Analysis Of Clinical Practice Issues In Ysabel Green’s Care Based On NSQHS Standards

Clinical practice issues in Ysabel’s care during all of her hospitalization

The National Safety and Quality Health Service (NSQHS) Standards is set in place by the Australian Commission on Safety and Quality in Health Care (ACSQHC) through consultation  with the technical experts, jurisdictions, and other relevant stakeholders such as healthcare consumers and healthcare professionals. The primary objective of these standards revolves around the protection of the healthcare consumers from harm and improvement of quality of services provided. In the present paper a case study analysis of Ysabel Green is presented that is based on the NSQHS. The paper identifies all clinical practice issues pertaining to the case study. All Standards that have been breached are pointed out and discussed how the same have been done. Two standards are selected and a discussion is put up regarding how the standards could have been maintained by healthcare staff. Recommendations are provided based on the standards for making changes to the healthcare practice. Recommendations are supported by rationales from evidence based literature.

Quality and safety are very important in healthcare which is based upon a number of clinical guidelines. These have a major role in maintaining the set standards of the healthcare services (Melnyk et al., 2018).  Some of the healthcare standard which could be applied within the present context is standard 1 standard 2, standard 6 and standard 9. The Standard 2 refers to partnering with consumers which is crucial for maintaining an informed practice within healthcare (Masters, 2015). The Standard 6 refers to clinical handover guidelines which are crucial to ensure that safe practices and effective practices are maintained within healthcare.

These have been discussed in correlation with the case study presented where Ysabel was a 33 year old woman at 37 weeks of gestation and was suffering from Cholelithiasis.  Following the birth of the baby the LFT and bilirubin levels within the patient were found to be stabilised. Hence, based upon the present condition of the patient the medical board decided not to remove the gall stones in the patient.  However, the patient started feeling pain and nausea in the upper quadrant of her abdomen following few weeks after she gave birth to her child. Her conditions worsened and she was represented to the emergency department of the hospital. Hence, there was a breach of standard 1, ‘Governance for safety and quality in health service organizations’ and standard 9, ‘recognising and responding to clinical deterioration in acute healthcare’ as the patient was sent home without an extended follow up or giving proper medications. The patient was prescribed metformin to control her pain and was discharged without further investigations. On recurrence of the problem situation again the patient was moved in a different hospital by her husband where she was given an additional medicine that is Ondansteron to control her pain. In this respect, some of the additional tests which were conducted on the patient were kidney function test by examining urea and electrolytes balance, liver function test and abdominal ultrasound. The patient was diagnosed with cholecystitis secondary to cholithiasis and was advised to undergo laparoscopic surgery for the same. The patient was advised to undergo surgery at 11 am the next morning.

National Health and Safety Standards that have been breached in Ysabel’s care

However, the surgery was inconsistently delayed and there was a lack of effective communication between the patient and the healthcare professionals. This is because Ysabel’s husband had called upon the hospital B many times in order to know regarding the medical procedures which are to be conducted on his wife.  The nurse or allied healthcare professionals were unable to inform Tom regarding the condition of his wife.  Neither the hand over nurse nor the ward nurse could provide any specifics to Tom regarding the condition of his wife. There was also delay in conducting the MRI procedure on the patient. Later the patient also developed a sepsis. Therefore, there was a clear breach of standard 2 whereby the family members of the patient were not given sufficient information regarding the specifics or the recovery of the patient. Additionally, there was a clear breach of effective documentation and follow up which resulted in the handover nurses not possessing sufficient information regarding the patient (Weber et al., 2014).

A thorough analysis of the issues pertaining to clinical practice for care delivery of Ysabel brings to the inference that a number of National Health and Safety Standards had been breached in due course. The first standard that has breached is Standard 1 ‘Governance for Safety and Quality in Health Service Organisations’ (safetyandquality.gov.au, 2012). As per this standard, care delivered in clinical practice is to abide by current best practice. Further, rights of patients are to be respected. In reference to the present scenario, Ysabel was prepared for surgery on day 1, Thursday; however, she was later advised that her surgery had been postponed. On the next day she was again informed that she would need to wait for the next day for undergoing surgery due to other urgent cases being scheduled. This incident breached the required standard of maintaining patient safety risks, and the standard of respecting rights of patient. Further, the nurse caring for Ysabel quickly removed her drain tube while assisting her discharge preparation, leading to infection at the drainage site after her discharge. This breached the required standard of using updated and best clinical practice.

The next standard that has been breached is Standard 2 ‘Partnering with Consumers’. The standard entails that healthcare consumers and other stakeholders such as family members of the patients are involved in the care planning process. Consumers are to be supported by organization to have an active participation in the betterment of patient experience so that health outcomes are effective. In the present case, when Ysabel’s husband inquired regarding her wife’ condition, limited information was presented to him. The organization did not assess the mental wellbeing of Ysabel in relation to her condition, which is of much significance since she was much distressed and anxious as her husband had to address challenges on the social front. Further, though the Assistant Nurse Unit Manager had assured that Tom would be informed about Ysabel’s development after the surgery, the same did not happen. The third standard that has been breached is Standard 6 ‘Clinical Handover’. As per this standard, service organizations must have an effective clinical handover system that is structured. Patients and care givers are to be included wherever applicable in the clinical handover process. In the present scenario, when tom inquired regarding Ysabel’s transfer to the ward, the nurse in charge of the afternoon shift did not have the required information to provide to Tom regarding her condition, implying that a proper clinical handover had not taken place.

Moving forward, another standard that has been breached is Standard 7 ‘Blood and blood products’. As per this standard, practitioners are to inform patients about the benefits risks of using blood and blood products as well as the manner in which they are drawn up. Proper clinical decisions are to be taken to ensure that safe practices of blood collection are done. In the present scenario, the nurse did not inform Ysabel regarding using her pre-existing IVC for drawing up blood. The nurse also did not carry out needed assessments for understanding suitability of this method. The last standard that has been breached is Standard 9 ‘Recognising and Responding to Clinical Deterioration in Acute Health Care’. According to this standard, appropriate and timely care is to be provided to patients with deteriorating conditions. As per the case presented, Ysabel was informed on Monday that her gall bladder had burst during the surgery and gall stoned had been blocking the bile duct. A MRI scan was scheduled to be undertaken the same day. However, the same got postponed to the following Monday, which again was not possible to be undertaken due to shortage of staff on a public holiday. The MRI was eventually done of Tuesday.

The two National health and safety standards which were chosen over here were standard 2 and standard 6. The standard 2 refers to partnering with customers which is based upon practising informed decision making and implementing a patient centred approach.  As mentioned by Sherwood and Barnsteiner (2017), the patient centred approach provides sufficient autonomy to the patients to take important decisions regarding health and related procedures. It has been seen that sometimes the patient lacks the effective capacity to make decisions that is when the interception of the family members is pivotal (Carayon et al., 2014). This has further been supported by the policies of informed decision making which states that the patient as well as their respective families needs to be constantly informed regarding all the vital medical procedures (Spatz, Krumholz & Moulton, 2016). The standard 2 states the customers need to be involved in the organizational and strategic processes. As mentioned by Taylor et al. (2014) and Pomey et al., (2015) the involvement of the customers in service delivery and planning can make the services more accessible and appropriate. The level of customer engagement could occur through different methods such as information sharing, consulting, directly working with the public, collaborating and empowering the public by making them an active part of decision making (Runciman, Merry & Walton, 2017; Nelson et al., 2016).  In this respect, the husband of the patient should be have been provided sufficient information which would help them in understanding the logic behind  particular steps or measure  implemented for patient care. As reported by Sherwood and Zomorodi (2014), directly working with the public and making them a part of the decision making can help in empowering the patient and reduce the organizational disputes.  In this respect, Tom had no clue regrading the present health condition of his wife or the medical procedures which had been applied on his wife.

The kin of the patient also failed to receive sufficient information from the handover nurse on visiting the ward. This made tom very anxious as the only source of information he had was his wife.  The lack of proper communication on the part of the hospital also resulted in breaching of effective risk mitigation strategies (Braithwaite, Wears & Hollnagel, 2015). Additionally, the gall bladder of the patient had burst during the surgical process resulting in some of the stone to enter her bile duct. This could have resulted in serious casualty damaging vital organs of the patient. However, none of the vital details were shared with the husband of the patient. Therefore, a huge communication gap was created over here which affected the quality of the care services. Additionally, lack of effective team working skills were noted over here which affected the quality of the health care services (McFadden, Stock & Gowen, 2015). In this respect, there was a gap of communication as none of the healthcare staff had proper instructions regarding the steps to be followed with the patient.

Another important healthcare standard which was followed over here was standard 6, which dealt with clinical handover. As mentioned by Wilson (2016), clinical handover is one of the vital aspects of patient care and should be handed with sufficient care. In this respect, handover could be determined as the stage where the responsibilities of a patient are passed on from one healthcare professional to the next. Thus presenting the right information of the patient to the handover nurse in extremely crucial in ensuring that safe practices (Wainwright & Wright, 2016). It was found that Tom lacked all the relevant details regarding the medical procedures of his wife and was simply made to drift between the doctors and the nurses for gathering sufficient information regarding his wife. The presentation of the handover has great variation like during shift change, when patient are transferred from one hospital to the next, during patient admission, referral or discharge. The method of the handover is equally important that is though face to face, via telephone, through written orders, through electronic handover tools. Further, a handover which has been followed through written orders is found to be the most effective over here as written instructions helps in understanding the specifics regarding the patient better (Anderson, Malone, Shanahan & Manning, 2015).  Some of these are crucial while providing effective medications to the patient. One of the standard protocols which could have been followed over here is use of electronic handover tools such as the electronic health records. These help in taking into consideration the past and present medical records of the patient including the allergies possessed by the patient towards specific medications (Johnson, Sanchez & Zheng, 2016). Additionally, the communication gap served as a major limitation over here such as both Tom and Ysabel were made to wait for an entire day in order to go through the important medical procedures.

At this juncture it would be desirable to put forward recommendations for enabling noteworthy changes to healthcare practice at ward level. The first recommendation is regarding Standard 2, ‘Partnership with consumers’ and it is suggested that family members of patients are informed on a regular basis regarding the improvements in patient condition. Receiving information in relation to patients undergoing surgery is crucial since it is an important need of the family members. Proper communication from healthcare professionals provides hope and encouragement to the family members (Mattila, Kaunonen, Aalto & Åstedt?Kurki, 2014). It is recommended that information is presented in a confidential manner. Therefore informed consent is to be taken for providing information over the telephone. Sensitive issues might be discussed in person and in presence of the patient himself. This would enable involvement of patient’s preferences in future care planning (Riley, White, Graham & Alexandrov, 2014).

The second recommendation is regarding Standard 6, ‘Clinical Handover’ and it is suggested that the ward implements a clinical handover guideline that all staffs within the ward are to follow. The Nurse Unit Manger is to be accountable for ensuring adherence to the set clinical handover guideline. The guideline must give special considerations to ensure that patient care continues when handover is occurring; the handover documentation tool is available to all staffs; the staffs have a proactive approach in handovers; ISBAR communication tool is used appropriately, and feedback is provided to the staffs regarding their participation (Fealy et al., 2018; Mannix, Parry & Roderick, 2016). Audits of the handover are also to be completed on a regular basis (van Sluisveld et al., 2015).

Conclusion

Therefore, based upon the above study we could identify that there was a clear breach of healthcare standards as the patient and her family members were not given sufficient information regarding the overall timing and the schedule of the medical procedures which were to be applied on the patient. The patient was delayed for the surgery along with this the critical health details of the patient was not communicated properly to her family members. Hence, there was a clear lack of effective communication. Additionally, the important health details of the patient were not provided by the handover nurse. Therefore, a lack of leadership along with effective team working skills affected the overall quality of the health care services. The hospital also lacked the accountability for the deterioration of the patient’s health on a primary basis as the patient was discharged home without providing her all the required medicine doses.

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