Nursing Essay: Implementing NSQHS in the Case of Helen Christine

Question

Task

Read the Western Australian Coroner’s record of investigation into the death of Helen Christine MacFarlaine.

You are then required to write a nursing essay that focuses on

• Two National Safety and Quality Health Service (NSQHS) standards
• Communicating for safety standard and
• Recognising and responding to acute deterioration standard
• Review the two NSQHS standards and identify which specific items and action points of the standards were not or poorly provided and may have contributed to the patient’s death.
• Use current literature to justify that the specific item and action points of the standards you have identified are supported through evidence.

Answer

National Safety and Quality Health Service Standards
The standards of NSQHS (National Safety and Quality Health Service) considered herein nursing essay were developed by the Australian government along with the collaboration of commissions, territories and states government, clinical experts, and private sector providers. The main aim of the standards is to provide protection to the public from harm and also ensures to enhance the quality of health service. There are a total of ten standards of NSQHS, and the integral focus is to ensure the safety of people (Jensen, 2020). In the present essay, the case of Helen Christine MacFarlane's death is analyzed in the limelight of two NSQHS standards. The two standards that are considered for the present study are the standard for Recognising and responding to acute deterioration and the standard for Communicating for safety (Tieman, 2019). In the light of these two standards, the case of Helen Christine is analyzed to reflect whether the entire terms of those standards are followed in the case of Helen Christine, or there are some specific items that are missed out. While analyzing these two standards, the essay will also reflect on whether the missed terms of the mentioned standards caused to patient's death or not.

The essay mainly aims to explain the two NSQHS standards and to analyse the proper implementation of these standards in the case of Helen Christine. The study also aims to reveal whether any terms of these standards are not followed, which caused the death of the patient.

NSQHS Standards
There are a total of ten standards of NSQHS, and among them, two standards that are identified in the introduction part are discussed below:

Communication for Safety Standard
This standard aims to maintain effective communication, ensure proper documentation, timely and purpose-driven communication. The main base of this standard is proper communication, which important to ensure for delivering safe patient care. Poor documentation and communication failure can lead to inappropriate treatment of the patient (safetyandquality.gov.au, 2019). Communication error leads to a major contributing factor in certain events that can cause negative consequences to the health of the patient. Among all the underlying factors in the Australian Healthcare System, communication issue is considered as the most common factor. The standard of communication for safety reflects the effective communication important in the healthcare system (safetyandquality.gov.au, 2019). Effective communication the healthcare ensures coordinated and safe care for the patients. The three areas include high-risk that are mainly considered under this standard are:

1. During the time of transferring part of patient's care or entire patient care with clinicians, organizations, or multidisciplinary teams, proper communication is needed.
2. At the time of the procedure, matching with the patient requirement and patient identification, quality communication is essential (safetyandquality.gov.au, 2019).
3. Emerging risk and change inpatient care requires effective communication of critical information.

This standard is mainly involved in high-risk situations, and at high-risk situations, effective communication is important to ensure continuous and safe care for patients. As per this standard, health organizations have to implement processes and systems to support effective clinical documentation and communication.

Recognizing and Responding to Acute Deterioration Standard
This standard mainly aims to ensure that the acute deterioration of a patient should be recognized properly, and adequate action needs to be taken accordingly. Acute changes in mental state and cognition and physiological changes are included in acute deterioration. According to this standard, if any patient's condition is deteriorating, then absolute action needs to be taken (safetyandquality.gov.au, 2012). Responding to the recognized deterioration is another term of this standard, and according to this, timely and appropriate care should be provided to the patients. Sometimes, the organizations and workforce fail to recognize the signs of deterioration and thus leads to a failure to respond to the condition (safetyandquality.gov.au, 2012). These conditions include:

1. Absence of formal system to respond to the signs of deterioration.
2. Inconsistent monitoring of physiological observations or not understood the observed changes.
3. Knowledge lacking about symptoms and signs of deterioration.
4. Inappropriate skills to manage patients with deterioration.
5. Failure in clinical communication or handover situations.

This standard is applicable for all patients, such as babies, adults, children, and adolescents. Along with that, the patients belong to the criteria of surgical, medical, mental health, and maternity patients are also can be treated according to this standard (Tieman, 2019). The acute healthcare facilities under this standard include such facilities in small district hospitals, community hospitals, and large tertiary referral centers.

Analysis of the Implementation of the Standards in Helen’s Case
The autopsy report of Helen Christine reflects that the death is caused due to natural causes. However, Dr. Jodi White, the forensic pathologist, said that there were certain complications in the surgical procedure of the patient, due to which certain changes occur in the body of the patient. According to the opinion of professor Strokes, the blood pressure of the patient can be managed in a better way. Managing the blood pressure is one of the key things that need to be done by medical carers to a carotid artery patient following two-three days after the surgery. According to the standard of Recognising and responding to acute deterioration, a patient should be provided adequate care and treatment according to the identified symptoms of deterioration (Hambrecht, 2020). The thing that seemingly contributed to the death of the patient is somehow inconsistent monitoring of physiological observations. After the surgery, the patient was feeling pain, but it was told that the pay is usual after such surgery.

Another major thing that is found in the case is the inadequacy of inpatient notes. The inpatient notes and related documentation of a patient should be clear and adequate because effective communication is important. According to communication for safety standards, effective communication and documentation about all information related to the patient are required. Documentation of essential information is required, and it should be documented in the healthcare record for patient's safety (Vermeir et al., 2015). Based on the review of Professor Strokes, it can be said that the medical notes during the first admission of the patient were inappropriate. It does not match the observation findings. The observation findings that are recorded by the medical staff and nursing staff are not matched with the medical notes of the first admission, which directly indicates that there was a miscommunication of information, which is against the communication for safety standard (Vermeir et al., 2015). As per the opinion of Professor Strokes, adequate medical notes are required for fair treatment of the patient. The medical notes are essential because it helps the decision-maker to refer adequate treatment course for the patient.

During the transfer of the information, all the crucial information related to the patient, diagnosis, results, and additional information needs to be transferred to the health organization, carer, or the professional who is going to carry out the further treatment. In this case, the initial medical notes were recorded wrong, so there were more chances of setting the wrong treatment for the patient (sahealth.sa.gov.au, 2020). On the review of Professor Strokes, Professor Knuckey agreed that documentation of information was wrong, and it was not done in the way that it should actually have. Dr. Griffin failed to record any important notes related to blood pressure. The absence of reference related to blood pressure is evidence that proper documentation of information is not followed in the case. The note of Dr. Riaz not captured any crucial information. The improper record of the patient's condition and related information indicates that there were severe mistakes in the documentation of information, and the communication between the staff and medical professional was not appropriate (Zaga, Leggat & Hill, 2018).

The discharge summary that was signed by Dr. Riaz was also criticized by Professor Strokes as he finds it inadequate. In the discharge summary, there was no mention of decreased blood pressure and the complaints related to headache and restlessness. This clearly signifies that only the documentation and communication were not wrong in this case, but the overall report of the patient was somehow not entirely right. Another thing that was found missing in the documentation is the absence of entry for April 7, 2012. Along with that, the information about the blood pressure of the patient was not recorded. Based on the information missed in the documentation process of the patient care, it can be said that there were severe mistakes in the communication between the two parties as well as in the documentation of the information (sahealth.sa.gov.au, 2020). The miscommunication between the medical staff and nursing staff and inappropriate documentation clearly indicates that certain terms of communication for safety standards were not followed, which somehow contributed to the death of the patient. Blood pressure management and relatable information are crucial for a patient who has done such surgery.

The blood pressure management and other symptoms of headache are somehow not considered crucially by the staff of SCGH hospital. The inappropriate care of the patient during the post-operative period shows that the staff of the hospital was failed to monitor the physiological conditions of the patient properly (Anstey et al., 2019). This indicates the SCGH hospital, as well as the management of the hospital, was not proper, and there was a failure to act according to the standard of Recognising and responding to acute deterioration.

Specific terms of the Standards that were not followed in the case of Helen Christine
Based on the analysis of the documentation of Helen Christine's treatment, the inappropriate observation during the post-operative period, and negligence of patient's conditions, it can be said that the two standards recognizing and responding to acute deterioration and communication for safety were not properly followed (Zaga, Leggat & Hill, 2018). There are many terms that are not following according to the communication for safety, such as the initial notes are not taken adequately, improper documentation, and not recording crucial facts about blood pressure and headache in the patient's report. The actions that actually needed to maintain adequate documentation and communication for this care were missed. Effective communication and proper documentation are required to ensure safe treatment and care for a patient. Failing to maintain proper documentation and communication can lead to negative consequences and can endanger the life of the patient. It can be said that SCGH hospital and the team treating and taking care of Helen Christine has not followed every term of the standard.

The thing that found inappropriate in the post-operative period and care of the patient is the negligence of blood pressure of the patient and other related conditions of the patient that caused after the surgery. The improper monitoring of the patient and lack of formal systems to respond to the patient conditions were the key things that lead to the negative conditions of the patient (Vincent et al., 2018). The standard, recognizing and responding to acute deterioration, is not properly followed during the monitoring of the patient. The initial medical note was different from the observation by the medical staff, which signifies that there was a failure in communication in handover situations (Vincent et al., 2018). The case of Helen Christine reflects that both the NSQHS standards are not properly followed during the treatment and care of Helen Christine. The consequences of this case caused severe changes in the management and documentation of SCGH.

Conclusion
The importance of NSQHS standards and their implementation in the medical practice are reflected in the essay. In the case of Helen Christine, there are certain terms and actions of two NSQHS standards that are not followed, and it leads to major consequences. The death of the patient is considered a natural consequence of the surgery she underwent, but the negligence of the SCGH and team who were handling the case cannot be avoided. Based on the consequences of this case, it can be said that every term of NSQHS standards needs to be followed to ensure patient safety as well as proper treatment and care to the patient. The death of Helen Christine raised severe questions on the management and ethical centricity of SCGH, and there are some changes ordered to be implemented. The change in the existing system is required at SCGH to minimize the risk of similar negligence in the future. Both standards recognizing and responding to acute deterioration, and communication for safety are important for adequate care of the patient because it allows the health organizations and the workforce to continue the treatment and care for patients in a proper setting.

References
Anstey, M. H., Bhasale, A., Dunbar, N. J., & Buchan, H. (2019). Recognising and responding to deteriorating patients: what difference do national standards make?. BMC health services research, 19(1), 1-7.

Hambrecht, K. (2020, February 13). Recognising and responding to deteriorating patients: a matter of life or death. Medcast.com.au. https://medcast.com.au/blogs/recognising-and-responding-to-deteriorating-patients-a-matter-of-life-or-death

Jensen, F. (2020). Partnering with consumers through NSQHS standards. Journal of Health Information and Libraries Australasia, 1(1), 18-19.

safetyandquality.gov.au. (2012). National Safety and Quality Health Service Standards. https://www.safetyandquality.gov.au/sites/default/files/migrated/NSQHS-Standards-Sept-2012.pdf

safetyandquality.gov.au. (2019). The NSQHS Standards | Australian Commission on Safety and Quality in Health Care. Www.safetyandquality.gov.au. https://www.safetyandquality.gov.au/standards/nsqhs-standards#:~:text=The%20primary%20aims%20of%20the

sahealth.sa.gov.au. (2020). Clinical Deterioration. Www.sahealth.sa.gov.au. https://www.sahealth.sa.gov.au/wps/wcm/connect/public+content/sa+health+internet/clinical+resources/
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Tieman, J. (2019). palliAGED Aged Care Standards Insight. Patient Education and Counseling, 102, 3-11.

Vermeir, P., Vandijck, D., Degroote, S., Peleman, R., Verhaeghe, R., Mortier, E., ... & Vogelaers, D. (2015). Communication in healthcare: a narrative review of the literature and practical recommendations. International journal of clinical practice, 69(11), 1257-1267.

Vincent, J. L., Einav, S., Pearse, R., Jaber, S., Kranke, P., Overdyk, F. J., ... & Hoeft, A. (2018). Improving detection of patient deterioration in the general hospital ward environment. European journal of anaesthesiology, 35(5), 325.

Zaga, C., Leggat, S., & Hill, S. (2018). Partnering with consumers in the public reporting of quality of care: review of the Victorian quality of care reports. Australian Health Review, 42(5), 550-556.