531
greater than that in the A.A. group accords with the
con-
clusion that the heatwave resulted in some or all of this excess mortality. Deaths in Greater London, especially in those aged 65 and over, increased significantly during the heatwave 14 and it is expected that this trend will be reflected by a national increaseY Similarly, deaths reported to the Manchester Social Services Department suggested a threefold increase compared with previous years, however, full statistics are not yet available.16 This increase is of the same order as occurred among the elderly in the c.c./R hospital group. It is our impression that the reported excess mortality chiefly affected those patients who were seriously ill during the heatwave. Patients so affected had a wide range of diseases. The condition of many more patients deteriorated as a result of high air temperatures. Most responded to rest, rehydration, correction of electrolyte disturbances, and, in severely affected patients, to tepid sponging and aspirin therapy. It is disturbing that otherwise fit elderly subjects within the community receiving social services support (residents in part III and sheltered accommodation) may also have been adversely affected by the heat. This confirms the view that abnormalities6 of thermoregulation are more common in the elderly.36 We believe that elderly subjects dying during the heatwave developed a combination of the heat-exhaustion syndrome (electrolyte and water depletion) and heatstroke (failure to lower body temperature due to autonomic disturbances). Others in the U.S.A. believed that excessive mortality in this group was caused by heatstroke syndrome alone.711 An awareness of the adverse effects of heat in elderly subjects will lead to greater recognition of the early stages of heat exhaustion by attendants within the hospital and within the community. The simple provision of shading, light clothing, and increased ventilation will go far to mitigate the effects of heat. Monitoring body temperatures of ill inpatients, preferably between 1 P.M. and 4 P.M., during heatwaves will allow prompt institution of specific therapy such as aspirin administration, parenteral fluids, and tepid sponging. More research is needed into all aspects of thermoregulation in the elderly. We thank the Manchester Station of the their advice and assistance.
Meteorological
Office for
Requests for reprints should be addressed to M.L., Department of Geriatric Medicine, University Hospital of South Manchester, Nell Lane, Manchester M20 8LR. REFERENCES 1. Emslie-Smith, D. Lancet, 1958, ii, 492. 2. Royal College of Physicians of London. Report of the Committee on Accidental Hypothermia, London, 1966. 3. Macmillan, A. L., Corbett, J. L., Johnson, R. H., Smith, A. C., Spalding, J. M. K., Wollner, L. Lancet, 1967, ii, 165. 4. Fox, R. H., Woodward, P. M., Fry, A. J., Collins, J. C., MacDonald, I. C.
ibid. 1971, i, 424. Exton-Smith, A. N. Br. med. J. 1973, iv, 727. Hockaday, T. D. R., Cranston, W. I., Cooper, K. E., Mottram, R. F. Lancet, 1962, ii, 428. 7 Rossman, I. (editor) Clinical Geriatrics. p. 471. Philadelphia, 1971. 8. Levine,J A. Am. J. Med. 1969, 47, 251. 9 Knochel, J. P., Beisel, W. R., Handon, E. G., Gerad, E. S., Barry, S. K. ibid. 1961,30, 299. 10. Leithead, C. R. Soc. trop. Med. Hyg. 1967, 61, 739. 11. Shibolet, S., Coll, R., Gilat, T., Sohar, E. Q. JlMed. 1967, 36, 525. 12. Ellis, F. P. Environmental Res. 1972, 5, 1. 13. Leonard, J. C. Br. med. J. 1976, i, 1335. 14 Office of Population Censuses and Surveys. Population Trends, no. 5, Sept. 5 6
1976. 15 0 P.C S. press release. July 16. Manchester Social Services
23, 1976. Department. Unpublished.
Making Efficiency in
Do
the National Health Service
LENGTH OF STAY As a measurement in clinical practice, length of stay has similarities to blood-pressure. Everyone accepts certain high values as inappropriate, and when they are recognised in the individual patient immediate efforts are made to put them right. Lesser abnormalities affecting many people have to be recognised and the point determined at which attention or treatment will bring benefit. Both in hypertension and in length of stay, there is variation with age, and raised values have different causes that it can be important to distinguish if action is to be effective. But the search for cause can be timeconsuming and ultimately frustrating if no remedial action is possible, or if the suggested regimen is not complied with. Finally, the ease with which blood-pressure and length of stay can be measured has meant that both are used as indicators of flow through a system, for which they are not entirely appropriate. AN INDICATOR OF FLOW
The two states of a hospital bed, occupied or empty, contribute to complementary indices of use-length of stay and turnover interval (the time during which a bed is empty between a discharge and an admission). The daily bed states over a period of time give totals that can be divided by the number of treated patients to arrive at mean values for length of stay and turnover interval. BarberI recommended that these be plotted (see accompanying figure) with length of stay as ordinate and turnover interval as abscissa. The bed-occupancy percentage and number of patients receiving treatment in the period of time can be read off the diagram, the single point replacing four numbers. A succession of points simplifies serial comparisons of a single unit or enables different units to be compared. The diagram can also help to interpret changes in practice. For instance, starting from point A (see figure), a clinical team might "improve" bed occupancy. This could happen in two ways, either by admitting the next patient sooner (AB) or keeping the last patient longer (AC). Either could represent better use of facilities, depending on circumstance. All this aids the interpretation of average data, but it does not help in determining the length of stay for specific diseases. CLINICAL POLICIES
Many consultants, finding themselves short of beds, have reviewed their bed policies. They have considered whether treatment or investigation can be carried out as an outpatient, whether a less severe treatment produces as good a result with a shorter stay (anal stretching for haemorrhoids), or, as Illich would ask, whether the treatment works at all. Often, however, the problem has been to determine the appropriate length of stay for established conditions. DAY CARE
The
commonest
approach
1. Barber, B. Personal Communication.
to
length
of stay has been
532
their services, and though the cost of treating the individual patient may fall, the number of patients cared for may increase so that the total cost rises. The main criteria for successful day-care practice have been established in the past twenty years, but putting them to good effect calls for much effort and organising ability. Day care requires partnership with the district nurse, general practitioner, and the social services, who must coordinate their efforts not only on the technical aspects but also in communicating information, supporting the home, and showing concern for the patient. As Kemp5 has shown this is not always achieved.6 "RIGHT STAY"
I urnuver liileíVi:i1
The Barber diagram (see text)
to
reduce it and try to demonstrate that there has been no deterioration in clinical outcome. For many years, this attitude ran contrary to the accepted importance of rest, but the work of Leithauser,2the advocacy of Asher,3 and the increasing knowledge of pulmonary embolism won the day for earlier ambulation. In particular, day-care units were introduced for the treatment of disorders with low priority for admission to a surgical ward, such as hernia and varicose veins; and the units came to be used by consultants from many specialties, including psychiatrists, oncologists, and haematologists. With 150 000 cases of dilatation and curettage, 130 000 terminations, 75 000 herniorrhaphies, and 40 000 operations for varicose veins in England and Wales annually, there is plenty of work for day-care units, but, as Ruckley et al. emphasised, this practice has far-reaching effects. Thus, in the outpatient department, more time must be spent in assessing the patient and explaining the system of care. In the day-care theatre, a more experienced surgeon and anarsthetist may be required so that brevity can be combined with accuracy. In the main theatre, the leavening of simple procedures is lost, an effect most noticeable in an all-day list. From the wards the younger and more active patient disappears, possibly leaving the tea trolley unattended, but giving the bed to an older person whose disease is more complicated and makes him more dependent. The ambulance service, the district nursing service, the general practitioner, and the central sterile supply department will have new calls for Leithauser, D.J. Early Ambulation and Related Procedures in Surgical Management. Springfield, Illinois, 1946. 3. Asher, R. A. J. Br. med. J. 1947, ii, 967. 4. Ruckley, C. V., Maclean, M., Ludgate, C. M., Espley, A. J. Lancet, 1973, ii, 1193.
Certain conditions have to be fulfilled if an arbitrary and fixed interval of stay is to be clinically appropriate. The surgical intervention or therapeutic insult has to be fairly consistent, each patient’s response to the trauma must be comparable, his future progress must be predictable by the time of discharge, and the complications that may arise after that time should be capable of being handled at home. A recent randomised controlled trial examined recovery from cholecystectomy and vagotomy, and compared a fixed interval of postoperative stay (ten days) with discharge when a number of criteria had been satisfied. A postoperative stay of five days was found to be the shortest and the most common length of stay after cholecystectomy for patients in the criteria group. But the more significant finding was the range of time in days that was appropriate to the various stages of care. Differences in rates of physiological recovery, independence from nursing care, and time needed to arrange departure for home were sufficiently great to suggest that tailoring the length of stay to the individual patient’s need was justified. A phrase "right stay surgery" was coined for that stay in hospital which was clinically safe, appropriate in the eyes of the patient, his family, and general practitioner, and yet no longer than was necessary for a safe clinical recovery. It is quite possible to think of circumstances in which this "right stay" will depend on these factors in differing proportion, as the nature of the disease, the type of hospital, and the conditions in the community vary. SOCIAL CIRCUMSTANCE
Until recently a patient completed his postoperative recovery in hospital, and it was presumed that in returning home to the social circumstances to which he was accustomed, any social inadequacy would not be exacerbated by the operation, nor the benefit of the operation prejudiced by the social inadequacy. As stay in hospital becomes shorter, the patient completes his surgical convalescence at home under the care of the general practitioner and district nurse. What can be achieved depends on the circumstances in the home and the help that family and friends can provide, thus emphasising the importance of the social history, which must be taken early enough for the social worker to be able to respond. CONCLUSION
Stay
in
hospital
can
be
prolonged by clinical error or
2.
5.
W. Value of the Day Bed Unit in General Hospital Practice. Report of the Scottish Home and Health Department, no. 32. H.M. Stationery Office, 1975. 6. Simpson, J. E. P. Br. J. Hosp. Med. December, 1976, p. 571.
Kemp, I.
533
complication, by the patient living alone in poor circumstances, by deficiencies in the geriatric services, the social services, or the convalescent home, or by a failure to make arrangements expeditiously. Nevertheless, the range in length of stay for particular conditions, as reported by Heasmanand others, results as much from force of habit or perverse necessity as from considered judgment. Hunter8 found patients who waited three days for herniorrhaphy (the housemen clerked them on Monday, the ward round was on Wednesday, and operation on Thursday). These arrangements were made inevitable by the timing of other clinical commitments, and several changes were needed if they were to be unscrambled. Efficiency demands that such an effort be made, but not without thought for the implications in other departments and for the staff. The key words in all these developments must be balance, control, and consideration, rather than merely speed. Otherwise patients will be left with exhausted staff.
a
second-rate service from
St Mary’s Hospital, London W2, and King’s Fund College, 2 Palace Court, London W2 4HS
7. Heasman, M. A. Lancet, 1964, i, 43. 8. Hunter, B. Administration of Hospital Wards.
J. E. P. SIMPSON Manchester, 1972.
Points of View THE PATIENT’S MORALE I write as a patient who believes that it is extremely difficult in the nature of things for any doctor to see things through the patient’s eyes. Even when a doctor becomes a patient himself, it is not the same thing at all, since he knows what is going on and what to expect. If it is accepted that the morale of the patient can be crucial in a serious illness, especially when diagnosis is in doubt and the patient is easily able to observe his own decline, then it may be worth recording some of the factors which affect his morale. A stay in hospital, even for those who have been in before, means much more than a temporary loss of freedom. As weeks go by, particularly if there is the fear and uncertainty associated with lack of diagnosis and therefore treatment, the patient becomes more and more concerned with the smallest details of his environment, and the most trivial things affect his morale to a marked degree. Speaking from personal experience (being in hospital with de Quervain’s thyroiditis), I would say that what demoralises the patient in the first place is the loss of personal identity. This will, of course, be less in a small hospital, and I was fortunate in never feeling that I was part of an assembly plant or even a large institution. I was given no number and my name was used throughout. None the less, patients inevitably have the feeling that they have not only lost freedom in the broad sense of the term, but that they have also been deprived of the right to take decisions. Whatever profession the patient pursues normally, he inevitably has many decisions of one kind or another, however minor, to take during every day. I believe that the loss of decision-making is probably the heaviest blow of all to most patients’ morale. I was fortunate to be in a sideward where I was, in fact, able to take some decisions which may seem laughably trivial now, but that at the time were to me, in my confined world, matters of the greatest importance. It happened to be in the heat-wave last summer, and I was able to decide for myself how much window I would have open by day and again by night; before setting the window for the
night, I consulted the thermometer. Thus I already had two decisions to make daily, and there was also the degree to which the door should be open, an apparently even more trivial matter but one which assumed very satisfactory importance, since it was left entirely for me to decide. After loss of the right to make decisions, the next blow to morale is loss of all responsibility, and the helpless feeling that you are no longer doing anything for yourself; you are like a lump of meat-things are being done to you. I was told that the normal time for washing was immediately after breakfast, but because of the extremely heavy sweat caused by my illness, this was, as it happened, the worst point in the day for me. I explained that the best time of day for me was around four o’clock in the afternoon, and the ward sister told me that she regarded me as a responsible person and that from then on it would be my responsibility to wash at the time in the afternoon which I found most appropriate; here was not only responsibility but even a small element of decision-making as well. Particularly nasty blows to morale can be dealt by being told, without any warning or explanation, "we are going to to you now". I give the highest praise to the particular hospital where I was fortunate to be, for always explaining everything and giving up to 24 hours’ notice before anything happened. It may seem ludicrous to people in the medical profession, but I am sure that for most patients it can be a real shock when a trolley of instruments or electrical apparatus is wheeled up to the bed without any warning as to what is to be done. This emphasises the helpless feeling once again, that one is no longer doing things but having things done to one. Only once in my own experience did anything like this happen. On a particularly bad morning, after four lots of blood had been taken for testing, a man arrived with a wheelchair and said "Mr Price, you are for the X-ray now". I have been X-rayed hundreds of times in my life and have no fear whatever of this, but the very low ebb I had reached at that stage was such that I burst into tears and said, "I am not going now". Looking back on this I find it unbelievable, of course. Greatly to the hospital’s credit, the attendant with the chair said, "Not to worry, we will come back this afternoon". This utterly trivial incident gave me tremendous encouragement, far more than I can explain in words, because it made me feel that I was being treated very much as a human being who could still take some decisions and who could still do things himself as well as have things done to him. When there were more important things, such as being taken by ambulance to another hospital twenty miles away for a scan on three occasions, I was given a day’s notice and always knew what to expect. Contributing to the loss of personal identity is, of course, the inevitable feeling of loss of personal possessions and property. This is recognised in most hospitals, and patients are provided with adequate bed-side lockers on which those last tiny vestiges of individual property can still be displayed. Anything which singles out one patient from another must help to break the deadly sense of identity loss. Because I am extremely tall, I was given a specially long bed on arrival, and I was as proud of this bed as a motorist would be of his new car; it sounds unbelievably childish now, but I pointed it out with the greatest pride to every visitor. I am not suggesting for a moment that large hospitals can be run without a high degree of uniformity and an inevitable loss of identity by the patient in his new environment. I do believe, however, that my own recovery from my illness, for which there was no treatment and the nature of which I did not even learn until I was already improving, was influenced without question in a most decisive manner by the understanding attitude taken by the medical and nursing staff, and by the fact that I never felt complete loss of identity, of decision-making, or even of responsibility. Is it too much to suggest that a great deal of attention be given to these things? I am sure that these apparently minor factors have a decisive effect on morale and on the will to recover. ...
greater than that in the A.A. group accords with the
con-
clusion that the heatwave resulted in some or all of this excess mortality. Deaths in Greater London, especially in those aged 65 and over, increased significantly during the heatwave 14 and it is expected that this trend will be reflected by a national increaseY Similarly, deaths reported to the Manchester Social Services Department suggested a threefold increase compared with previous years, however, full statistics are not yet available.16 This increase is of the same order as occurred among the elderly in the c.c./R hospital group. It is our impression that the reported excess mortality chiefly affected those patients who were seriously ill during the heatwave. Patients so affected had a wide range of diseases. The condition of many more patients deteriorated as a result of high air temperatures. Most responded to rest, rehydration, correction of electrolyte disturbances, and, in severely affected patients, to tepid sponging and aspirin therapy. It is disturbing that otherwise fit elderly subjects within the community receiving social services support (residents in part III and sheltered accommodation) may also have been adversely affected by the heat. This confirms the view that abnormalities6 of thermoregulation are more common in the elderly.36 We believe that elderly subjects dying during the heatwave developed a combination of the heat-exhaustion syndrome (electrolyte and water depletion) and heatstroke (failure to lower body temperature due to autonomic disturbances). Others in the U.S.A. believed that excessive mortality in this group was caused by heatstroke syndrome alone.711 An awareness of the adverse effects of heat in elderly subjects will lead to greater recognition of the early stages of heat exhaustion by attendants within the hospital and within the community. The simple provision of shading, light clothing, and increased ventilation will go far to mitigate the effects of heat. Monitoring body temperatures of ill inpatients, preferably between 1 P.M. and 4 P.M., during heatwaves will allow prompt institution of specific therapy such as aspirin administration, parenteral fluids, and tepid sponging. More research is needed into all aspects of thermoregulation in the elderly. We thank the Manchester Station of the their advice and assistance.
Meteorological
Office for
Requests for reprints should be addressed to M.L., Department of Geriatric Medicine, University Hospital of South Manchester, Nell Lane, Manchester M20 8LR. REFERENCES 1. Emslie-Smith, D. Lancet, 1958, ii, 492. 2. Royal College of Physicians of London. Report of the Committee on Accidental Hypothermia, London, 1966. 3. Macmillan, A. L., Corbett, J. L., Johnson, R. H., Smith, A. C., Spalding, J. M. K., Wollner, L. Lancet, 1967, ii, 165. 4. Fox, R. H., Woodward, P. M., Fry, A. J., Collins, J. C., MacDonald, I. C.
ibid. 1971, i, 424. Exton-Smith, A. N. Br. med. J. 1973, iv, 727. Hockaday, T. D. R., Cranston, W. I., Cooper, K. E., Mottram, R. F. Lancet, 1962, ii, 428. 7 Rossman, I. (editor) Clinical Geriatrics. p. 471. Philadelphia, 1971. 8. Levine,J A. Am. J. Med. 1969, 47, 251. 9 Knochel, J. P., Beisel, W. R., Handon, E. G., Gerad, E. S., Barry, S. K. ibid. 1961,30, 299. 10. Leithead, C. R. Soc. trop. Med. Hyg. 1967, 61, 739. 11. Shibolet, S., Coll, R., Gilat, T., Sohar, E. Q. JlMed. 1967, 36, 525. 12. Ellis, F. P. Environmental Res. 1972, 5, 1. 13. Leonard, J. C. Br. med. J. 1976, i, 1335. 14 Office of Population Censuses and Surveys. Population Trends, no. 5, Sept. 5 6
1976. 15 0 P.C S. press release. July 16. Manchester Social Services
23, 1976. Department. Unpublished.
Making Efficiency in
Do
the National Health Service
LENGTH OF STAY As a measurement in clinical practice, length of stay has similarities to blood-pressure. Everyone accepts certain high values as inappropriate, and when they are recognised in the individual patient immediate efforts are made to put them right. Lesser abnormalities affecting many people have to be recognised and the point determined at which attention or treatment will bring benefit. Both in hypertension and in length of stay, there is variation with age, and raised values have different causes that it can be important to distinguish if action is to be effective. But the search for cause can be timeconsuming and ultimately frustrating if no remedial action is possible, or if the suggested regimen is not complied with. Finally, the ease with which blood-pressure and length of stay can be measured has meant that both are used as indicators of flow through a system, for which they are not entirely appropriate. AN INDICATOR OF FLOW
The two states of a hospital bed, occupied or empty, contribute to complementary indices of use-length of stay and turnover interval (the time during which a bed is empty between a discharge and an admission). The daily bed states over a period of time give totals that can be divided by the number of treated patients to arrive at mean values for length of stay and turnover interval. BarberI recommended that these be plotted (see accompanying figure) with length of stay as ordinate and turnover interval as abscissa. The bed-occupancy percentage and number of patients receiving treatment in the period of time can be read off the diagram, the single point replacing four numbers. A succession of points simplifies serial comparisons of a single unit or enables different units to be compared. The diagram can also help to interpret changes in practice. For instance, starting from point A (see figure), a clinical team might "improve" bed occupancy. This could happen in two ways, either by admitting the next patient sooner (AB) or keeping the last patient longer (AC). Either could represent better use of facilities, depending on circumstance. All this aids the interpretation of average data, but it does not help in determining the length of stay for specific diseases. CLINICAL POLICIES
Many consultants, finding themselves short of beds, have reviewed their bed policies. They have considered whether treatment or investigation can be carried out as an outpatient, whether a less severe treatment produces as good a result with a shorter stay (anal stretching for haemorrhoids), or, as Illich would ask, whether the treatment works at all. Often, however, the problem has been to determine the appropriate length of stay for established conditions. DAY CARE
The
commonest
approach
1. Barber, B. Personal Communication.
to
length
of stay has been
532
their services, and though the cost of treating the individual patient may fall, the number of patients cared for may increase so that the total cost rises. The main criteria for successful day-care practice have been established in the past twenty years, but putting them to good effect calls for much effort and organising ability. Day care requires partnership with the district nurse, general practitioner, and the social services, who must coordinate their efforts not only on the technical aspects but also in communicating information, supporting the home, and showing concern for the patient. As Kemp5 has shown this is not always achieved.6 "RIGHT STAY"
I urnuver liileíVi:i1
The Barber diagram (see text)
to
reduce it and try to demonstrate that there has been no deterioration in clinical outcome. For many years, this attitude ran contrary to the accepted importance of rest, but the work of Leithauser,2the advocacy of Asher,3 and the increasing knowledge of pulmonary embolism won the day for earlier ambulation. In particular, day-care units were introduced for the treatment of disorders with low priority for admission to a surgical ward, such as hernia and varicose veins; and the units came to be used by consultants from many specialties, including psychiatrists, oncologists, and haematologists. With 150 000 cases of dilatation and curettage, 130 000 terminations, 75 000 herniorrhaphies, and 40 000 operations for varicose veins in England and Wales annually, there is plenty of work for day-care units, but, as Ruckley et al. emphasised, this practice has far-reaching effects. Thus, in the outpatient department, more time must be spent in assessing the patient and explaining the system of care. In the day-care theatre, a more experienced surgeon and anarsthetist may be required so that brevity can be combined with accuracy. In the main theatre, the leavening of simple procedures is lost, an effect most noticeable in an all-day list. From the wards the younger and more active patient disappears, possibly leaving the tea trolley unattended, but giving the bed to an older person whose disease is more complicated and makes him more dependent. The ambulance service, the district nursing service, the general practitioner, and the central sterile supply department will have new calls for Leithauser, D.J. Early Ambulation and Related Procedures in Surgical Management. Springfield, Illinois, 1946. 3. Asher, R. A. J. Br. med. J. 1947, ii, 967. 4. Ruckley, C. V., Maclean, M., Ludgate, C. M., Espley, A. J. Lancet, 1973, ii, 1193.
Certain conditions have to be fulfilled if an arbitrary and fixed interval of stay is to be clinically appropriate. The surgical intervention or therapeutic insult has to be fairly consistent, each patient’s response to the trauma must be comparable, his future progress must be predictable by the time of discharge, and the complications that may arise after that time should be capable of being handled at home. A recent randomised controlled trial examined recovery from cholecystectomy and vagotomy, and compared a fixed interval of postoperative stay (ten days) with discharge when a number of criteria had been satisfied. A postoperative stay of five days was found to be the shortest and the most common length of stay after cholecystectomy for patients in the criteria group. But the more significant finding was the range of time in days that was appropriate to the various stages of care. Differences in rates of physiological recovery, independence from nursing care, and time needed to arrange departure for home were sufficiently great to suggest that tailoring the length of stay to the individual patient’s need was justified. A phrase "right stay surgery" was coined for that stay in hospital which was clinically safe, appropriate in the eyes of the patient, his family, and general practitioner, and yet no longer than was necessary for a safe clinical recovery. It is quite possible to think of circumstances in which this "right stay" will depend on these factors in differing proportion, as the nature of the disease, the type of hospital, and the conditions in the community vary. SOCIAL CIRCUMSTANCE
Until recently a patient completed his postoperative recovery in hospital, and it was presumed that in returning home to the social circumstances to which he was accustomed, any social inadequacy would not be exacerbated by the operation, nor the benefit of the operation prejudiced by the social inadequacy. As stay in hospital becomes shorter, the patient completes his surgical convalescence at home under the care of the general practitioner and district nurse. What can be achieved depends on the circumstances in the home and the help that family and friends can provide, thus emphasising the importance of the social history, which must be taken early enough for the social worker to be able to respond. CONCLUSION
Stay
in
hospital
can
be
prolonged by clinical error or
2.
5.
W. Value of the Day Bed Unit in General Hospital Practice. Report of the Scottish Home and Health Department, no. 32. H.M. Stationery Office, 1975. 6. Simpson, J. E. P. Br. J. Hosp. Med. December, 1976, p. 571.
Kemp, I.
533
complication, by the patient living alone in poor circumstances, by deficiencies in the geriatric services, the social services, or the convalescent home, or by a failure to make arrangements expeditiously. Nevertheless, the range in length of stay for particular conditions, as reported by Heasmanand others, results as much from force of habit or perverse necessity as from considered judgment. Hunter8 found patients who waited three days for herniorrhaphy (the housemen clerked them on Monday, the ward round was on Wednesday, and operation on Thursday). These arrangements were made inevitable by the timing of other clinical commitments, and several changes were needed if they were to be unscrambled. Efficiency demands that such an effort be made, but not without thought for the implications in other departments and for the staff. The key words in all these developments must be balance, control, and consideration, rather than merely speed. Otherwise patients will be left with exhausted staff.
a
second-rate service from
St Mary’s Hospital, London W2, and King’s Fund College, 2 Palace Court, London W2 4HS
7. Heasman, M. A. Lancet, 1964, i, 43. 8. Hunter, B. Administration of Hospital Wards.
J. E. P. SIMPSON Manchester, 1972.
Points of View THE PATIENT’S MORALE I write as a patient who believes that it is extremely difficult in the nature of things for any doctor to see things through the patient’s eyes. Even when a doctor becomes a patient himself, it is not the same thing at all, since he knows what is going on and what to expect. If it is accepted that the morale of the patient can be crucial in a serious illness, especially when diagnosis is in doubt and the patient is easily able to observe his own decline, then it may be worth recording some of the factors which affect his morale. A stay in hospital, even for those who have been in before, means much more than a temporary loss of freedom. As weeks go by, particularly if there is the fear and uncertainty associated with lack of diagnosis and therefore treatment, the patient becomes more and more concerned with the smallest details of his environment, and the most trivial things affect his morale to a marked degree. Speaking from personal experience (being in hospital with de Quervain’s thyroiditis), I would say that what demoralises the patient in the first place is the loss of personal identity. This will, of course, be less in a small hospital, and I was fortunate in never feeling that I was part of an assembly plant or even a large institution. I was given no number and my name was used throughout. None the less, patients inevitably have the feeling that they have not only lost freedom in the broad sense of the term, but that they have also been deprived of the right to take decisions. Whatever profession the patient pursues normally, he inevitably has many decisions of one kind or another, however minor, to take during every day. I believe that the loss of decision-making is probably the heaviest blow of all to most patients’ morale. I was fortunate to be in a sideward where I was, in fact, able to take some decisions which may seem laughably trivial now, but that at the time were to me, in my confined world, matters of the greatest importance. It happened to be in the heat-wave last summer, and I was able to decide for myself how much window I would have open by day and again by night; before setting the window for the
night, I consulted the thermometer. Thus I already had two decisions to make daily, and there was also the degree to which the door should be open, an apparently even more trivial matter but one which assumed very satisfactory importance, since it was left entirely for me to decide. After loss of the right to make decisions, the next blow to morale is loss of all responsibility, and the helpless feeling that you are no longer doing anything for yourself; you are like a lump of meat-things are being done to you. I was told that the normal time for washing was immediately after breakfast, but because of the extremely heavy sweat caused by my illness, this was, as it happened, the worst point in the day for me. I explained that the best time of day for me was around four o’clock in the afternoon, and the ward sister told me that she regarded me as a responsible person and that from then on it would be my responsibility to wash at the time in the afternoon which I found most appropriate; here was not only responsibility but even a small element of decision-making as well. Particularly nasty blows to morale can be dealt by being told, without any warning or explanation, "we are going to to you now". I give the highest praise to the particular hospital where I was fortunate to be, for always explaining everything and giving up to 24 hours’ notice before anything happened. It may seem ludicrous to people in the medical profession, but I am sure that for most patients it can be a real shock when a trolley of instruments or electrical apparatus is wheeled up to the bed without any warning as to what is to be done. This emphasises the helpless feeling once again, that one is no longer doing things but having things done to one. Only once in my own experience did anything like this happen. On a particularly bad morning, after four lots of blood had been taken for testing, a man arrived with a wheelchair and said "Mr Price, you are for the X-ray now". I have been X-rayed hundreds of times in my life and have no fear whatever of this, but the very low ebb I had reached at that stage was such that I burst into tears and said, "I am not going now". Looking back on this I find it unbelievable, of course. Greatly to the hospital’s credit, the attendant with the chair said, "Not to worry, we will come back this afternoon". This utterly trivial incident gave me tremendous encouragement, far more than I can explain in words, because it made me feel that I was being treated very much as a human being who could still take some decisions and who could still do things himself as well as have things done to him. When there were more important things, such as being taken by ambulance to another hospital twenty miles away for a scan on three occasions, I was given a day’s notice and always knew what to expect. Contributing to the loss of personal identity is, of course, the inevitable feeling of loss of personal possessions and property. This is recognised in most hospitals, and patients are provided with adequate bed-side lockers on which those last tiny vestiges of individual property can still be displayed. Anything which singles out one patient from another must help to break the deadly sense of identity loss. Because I am extremely tall, I was given a specially long bed on arrival, and I was as proud of this bed as a motorist would be of his new car; it sounds unbelievably childish now, but I pointed it out with the greatest pride to every visitor. I am not suggesting for a moment that large hospitals can be run without a high degree of uniformity and an inevitable loss of identity by the patient in his new environment. I do believe, however, that my own recovery from my illness, for which there was no treatment and the nature of which I did not even learn until I was already improving, was influenced without question in a most decisive manner by the understanding attitude taken by the medical and nursing staff, and by the fact that I never felt complete loss of identity, of decision-making, or even of responsibility. Is it too much to suggest that a great deal of attention be given to these things? I am sure that these apparently minor factors have a decisive effect on morale and on the will to recover. ...
