57 In relation to various clinical areas and the issue of acuity levels, the HAC submitted as follows:
Intensive Care Units: ICU is now, and has always been, an area of nursing requiring intense nursing effort under high pressure. The general rule is that patients in ICU are nursed on a 1 to 1 basis, which has been the case since well before July 1996.
APACHE scores were relied upon to show changes in acuity in ICU. APACHE, a measure of the patient's likelihood of surviving, usually conducted in the first 24 hours, is not intended or designed to be a measure of acuity nor a measure of the amount of nursing time required, and will not measure any changes in acuity over time. APACHE scores are not entirely objective, with variation of about 15% between different scorers, which means that small changes must be treated with caution. Further, APACHE scores are volatile from month to month. To the extent that there is an increase in acuity in ICU such that more staff are required, then more staff can be rostered to meet that need such that the patient-staff ratio goes above 1:1. Accordingly, as with other areas of nursing, one must take into account staffing levels when considering evidence about changing patient mix and acuity.
An increase in acuity in a particular area (e.g., Westmead and St George) does not necessarily point to any system-wide change in work value (being essentially a change in location) or even an increase in the work value of the nurses working in that particular ICU (given the increase in staff).
Surgical wards: There has been a reduction in stay as a result of the growth of minimally invasive surgery and new anaesthetics. These changes mean patients mobilise more quickly and are more quickly independent for their daily living needs. Patients have lesser wounds and recover more quickly. The increase in day only surgery means less patients staying overnight. The Association's submissions regarding workload on surgical wards ignore the reduction in the work that obviously flows from such changes. As to the Association's submission that there are now no longer the 'light' patients, as noted above this must be considered in light of the decisions of Wells CC in 1986. Even to the extent that there has been a reduction in 'lighter' patients, that was still a reduction in work that otherwise had to be done. The net result of the changes on nurse workload is not to be derived from examining changes in acuity alone.
Mental health: HAC accepts there has been a trend over a number of years towards increased identification of mental disorder, increased acute admissions and increased reports of drug and alcohol co-morbidities. In other words, mental health is an exception to the general position that people are not generally sicker than they were before. These are changes, however, that commenced before 1996.
Such changes do not necessarily translate to increased workload for individual nurses. One needs to understand the staffing levels and availability of other services before one can draw a conclusion that increased acuity necessarily translates to increased workload for individual nurses.
Much of Ms Hoot's evidence as to the pressures that arise from reduced beds, such as the statement that patients now remain inpatients only during the most acute phase of their illness, must be seen as a change that had overwhelming occurred prior to 1996.
Midwifery: The earlier discharge of obstetric patients into the community is said to mean that the nurses in hospital only deal with patients in their more acute stage (i.e., they no longer get the relief of caring for the 'light' patients at days 4 and 5 after birth), and also increase the workload of the community nurses (because those same patients become 'heavy' patients for community nurses). In truth changing the location of the patient's care does not increase the overall acuity of the patients, and the workload associated with their care.
The Association's witness, Dr Caroline Homer, Clinical Midwifery Consultant Grade 3, Division of Women and Children's Health, St George Hospital, Kogarah, acknowledged that early discharge from major hospitals was a general feature of the system by the mid-1990s. Accordingly, while there may have been an increasing trend, the Commission would be careful to take into account that much of this change had occurred prior to July 1996.
The increased rate of intervention demonstrated by the Association's evidence was affected by the fact that the figures used were for all births in NSW, not just births in public hospitals (where rates of intervention are lower). For example, the number of epidurals in the NSW Public Hospital system between 1995 and 2001 increased by only a small amount: from 13,727 to 14,229.
A significant offsetting factor against any increase in acuity is that, in the period 1995 to 2001 the total number of confinements in the NSW Public Hospital system decreased from 71,741 to 63,271, a decrease of 11.8 per cent.
Emergency departments : The change in policy that occurred in 1997/98 to have mental health patients presenting at hospital admitted via emergency departments instead of directly to mental health units meant that those attending hospital with co-morbidities could have those properly identified in the emergency department and any other medical conditions treated. Further, the emergency departments are better equipped to deal with dangerous patients. While the policy increases the number of patients presenting at the emergency department, adding to workload there, it assists those working in the mental health units.
Non-metropolitan hospitals: The limited evidence relating to non-metropolitan hospitals (mainly Tamworth) does not suggest that change had occurred at the same rates as elsewhere.
The shortage of nurses, relied upon by the Association as part of its work value case, was not evident in some regional areas, including coastal towns and the Hunter, the Northern Rivers Area Health Service, Tamworth and Armidale hospitals and the Mid North Coast, New England, Macquarie Area Health Services.
Community nurses: There is a trend over the last 15 years or more to send home patients at an earlier point in their recovery, at least following some types of surgery, to be cared for by community nurses. As a result community nurses have been increasingly responsible for more acute patients. This is a trend that was identified and taken into account by Wells SCC in 1986. Post acute care teams/hospital in the home care existed well prior to 1996. Earlier discharge of patients with " higher dependency " in liaison with " early discharge teams or community based teams " was a recognised part of the system in 1996, and were included as part of the work value change of Nursing Unit Managers. The total volume of such services has been relatively stable in recent years.
An increase in acuity in community nursing does not, in itself, lead to an increase in work value. Other considerations must also be taken into account. The first of those is staffing. Post-acute teams are newly staffed teams of community nurses, set up with nurses who have acute care training. Such teams have nurses with special training and skills. In the same way as nurses in the ICU have special skills for that type of work, so are there nurses in acute care teams who have special skills. The Association submitted that the post-acute care teams have "additional specialised training" and hence have higher work value. The first thing to note is that the nurses who make up such teams have acute care skills of the same type as held by nurses in acute facilities. They might be better qualified to deal with highly acute patients when compared to other community nurses, they are not more highly skilled in that regard than the nurses who did that work previously in a hospital setting. Changing the location of their work cannot lead to an increase in overall work value. The Applicant never addresses the logic of the submission that it cannot call these patients 'light' patients when they remained in hospital recuperating, and yet call them 'heavy' patients when they are cared for in the community.
The changes to community nursing have not led to an overall increase in the acuity of the patients being treated nor new nursing treatments, just a change in the location. Indeed, the introduction of minimally invasive surgery and other medical advances have reduced the overall acuity of patients when viewed in and out of hospital.
It is also relevant that in the community nursing sector as well there have been changes that positively impact on nursing workload. Dr Diana Horvath, Chief Executive Officer, Central Sydney Area Health Service and Ms Lynette Nancarrow, Director of Nursing and Manager of Clinical Operations, Griffith Base Hospital, gave evidence as to an improvement in dressings available for patients in their homes, which has reduced the work that was previously required for community nurses to scrub up, glove and do detailed dressing on a repetitive basis.
The Association seeks in these proceedings a special allowance for community nurses, due to the environment in which they work. Yet the Association also relies on the environment of the work to justify a work value increase for community nurses. The Commission would be mindful of the need not to double count such factors.
Outpatients : The Association led evidence to the effect that the increasing trend for some procedures to now be done as outpatient services (eg chemotherapy) has meant that 'lighter' patients have been removed from the hospitals, contributing to the increase in acuity.
While the trend to increase the number of procedures that can be done as outpatient services has reduced the need for some procedures to be done in the wards, and so removed a level of work from those wards (now categorised by the Association as 'lighter' work), it cannot be said that has had the effect of increasing the overall acuity of the public hospital patient. These outpatients are still part of the public hospital system, and so when considering overall acuity, are still to be considered. The change to outpatients, where they will still need nursing, is a change of location.
In fact, the improvements in medical procedures that allow these procedures to now be done on an outpatient basis has meant that the amount of total nursing work required for such patients has reduced.
Diagnostic Related Groups (DRGs) : The Association submitted DRG statistics were not a useful measure of acuity because of certain limitations. While the DRG process is not without error, it has a high degree of accuracy. As a general statement, if there were an increase in the acuity of patients one would expect that there would be an increase in the resources (including nursing resources) required to care for those patients. That should in turn be reflected in an increase in the case weight average. Yet the average case weight for acute patients in NSW public hospitals has increased only marginally since 1995/96, at an annual rate of only 0.8 per cent, and that is before taking into account changes in counting that have occurred since 1995/96 which would have had the effect of inflating the rate of change.
While the DRG process is not intended to be a measure of acuity, it can be used to assess changes in the overall cost of episodes of patient care. It reveals no substantial change, which, at the very least, is not consistent with the suggestion of a substantial increase in patient acuity. It would be wrong for the Commission to proceed on the basis that the picture to be drawn from the DRG data is to be ignored.
Consideration regarding acuity