Contemporary Health Care - Case Study Example

CONTEMPORARY HEALTH CARE: PART 3 Introduction The basic theme of contemporary health policy is provision of healthcare as a moral right secured for all. The current policy in the NHS is to change the burden of disease and to ensure availability of latest, evidence-based, guideline-driven healthcare based on assessment of personal needs. In 2000, the NHS Plan was launched in order to improve the basic standards of healthcare in the NHS. This has resulted in a great skill mix of healthcare professionals, leading to enhanced access to care and greatly improved outcome. After the end of the NHS Plan in April 2010, it is expected that the services would be more responsive to the individual needs of the consumers, yet focused on prevention (Nolte and McKee, 2008). Lord Darzi (2008) recommended investment in new services, reform, and new ways of service delivery. If the main goal was to provide high quality care, the contemporary health policy had been successful in creating an environment of delivering high quality care in all respects. By quality as Lord Darzi had described, it means safe, personalised, and clinically effective care. There are many sections in this review document, quality in care is a recurrent theme, and it has been suggested that better control over individual health and treatment of conditions is possible only through a coalition between consumers and commissioners (Darzi of Denham KBE, 2008). Although investment in different areas has increased over time, the investment in preventive health has increased considerably. The patients are allowed more autonomy. Improvement in safety and reduction in healthcare associated infections are two important objectives of this plan. For the staff to be able to get information and practice to deliver quality care, evidence from research is an important tool. The staff has been proposed to have access to authoritative evidence that can guide best practice. This policy also ensures that clinically and cost effective innovations in the science of medicine are also adopted (Darzi, 2008). Obviously, these would involve change in the structure of the organisation and attitudes of the healthcare professionals in resisting change. Changing the orthodox and conventional practice had always been an issue in implementation of plans and policies in the history of NHS. In fact previous and frequent policy changes led to much confusion among NHS staff, which could have made matters confusing. Towards the end of NHS Plan, it has now been accepted that clinician-led changes in practice which are evidence based would be complied by the NHS staff since it was expected to improve quality of care, outcomes, and increased job satisfaction among staff (Department of Health 2008b). Although no new national targets are mentioned in this plan, one of the important aspect of this contemporary policy is to have a care process that is locally led, patient-centred, and clinically driven. If a change in the practice is needed to comply with the policy change, it is best to have the change is determined by the people involved. This justified the locally led changes in practice, and this led to adoption of different pathways of care across specialities. When the stakeholders are convinced about the best available evidence and the need for work with patients, this policy principle is expected to work (Department of Health 2008a). Healthcare commissioners, clinicians, and other professionals have worked together to frame conclusions on different aspects of healthcare and have determined the best possible frameworks for care. There has been evident progress, but still identification of areas where further change is needed based on clinical evidence for provision of high quality care is underway. Across different populations and age groups in different localities, these measures are supposed to prioritize action and are expected to demonstrate the difference in benefits post implementation (Department of Health 2007). Shircore and Ladbury (2009) termed this policy implementation process to be a transition from service delivery to solution delivery leading to health improvement through commissioning. This is a decentralised, down-top, and professionally prescribed and involved method of locally designed policy implementation where client satisfaction and engagement are prime elements. For healthcare professionals, this stage of evolution in care policies would evidently lead to a plethora of opportunities which have just begun to emerge (Shircore and Ladbury, 2009). This model of care accepts the need for universality of care within the NHS, but this factor of local implementation based on local needs allow modification of the care framework locally by the professionals within in the basic policy principles, thus allowing diversity in care proposals and methods (Hales and Pronovost, 2006). In this way, the local choice, needs, and the professional satisfaction are guaranteed ensuring involvement of all stakeholders in implementation. Freedom to modify care based on evidence and local needs is the most important professional benefit in this policy model. This is applicable across population in different care pattern related groups such as “staying healthy”, “planned care”, “acute care”, “mental health”, and “child care” (Black, 2008). The other relevant parameters are more control for the patients, timely access to care, prevention of ill health, improved diagnostic services, and more control to the patients, even inclusive of control in healthcare spending. However, the most noteworthy component of this form of care is ensuring effective and safe care, specially for people with life-threatening illnesses such as heart attack, stroke, and major trauma (Leatherman and Sutherland, 2008). This population would need specialised care, and evidence demonstrates that both quality of care and outcomes are greatly improved if these conditions are managed in specialist centres, and each region is now poised to establish such centres and have these treatments conducted in there. Patient safety is a major mandate in all areas, so also in such centres, and due to strong emphasis on its importance, these centres are to be made clean and as free of infection as possible. It is anticipated that by April 2010, there will be full separation of commissioning from provision. However, professional skill and evidence based practice are the two main determinants of such a change. Out of 300 different targets of NHS Plan, setting clinical standards to provide quality and safe care with an eye to prevention at each local level is the most important target. National Service Frameworks and National Institute for Clinical Excellence (NICE) should jointly provide guidelines of care in different conditions. This would, as expected, lead to improvement in practice. However, so far only four established guidelines are available for use in practice. In many other cases, guidelines are debatable, and even of available, their transmission is not optimal. In the current policy, however, this is less then acceptable since these do not make things better from the point of view of the task of care providers, since in many cases improvement of patient satisfaction, health outcomes, and efficient use of resources are not happening (Smith, 2000). It is thus clear that despite the complexity of issues with the vast NHS, there are more than 300 target issues, which cannot be addressed even within the broad range in this assignment. Thus to get an idea how changes are slowly and definitely occurring, this author’s facility can serve as a model scenario, where these changes can be studied. The author’s clinical practice setting is ICU, and changes in practice there could be analysed to examine and to see whether the practice is protecting and promoting patient safety, which according to the NHS Plan should be the first priority, which can be accomplished through effective evidence-based care delivery. This author works in a 12-bedded Intensive Care Unit (ICU) which is a part of Critical Care Services (CCS) of this hospital. ICU is used for care of the patients who present with emergent conditions which can be critical and life-threatening or patients who have deteriorated or who need Level 2 care or who are stepping up for higher levels of critical care. Consequently, these patients would need high-dependency care, which would involve extended postoperative monitoring with provision of basic cardioplumonary support. The care would also involve maintenance and management of central venous catheter through which multiple drugs and total parenteral nutrition is provided. Care procedures and guidelines for these devices should be displayed or be available, but in their absence, the CCS staff including this author are in the process of adapting to these changes in care procedures. This is the beginning, and this change is not that significant, although this change would affect the care of the majority of the patients in this area. Thus all nurses and clinicians across the service are subject to these changes, and the scenario suggests involvement, since most are either driving these changes or are modifying their practice according to the needs (Berenholtz et al., 2004). It has been indicated earlier that prevention of healthcare associated infections (HCAI) is one of the priorities set in this plan. This has been defined as hospital acquired infections in the wake of healthcare. This type of infection has propensity of spread within the hospital environment, leading to serious morbidity and mortality to the patients affected. Apart from its negative implications on patient safety and quality in care (Tolentino-DelosReyes et al., 2007), it has financial implications for both the patient and the NHS. Occurrence of such infections leads to prolonged stay, increased cost, increased bed occupancy, high morbidity, and considerable mortality. NHS spends £1 billion per year, and Department of Health indicates CCS to be a hotspot for such episodes due to it high incidence in the CCS. The high quality care for all propositions by Darzi (2008) has policy implications in this area, since such infections act as a barrier to the goal of protection of patient safety. Therefore, in order to ensure patient safety and to prevent infection, combating HCAI should be an NHS priority. This conforms to a Darzi principle that public trust on NHS can be ensured only to keeping them safe while under care. One particular area in the ICU practice is ventilator care bundle (Walsh et al., 2004). While HCAI is concerned, patients on ventilator are often noted to develop ventilator associate pneumonia. This author has chosen this topic since this is an area that needs attention since ventilator associated pneumonia is the commonest healthcare associated infection in patients who are mechanically ventilated in this authors unit. Current evidence indicates that this can be prevented with ventilator care bundle approach, and if not prevented, this accounts for 60% mortality in all patients who have acquired pneumonia during treatment in the hospital. Those who do not die, their stay in the critical care setting are increased by 4 to 9 days. However standardized preventive and proactive treatment for the ventilated patients are not available, and now ventilator care bundle has been established as a standard practice for such interventions (Blamoun et al., 2009). With growing concern both on the part of people and the government, the 2006 Health Act suggested a code of practice to prevent and control HCAI. These thus would be need for implementation of some care practices which would fulfill the requirements of this legislation, but would also follow the contemporary health policy according to Darzi NHS Plan (Darzi, 2008). The ventilator bundle parameters have four main aims. They are faster extubation and weaning from ventilator, reduction of aspiration, and maintenance of cleaner oropharynx and hypopharynx (Cook et al., 2002). However, only knowing the skills of ventilator would not be able to produce the desired results (Boles et al., 2007). It needs regular practice, education, practitioner compliance with the parameters of ventilator bundle. This initiative was started in this unit for last 9 months, and guideline has been created at the local level in our unit. This would involve a way to improve current practice through the critical and thoughtful integration of best available evidence from research into clinical practice. Blamoun et al. (2009) indicated a statistically significant reduction of VAP through use of modified protocol of standard ventilator bundle. They defined ventilator bundle to be a group of clinical measures to improve outcomes of patients undergoing mechanical ventilation. These included sedation vacation, deep vein thrombosis prophylaxis, prophylaxis for peptic ulcer disease, and elevation of head end of the bed (Blamoun et al. 2009). Zaydfudim et al. (2009) indicated six parameters of ventilator bundle practice, which are daily screening of spontaneous breathing and extubation trials to achieve speedy extubation, targeted assessment of sedation by sedation scores and to maintain adequate levels of consciousness to prevent aspiration, elevation of head of bed to 30 to 45 degrees, dental care, oral care, and suctioning of the hypopharynx. Since compliance is an important part compliance monitoring and training of the staff are also important measures to effect these (Zaydfudim et al. 2009). Consultant intensivists may play important roles in implementation since they can educate the nurses on the rationale of the bundle practice and demonstrate how the care outcomes may actually be better with this. They have also helped developing the check lists that the nurses use while implementing the bundle practices. The infection control link nurses also educated the nurses about each of the elements in the practice would control HCAI and ventilator associated pneumonia (Gursel et al., 2007). The group of nurses also participated actively in conducting the audit for implementation and compliance to the bundle practices. This indicates understanding, participating, and getting involved in the process and change in practice. Ventilator associated pneumonia can easily lead to bacteremia, and hence according to contemporary health policy prevention of these are of utmost importance. This would conform to safety policy and policy of prevention of HCAI. Many studies have been conducted in the critical care settings, and CDC has a recommendation about ventilator bundle practices. This is also evidence based as indicated above. Use of checklists for nurses in the complicated environment of CCS has also been proven to be useful for accuracy and compliance (Cutler and Davis, 2005). However, despite all these there are barriers to implementation. Following the local decision of changing the practice to ventilator bundle, there has been considerable drop in ventilator associated pneumonia, which is a major advantage. However, it seems there is a gap in training, education, and learning, which was evident in the re-audit which demonstrated that 30% of the cases there were noncompliance (Hanneman and Gusick, 2005). Moreover, the trial of extubation needs presence of intensivist which in such a busy environment is not always feasible. It would be beneficial if there is a guideline for the nurses to independently do the trial for extubation. Evidence do not demonstrate whether other nosocomial causes are there for such HCAI, and concurrent drive to prevent other associated factors must be in place. It was also suggested by the nursing staff that a printed guideline should be available in the practice area, and none such guide is available, and it is not always possible for all to remember all detailed step in practice (Hyllienmark et al., 2007) Staffing was a real problem, since staff skill mix is an important quality and safety parameter in the PACU environment. Lack of staff led to increased workload for the nurses. There must be provision for rostered time to examine evidence base, design need based and person centred care, deploy best practices, implement changes, provide education, and document care. However in the bust environment of the CCU, this was not possible, and there would be many misses even in a single care episode. Staff did tale initiative to solve these problems, despite the fact successful implementation of ventilator care bundle should happen through a team approach (Zaydfudim et al., 2009). Conclusion As contemporary health care is subject to frequent updates and revisions, the group will continue to monitor any new relevant initiatives and evidence and update practice accordingly, but the main objective of the safety and quality of patient care in order to generate best patient outcomes should remain intact. Continuous monitoring of compliance with the care actions and a rolling programme of education are important needs, and the best solution should be a competence guideline on this matter in order to be able to provide consistent high quality care. Despite frequent changes in policy parameters, this approach could provide the best results. References Berenholtz, SM., Pronovost, PJ., and Lipsett PA, et al., (2004). Eliminating catheter-related bloodstream infections in the intensive care unit. Crit Care Med; 32(10):2014-20. Black, DC., (2008). Working for a Healthier Tomorrow, Crown Copyright, March 2008. Blamoun, J., Alfakir, M., Rella, ME., Wojcik, JM., Solis, RA., Khan, MA., and DeBari, VA., (2009). Efficacy of an expanded ventilator bundle for the reduction of ventilator-associated pneumonia in the medical intensive care unit. Am J Infect Control; 37(2): 172-5. Boles, JM., Bion, J., Connors, A., Herridge, M., Marsh, B., Melot, C., Pearl, R., Silverman, H., Stanchina, M., Vieillard-Baron, A., and Welte, T., (2007). Weaning from mechanical ventilation. Eur. Respir. J.; 29: 1033 - 1056. Cook, DJ., Meade, MO., Hand, L., McMullin, JP., (2002). Toward understanding evidence uptake: semi-recumbency for pneumonia prevention. Crit Care Med.; 30:1472-1477. Cutler, C. and Davis, N., (2005). Improving oral care in patients receiving mechanical ventilation. Am J Crit Care.;14:389-394. 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