“Failure to maintain”: do hospitals cause suffering in older people?

Today Palliverse talks to Assistant Professor Kasia Bail (@Kasia_Bail) from the University of Canberra. Kasia is a nurse, a researcher, a kung fu instructor and a drummer in a metal band. She came to our attention via social media when we noticed her crowdfunding campaign for the next stage of her research into nursing care of complex, hospitalised older people. Here at Palliverse we are fans of crowdfunding, although we’re yet to use it for research purposes!

Kasia’s research aims to improve sustainable acute care health delivery for an ageing population, while her clinical experience includes general medical and acute palliative care. In her PhD, Kasia developed an approach to measure nurse-sensitive outcomes, which is currently being used to evaluate a Government-funded implementation of a cognitive identifier. Kasia has a passion for identifying and researching the structures and processes which impede or enable quality patient care, and sharing her learning and inquiry with nursing students, industry and professional groups. Here, Palliverse asks her about her latest research project and dipping her toe into the world of social media.

kasiabail

Dr Kasia Bail (image via Dr Bail)

Your research has led to a new concept in the care of older people with complex medical problems, “Failure to Maintain”. What does this mean?

‘Failure to Maintain’ is the inadequate delivery of fundamental (also often called ‘basic’) nursing care to a complex older person in hospital. ‘Failure to Maintain’ can be measured by the patient outcomes including in one of four common, but potentially preventable, complications: urinary tract infection, pressure ulcers, pneumonia and delirium. (The name is derived from another term used to assess hospital quality: ‘Failure to Rescue’, where inpatients die after a complication in hospital.)

This new term gives a name to the challenges in providing simple interventions (such as mobility, skin care, hydration, nutrition and communication) in complex environments (such as hospitals) to complex patients (such as people with dementia). We know that when demand for nursing care exceeds supply, patient care is rationed. We also know that the care most often rationed is essential cares such as mobility, skin care, hydration, nutrition and communication – this is not unreasonable necessarily as acute health settings do need to prioritise life-threatening conditions first. However, we need indicators of care before patients get to the life-threatening stage, particularly given that most hospital admissions include chronic, as well as acute, conditions.

Finding a way to measure this rationing, as well as setting suitable methods for achieving quality bedside care, will be important for the future efficiency of healthcare. Above all, we can work towards systematic ways to reduce the unnecessary suffering of people in hospital.

“Above all, we can work towards systematic ways to reduce the unnecessary suffering of people in hospital.”

How has your research backed up this concept?

I found that people with dementia – who are a classic example of a complex older patient – have nearly three times the rate of these hospital-acquired complications than people without dementia. I found that 21.9% of patients with dementia experienced an hospital-acquired complication, and people with dementia spent 8 times longer in hospital that people without dementia. Acquiring one of these complications in hospital added 26% to costs for people with dementia and doubled the cost for people without dementia.

I also found that these complications cost $225 million dollars in extra length of stay [in NSW] – that’s dollars in one state, in one year, that is potentially preventable length of stay for the patient, and preventable cost for the hospital/state.

There is an assumption that it is the age of the population and the increasing comorbidities that are expensive, but in my research I identified that dementia diagnosis and the presence of complications during admission affected the cost of hospital stays more than comorbidities or age. This research was looking at all patients over the age of 50 in public hospitals in NSW in 2006/07.

What is the next phase of your research?

I want to compare the approach that I used to examine these complications (known as the ‘Needleman approach’ to counting which complications were hospital acquired) with the approach currently used by IHPA (the Independent Hospital Pricing Authority) and the Commission (the Australian Commission on Safety and Quality in Health Care), called ‘condition onset flags’. I want to refine the science in measuring these outcomes using more recent data from 2014/15, and continue to analyse them in relation to the nursing evidence about processes of patient care delivery.

You are crowdfunding for the next stage of your research – what led you to try this?

I was pretty reluctant to even use much social media in my work, let alone ask for money! But I participated in the ‘Three minute thesis’ (3MT) most years of my PhD and found it very helpful for my thinking and communication skills.

(I actually really liked having 5 years and 90,000 words to work out, and communicate, my thoughts. 3 minutes for the 3MT, let alone 140 characters for a Tweet….. these are all against my grain! But I can’t claim to be a Dr of Philosophy if I can’t learn new things : ).

Our University progressed the 3MT into a post-PhD style 90-second ‘Pitch for Funds’ (P4F). I was one of 4 winners! It was great that there were 4 of us, but it meant we had to share the prize money, as none of us had what we had asked for to run our project. So our Research and Development Guru aka Melanie Haines roped us all in encouraged and enabled us, to do Crowdfunding. And in the process taught us (and gave us a purpose to) Tweet.

I’ve always tried to keep my social and work life a bit separate – sometimes I think that this is functional coping mechanism with nursing work. However, I realised at any social gathering I will tell anybody who will listen about my nursing research, and how suffering could be prevented. So if I’ll do it at dinners and bars, why not on blogs and internet spaces?! I do truly want to make a difference for people suffering unnecessarily in hospital, so if this is one way to achieve that, I’ll give it a try.

You are hoping to raise $5 444 – how will you use it to help your research? And how do you hope it will improve the care of older people?

The money will be used to apply for and access the large historical datasets of Australian hospitals held at the Australian Institute of Health and Welfare. There is often quite a bit of administrative work (and time = money!) to make sure the data set is accurate, holds only the information required for the analysis, and is appropriately de-identified. The money will also be used to employ analysts and researchers to run the inquiries, as the more statistically minded people who start looking at these issues I have identified, the greater the scope for broader involvement and development of research, policy and practice. I want to lead non-nursing researchers in examining these significant issues for the health system, because I don’t believe this is a nursing problem.

I know that using the ‘big’ (-ish) data might seem a long way away from the patient experience, but I know that a lot of the scaremongering about the costs and ‘epidemic’ of old people in our health system needs suitable insight and analysis to address them. Nursing care is currently invisible in many of the quality indicators and costing analysis, and minimally funded in terms of research grants. And yet, each and every patient intervention, care and treatment will pass through the hands of a nurse in order to reach a patient. Reorienting analysis to look at nursing care as an intervention, rather than just a labour cost, will be essential as we move into many future decades of having increased older populations. These are the three largest most expensive populations in health care: older people, hospitals and nurses. Getting the right data to inform development of the right systems to meet the needs of the largest population needing health care is the most caring thing that needs to be done for older people right now.

“…[Let’s] look at nursing care as an intervention, rather than just a labour cost…”

Thanks Kasia for talking to us and giving us an insight into your research and your experiences with social media! For more information about Kasia’s crowdfunding campaign (and maybe make a pledge), please visit her Pozible page. She’s two-thirds of the way to her fundraising target and needs to reach it by December 16th to receive the pledges!

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