up with''

Is asking them to wash their fu**ing hands afterwards too much to ask?

This is a classic ''lessons will be learned'' episode

Devil's Kitchen said...

My dear Dr De'Ath,

Where to start? Well...

"It's very easy to sit and judge from your ivory towers, however most of you would not believe the sh*t that nurses have to put up with, I certainly would not do their job."

As you may or may not know, I worked for a year as an Aux nurse, so I am aware of a good deal that they have to put up with.

Crucially, none of it stopped me washing my damn hands (much of the time I was desperate to!). However, I will acknowledge a nasty side-effect of constant hand-washing: dry, cracked skin.

"By casting so much blame locally you are missing the point and being sucked in as the politicians like Alan Johnson want you to be. They want to pretend that this is a one off, and that Tunbridge Wells is just a bad apple."

We know that Tunbridge Wells is not a one-off for "superbugs"; I also sincerely doubt that it is a one-off in terms of nurses not washing their hands.

"The problems are systematic and they stem from Whitehall. The majority of the blame should be at the door of this government for the way in which their systematically failing policy is inflicted upon the NHS, resulting in these side effects."

With all due respect, this is crap. Yes, there are systematic failings at Whitehall (which is why we need to remove the NHS from the politicos greedy fingers asap); however, nurses not washing their hands is a personal failure, not a Whitehall failure. Sorry.

"A bit of scientific knowledge would also help, as the media is bloody useless as reporting on this issue, meaning that 'superbugs' become an emotive frenzied topic and not something that can be rationally discussed."

This is true. How fortunate that my (admittedly unfinished) degree course was microbiology; it is also fortunate that we studied these so-called superbugs (C. difficile, Methicillin Resistant Staphylococcus Aureus, etc.); perhaps I shall elaborate on this subject in due course.

Having had extensive microbial training, you will realise that, whilst they are resistant to antibiotics, most of these bacteria are not resistant to most bacteriological chemicals; hence the importance of hand-washing.

"A lot of NHS staff are far from perfect, however you are doing a great diservice to the majority of hard working ones who have put up with a hell of a lot of crap forced upon them by this Labour government. A witch hunt will not help prevent this type of thing happening again."

Yes, yes, the majority are all lovely, lovely people: this does not alter the fact that hand-washing is a fairly fucking basic requirement.

In fact, this argument is a total straw man: working hard does not necessarily mean that they do not kill people through negligence.

"What needs to happen is that Hospital Acquired Infection must be dealth with in an all encompassing manner. All the aspects of policy that have resulted in it getting out of control such as bed cuts, staff cuts, high bed occupancy, no isolation rooms, poor cleaning, endless targets meaning patients moved too fast endangering infection control etc-"

Yes, I agree with all of this. And nurses washing their fucking hands could also be added to that list.

"these need to be addressed by a government that thinks holistically."

Yes, true enough. However, they also need to think locally. Like getting nurses to wash their fucking hands.

"This government does not tackle things holistically,"

That's right. So, we need everyone, from the highest minister to the lowest fucking auxiliary to do what is required.

"This is why you are so wrong to pin all the blame to the staff on the frontline."

Neither I nor Prodicus were putting all of the blame on the front-line.

However, it is utterly wrong for you to try to exempt totally those on the front-line: they must bear some of the blame – and we can argue endlessly about how that blame should be apportioned – for what goes on in their hospital.

And, I'm sorry, but hand-washing with an alcohol or iodine based hand scrub would be a really good fucking start.

DK

Henry North London said...

Nurses are the spawn of the devil

Nuff said

I hate them and I hate their patronising , stupid sociopathic little minds.

Oh God I am pissed off today

Dr De'Ath said...

indeed I agree,

I'm not condoning their actions, and I have not condoned their actions

The blame is not particularly fairly proportioned in my opinion, that's all I'm trying to get at

I don't think humiliating and disgracing people would be particularly productive either

Dr De'Ath said...

ps "It's very easy to sit and judge from your ivory towers, however most of you would not believe the sh*t that nurses have to put up with, I certainly would not do their job."

as you can see, this comment was addressed to everyone in general DK, I stand by it, most people do not appreciate what nursing entails

lost_nurse said...

Individuals are culpable on grounds of poor practice, but holy fug, is there some rubbish being spouted about C.Diff in the media. Rarely do I see anything mentioned about antibiotic usage (and resistance).

Hand washing is majorly important - berate 'em, report 'em if you don't see it happening - but it will do fcuk all for safety, if you are still being forced to play musical beds with vulnerable patients. Short-staffing + lack of isolational capacity = not things you can blame frontline grunts for. Both key factors in any HAI crisis. Johnson knows this. He just doesn't want to admit it.

Garth Marenghi said...

UK population increasing rapidly, partly down to large EU migrant worker group

UK population demographic top heavy and this top heavyness is going to increase for many years, more and more elderly patients who need care and who will need admissions to hospital

Acute bed numbers:

1999/2000 135,080
2000/1 135,794
2001/2 136,583
2002/3 136,679
2003/4 137,247
2004/5 136,184
2005/6 133,033

http://ferretfancier.blogspot.com/2007/09/deep-clean-but-still-up-to-our-necks-in.html

Wrinkled Weasel said...

Not until the CEO of a hospital trust or other public body such as railtrack, etc, goes to JAIL, will health and safety be taken seriously.

As a side issue, all that extra money that is supposedly being spent on the NHS is going straight into the PFI crooks' pockets.

Well. Nothing is forever. The National Health Service seems to have reached its sell-by date. It should be abolished for all but the very very poor. No private hosp would last five minutes with the kind of reputation that Maidstone currently enjoys. nuff said.

Caractacus said...

I'm surprised so few people die in NHS hospitals.

Four years ago, I was admitted to a 'flagship' NHS hospital suffering from acute TB. As my immune system had totally collapsed due to advanced HIV, I was placed in an air-sealed room to keep out any infection. This would have been all well and good were it not for the fact that the room was fucking filthy. I mean really disgustingly filthy, not just a tad shabby. The bathroom had blood, shit and piss stains. No-one amongst the hospital staff would do anything about it or, indeed, seem to think it was anything out of the ordinary. Ultimately, my partner and friends spent a day scrubbing the place clean after having to argue with some fucking NHS jobsworth who tried to stop them as they were not "authorized" to clean NHS property.

I discharged myself the minute I was physically able to leave.

Soddball said...

Tunbridge Wells' hospital, the Kent and Sussex, is known amongst the locals as the 'Kent and Snuffit'.

Reassuring, wouldn't you say?

the a&e charge nurse said...

Perhaps one possible solution would be for nurses to have a much greater say when it comes to determining if a new admission to hospital is actually feasible, or not - so instead of docs simply deciding, that yes, Mr Jones needs to come in today, medical staff would be expected to negotiate with the ward nurses to find out how realistic it is increase the care burden.

Once ward acuity [or dependency] i.e. the number of incontinent, confused, or very sick patients reaches a certain threshold, then the door to any further admission would automatically close.

Minimum nurse-patient ratios should also be introduced as a further basic starting point.

Of course there is a risk that many more patients might die while waiting for their turn to be admitted to the now pristine and optimally staffed in-patient facilities.

But surely it would be a small price to pay to be free, finally, from the dreadful situation that has arisen in Kent ?

Commentators have, no doubt, drawn their own conclusions about the motives for the nurses failure to comply with basic infection control measures - but if we really want to see the sort of hospitals that tend to appear in advertisements for private insurance schemes, then we must reduce admission rates by at least 20-30%, while ensuring that labour intensive work like incontinence care, feeding, walking/mobilising, listening, and so on is adequately resourced.

James said...


Of course there is a risk that many more patients might die while waiting for their turn to be admitted to the now pristine and optimally staffed in-patient facilities.

But surely it would be a small price to pay to be free, finally, from the dreadful situation that has arisen in Kent ?


Are you serious? Instead of maybe doing the job properly and having enough nurses to care for every patient, you suggest limiting people's access to something THEY HAVE ALREADY PAID FOR? And its a small price to pay if some of the die?!

Jesus, titty-fucking Christ! I hope to god nobody with your attitude works anywhere near any hospital I might have to be dragged to..

Although:

Minimum nurse-patient ratios should also be introduced as a further basic starting point.

That I agree with - but by making sure there are enough staff, NOT cutting the amount of patients allowed through the bloody hallowed doors.

Roger Thornhill said...

a&e: Negotiate with Matron, do you mean? It would make sense if at least strong protest at overcrowding and constant tinkering is made visible.

And where is Matron in all this? For nurses to habitually not wash hands shows the rot rises high and as such, to me, unless the nurses always wash in the presence of superiors but not when they are absent, the ultimate responsibility lies in the discipline and drill on the ward.

As for the CEO, I think she should be re-hired. No, honestly...but just so she can be unceremoniously FIRED in front of the assembled senior staff, have her ID taken off her like some C19th Austro-Hungarian Officer having their braid ripped from their shoulders and have Security watch as she empties her desk of "personal belongings" and walks out with said box during office hours just as any other sod fired has to do.

Post it all on Youtube.

"pour encourager les autres".



p.s. The ex CEO should never be permitted to hold a public job. I do wonder if this is more frightening than anything else! My god! she'd have to work in the real world!!!!

the a&e charge nurse said...

james - let me lay a little analogy on you.

Supposing aeroplanes started crashing on a regular basis.

The air traffic controllers complain that there is no way they can safely manage the volume of air traffic arriving that arrives at the airport every few minutes.

Given these circumstances would you advocate fewer or more flights ?

So if the ratio between the care burden and nursing resources is not tenable [as many nurses have been warning, long before the situation in Kent developed] how does it make sense to cram yet more patients onto the wards, especially when a significant proportion are highly infectious ?

Sorry if a few simple facts are unpalatable, but as they say, there is not much point in shooting the messenger, is there ?

James said...

Given these circumstances would you advocate fewer or more flights ?

Neither - I'd advocate more air traffic controllers and more runways to cope with the increased demand.

how does it make sense to cram yet more patients onto the wards, especially when a significant proportion are highly infectious ?

Thats a straw man - I never said anything about cramming anyone into the same space - in fact I agreed with your idea of an ideal nurse to patient ratio.

Hell, we doubled the damn money pumped into this monolith, but seem to keep closing hospitals and wards.

Expand hospitals, refurbish older ones, open new ones. That way you don't have to have highly infectious people anywhere near vulnerable patients.

Sorry if a few simple facts are unpalatable, but as they say, there is not much point in shooting the messenger, is there ?

They are only facts because you wont take a separate approach to the problem.

However, if the messenger is someone that believes deaths are a small price to pay for anything, I'd be inclined to pull the trigger myself.

lost_nurse said...

"...if the messenger is someone that believes deaths are a small price to pay for anything..."

The irony seems to have escaped you. A+E C/N merely states grim reality. Be glad you don't have to take his decisions.

Nurses have long been warning of this exact scenerio (Kent and Sussex) and the dire need for better staff:patient ratios, not to say acute capacity. Did anybody listen? No.

the a&e charge nurse said...

Come off it James - do you really think I am proposing a massive cull of the sick ?

Why do you think I'm droning on about safe nurse:patient ratios and safe clinical environment [as many other nurses have for some time now: see mental nurse and militantmedicalnurse blogs] - surely if I just wanted a cull, then it would be quicker [and cheaper] to do less, not more.

Unfortunately, new hospitals cannot help us today, c-diff would be unlikely to wait for tenders to be processed - we have to admit around 40 patients EVERY DAY through A&E.

And you are plain wrong when you claim that we have doubled the amount of cash spent on the "monolith".

You are correct to point out that [most] of the public have paid for health services, but it is only a very modest amount, and that is part of the problem.

According to the Institute of fiscal studies less than 10yrs ago the UK spent 6.7% on health, the lowest of the G7 countries - in the same year France hit 10%, while the Germans devoted 10.6% of GDP to health.
http://www.ifs.org.uk/election/ebn3.pdf [page3].

In fact we still haven't caught up, the gap has closed slightly, that's all.

In 2004 the UK spend was 8.3%, well below the OECD average of 8.9%.
Switzerland topped the list spending 11.6% of GDP
http://www.oecd.org/dataoecd/29/53/36959993.pdf

The chickens may have come home to roost in Kent but why worry about years of underfunding when the lynch mob can go after a few hapless frontline grunts - yes, it must have been well worth it trying to nurse 30 patients per day in crammed wards with almost no support except for the odd agency nurse.

the a&e charge nurse said...

Incidentally James - there is a place where 2million patients suffer a hospital acquired infection [HAI] each year.
90,000 infections are fatal [yes, that's 90,000 not 90].

70% of the bugs are resistant to at least one of the antibiotics commonly used to treat them - while strains of staph aureus resistant to methicillin [MRSA] are endemic in hospitals and are increasing in non-hospital settings, such as locker rooms and day care centres.

Prodicus must be horrified at the sort of nurses that would permit such conditions to develop, but suprisingly, this time it's not Kent.

I'll give you a clue though: it's a country that spends more on health than anywhere else in the world [15.3% of GDP in 2006, i.e. well over twice what the UK was spending up until fairly recently].
http://www.niaid.nih.gov/factsheets/antimicro.htm

Curioser and curioser ?

Roger Thornhill said...

A&E:According to the Institute of fiscal studies less than 10yrs ago the UK spent 6.7% on health, the lowest of the G7 countries - in the same year France hit 10%, while the Germans devoted 10.6% of GDP to health.
http://www.ifs.org.uk/election/ebn3.pdf [page3].


Two points.

1) Uncle Joe Cyclops keeps banging on about how he has doubled healthcare spending.
2) You keep banging on about how other countries spend so much more than in the UK as if it is a bad thing.

Please make up your mind.

the A&E Charge Nurse said...

Thanks Roger - I try not to listen to cyclops, anyway the actual figures are out there for all to see.

The UK has always lagged behind the big 2 [France/Germany] and way behind the Swiss.

Its true that more cash was poured into the NHS, but you know just as well as I do, how badly most of it has been mismanaged - the recent boom and bust approach was a significant contributory factor in the awful Kent situation IMHO.

I suspect that the nurses involved will be subject to at least disciplinary, and perhaps even criminal proceedings [great I hear some commentators shout] - but think about some of the other culprits who will probably just slink back to a comfy committee room, and get away scott free.

The real argument here [in the kitchen] is usually about the way in which OUR money should be spent: the market vs state if you like, and you know where I stand on that one.

Kent is a shameful abomination but the worlds most expensive health market seems to have an equally abysmal rate of HAIs - do you think that the nurses should be blamed for that as well ?

Prodicus said...

Just looking in to read the comments.

I notice no-one's actually yelling: 'Of course the nurses wash their hands! How very dare you say otherwise!'

On Any Answers today, on this topic, nurse after nurse of the old school phoned or emailed to say the standard of nurse training and professionalism was the root cause and could be cured by old-fashioned nurse management systems and getting nurses to actually nurse (they don't do all the dirty patient-contact jobs they used to do - those are left to unqualified HCAs) along with putting ward cleaning and cleaners under the control of the Ward Sister.

Yup.

Money has rock all to do with these measures. It's attitude. With all the dosh going into the NHS, money is clearly not the question. It's what the people employed in the NHS do with the bloody money. Like I said, systems and attitude.

the a&e charge nurse said...

prodicus - of course nurses should be washing their hands, not doing so is simply indefensible, and would leave any nurse open to disciplinary, or in the Kent case, criminal proceedings.

But I don't think that's what we are really blogging about here, is it ?
[otherwise we could all quickly agree and move onto something else].

Look at other frontline situations where things have gone horribly wrong, such as Abu Ghraib or Mei Lai - these soldiers were merely the last link in a long dysfunctional chain but this didn't stop the finger waggers from straining at the leash to punish those directly involved.

Incidentally, I've got little time for nurses phoning into radio stations to perpetuate myths about how crap nurse training and education is these days.

First of all there is very good evidence to demonstrate that higher academic attainment is associated with reduced mortality.
http://www.rcn.org.uk/downloads/policy/FutureNurse-ImpactofRegisteredNurses.rtf

And secondly if they were really that good they'd be doing rather than talking about it [believe me I have met too many nurses that fall into this category] - I suspect that these old farts would last about 10 minutes on the wards in Kent before they ran screaming back to day time telly [and perhaps looking up old colleagues on friends reunited].

These old dinosaurs would soon realise that bunk beds, 95+% patient turnover, too few side rooms, and inhuman nurse:patient ratios is not exactly condusive to the best infection control measures, even if the x1 nurse on duty [for the 5th shift in a row] scrubs his/her hands down to the bone.

I actually trained in the pre-diploma days [yes, I'm an old fart too], but I have no doubt that under-graduate students on placement in A&E are VITAL to the future of the nursing profession.

Student drop out rates are already way too high, in part, due to the attrirional nature of working in conditions of chronic stress [Kent was an exemplar of this problem] - if we continue to rubbish them from all sides [retired nurses, centre right marketeers, etc] do you think they are more, or less likely to stick the course ?

If you think money has got nothing to do with it then I think you show, at best, only a limited grasp of what it is really like to work [day after day] in places like Kent.

lost_nurse said...

Well said, A+E C/N.

"...putting ward cleaning and cleaners under the control of the Ward Sister."

Prodicus, I do hope you phoned in and defended your belief in outsourced cleaning. Or have you changed your tune?

As for cliches about carbolic soap - if only life was as simple as ITV's The Royal, eh? I know The Devil loathes enforced servitude, but everybody doing a year as an auxiliary nurse would do marvels for this debate. Especially if they are journalists.