12 March 1991 - Current
SAFE PATIENT CARE (NURSE TO PATIENT AND MIDWIFE TO PATIENT RATIOS) AMENDMENT BILL 2020
17 June 2020
|ASSEMBLY||Second reading||Tim Read|
Dr READ (Brunswick) (18:05): I too am speaking about the Safe Patient Care (Nurse to Patient and Midwife to Patient Ratios) Amendment Bill 2020. This bill amends the original 2015 bill setting minimum nurse and midwife staffing levels in public hospitals and has the support of the Victorian Greens. It hardly needs to be said that the care of hospitalised patients is dependent on the level of attention that they receive. Before coming to Parliament, I was, I am going to admit, a little bit dismissive of the quality of debate here—full of anecdotes and personal stories and no proper randomised trial evidence—and yet here I am with an anecdote just after the member for Mildura has quoted a randomised trial, so I know my place.
It makes sense to all of us, without a lot of thought really, that stressed and overworked staff cannot be expected to notice early deterioration. This was driven home to me as a very junior intern in a very large and busy Royal Melbourne Hospital one night when admitting a patient who had bumped her head and was a bit unsteady on her feet. We thought she needed just careful observation overnight but just might possibly have an intracranial bleed. The next morning I came in early and checked on her, and she was in a near coma. There were not a lot of staff on overnight, and they were run off their feet. The message was clear that overworked staff and insufficient staff can make the difference between life and death. I well remember the surgical registrar on the phone to the family saying, ‘No, don’t come in and see her. I need your permission on the phone to operate or she’ll be dead’. She survived.
After that very important lesson I have always been aware of the need for adequate staff. Nevertheless, it was interesting to hear the member for Mildura’s report on this randomised trial published in November. In fact it was an observational analysis of a randomised trial population, and it found a very strong, significant negative correlation between nursing hours per patient and the mortality rate in the hospital—very convincing evidence. Not only are overworked staff less likely to notice the deterioration or the early deterioration of patients, but importantly, they are less likely to learn and participate in the continuous improvement processes that are now essential in modern hospital care. You have only got to think about the last few months and how this coronavirus in China was maybe a bit like the flu, only a little bit worse, and how much we have had to learn and how not just researchers but health workers at every level have had to learn a lot in a short time. And people do not learn and do not turn up to lunchtime talks and so on if they are stressed and overworked.
I have noticed that many speakers from both sides of the house have heaped praise on nurses, midwives and other health workers for their heroism during this COVID-19 outbreak—an outbreak that, mercifully, appears to be sputtering ever so slowly to a close in Victoria. At times this praise has sounded fulsome, but I was listening to the member for South-West Coast earlier during the matter of public importance and I know she gets it, and I know in fact most of the MPs here really do understand it, because most of us have seen the death toll in health workers in Italy and around the world. The figures I could find were from 1 May, so no longer up to date, but it was reported that 40 nurses in Italy have died as a result of COVID-19; 8800 nurses in Italy have been infected, and the numbers will be higher now in June; and 168 doctors—only 24 of them retired, the rest in active patient care—have died in Italy during this outbreak. So it is a particularly pernicious virus, and I am guilty of teleology here, but it appears to target the health system. Only this week I think there was a healthcare worker infected in the Monash network. Nurses therefore are at great risk of serious illness and, even if they are not very sick, of needing time off for either proven or suspected infection.
Now, while this outbreak appears to be ever so slowly petering out, it is very possible that another outbreak in Australia could become established and defy our attempts to eradicate it. We need to think about: if that happens, what can we do to protect nurses and midwives and other healthcare workers? The first step obviously is to prevent infection. It is pleasing that the government has, after some faltering missteps early on, addressed early shortages of personal protective equipment, or PPE. Healthcare workers a couple of months ago were contacting me very concerned about the lack of transparency and indeed even the secrecy at the level of hospital middle management around the rates of use and availability of PPE stocks in individual hospitals. That seems to have improved now with the consolidation of statewide stocks and a more efficient distribution system.
Nevertheless, we need to pay close attention to what has become known as the burn rate of PPE, the rate at which it is being used up and chucked in the bin. There are the obvious cost effects and the fact that a large amount of this is actually winding up in waterways, believe it or not—I think that is an international problem rather than an Australian one—but most importantly there are the implications for availability. The faster we use it the less we have got available when we really need it. PPE is still being used at an extraordinary rate just in case the next patient who walks in actually has COVID-19. It makes sense that it be done, but of course most of those bits of PPE have never been anywhere near a virus.
It seems to me, and other health workers have contacted me about this, that we need to look into reusable PPE—stuff that can be washed and hung up and re-used rather than chucked in the bin. Now, this stuff exists. There are expensive rubber masks that look a bit like World War I gas masks but are way more expensive than that and have replaceable filters. These things are used in some hospitals around the world. They are highly effective and could be manufactured here or imported, and some hospitals have this year bought stocks of them for their intensivists and anaesthetists. Acquiring more of that stuff, ideally locally manufactured to get around problems with still-incomplete international supply chains, would appear to be a long-term solution. I say it is expensive, but it only seems expensive until you have used up a few more months of disposable stuff and spent as much money as you would have buying something re-usable. So I would urge the government to investigate and look at the feasibility of the manufacture of re-usable PPE, particularly respirators.
There have also been concerns about the quality of PPE. Healthcare workers have used PPE here that has had Mandarin script on it, and when those of them able to read Chinese read it, they saw it said, ‘Not suitable for medical use’. We have to question: if we have got adequate PPE in Victoria and if our procedures are adequate, why are we still seeing—even this week—healthcare workers infected? You could have argued maybe six weeks ago that they caught it at the shops or on public transport, but you cannot say that now. Just about all the coronavirus now that a healthcare worker is going to bump into will be at work.
GPs are also catching COVID-19. Their supply chain is different, and the federal government is responsible for that as well as the general practices having to buy it, so what happens in one general practice and the next can be very different. There are still GPs working from home, there are still GPs refusing to see anybody with a cough or a cold and there are other GPs who are doing all of that and just using lots of PPE.
Finally, I do not know if other MPs here have received them, but I have received letters signed by thousands of healthcare workers urging governments, state and federal, to commit to a target of zero healthcare worker deaths from COVID-19. I understand Tasmania has agreed to commit to this, but I do not think any other jurisdiction has yet.
Now, such a promise is in a sense impossible to keep because we have had healthcare workers infected this week, and once they are infected we are still not able to guarantee that they will not die, although I will note some very promising research on dexamethasone seems to suggest that medical care is finally improving. However, the idea of committing to a target of zero healthcare worker deaths from COVID-19 as an aspiration would essentially focus the mind of governments on genuinely protecting staff and on continuing to refine and improve the quality of both the protective equipment and the necessary processes. It is all very well to have N95 respirators, but you have to be fit tested—you have to put this thing on and get sprayed with something that smells like banana, and if you can smell banana, you are not wearing it properly. Finally, we need to continue publishing healthcare worker infections on the Department of Health and Human Services website. I am told that that has not been updated for some time, when clearly these infections are continuing. So if we were to set this as a statewide or national objective, it is something that we could report on and at the very least aspire to.
Nevertheless, it is probably impossible to prevent every healthcare worker from becoming infected, and we could do more to look after those that are infected. They should not have to, for example, jump through legal hoops to prove that they were infected at work. Just as we recently legislated to give firefighters presumptive rights to workers compensation and medical care for cancers associated with firefighting work, so too we could give presumptive rights to healthcare workers—whatever system they are in, public, private or otherwise—to necessary workers compensation, leave for casuals, whatever they need, without their having to prove that they were infected at work. If we have another large outbreak, it will be impossible to prove that they were infected at work, so why make them do it? Why not say at the very least, ‘If we can’t protect you from being infected, we will look after you regardless’. That is why we first read a workers compensation COVID-19 bill—or, rather, Dr Ratnam in the other place first read this bill—during the emergency sitting on 23 April, to give those rights to healthcare workers.
So I think steps like this need to be taken and should still be taken even though the current outbreak seems to be coming to an end, because we do not know when we will be dealing with the next one. That said, I commend the bill to the house.