Cuts threaten patient safety
Fewer nurses caring for more patients increases likelihood of death, see here for column from Medical Independent from 21 March 2014. Three publications in the past three weeks have added greatly to our knowledge of the impact of staffing, in particular nursing staffing, on patient care.
The Lancet publishing findings from a study of more than 420,000 patients in 300 hospitals across nine countries, including most Irish public hospitals. The study examined 30-day mortality rates for all common surgical patient admissions, in conjunction with the level of nursing staff and their education.
The key finding is that one is mo-re likely to die after common surgery in a hospital with low nurse staffing levels and where nurses have inferior levels of education.
Despite the findings telling us the obvious – patients fare better where there are more nurses and when more of the nurses are better educated – they are significant because this is the first such data from Europe, and the study scope was so vast that it is very reliable.
Generally, a ratio of one nurse to eight patients is considered safe. The Lancet study found Ireland had a staff ratio of one nurse to approximately seven patients, with large variations between hospitals and units when the survey was carried out in 2009. Ireland came out at the better end of the ratios. Typically, Norway was top of the class with 1:5 nurse:patient ratio and Spain was at the bottom at 1:12.
The HSE or hospitals do not collect current nurse-patient ratios or if they do, they do not publish them. Recent research from the resilience project* using HSE data show there was a 10 per cent cut in nursing staff alongside a 10 per cent increase in hospital activity between 2009 and 2013. That is 180,000 more hospital patients being cared for by 3,985 fewer nurses. Hospital activity was measured by using all in-patient and day cases, emergency admissions and births in 2009 and 2013.
While there has been a small increase in the number of health care assistants and doctors during this period, fewer nurses are caring for more people.
The care being provided is more intensive and complex with shorter lengths of stay. The Lancet study made clear that increasing staff workload increases the likelihood of patient deaths.
Two days after The Lancet publication, Chief Medical Officer Dr Tony Holohan published a damning report into the deaths of five babies in Portlaoise hospital. This followed RTÉ’s Prime Time Investigations Unit exposure of four of these deaths. The report concluded that the maternity service in Portlaoise was neither safe nor sustainable.
It specified that there were “unrealistic clinical and administrative workloads”. A new management team has been put in place in Portlaoise and HIQA is carrying out a statutory enquiry. The Holohan report found there were clear failures in terms of patient care and safety in Portlaoise and outlined the implications for similar sized maternity units around the country.
These reports tell us about patient deaths, which is the most extreme result of poor patient care. But what they do not tell us is what happens in more complex surgery, in other medical cases, and also in all maternity units across the country.
The Irish Nurses and Midwives Organisation (INMO) published a survey on midwifery staffing levels in the country’s 19 maternity units, a week after the Portlaoise report. A ratio of one midwife to 29.5 births is considered safe. No Irish maternity unit had that. Critically, 15 of the 19 units had 1:35 or more, including the three main Dublin based maternity hospitals demonstrating a serious shortage of midwives in the majority of Irish maternity hospitals or units.
Since the Portlaoise deaths, there has been renewed emphasis on quality of care and patient safety in the HSE, which cites the Francis Inquiry into events at Mid-Staffordshire. That inquiry showed how nurse staffing was reduced to meet ﬁnancial targets, how nurses were criticised for failing to prevent poor care, and how inadequate nurse staffing was an important factor in persistently high mortality rates.
Ensuring and improving patient care is not compatible with relentless staffing cuts. Minister Reilly and health service managers have serious choices to make. Do they continue to tow the austerity line, where cuts will continue?
Or do they stand by their rhetoric on patient safety and the importance of care, and ensure safe staffing levels across the health system?
*Sara Burke works part time on the resilience project info at http://www.medicine.tcd.ie/resilience4health/indicators/