A Mid Staffs case that illustrates a bigger challenge

Following the Francis Report into Mid Staffs  The Health and safety Executive are finally taking up a specific case. as reported here in the Telegraph http://t.co/kv2gRw2F

This case was the focus of a great deal of attention at the PI. To me it illustrates perfectly why it is really innapropriate to place blame on individuals in the front line.  I have heard from clinicians unconnected to Mid Staffs about the scale of the central problem in this case nationally. It is estimated that around 600 people die annually because they did not get their insulin on time.

I have transcribed a twitter converstaion with a nurse in which I tried to understand how this can happen, especially on an understaffed or underskilled ward.

The case is one of the two major test cases explored by the Francis inquiry into Mid Staffs. It is a distressing case of a very elderly lady with a complex mix of medical conditions in addition to dementia, who may have died because of failure to administer insulin at the correct intervals. 

I wanted to understand a little more about how insulin should normally be administered and why that could potentially fail.

This twitter conversation with a very experienced nurse (not from Stafford) answered many of my questions.

 Nurse: Neglected: The Lessons of Fatal Error in NHS Care - Home News - UK - The Independenthttp://www.independent.co.uk/news/uk/home-news/neglected-lessons-of-fatal-error-in-nhs-care-8468873.html

…
Diana: This case was one of the two main cases explored by the Francis inquiry. There were clear issues with drug handling

 Nurse: When diabetic patients are hospitalized prescribing their insulin is dependent on stability of their blood sugars

 Diana: What are you saying? Do you mean that their other condition can cause greater than normal variation in levels in Blood sugar?

 Nurse: Illness frequently causes fluctuating blood sugars - therefore it quite common for hospitalised diabetics to have their insulin prescribed via a sliding scale where insulin dosage is dependent on the blood sugar level.

 Many hospitalised diabetics will have their insulin prescribed at their normal intervals.

 Hospital may agree to allow patients to medicate themselves Patients who self medicate their insulin while hospitalised are patients who will not be compromised by doing so

 Diana: This lady was certainly unable to self med. Probably insulin unstable. (complex comorbidities) very unwell.

 Nurse: patients with unstable blood sugars will have their insulin prescribed -on sliding scale regime --- frequent testing for Blood Sugar & dosage of insulin prescribed is dependent on BS

 Diana: How long does it take to test Blood sugar, calculate dose & Administer

 Nurse: using BM machine (blood sugar testing kit) I would say 5 minutes from arriving at patients bed to giving insulin

 Diana: which is quite a chunk of time - if ward is not well staffed. How often do you need to test?

 Nurse: patients with unstable BS on sliding scale maybe require BS every 30mins / hourly /every 2 ,3 ,4 hourly

 Diana: Every 30 minutes! good god - no wonder this is a problem -so 6 unstable patients needs 1 nurse just for this

 Nurse: when giving insulin so frequently the reason for regular checking is to ensure the insulin doesn't lower BS below safe levels

 Diana: if patient was asleep when test due would it be normal to wake them or wait? -

 Nurse: if these patients are sleeping when due BS check then I would waken them - their BS are unpredictably unstable. That 30 min checking is usually not for lengthy periods - if a patient is very ill the sliding scale prescribing method can continue for days but these are patients who very ill with problem aside from diabetes

 Diana: back to the lady - she was very ill - about 5 conditions. but can now see how testing regime could slip. would guess that the Birmingham prompt system, (Birmingham university hospital have developed a prompt system to remind clinical staff if tests or doses are overdue) might help to ensure either regular doses or regular testing. I think the challenge may be to ensure that care that would always occur in best well run wards is possible across the board.

 Nurse: unless you have experienced the sense of chaos that under staffing can cause -you would be unable to understand

 Another Tweeter: I did yesterday, people throwing up in corridors and waiting rooms. Not enough staff

 Diana I think I can understand. - have seen the chaos my confused mother brought to understaffed wards -

 Nurse: Sliding scale regime for insulin prescribing is time consuming if there are numerous other patients

 Diana: Thank you for you patient explanation – I feel I understand what actually will have happened in this case a little better now. The Francis report will bring a lot of criticism of nursing staff, but I think it is important to understand something of why things can sometimes go wrong..

 Nurse: Francis report will be soon upon us and we have to face every single fact criticism that it contains. We have to be accountable and learn huge lessons to prevent further patient neglect ever again, but there is a side show - irresponsible- media Government - we have to find way not to damn all nurses otherwise care will be affected as it becomes harder to recruit nurses and the best ones leave

 Nurse: NHS being hammered and there are so many excellent nurses just thinking .- whats the point

 Diana: Hang in there - we need you!

 Nurse: wasn't referring to me - there are nurses in NHS & their expertise commitment is never acknowledged but when the attack is relentless - it can zap all the zeal & enthusiasm you once had. We don't want acclaim. We don’t want to be seen as unable to deal with criticism, We know the challenge ahead