Productive Ward

Many trusts seem to be adopting a fairly interesting new system known as Productive Ward. This is where for one shift on a regular basis a nurse is taken off of his/her clinical duties and sits down and trys to think of ways to make the ward more productive. Something as simple as moving the commodes nearer the door in the sluice room so that it takes a fraction of a second less time to get the commode to the patient(which apparently adds up).

A ward in bath has made the news because rather than having the one set of keys for the drugs trolley floating around different members of staff depending on who used them last they keys are now locked up in a safe and every member of staff is given a key for the safe. The benefit here is that they can now avoid a very regular occurrence on all wards - a member of staff has gone home with the keys in their pocket and has now got to be dragged back in because none of the patients can get their medications. I would strongly argue that the downside of this system is that when they keys are floating they are always in the possession of a member of staff, someone relevant always knows where they are. If they are in a safe they are unobserved for long periods of time, added to which there are now keys for the safe all over the place. This seems far less secure and potentially very dangerous.

All in all the productive ward scheme seems to be keeping peoples attention on the importance of ward efficiency however I am not certain that the changes made are really making a difference. Another drawback is the nurse working a productive ward shift has to do it on the ward. If you are a nurse on your ward you are going to get roped into checking IV's, answering buzzers, and generally chipping in during those day to day crisis moments on the ward(which frankly I would prefer). This wouldnt be too bad if most wards didnt insist that a nurse in a productive ward shift has to wear plain clothes(no uniform).

However it does make you think how much time and energy is wasted at work through tiny inefficiencies. It does all accumulate.

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Failure

In this profession you standardise you're level of success or failure based on how many patients are alive when you leave the ward. If you have worked a shift and none(or in critical care very few) of your patients have died then you mentally tick that off as a successful shift.

Many wards at any one time have patients who are palliative, they are dying and there is nothing that can be done medically to prevent this. Fortunately there are care pathways(protocols) in place for any patients who meet very specific criteria. This takes a lot of the difficult decisions out of the hands of doctors, nurses and the patients family. The standard care pathway in my trust is the Liverpool Care Pathway. Once a patient has started on this care pathway their treatment is purely for comfort. Analgesics, Anti-emetics, etc are administered
more or less constantly via a syringe driver. A device that slowly injects medications over a given period so rather than a patient getting a dose of morphine for their pain at 1300 and needing another dose at 1500, the driver releases the same dose into the body constantly over x amount of hours. This not only means the patient is constantly receiving pain and sickness relief but the nurse doesnt have to wake the patient up every three hours to administer the drug.

Once a patient is on the LCP and non-essential medications are discontinued(pretty much anything they wont die immediately if you take them off) and their observations are either ceased or taken only once a day as it is an uncomfortable thing to do to a patient but absolutely necessary for a patient who has a chance of recovery. In patients with no chance of recovery whats the point of waking them up at 0500 every morning to take their blood pressure, pulse, oxygen levels, etc. On a regular basis the patient is assessed for pain, agitation, nausea,
breathlessness, etc and if there is any variance on these then the medication the patient is on is adjusted so that they are as comfortable as possible.

This phrase always made me laugh "as comfortable as possible". The patient is dying, they are scared, exhausted, probably in pain. What we make the patient isnt anywhere near comfortable. And to add to the discomfort we take them off fluids and food and of course they are bed bound so they will be cathatarised. Ethically is this the right thing to do? they are dying and food, fluids, etc will prolong this however do we want their last hours to be spent, thirsty and hungry?

And back to my original point when you leave the ward and one of these patients has died how do decide if it was a success or a failure on your part?