"Documenting my observations."

This is an expression of appreciation for the care I received during my recent admission to Bunbury Hospital and an expression of concern for what I observed to be the potential for the well-being of patients and staff to be compromised as front-line staff sought to work under conditions of quantitative and qualitative overload that seemed to flow from bed shortages, ward-bumping and apparent under-staffing.

My experience would not be atypical for folk engaging with the hospital system these days, I suspect. Three presentations to ED (two to Bunbury Hospital; one to Harvey Hospital) within 17 days; over four hours lying vomiting in ED reception on the second presentation; successful laparoscopic cholecystectomy for a severely inflamed gall bladder with gangrene patches. Located in five wards and six beds over five days; ED; DPU (Day Procedure Unit); SARU (Sub-acute Rehabilitation Unit); Surgical; Paediatrics). Resisting pressure for early discharge and being vindicated in that, needing oxygen throughout the final night.

Throughout my hospitalisation, I was grateful for the care I received, for example from the exemplary collaborative relationship between my two doctors, a Paediatric Clinical Nurse, who both worked to ensure the successful functioning of my 5th cannulation site, enabling 3 hours of IV potassium to proceed unhindered. To the young PCA (Patient Care Assistant) who seemed to go to great lengths in DPU to find some jelly for me, the only food I could imagine tolerating, having not eaten for 24 hours & shortly before being fasted for surgery.

I was however, very aware of the challenging circumstances in which staff seemed to be operating. I noted how frequently staff were contending with competing demands from multiple patients, alarms & IV lines beeping & considered how difficult it must be to prioritise in such circumstances. From the frequency with which I saw staff either at my bedside or at that of other patients, it seemed many staff were not taking breaks and were working beyond their shift hours. It was distressing to see committed staff trying to deliver quality care in conditions that impeded that.

I emphasise that my expression of concern is based on my own observations, not from anything verbalised by staff, who behaved with consummate professionalism. Why I even mention that explicitly is that, when I voiced to a teams of doctors that I did not feel safe to return home that afternoon because I had had two incidents of bleeding throughout that day, lived some 30km out of town on a bumpy country road and have some history of post-operative haemorrhaging, one doctor gestured the nurses and asked, have they worded you up to scare junior doctors?. They had not, nor, as was also suggested, had I been coached by a relative. In retrospect, this crystallised for me the pressure decision-makers must be under to manage bed shortages possibly by sending potential patients home from ED rather than admitting them or by discharging them sooner than might usually be preferred.

Throughout my treatment, I was aware of missed opportunities in service delivery and, whilst in my case thankfully no harm ensued, each gap represents both the potential for patient recovery to be compromised and a work-multiplier effect, in that the situation had to be addressed by someone else, later in the admission. Some of the specific gaps I believe were:

Missed opportunity for clinical investigation: When I presented to ED no blood test or scan was conducted, only a urine sample and digital rectal examination. I wonder if, had a blood test been done, would there have been an indication of the severity of gall bladder inflammation with which I subsequently re-presented to ED on another date. In fairness, I had no gall bladder pain on that first occasion, although back muscles were armouring.

Missed opportunity to collect clinical data: When I attended ED on the second occasion, arriving at 3.30pm and logged at about 4pm, I spent over four hours lying across chairs in ED reception, vomiting. Four days later, a doctor acknowledged he had been unaware of that and it may have accounted for my low potassium. In my view, perhaps potassium level could have been monitored and addressed sooner, had staff been aware of the extent of the vomiting.

Missed opportunity to provide educative information: The surgeon gave me a very clear diagrammatic explanation of a gall bladder and the risks in its removal, however I was given no printed information immediately prior to or immediately after surgery, possibly because I went to Theatre from SARU, not Surgical ward, so I was unaware of likely after-effects and precautions to observe. This was rectified three days later by Paediatric staff.

Missed opportunity to note signs of deterioration: One the evening a few days later, I began to be increasingly concerned about a number of emerging symptoms: radiating left chest pain; chills; nausea; sudden onset tiara headache; pitting oedema to legs and feet. Whilst I endeavoured to raise these, the paediatric RN did not seem cognisant of their potential significance. On the advice of a former colleague whom I’d contacted, I requested a medical review which may have already been in train as my low potassium was detected and treatment commenced shortly thereafter. I found myself wondering though, about the unfairness of expecting an RN working in Paediatrics to be conversant with symptoms of potential deterioration in an older adult surgical patient.

Missed opportunity for staff proactivity: The following day I had had two incidents of bleeding, one from a cannula and one from a drain site. Given I have some history of post-operative haemorrhaging and was now ambulant, I was surprised to be offered a heparin injection again that evening; I declined, but had assumed it would have been withheld without action on my part, given in my view the risk of bleeding was now greater than the risk of clotting.

Missed opportunity for staff supervision: Prior to my discharge, I was aware my laparoscopic wound was still weeping so asked for it to be checked. A doctor did so and indicated it needed to be stitched. What I took to be a junior doctor, unsupervised, did so, but his body language indicated he was very nervous about the procedure. He asked a nursing student to do the stitching but she declined, respectfully but firmly saying it was beyond her current scope of practice. His lack of confidence was well-founded in that I presented to ED at Harvey Hospital the day after discharge so the wound could be further attended to.

Delayed communication with GP: I was advised to see my GP so she could monitor my potassium level and investigate further if warranted. At my appointment, she had received the pre-surgery report but not the discharge summary.

From my perspective, the individual gaps and overall pattern are indicative of a system under stress. I would anticipate that statistics are reflecting that: elevations of or upward trends in ED waiting times; re-admissions within a short time-frame; number of bed and ward relocations per patient; unscheduled staff leave. In a former role, I believe I was aware of how sanitised statistics can be, not in any conspiratorial sense but simply that they do not adequately capture the daily lived experience of patients and of staff on the front line of health care delivery.

My hope in documenting observations from my recent admission is that it may provide a snapshot of the front-line realities, adding a consumer perspective to the critical mass needed to effect change.