by Lynn McDonald

1
Florence Nightingale andCrimean War Statistics
Lessons for Public Administration,Hospital
Safety and Nursing

• by Lynn McDonald
• for Gresham College
• October 30, 2014

2
Sources

• Lynn McDonald, ed.,Collected Works of Florence
  Nightingale (2001-12, 16 vols), of which
• 2 volumes on civil nursing, 1 on health care
  2 on military nursing, 1 on hospital
  reform, 1 on society and politics (statistics)
• former Canadian MP, author, Non-smokers Health
  Act, 1988

3
The Collected Works Of Florence Nightingale, 16
vols. 2001-12
4
Florence Nightingale (1820-1910)

• Fame from the Crimean War 1854-56
• Major founder of the modern profession of nursing
• Social scientist, first woman Fellow of the Royal
  Statistical Society pioneer of evidence-based
  health care
• Pioneer environmental health theorist (from the
  lessons of the Crimean War)

5
The glorified view of the Crimean War, Jerry
Barretts portraits
6
The Lady with the Lamp, the enduring legacy,
which can be misleading
Stained glass window in a chapel in Ontario
7
Hospital conditions in her day

• Death rates per admissions, at London teaching
  hospitals were around 10, when her nursing
  school opened in 1860
• In Crimean War hospitals at 40 in the worst
  months of the war (early 1855)
• British Army death rate in Crimean War 22
• U.S. Army death rate in Vietnam 2.3

8
Nightingales role

• Much of Nightingales time spent on cleaning up
  the hospitals (faeces on the floor) getting
  supplies in (food, bedding, clothing)
• Laundries established (laundresses quit from the
  smell)
• But the significant change not until March 1855,
  with the Sanitary Commission

9
Learning the lessons

• Nightingale saw the terrible conditions, and saw
  the changes made when the (civilian) experts were
  sent by government to the war hospitals the
  Sanitary Commission (headed by Dr John
  Sutherland, with Robert Rawlinson, C.E.) and the
  Supply Commission, which improved nutrition,
  clothing and shelter

10
Sewers and drains, vermin

• Massive clean-up, with nuisance inspectors from
  Liverpool, the city that pioneered public health
  measures
• Removed dead horses from the water supply,
  improved ventilation, removed tons of filth
  (faeces) from the sewers and drains

11
Comparing the British and French

• The British Army made changes
• French Army did not
• The results in the statisticsoverwhelming
  success for the British

12
Comparison of French and British Mortality in the
2 War Winters

• 1st winter dead total effectives percent
• French 10,934 89,885 12
• British 10,989 47,749 23
• 2nd winter
• French 21,191 106,634 20
• British 606 27,384 2.2
• Source Jean Charles Chenu, De la mortalité dans
  larmée et des moyens déconomiser la vie humaine
  (Paris Hachette 1870) 131

13
Get chart in here
Yet no fighting in the second winter!
14
Alternative Different interpretations

• Nightingale and her team learned and applied the
  lessons of the war in radically reformed public
  administration, improved hospital design and the
  creation of a new profession, nursing
• My view--based on primary sources
• Other views still popular, both positive and
  negative

15
False claims for patient care

• Within several months of her arrival, she
  implemented hygiene practices--use of clean
  water, clean sheets and hand washing--that
  decreased the facilitys mortality rate to
  approximately that of London hospitals at that
  time. Gawande, Notes of a Surgeon On Washing
  Hands, New England Journal of Medicine 350
  (2004)

16
Some exaggerated claims for FN

• She kept extensive and accurate records of
  military hospital conditions and mortality and
  differentiated deaths related to hospital
  conditions (Munro, The Lady With the Lamp
  Illuminates Critical Care Today, American
  Journal of Critical Care 19,4 (July 2010).
• Nor did she invent triage

17
Negative views

• Hugh Smalls claim that the death rates highest
  at her hospital, and she to blame, that she was
  criminally negligent
• With not one table or figure to document this
  yet this view taken up by nurses, many
  historians, the BBC, etc.--rough estimates,
  general and regimental hospitals compared

18
Hospital deathswhich the worst?

• Mortality high everywhere, but the highest, when
  disaggregated data available, were at Koulali,
  nursed by the Irish Sisters of Mercy
• And this known since the war, in the official
  statistics collected by the War Office (which
  Small did not use)

19
Note 2 last columns, Feb 1855,disaggregated
figures
20
Why the highest at Koulali?

• Koulali had the worst sanitary conditions, noted
  by Dr Sutherland in the report of the Sanitary
  Commission
• Major clean up helped, but Koulali given back to
  the Turks

21
Learning the lessons

• Get the science right
• Get the best experts
• Get hard data
• Review rigorously
• The decline in death rates NOT from nursing
  careit required structural changessewers and
  drains

22
Lessons from Quetelet

• Different treatments have but a small
  influence on the death rate
• Administration saves more hospital patients than
  the best medical science (comments on Quetelets
  Physique sociale)
• Sidney Herbert her collaborator on improving
  public administration

23
Army Sanitary Administration its Reform under
the Late Lord Herbert
Row 1 Deaths in the English male pop. Row 2
Army deaths pre-Herbert Row 3 Army deaths after
his (their) reforms
24
Knowledge for application

• To compare results when neglect of the laws of
  nature and what may expect from their
  observance
• Nature is the same everywhere, and never permits
  her laws to be disregarded with impunity (A
  Contribution to the Sanitary History of the
  British Army)

25
Research on surgical outcomes

• The law of life after operations has not yet
  been ascertained. And no hospital statistics have
  yet been kept so as to ascertain it.
  (Nightingale letter 1861)
• Death rates post-surgery then around 50
  (pre-Lister and anti-septic surgery)
• Nightingale published on safety from 1858 papers
  to her full Notes on Hospitals, 1863

26
Hospital defects

• Four great defects of hospitals (from 1858)
• large numbers under one roof
• deficiency of space
• deficiency of ventilation
• deficiency of light
• Later editions of Notes on Nursing expanded to
  16 causes

27
Hospital-acquired infections

• Every nurse ought to be careful to wash her
  hands very frequently during the day. If her
  face, too, so much the better. Florence
  Nightingale, Personal Cleanliness, Notes on
  Nursing, 1860.
• Proper hand hygiene is the primary method for
  reducing infections, A. Gawande, in Notes of a
  Surgeon On Washing Hands, New England Journal of
  Medicine, 2004.

28
Using charts

• Her most brilliant charts combine cross-sectional
  data (normal death rates and excessive death
  rates)
• With longitudinal (declining death rates over
  time as reforms brought in)
• Still a model to use!

29
1854- March 55
April 1855 to end of war
Nightingale and Farrs classic polar area
charts note break between the 2 charts on the
arrival of the Sanitary Commission
30
War hospital death rates and London
peacetime hospital death rates--
centre circle
X start here Oct 1854
Y
Y sanitary improvements begin, March 18, 1855
31
Comparisons

• No other army learned the lessons of Crimea as
  the British
• French Army its next war, Italian Wars of
  Independence, 1859
• At Solferino, the dead and dying left on the
  battlefield for days (Henri Dunant was there and
  went on to found the Red Cross)

32
American Civil War

• Nightingale gave advice to the Northern Army
  (Harriet Martineau also acted for her)
• Her Notes on Hospitals used by both armies
• Nightingale concluded that, if the Americans (the
  North) had used her advice properly, their
  hospital death rates could have been 3, instead
  of 10 (Wars and the War Office, vol 15679)

33
Franco-Prussian War, 1870-71

• French Army hospital death rates in the
  Franco-Prussian War were 12, although France
  declared war.
• Better than Prussian Army hospital death rates
  (they won the war) at 20.

34
British Army applied the lessons

• The British government acted on the comprehensive
  recommendations of the official royal commission
  (FN briefed witnesses as well as giving her own
  evidence)
• Sidney Herbert chaired the royal commission, then
  the 4 sub-commissions created to implement key
  recommendations

35
Public administration

• Barrack and Hospital Improvement Commission,
  later called the Army Sanitary Commission (John
  Sutherland)
• Army Medical School
• Army Statistics Department
• Army Cooking School

36
British Army death rates fell

• In China, reforms brought the army death rate
  down to 3 per year (like Crimea in the second
  winter, 2.2).
• This in a hostile country, on the opposite
  side of the world, notorious for its epidemic
  diseases (15347)

37
British Army peacetime hospitals

• Netley Hospital and Herbert Hospital both
  overbuiltbeds provided for 10 of troops
• With the reforms, beds needed for only 5-6.
• It is not our fault if the number of sick has
  fallen so much that they cant fill their
  hospitals (Nightingale letter 15408)

38
Unsafe hospitals

• I know no class of murderers who have killed so
  many people as hospital architects. At this
  moment (1877) there are many diseases less fatal
  in their most wretched homes than in hospitals
  i.e., hospitals secure a higher mortality.
• FM advised on design St Thomas London (civil),
  Herbert Hospital, Woolwich (army)

39
Making hospitals safer

• Solution in Nightingales day the pavilion
  model, in effect each pavilion (28-30 beds)
  became a hospital on its own
• In effect reducing the scope for cross-infection

40
Plan for general military hospital, Malta
Pavilion style With gardens between pavilions
(each is a ward)
41
Pavilion style plan for 120-bed
regimental hospital
From Nightingale, Notes on Hospitals
42
Hospitals around the world

• (previous) Edinburgh Royal Infirmary
• Royal Victoria Hospital, Montreal
• Johns Hopkins University Hospital, Baltimore
• City Hospital, Berlin (Friedrichshain)
• Hospital experts made the pilgrimage to London,
  when before Nightingale sent them to Paris

43
Hospitalsstatistics key

• Hospital statistics key to saving lives
• they enable tracking of epidemics,
• judging success or failure of hospitals
• (mortality rates, duration of stay)
• There are laws which regulate disease. With
  fixed data...the laws which regulate diseased
  action would become better known.

44
Statistics needed

• Yet workhouse and hospital statistics were an
  unworked mine
• While both types of institution were created
  for the relief of human distress, they did not
  know whether they relieve it or not (1858, at
  the National Association for the Promotion of
  Social Science)

45
From the war to Notes on Nursing

• Chapters in Notes on Nursing on ventilation,
  cleanliness, light, nutrition, patient comfort
• From the causes of high death rates at the
  unsanitary Barrack Hospital, Scutari
  environmental causes overcrowding, lack of
  ventilation, faulty toilets, overflowing sewers,
  lousy food (scurvy frequent), polluted water,
  dirty bedding, vermin and faeces in clothes

46
Environmental health

• Nightingales theory of health and nursing called
  environmental
• From the lessons she learned in the Crimean War
• Basic external factors MUST be dealt with first
  clean air, water, floors, bedding, etc.

47
To achieve good results

• May need political change, legislation, more
  money, new building, different hospital site,
  better training, different personnel and mode of
  appointment, improved reporting prodcedures
• Must monitor, check results (causal links are
  complicated)

48
Nightingales methods

• Still needed?
• Hospital-acquired infections (AKA
  healthcare-associated infections) in U.K.
  estimates of 6 of hospital patients
• U.S. estimates 1,200,000 patients, of whom some
  100,000 die

49
Todays challenges

• Antibiotic resistant pathogens pose new threats
  which may require revisiting old solutions
  (pre-antibiotics) MRSA, Ebola
• Issues of priorities for spending and centrality
  of patient care the same now as ever

50
Causes of death--global (WHO)

• 6,000,000 cigarette smoking (increasing)
• 2,200,000 alcohol-attributable
• 2,000,000 indoor air pollution
• 1,700,000 diarrheal
• 1,700,000 HIV/AIDS
• 1,300,000 outdoor air pollution
• 1,200,000 road injuries
• 660,000 malaria (decreasing)
• 300,000 maternal (decreasing)

51
Relevance to health care today

• Nightingales research methods and examples
  should be taught at the graduate level, in
  nursing and public health
• Also her policy work, briefs on legislative
  changes needed, new programs
• Useful for nursing leaders in advocacy

52
The Nightingale method

• Get the best information available
• Use government reports and statistics
• Read and interview experts
• If the available information is inadequate
  collect your own
• Draw up a questionnaire
• Consult relevant practitioners

53
The Nightingale method

• Test questions (pre-test) before using
• When writing up, consult experts (informal peer
  review). practitioners who will actually use the
  results
• Use charts for major points use stories to flesh
  out the data

54
Then on to application

• Reports are not self-executive
• A strategy for implementation is required
• Media campaign
• Political support (all-party desirable), leading
  academics, NGOs
• Nightingales great legacy both the science AND
  the application

55
A stainedglass window in Chautauqua, New York
This volume reports her pioneering study of
maternal mortality post- childbirth
56
Nightingale statue at The Glasgow Royal Infirmary
(before the Collected Works)
57
(No Transcript)
58
Nightingale statue re-located to the Main Lobby
of the Glasgow Royal Infirmary, with a relief of
Joseph Lister, who pioneered anti-septic surgery
at Glasgow
59
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