Intensive and Critical Care Nursing (2006) 22, 251—252

EDITORIAL

Sick hospitals—–Is there a cure?

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cross the Western hemisphere it has becomencreasingly apparent that hospitals are potentiallyangerous places to be in. As Julian Bion Pres-dent of the European Society of Intensive Careedicine, asked at a recent conference ‘if your hos-ital was an aeroplane would you fly in it?’ Overhe past two decades it has been the policy ofost Governments to achieve economies of scale

n order to reduce the cost of healthcare. As aesult many services were ‘contracted out’. Thesencluded catering, cleaning, portering, supplies andaintenance. Nursing was emasculated and control

ver these elements, which supported and main-ained an acceptable environment for care, wasemoved. The coordination of care ceased to be theesponsibility of experienced nurses in whom powernd authority were vested and nursing itself wasiewed as an expendable commodity. As a result weave seen an exponential rise in the incidence ofdverse events. Adverse events have been defineds ‘an unintended injury that results in temporaryr permanent disability, including increased lengthf stay, which is caused by health care manage-ent rather than the disease process’ (Wilson et

l., 1995, p. 461). The frequency of these eventsanges from 16.6% (Wilson et al., 1995) in Aus-ralia, 10.8% in the UK (Vincent et al., 2001), 7.5%n Canada (Baker et al., 2004) and 2.9—3.7% inhe USA (Thomas et al., 2000). It is unlikely thathere is any great difference in the incidence acrossountries rather that reporting mechanisms areore sensitive and specific in some countries than

thers.Adverse events include medication errors, falls

nd incidences of failure to rescue. Failure to res-

ue implies patients sustain complications which,f they had been acted upon earlier, could haveeen avoided. They include myocardial infarc-ion (MI), cardiac arrest, re-intubation, acute pul-

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964-3397/$ — see front matter © 2006 Published by Elsevier Ltd.oi:10.1016/j.iccn.2006.05.002

onary oedema, pulmonary embolus, stroke, sepsisnd acute renal failure. The result of which is oftenn unplanned intensive care unit admission.

Commensurate with these findings is researchhich demonstrates the effectiveness of nursing if

taffing levels are appropriate. Examples of this aren MI patients where an increase in nursing hourser patient day resulted directly in improved sur-ival (Schulz et al., 1998). A higher proportion ofours and a higher number of care days by regis-ered nurses resulted in lower rates of urinary tractnfections, upper gastrointestinal bleeding, pneu-onia, shock and cardiac arrest (Needleman et al.,

002). These are precisely the factors associatedith the adverse events identified earlier. In sur-ical patients each additional patient in excess offour patient workload resulted in a 7% increase

n mortality and a 7% increase in the odds of fail-re to rescue (Aiken et al., 2002). Failure to res-ue is a term used to denote an outcome wherebyhe patient demonstrated signs of deteriorationut these were not acted on appropriately andn a timely manner. This has often been associ-ted with a lack of knowledge, failure to appre-iate clinical urgency and a failure to communi-ate effectively (McQuillan et al., 1998). Might itot also be an effect of decreased staffing lev-ls and the replacement of nursing staff with sup-ort staff as demonstrated by the research outlinedbove?

In response to this some states have legislatedor safe staffing ratios, namely in California, USAnd more recently in Victoria, Australia (ICN,006). The ratios indicate the maximum numberf patients to be assigned to a nurse during one

hift and vary according to levels of acuity. At firsteading this can appear to be a positive innovationotentially resulting in the improved recruitmentnd retention of nurses and enhanced well being,

252

with the concomitant effect of improved qualityof care and outcomes for patients and increasedconfidence in the public health system. However,established ratios may not accurately reflectthe needs of patients or the complexity of carerequired. For example if the number of patientsassigned to a nurse is dependent on ‘acuity’how is acuity defined? Usually it directly relatesto the consumption of resources, i.e. increasedtechnological requirements by which a hospital canmeasure the cost of care. It would not determinethe time needed to support the relatives of abrain dead patient or the waking head injurypatient who is restless and has made clear hisabhorrence of technology by pulling out all intra-venous cannulae and removing monitoring systems.Established ratios are a very blunt measure ofstaffing requirements which also fail to account forthe lay-out of particular ward or unit areas, thepresence of non-RN staff and specific workplaceissues characteristic of a particular hospital.Therefore it is not just an issue of numbers butalso of the risk presented by particular patients inspecific environments which needs to be assessedin determining appropriate nurse patient ratios,issues which have been raised by this journal inthe past (Ball and McElligott, 2003; Ball et al.,2004).

Hospitals will always be required for the care ofthe acutely ill and injured and nurses are the keyto efficient and effective care (Black, 2005). Thecure for the current sickness in hospitals is there-fore to recognise the unique contribution made bynurses and empower the profession to establish theeffect it so clearly had and still has the potentialto achieve. The answer is not to reduce the num-ber of nurses yet further only to reap the results

in increased adverse events, clinical incidents andhigher mortality rates which, whilst these are dis-appointing in terms of hospital league tables andsources of irritation to policy makers can repre-

Editorial

sent real tragedy to individual patients and theirfamilies.

References

Aiken LH, Clarke SP, Sloane DM, Sochalski J, Silber JH. Hospitalnurse staffing and patient mortality, nurse burnout and jobdissatisfaction. J Am Med Assoc 2002;288:1987—93.

Baker GR, Norton PG, Flintoft V, Blais R, Brown A, Cox CJ, et al.The Canadian adverse events study: the incidence of adverseevents among hospital patients in Canada. Can Med Assoc J2004;170:1678—86.

Ball C, McElligott M. Realising the potential of critical carenurses. Intens Crit Care Nurs 2003;19:226—38.

Ball C, Walker G, Harper P, Sanders D, McElligott M. Moving onfrom patient dependency and nursing workload to managingrisk in critical care. Intens Crit Care Nurs 2004;20:62—8.

Black N. Rise and demise of the hospital: a reappraisal of nursing.Br Med J 2005;331:1394—6.

International Council of Nurses. Advancing nursing and healthworldwide www.icn.ch; 2006.

McQuillan P, Pilkington S, Allan A, Taylor B, Short A, Morgan G, etal. Confidential inquiry into quality of care before admissionto intensive care. Br Med J 1998;316:1853—8.

Needleman J, Buerhaus P, Mattke S, Stewart M, Zelevinsky K.Nurse staffing levels and the quality of care in hospitals. NEng J Med 2002;346:1715—22.

Schulz MA, van Servellen G, Chang BL, McNeese Smith D, Wax-enberg E. The relationship of hospital structural and finan-cial characteristics to mortality and length of stay in acutemyocardial infarction patients. Outcomes Manage Nurs Pract1998;2:130—6.

Thomas E, Studdert D, et al. Incidence and types of adverseevents and negligent care in Utah and Colorado. Med Care2000;38:261—71.

Vincent C, Neale G, et al. Adverse events in British hos-pitals: preliminary retrospective record review. Br Med J2001;322:517—9.

Wilson RM, Runciman WB, Gibberd RW, Harrison BT, Newby L,Hamilton JD. The quality in Australian Health Care Study.Med J Aust 1995;163:458—71.

Editor in Chief

Carol Ball

E-mail address: carolball271@hotmail.com