Posted on Sep 19, 2013 by Michael Loftus
Recent events have resulted in public concern regarding the quality of care provided within the hospitals of Britain’s National Health Service. Now, the body tasked with setting standards for clinical management (the National Institute for Health and Clinical Excellence – NIHCE) has highlighted another failing which it estimates could be leading to some 12,000 avoidable deaths each year. By effectively treating one condition in particular, acute kidney injury, this could be a major factor in restoring real confidence in the service of the NHS as a whole.
General concerns over hospital care reached a crisis point when investigations were carried out at the Stafford Hospital and its overseer, the Mid Staffs Hospital Trust. Initial concerns which surfaced a few years ago related to higher levels of patient mortality in the hospital than in other comparable institutions. This triggered a series of reviews and investigations which scrutinised the performance of the hospital itself and also of the strategic and regulatory bodies with responsibilities for its oversight. The final inquiry was reported earlier this year but the extended period of review of this particular hospital has highlighted concerns about aspects of general hospital practice across the country.
The final report published in February this year spoke of a fundamental and profound cultural crisis sitting at the very heart of the health service. The report was coruscating in its views of management at this hospital (and many others by implication), describing it as being wholly unfocused on vital issues and almost perpetually distracted by political concerns, statistical manipulation and the superficiality of marketing. The hierarchy of audit and regulatory bodies were also the subject of sustained criticism.
For the majority however, it was the failure of primary care in the ward and at the bedside that was the most distressing and revealed how the professional standards of nurses and their immediate operational managers had fallen calamitously short of what was expected. The evidence to the enquiry described in the final report brought forward other evidence of similar failure – but also saw many other patients and their families eager to stress that in many areas, the highest standards of both professionalism and compassion were still readily found.
The final Mid Staffs report made specific reference to the issue of nurse training and development saying that nurse training, education, and professional development demanded a renewed focus on delivering compassionate care. It insisted that the responsibilities of nurse managers should not be discharged in an office-based style and that they had a specific responsibility to know the care plans of every patient on their ward.
The response of NIHCE tothe evidence about the mismanagement of acute kidney injury ( AKI) should perhaps be viewed in the light of the conditions troubled history. Acute kidney injury is poorly understood and has stayed somewhat under the radar until now with regard to patient safety priorities. The rapid failure of kidney function can rapidly develop in anyone who is already ill through common infections or as a consequence of cardiac attack. Dehydration, and also commonly used medicines can also lead to acute shut down of the kidneys. After onset, the condition can become life-threatening within only a few hours.
A national investigation in 2009 found half of those in critical condition due to AKI in hospitals across England and Wales had failed to receive an appropriate standard of care and although things have improved since then, there is still a demand for improvement.
In one third of cases, AKI can be prevented through the use of very of basic clinical care. Proper hydration is the vital issue and professionals should keep patient's kidney function under review by checking they have enough to drink or have a drip. They should also monitor urine production and consider the need for blood tests to provide early warning signs of dehydration. Finally, patients medication should be reviewed to guard against the possibility that the medication itself is not creating problems.
Evidence suggests that there is a lack of awareness about the condition among healthcare workers. Consequently, new guidelines have been put in place with aims of improving this awareness, not just for front line staff but across the board in general.
There is a strong view that dealing with conditions such as AKI appropriately (ie training staff to anticipate the possibility and risks of the condition and take appropriate action) could be a benchmark for the changes in culture and practice that the Mid-Staffs crisis has demanded.
By ensuring that all healthcare professionals see the kidneys as specific indicators of health levels and that they factor in the possibility of AKI as a matter of course, this should help to deliver the treatment needed to make certain that patients are always treated with dignity and respect.