Essay: Analyse and identify key points in the patient journey that are considered high risk for error

Operating rooms (OR) are among the most complex cultural and expeditiously changing environments in the medical world. This paper aims to analysis and identify key points in the patient journey that are considered high risk for error. Issues such as safety, mis-communication, teamwork and conflict directly impact on the individual patient journey. Nurses have a long standing tradition of ensuring continuity of patient care by creating a culture of safety and maintaining responsibility of the patient. Patients benefit substantially from collaboration of the surgical and anaesthetic teams to provide optimal care (Blomberg et al., 2014). Peri-operative nurses play a primary role in ensuring these risks are minimised (Blomberg et al., 2014). This starts at the beginning when the patient arrives in the theatre complex (Low et al., 2013, p.572). The patient discussed today will be assigned the pseudonym “Lois” to maintain privacy and avoid identification.
Lois presented to the emergency department in a tertiary, teaching public hospital with two days of acute upper right quadrant abdominal pain, nausea and vomiting and fever of 38.1°C. She had a past medical history of obesity, gastro-oesophageal reflux disease and no allergies. Lois had bloods taken, an intravenous cannula inserted, an ultrasound and was reviewed by the surgical registrar on call and admitted to the acute surgical unit. Lois was consented and booked on the emergency surgical list for a laparoscopic cholecystectomy +/- open and kept fasted from admission to the ward. The patient was allocated a category three and surgery was required within eight hours of being booked (Coccolini et al., 2015, p.197). Emergency surgery is frequently undertaken by trainee registrars without consultant supervision, increasing the potential for adverse patient outcomes (Crouch, 2014). However, this is a tertiary hospital with a large general surgery workload there is a dedicated emergency theatre session in standard operating hours with a consultant surgeon on site (Emergency Surgery Guidelines, 2009).
Laparoscopic cholecystectomies have become the gold standard treatment for the management of acute cholecystitis (Coccolini et al., 2015, p.196). Its advantages demonstrably outweigh the open technique and are associated with significantly shortened hospital stays, a faster recovery time, reduced pain and a decreased chance of major surgical complications (Taye et al., 2016). As individual patient factors affect surgery outcomes (Lowndes et al., 2016), Lois’ history has to be considered. Her age of forty-six years old, her gender and her obesity predict surgical difficulty and the strengthened risk for conversion to an open procedure. The ultrasound performed indicated gall bladder thickness >3mm, indicating inflammation, alongside the physical symptoms of a palpable gallbladder and severe abdominal pain statistically indicate a difficult procedure and an increased risk of conversion to open for Lois (Bilimoria, Chung and Soper, 2013).
The anaesthetic nurse (AN) assigned to the acute surgical list that day liaised with the team leader of the operating theatre complex and organised for Lois to be called to the holding bay as she was next on the emergency list per the general surgical team. Lois arrived in holding bay and was checked in by the holding bay using the pre-operative anaesthetic checklist. Per the National Safety and Quality Health Service Standards (2017, p.50) he holding bay nurse handed over to the AN and Lois was taken to the anaesthetic bay outside the operating theatre. The AN role is to be Lois’ advocate, to assess her airway, ascertain allergies, check the consent, skin integrity and ensure she is covered up and feels heard, respected and empowered during her surgical journey (Page et al., 2017, p.1739 ). Through reviewing and assessing Lois; the AN develops a nursing care plan specific to her and collaboratively works with the peri-operative team to ensure the best patient outcome based on recent evidence based practise (Hamlin et al., 2016).
During a surgical journey there a certain risks, actual or potential, that can be avoided through proper evaluation and communication between team members to ensure that any interventions required are carried out for the best overall outcome (National Safety and Quality Health Service Standards, 2017, p.50).
Lois’ continuing nausea, obesity, short neck and gastric-reflux increased chances of difficulty in ventilating and intubating. The AN collaborated with the anaesthetist and they formulated a plan to maximise airway accessibility during induction and rescued aspiration risk. It was decided that tru pillows would be used to ramp Lois up, exposing the airway through head and neck flexion and allowing the best view for laryngoscopy (Ortiz & Wiener-Kronish, 2016, p.92-95). This was to counteract the effect of the anaesthetic drugs in which muscle tone would be lost and Lois would be unable to protect her airway. Lois’ obesity meant she had excess soft tissue around her neck and this contributes to oropharyngeal obstruction that the anaesthetic team aimed to minimise (Ortiz & Wiener-Kronish, 2016, p.90). Lois was to be induced using a rapid sequence induction (RSI).
Once the theatre was appropriately set up for surgery, Lois was wheeled in. Her trolley was lined up with the operating table and she manoeuvred herself across on top of the tru pillows. Haemodynamic monitoring is a vital component of patient management which decreases mortality and morbidity during surgery. This follow standards set by ANZCA (2013b) and ACORN (2014) that a patient has available monitoring to them such as electrocardiograph, non-invasive intermittent blood pressure (BP), bispectral monitoring, O 2 & CO 2 analysis, temperature monitoring, alarms for oxygen supply failure and pulse oximetry. Lois was connected to the ECG, BP, SpO 2 and was pre-oxygenated by the anaesthetic registrar while the consultant ensured the drugs were ready.
The anaesthetic team were quite vocal and ensured they all understood Plan A of a straightforward RSI, Plan B if they faced difficultly intubating to use an assisting device called a Bougie and a Plan C of using a Proseal-Laryngeal Mask Airway. The RSI was deemed necessary by a variety of factors; Lois was at increased chance of aspiration due to her severe nausea, her weight, her history of gastro-oesophageal reflux disease, her difficult airway and her delayed gastric emptying from the pain. Lois pre-oxygenated satisfactorily and the anaesthetic consultant induced her with Fentanyl, Propofol and Suxamethonium; a short acting depolarising muscle relaxant that is indicated in rapid sequence inductions or emergency airway management (McCahon, 2012). Its onset of action is 30-60 seconds which minimises that time available in which the patient could aspirate. Propofol was the induction agent of choice as it also has a rapid onset of action (McCahon, 2012). Once the propofol was injected, the AN applied cricoid pressure while the registrar used bag mask ventilation with a PEEP of ten to oxygenate the patient. Cricoid pressure has been utilised to occlude the upper end of the oesophagus by compressing the cricoid cartilage against the bodies of the cervical vertebrae therefore preventing pulmonary aspiration of gastric contents (Hamlin et. al, 2016, p. 193-261). After 30 seconds the anaesthetist intubated Lois with a size 7 endotracheal tube with nil issues. Once the cuff was inflated, the anaesthetic team determined that the tube was correctly positioned via capnography, the rise and fall of the chest, fogging of the tube and via auscultation to ensure both lungs were being equally ventilated (Hamlin et. al, 2016, p. 193-261). Lois was put on the anaesthetic machine to control her breathing and once verbally confirmed, cricoid pressure was stopped as the airway was deemed protected.
All OR function with a peri-operative surgical checklist per ACORN standards. Several studies have evaluated the use of checklists and briefings to reduce adverse events in surgical care (Tang, Ranmuthugala and Cunningham, 2013, p.153). In particular, Haynes et.all (2009, pg. 494) reported that the use of a surgical checklist was associated with significant reductions in patient morbidly and mortality. This checklist established patient identity, consent for procedure, allergies, fasting status and other general factors that impact the overall safety of the patient such as dentition, implants, concerns, equipment and skin integrity. WHO started promoting the use of surgical safety checklists (SCC) in 2008 and recommends three occasions in which the operating room needs to stop and check and communicate with each other to best reduce pre-, intra- and post-operative complications. reference These three events are as follows; the sign in; pre anaesthesia, the team time out; post anaesthesia and pre surgery and and the sign out; post closure and before exiting theatre. These three moments ensure the surgical and anaesthetic teams communicate and statistically has shown a decrease in blood loss, infection, prolonged theatre time due to equipment failure and mortality by one-third (Braaf, Manias, Finch, Riley & Munro, 2013). Checklists contribute to an increased situational awareness among team members and methodical communication and workload.
In Lois’ case, there was no team time out before the initial incision was made. This minor yet significant error is problematic because whilst it was individually unimportant and didn’t affect our patient, it could affect the next patient if missed again. The team acknowledged this was missed due to high volume, rapid turnover cases but the error essentially demonstrated that minor problems and distractions are associated with increased operating time and a reduction in operative performance and increased near misses.
Any patient having a general anaesthetic is at risk of a positioning injury. This is avoided through an original assessment of the baseline skin condition and tissue perfusion and any limitations in movement the patient might have. The position for a laparoscopic cholecystectomy is for the left arm to be tucked in and the right arm out at a 90° angle (Rothrock and McEwen, 2018). The AN plays a vital role in positioning the patient; implementing protective measures to prevent skin/tissue injuring, applying safety devices such as seatbelt and continuously evaluating tissue perfusion and musculoskeletal status during the case. This consistent surveillance of the patient is to decrease any chance of nerve damage or injury.
Lois’ obesity increased her chance of peripheral nerve and pressure injuries whilst under anaesthesia (Ortiz & Wiener-Kronish, 2016). Once Lois was asleep, her left arm was secured with a pillow case and tucked in next to her abdomen with her thumb facing upwards to ensure protection of the median, radial and ulnar nerves. These nerves can be damaged from the restraints being too tight and from the patients body weight lowered onto the arm (Drake, Vogl & Mitchell 2015, citied in Hamlin 2016, p. 245). As the table is tilted right side up during a laparoscopic cholecystectomy to expose the gall bladder, there is substantial risk in an obese patient for this to occur. The excess fat in the abdomen falls onto the arm as the table tilts further for better surgical visualisation. As the anaesthetic team cannot get access to this arm as it is where the surgeons are standing and operating there is no way to assess this limb until surgery is complete. For Lois, her arm remained undamaged with no interruptions to circulation or perfusion during the procedure. Another concern of the anaesthetic team is the hyper extension of the right arm or it becoming unsecured and falling off the arm board and thus damaging the brachial plexus nerve (Hamlin 2016, p. 245). Lois’ arm was padded with a long gel and secured into place loosely with the palm facing up and diligently checked every 30 mins and everytime the table was angled. This ensured the right arm had its peripheral vasculature and nerves proceed from damage (Rothrock and McEwen, 2018)
Creation of the pneumoperitoneum is the first step during a laparoscopic cholecystectomy . Its the introduction of CO 2 into the peritoneal cavity which pushes the abdominal wall away from the organs so they are not damaged when the trocar is inserted. (Theodoropoulou et al., 2008). This allows for visualisation of the contents of the peritoneal cavity. There is a risk of bleeding, gastrointestinal tract perforation, minor and major vascular injury and intraperitoneal adhesions associated with abdominal access and inevitable creation of pneumoperitoneum. The risks are highly dependable on the technique used for laparoscopic surgery; classical closed technique (Verres needle) and the open classic technique (Hasson) (Taye et al., 2016). Comparative studies by Tinelli et al., (2013) have found that the open technique is safer as it is performed in stages. It involves making an incision and then dissecting the fascia to the peritoneal cavity and then visualising the introduction of the cannula. Whereas in comparison; the closed technique involves the blind insertion of the Veress needle into the peritoneal cavity. The concerns specifically for Lois is her obesity. In an average sized person there is short distance between the anterior abdominal wall and the retroperitoneal vascular structures; less then two centimetres (Vijayalakshmi & Raghunath, 2018). Due to Lois’ extra fat around her abdominal section, the blind technique poses extra risks as the surgeons used a bariatric trocar set (longer Veress needle) to create the pneumoperitoneum and her excess tissue challenges the judgment and surgical expertise when inserting the trocar as her anatomical landmarks have varied and its arduous to identify a safe insertion distance (Tinelli et al., 2013).
In Lois’ case, her laparoscopic cholecystectomy was an uneventful and smooth surgery. It was a short surgery time of 45 minutes. An integral aspect of patient safety in perioperative settings is the sign out which involves the surgical count and securing of specimens. performance of the surgical count is handled by the scrub nurses (Hamlin et. al, 2016, p. 269-303). The instruments, sponges, swabs and sutures used during surgery are at risk of being retained in patient’s body cavity (Edel., 2012, p. 232). The scrub team confirmed at the end of the procedure that the surgical count was correct and informed the surgeon per ACORN standards (2016f). The scrub team also ensured the correct management, identification, collection and transportation of the gall bladder. A final team check is conducted of all specimens and associated paperwork prior to the patient leaving the OR.
Lois was escorted to Recovery Stage I (PACU) with the anaesthetic and the scrub nurse on 6L of 02 via a Hudson mask after a successful extubation. Lois responded to verbal commands, took deep breaths and coughed appropriately, indicating she could support and clear her own airway and by obeying verbal commands she indicated that the anaesthesia had worn off appropriately to which she could be delivered to PACU. The PACU registered nurse (RN) receives handover from the anaesthetist regarding past medical history, the type of anaesthesia given and post-op instructions for pain relief and fluids. The scrub nurse completes an official handover by correctly identifying the patient with the RN(Australian and New Zealand College of Anaethetists [ANZCA], 2013), listing the procedure that occurred, allergies, dressings insitu, any drains/catheters and the insertion of local anaesthetic post op. The RN assess the patients airway, saturations, respiratory rate, heart rate and rhythm, surgical wounds and ascertains the status of pain/nausea and vomiting, patency of drains/IVs and sedation level (Brenner & Kautz, 2015). The RN uses clinical judgement and evidence based practise to intervene appropriately against any abnormalities until the patient is stable and meets the discharge criteria for the ward or Recover Stage II.
Guidelines at federal and state level are used to provide patient-centred, high-quality, effective and adaptable healthcare by demanding increased consultant-led emergency surgery management (Australian Commission on Safety and Quality in Health Care [ACSQHC/the Commission], 2012a). These benefits are observed clinically; resulting in decreased surgical time, minimised complications and rarity in conversions to open. This active partnership between health policies and surgeons improved patient outcomes, enhanced patient and surgical team satisfaction and increased trainee supervision in emergency surgery. Lois was lucky to be operated on in the middle of the day, with a consultant on-site and without being cancelled due to other surgeries taking high priority as is the case with most category three patients. Lois’ case was quite straightforward from admission to discharge to the ward, no adverse outcomes occurred and she made a full recovery.
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