The Victorian Hospital Incident and Breach of NSQSH Standard 3

Question:

Discuss about the Role of Safety and Quality in Health Care.

The report is based on an incident that took place in a Victorian hospital, where the death of several newborns occurred due to the negligence of the hospital staffs. According to the the accounts of this incident, it was found to breach the standard 3  of the NSQSH standards. Standard 3 refers to the preventive interventions to control the health care- associated infections. The main issue that has been addressed in this paper is the death of the neonates due to postpartum infections. As per the news, those incidents were avoidable and were caused mainly due to the negligence and lack of awareness of the clinical staffs and the health care practitioner. The newborn babies and their respective families are the ones who were affected the most by the negligence and malpractices of the administration of the healthcare administration.

Several databases have been searched using appropriate search terms in order to review literature associated with the causes of neonatal deaths and the possible measures that should be taken to mitigate such deaths in any clinical settings. It also sheds light on the the findings that can mitigate the mortality of the neonates. In this case, it was reported that the hospital staffs did not pay heed to the deteriorating conditions of the babies. According to the complaint lodged by the parents, the registered nurses did not monitor the vital signs properly and also did not provide proper handover during the clinical shifts. Therefore, the lack of effective communication resulted in the spread of the postpartum infections and claimed such a  huge number of lives in the Victoria hospital.  The problem focussed in the following report lines up with the national standard 3 (Gabrysch et al., 2012). As per Gabrysch et al., 2012, proper quality improvement techniques and risk management can mitigate future problems related to the issue.

This review of the literature provides insights about the neonatal deaths all over the world and the steps or measures which could be employed for reducing the risk of neonatal deaths in the hospital beds. The report provides an information regarding  incident in Australia  health care that aligns with NSQHS standard 3(Gabrysch et al., 2012)

The literature sources have been cultivated to gather similar and relevant data regarding the occurrences of neonatal death due to postpartum infection in a clinical setup. The reports and evidence have pointed to the lack of sufficient safety methods and practices which resulted in the major outbreak of such infections. Additionally, the lack of sufficient support form the collaborating health channels also affected the care quality and standards. The cause of the neonatal infections is often attributed to neonatal sepsis, which is the infection of the maternal genital tract during labour. Therefore,  sufficient infection prevention or control methods need to be employed for reducing the chances or the risk of such infections. Additionally, another major cause of such infections is the use of the same contaminated articles by the nursing professional to attend more than one baby. Therefore, the implementation of the National Healthcare standards can reduce the chances of such infections (Buchnall et al., 2015).

Causes of Neonatal Deaths Due to Postpartum Infections

Research has been done using Pubmed, Google Scholar, CINAHL AND MEDLINE to get an idea about the 3 NSQHS standards. The search terms have been listed below as follows:-

The standard 3 of the NSQSH guidelines focuses upon ‘preventing and controlling health care associated infections (Twigg, Duffield & Evans, 2013).

These are some procedures that have been taken up to conduct a search regarding the discussed topic, which revealed the death scandals of several newborn babies in a healthcare setting inVictoria. It has been reported that the adverse events have occurred due to the indifference and the malpractice of the healthcare staffs within the hospital. Keeping the main concept of this report in mind, the main aim is to find out the causative factors of the neonatal deaths and the known approaches to prevent the adverse effects. A thorough literature review has been conducted to analyse the different avenues of the concept.

According to Anderson et al., 2014, every year nearly 41% of child death is caused, worldwide in the newborn infants (Griffiths & Burke,2012). It has been reported that here a quarter of the newborn death occurs in the first 28 days after birth. The review suggests that about two third of the neonatal death can be avoided if measures are taken at the first week after the birth (Anderson et al., 2014).

The main reasons behind the neonatal death worldwide are infections, which are mostly hospital-acquired infections like Septimius Pneumonia, tetanus and diarrhoea, birth asphyxia. The report is based on the death scandal of several babies in a hospital in Victoria, which is mainly due to the hospital-acquired infections(Gabrysch et al., 2012). Gabrysch et al., 2012 has again argued that some sentinel events related to hospital are not always avoidable and hence it is necessary to asses the reasons behind the adverse events. It was found that in most of the cases of neonatal deaths and pregnancy, complications were avoidable and could be managed by the healthcare professionals (Gabrysch et al., 2012).

According to Buchnall et al., 2015 the most common reasons behind stillbirths include placental problems like placental abruption, preeclampsia, hypertension and several others. They took no measures to reduce the probability of the hospital-acquired infections (Buchnall et al., 2015). Gabrysch et al., 2012 has said that it is the duty of the professionals to monitor whether the baby is growing inside the mother’s womb or not. If the growth pattern of the baby tails off then it should be understood that the placenta is not working properly and specific measures have to be taken. It has been investigated that the would-be  mothers were not properly addressed in the concerned clinical settings.

Measures to Mitigate Neonatal Deaths in Clinical Settings

The NSQSH standard 3 refers to the prevention and controlling of the healthcare-associated infections (Gottwald, M., & Lansdown, 2014). The goal of this standard is to avoid the healthcare-associated infections in babies. Therefore it can be clearly seen that standard 3 is being breached clearly in the hospital scandal, the concerned clinical setting could not meet up to the standard 3(Gottwald, M., & Lansdown, 2014).

In relation to the given scenario, there are certain criteria that are required to be fulfilled in order to achieve the standard.

Clinical governance and system to prevent infection, surveillance and control. It can be clearly seen from the case mentioned in the topic, that the would-be mothers did not get safe treatments or no measures have been taken even after facing few neonatal deaths, thus the concerned organization beached the standard (Yokoe et al, 2013). Other criteria are the prevention and the control of the infections.

Separate strategies have to be taken up to control the infections in clinical settings, which can be done by chalking out a thorough CQI( Continuous quality improvement)  plan for the clinical setting. Regular monitoring of the status of the neonatal ward should be taken care off. The neonatal ward and the incubators should be sterilized regularly to prevent infections.  According to Yokoe et al, (2013), there should be emergency settings to deal with the deteriorating neonates. As per the review is taken from the admitted mothers or those who have lost their child, have mentioned that the hospital did not emphasize on the prevention of the infections, despite repeated complaints (Yokoe et al, 2013).

As per the Yokoe et al, (2013), another criteria for achieving the outcome is the administration of safe antimicrobial agents. Infection can be controlled by dose-dependent antibiotics to the neonatal or the expected mothers. Appropriate antimicrobial agents should be administered into the ward to kill the germs (Yokoe et al, 2013).

Special isolated units are required for the infected babies, and skilled professionals are required if the health status of the baby turns adverse due to the infection. According to the paper by Leis & and Shojania (2016), the environment associated with the healthcare setting should be absolutely clean. Reprocessing of equipment and instrumentation should be able to meet current best practice guidelines. Thorough cleaning and disinfection of the baby ward are necessary (Leis & and Shojania, 2016).

According to the NSQSH guidelines, communication with the carers and the family of the neonatal are required for imparting education regarding the hospital-acquired infections, which would help the family to deal efficiently with the postpartum period.

Literature Review of Similar Incidents Worldwide

According to Yokoe et al., 2014, the hospital-acquired prepartum and the postpartum infections have become a major concern throughout the nation. Worsening of the  health condition of the babies is trailed along with cardiac arrests and unexpected mortalities. Prompt determination of deterioration level, followed by a prompt and effective action, can reduce these uotoward incidents and help in improving the care results and outcomes and reduce the number of measures required for stabilizing the deteriorating condition of the neonatals(Gottwald& Lansdown, 2014). 

According to Gottwald & Lansdown, 2014, the clinical leaders and the senior manager of the concerned hospital should have implemented systems to prevent and manage the healthcare-associated infections.  Journals like American Journal of Medical Quality provides an information regarding interventions that enhances the treatment quality and would provide technical support on different mutual approaches, that are specific to community.  Collection of data, maintaining of proper risk management registers and tools can reduce hospital readmissions (Donskey, 2013).

Healy, (2016) the author had shared her experience in analyzing and assessing the healthcare system of several countries. She had noticed that raised regulation has increased the safety of the neonatal and quality of the healthcare in different countries. It had focussed towards the new ways for the improvement of health care systems in Australia,  Europe and North America (Healy J, 2016).

According to Gottlab& Lansdown (2014), certain measures should be taken up, like audit, risk management drills. Adverse events centring the babies should be identified promptly, assessed and resolved (Gottlab& Lansdown, 2014). Reduction in the number of records would indicate quality improvement (Morello et al., 2013).

The implementation of the required changes in health care should be done after proper documentation and scrutiny. The modifications that would cater to the betterment of the babies are by adopting well-researched methods and technologies. It is often difficult to implement any changes in a healthcare setting, as the clinical staffs are accustomed to the old conventional ways, (Donskey, 2013) has emphasized on changes in the age old strategies for better outcomes in baby’s health.

According to (Bucknall et al., 2015) in order to evaluate that that improvement strategies have been implemented or not, it is necessary to program audits that would compare the data and the statistical analysis of the baseline data of the neonatal morbidity. According to Bucknall et al.,2016 in his “ An analysis of nursing students’, the author has proposed that partial information regarding the babies and  not looking after the alternatives while assessing the baby’s condition and premature diagnosis leads to poor quality decisions.

Importance of Infection Prevention and Control Methods

This topic proposes about the death of newborn babies that occurred in a Victorian hospital. It has been reviewed that most of the neonatal death that had occurred was avoidable. In a low-risk maternity service, neonatal deaths should not exceed more than four in a year., but in this case, high level of morbidity had been recorded (Bucknall et al.,2016).

Thus it can be clearly seen that the hospital staffs have breached the NSQSH  standard 3. The implementation of the NSQSH standards helps in reducing the chances of human errors within the clinical set up by providing sufficient training skills to the responsible healthcare professionals and also focuses on the communication standards. The inculcation of the right communication practices and approaches would enhance the process of information exchange. This is particularly helpful during the change of shifts where any gap in the provision of the required amount of information can claim the life of an individual (Hall et al.,  2015).

The above-discussed literature review focuses on the probable factors responsible for the neonatal mortality all over the world, and it can be easily linked to the adverse event that took place in the concerned hospital of the Victoria. (Donskey, 2013). Families often do not get the chance to escalate their problems to the customer service of hospitals.  Therefore, application of stricter practising norms along with a transparent or virtual interface for maintaining direct communication with the family members of the patients could be helpful. However, the patients have a right to receive a minimum level of basic care (Griffiths & Burke,2012), failing which the patient has a legal right to compensation. (Hall et al, 2015).

Conclusion

The following report is aligned with a case that occurred in a hospital in Victoria, which caused huge political ups and downs in Australia health ministry. The clinical setting of the concerned healthcare has been found to breach the NSQHS standard of healthcare that states –Preventing and controlling healthcare associated infections standard. The following issue provides with an idea about the indifferent attitude of the hospital staffs as efforts were not made in mitigating the deterioration of the babies. The literature review conducted provides us with the fact that negligence and lack of education regarding the maintenance of hygiene in  the baby ward is responsible for the neonatal mortality. The report further throws light upon the fact that a proper quality improvement planning and different risk management strategies in combination with cleanliness in the hospital ward can mitigate the death of the neonatal due to infections.

Criteria for Achieving Standard 3 of NSQSH Guidelines

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