North Shore Hospital report - New Zealand Doctor

Opinion 07HDC217426. Please comment on Waitemata DHB’s initiatives designed to improve patient flowand hospital capacityThe organisation is building more capacity. Meanwhile they need to manage the continuedhigh demand and its impact on care. The Operational Capacity Escalation Plan-NSH wasdeveloped in February 2008. In my opinion the RED alert level is set too high as it hascorridor beds already in place and the nurse to patient ratio is 1:8. Aiken‘s work would showthe added unnecessary rise in level of complications and mortality at this level would be inexcess of 9/1000. The orange staffing is unsafe at 1:6, green is acceptable but not what isbudgeted (1:6 is budget).The chaotic environment and lack of consistent senior supervision on the floor was addressedthrough the paper ―Programme Budgeting and Marginal Analysis‖, submitted [by] theGeneral Manager Adult Services, for funding in December 2007. [It] requestedsupernumerary co-ordinator positions for wards for morning shifts. [This] needs to beaddressed to make the environment attractive for nurses to want to work within. I don‘t thinkthis went far enough, given the levels of junior, bureau and casual staff. Shift co-ordinatorsare needed in the afternoons and weekends to match patient demand and improve after-hoursstaffing support.The current structure doesn‘t value the Charge Nurse Manager role as a practising nursemanager as it does not provide a professional management line for coaching in practice,participation, engagement in the direction of the organisation, involvement in solutionfinding, or a sense of ―voice‖. The organisation needs to tip itself upside down and put theclinicians and their first-line supporters to the top.There was no visibility of the ECC remotely; this was going online after the site visit. TheDuty Nurse Managers had one computer between them to work with on the shift.The implementation of a discharge planner is an important step and this will need to be 13hours per day, seven days per week to maximise effect.The increased number of health care assistants to support the clinical areas is fantastic.The NEWS scoring system provided a framework for trending the condition of the patient andflagging concerns. The Critical Outreach Service that can be called when there is frequenttriggering of scores or high scores is an asset to the organisation. The NEWS use in themedical wards was extremely limited in the cases reviewed. There remained an ObservationProcedure that needed to acknowledge and position the NEWS system within it to reduceconfusion about the trending requirements. There needs to be monitoring of the NEWSsystem along with physical assessment to ensure nurses get to understand how it works andhow it can help track and trend.Late in 2007 the organisation piloted software that could predict workload, and it had beenrecommended for purchase. The information system support for the Duty Nurse Managerswas very limited. Supporting nursing with tools to manage is the core business of theorganisation. One of its largest and most expensive resources did not seem to be a priority. Anote on the index of additional documents WDHB provided on 28 April 2008 states―Waitemata DHB had an acuity system called Nightingale since 1998 (not Trendcare). Thesystem has not been maintained over time as not prioritised by the IS [Information Systems]manager at NSH ... A number of wards have acuity measures (Wds 6, 11, 8, all Waitakeremedical wards) … Managers have not taken any notice of the data, so CNMs have notpersisted‖.7. Please provide any recommendations for improvementI acknowledge the work already underway and know Waitemata Health will continue toimplement the recommendations of the Safe Staffing/Healthy Workplaces Committee ofApril 2009 105