Peri-operative Care Case Studyof Olivia Randell

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Peri-operative Care Case Studyof Olivia Randell

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Question:
Review the care of a patient who is underwent major surgery from any of the surgical specialties covered this semester. Analyse the key patient safety and communication and teamwork issues, actual or potential, that arose during the patient’s surgical journey.

Answer:

The purpose of this paper is to review the care taken of a 38-year-old female patient who underwent a laparoscopic cholecystectomy. The discussion will focus on the brief description of the patient’s medical history, journey of the preoperative, intra-operative and post operative surgical procedures as well as the methods used by the healthcare providers to address patient safety, communication between the service care providers and efficacy of the teamwork among the system (Halverson et al. 2011 pp.305-310). Peri-operative care is a critical procedure that requires skilled professionals who can perform effective clinical assessment, surgical requirements and strict monitoring after the operation until the patient fully recovers (Krajewski et al. 2014pp.24-36). The whole process starts with preliminary assessment to determine the problem with the patient and devise a plan of action before commencing the surgical procedure (Nygren et al. 2012pp.801-816). During this time, a team is formed which consists of a surgeon, an anaesthetic nurse, an anaesthetist, a circulating and scrub nurses. It is the duty of the registered nurses to look after the patient and monitor for any signs of distress. The paper will reflect on the mistakes of the procedure and support with evidence based research to understand the implications of clinical mal practice.
The patient is a 38-year-old woman named Olivia Randell, who had been suffering for the previous six months with pain and discomfort on her right hand side of hypochondrium. She came in with bitter taste in her mouth, nauseous, releasing gas from her upper gut, burning sensation in heart and alternative diarrhoea and constipation like conditions. The physician diagnosed her with acalculous cholecystitis on analysis of ultrasound report of gallbladder scan (Huffman and Schenker 2010pp.15-22.). The report showed that the patient’s gall bladder lining has thickened to form 6mm sludge like structure obstructing functionality. The patient had been referred to a surgeon who suggested laprascopic cholecystectomy (Tsimoyiannis et al. 2010pp.1842-1848). The patient underwent a laparoscopic sleeve gastrectomy prior to this surgery to lose weight by restricting the stomach food intake (Eid et al. 2012pp.262-265). This procedure lowered her basal metabolic rate (BMI) from 40 to present day 30. Frequent hydration was the given advice to the patient after her weight loss procedure. The previous procedure of the patient subjected her to post operative vomiting and nausea (PONV) which was not properly addressed in the previous healthcare setting (Apfel et al. 2012 pp. 742-753). She was worried about the repetition of the same incident after the current procedure as well and was anxious about it, as she did not have prior acquaintance with the surgical crew, which she mentioned to the anesthetist (Jlala et al. 2010 pp.369-374).
The first pre-operative mistake observed in the following situation, is that the anesthetic nurse who noticed that the consent form was completed by the ward nurse but the signature of the patient was missing. The anesthetist questioned the ward nurse to whom she replied that she was not the assigned nurse for the patient, only helped her move into the operation theatre (Jeyaseelan et al. 2010 pp.407-408). The anesthetic nurse was quick to make sure that the patient was completely aware of the procedure about to performed on her, to which the patient responded positively after which the patient was escorted to the anesthesia ward.

The traditional intraoperative surgical crew consists of an experienced surgeon, an anesthetist, circulating nurse and scrub nurses. The surgeon was experienced with laprascopic cholecystotectomy for 25 years. The anesthetist was a registered nurse whom the surgeon was training under the supervision of consultant who was then working in another operation theatre. The surgeon and the anesthetist did not have any prior professional acquaintance or familiarity. The usual scrub nurse assigned to the surgeon was on leave due to illness that day and replacement was an experienced nurse from agency, but had not previously worked for the current hospital. The circulating nurses was professionally acquainted with the surgeon and his working procedure abut was then supervising a registered nurses who was in her preliminary weeks of practice in the operation theatre. The operation list arrived late due to unavailability of instrument supply while another operation was taking place.
Anesthesia was performed using a combination of 1.5 mg/kg Propofol Intra Vitreal Injection (IVI) of bolus, using 1.5 mcg/kg fentanyl, 0.03 mg/kg midazolam, and 0.01 mg/kg vecuronium. The oxygen maintenance was provided with a ProSeal laryngeal mask airway (LMA) (Seet et al. 2010 pp.602-607). Anaesthesia was kept with sevoflurane and 50% N20/O2 ventilation, and a blend of Propofol (75 mcg/kg/min) and remifentanil (0.05 mcg/kg/min infusion). Intra-operative checking was done using standard procedures which comprised of using non-invasive blood pressure, ECG, pulse oximeter, end tidal carbon dioxide (ETCO2), and thermal measurement. The anesthetist was at that time concerned that during initial mask aeration the patient’s abdomen had insufflation from previous weight loss surgery (Chaudhuri et al. 2012 pp.646-653). IVI Cefazolin 2 g administered immediately adjacent to the previous incision. The patient was in supine position, and later positioned to reverse Trendelenburg (Hathorn et al 2013 pp.308-313). Laparoscopic port insertion and induction of the pneumo-peritoneum were commenced with CO2 performed after prepping and draping. The circulating nurse directed the new graduate RN to connect the light, video, and gas leads and to verbalize the pressure on the insufflator, which was 10 mmHg.
The surgery took one hour instead of the designated 45 minutes due to following issues of removal of surgical adhesive from the area of the patient from her previous surgery (Rothrock 2014). The scrub nursed warned the circulating nurse that the procedure might have to do open surgery. The surgeon requested for an intra-operative cholangiogram, which consumed another few minutes as the technician was attending another operation theatre. The image intensification procedure also was delayed, as the operation table was not in proper position.
The patient was administered with 4 mg ondansetron and 8 mg dexamethasone IVI to prevent PONV, ten minutes prior to the end of procedure (Alghanem et al. 2010 pp.353-358). The patient experienced, coughing and slight regurgitation, after position reversal and the anesthetic registrar was worried that the patient has undergone aspiration. After the completion of the procedure the circulating nurse questioned the RN why surgical “time-out” was not performed before the procedure but she replied that the new graduate nurse did not mention it in the beginning (Oszvald et al. 2012 p.E6).
The postoperative description is as follows- The patient transfer was done to Post operative Anesthetic Care Unit of PACU, the nursing staff who had received the patient felt that she had not received adequate handover information from the anesthetic RN, who seemed to be in hurry (Riesenberg Leisch and Cunningham 2010 pp.24-34). However, she did not cross-question him at the time, but has spoken about it with the in-charge nurse. The Pain Protocol was followed according to the regulations of the National Inpatient Medication Chart, by preparing a solution of fentanyl 100 mcg/10mls (normal saline). During the patient’s admission in PACU her vital signs were within normal level, however her pain and nausea were not properly treated. She had two episodes of convulsing and gastric aspiration. This left her in tears and distress. She had received 10mls of Pain Protocol. The consultant anesthetist was called for checking the patient. He was surprised by the use of an LMA. He ordered for ondansetron 16 mg, metoclopramide 10 mg, prochlorperazine 10 mg, and hydromorphone 1 mg/10mls, and an overnight transfer to High Dependancy Unit or HDU (Seet et al. 2010 pp.602-607). After a couple of hours, she was deemed eligible for discharge although, the patient was in state of sedation. An afternoon staff member freed the assigned PACU nurse from duty. The patient had to be kept waiting for the HDU admission, due to unavailability of beds at that time. After taking the patient to the HDU, the PACU staff member realized that the sedation score had not been reported in the handover form. The patient was left in temperament, as she wanted to see her family members who were in the waiting room, even before entering the HDU, which left her distressed.

The Critical Analysis of the perioperative care is described as follows; firstly, the problem with the clinical management was that the handover nurse did not make sure whether the patient had signed the consent form, which would have been problematic if it was left unnoticed until after the anesthesia. The patient would have had no motor skills to sign the form and the procedure would have been delayed for hours. It is the duty of assigned nurses to properly check and assess the consent form and duly fill up according to the situation as soon as the procedure was finalized (Vather and Bissett 2013 pp.319-324).
The second problem with the procedure was selection of the crewmembers for the surgical procedure (Oszvald et al. 2012 p.E6). The choice of surgeon had been excellent with lots of experience in the field, but the rest of the crew including the registered nurse, anesthetist nurse the anesthetist itself were not acquainted with the surgeon. Only the circulating nurse had professional acquaintance with the surgeon. It is very difficult for a surgeon to perform a critical surgery if the crew is not efficient. There were two nurses, one was a newly assigned registered nurse in her first few weeks of professional career and another nurse was from a different agency who was accustomed to working the hospital at that time. This is very problematic and lead to the development of post operative as well as intra-operative errors due to communication error (Halverson et al. 2011 pp.305-310). This reflects a bad picture of teamwork in healthcare services. There was also communication gap between the nurses that lead to further assessment problems.

The anesthetist nurse was concerned about the already existing insufflated area on the patient’s body from previous weight loss surgery. She did not speak up and discuss about the problem, which could avoided the issue of the patient having no time-out sessions to finalize the procedure to make sure not stones were left unturned before commencement of the procedure (Oszvald et al. 2012 p.E6). This suggests that the patient’s previous surgery was not properly recovered which could have lead to further complication after the laparoscopy, this problem was left un-discussed by the surgeon as well the nursing crew.
There was delay at the time of the surgery due to the fact that, the operational list as well as the instruments unavailable as they were being used in the operation procedure before this one. The radiography technician uninformed that he would be needed in the procedure, which shows lack of presence of clinical decision-making skills in the surgeon’s part and the procedure had to be halted for ten to fifteen minutes until the technician reached the place (Elwyn et al. 2012pp.1361-1367). Even after that the operation table was not properly adjusted which is the image detector was not working. This suggests lack of preparation on the crew’s part and shows that the procedure was done in a hurry. This could have had severe clinical implications and sepsis could have occurred in the operation theatre (Buck et al. 2013 pp.1045-1049).
The nurse who received the felt like she did not adequate information from the previous handover nurse, as the handover nurse was in a hurry and this suggests lack of communication, or the involvement in the patient care (Halverson et al. 2011 pp.305-310). This is a bad form of clinical practice, which nurses should avoid. Communication is also another important factor that keeps the workforce of the healthcare facility supported (Halverson et al. 2011 pp.305-310). It is important to convey information among the care givers involved in the care plan of a particular patient. Missing information or withholding information can have severe clinical repercussions. Nurses always have to provide complete attention to the need of the patient up until their duty ends. This was not seen in this case. Another point that needed to be mentioned, is that the handover nurse did not mention or question the previous handover nurse but only mentions it to the nurse- in charge when questioned about it. This is also an example of communication gap in the workforce (Halverson et al. 2011 pp.305-310).
The was given LMA, which is sometimes an invasive technique of airway management leading to gastric aspiration, the patient felt nauseous and belching after the procedure and felt distressed (Seet et al. 2010 pp.602-607). This could have been avoided or handled properly since, the patient had a previous trauma regarding postoperative care, but had to go through the anxiety once again (Gustafsson et al. 2012 pp.783-800). This could have stressed her vitals and clinical complications could have been enhanced. The consultant anesthetist was surprised at the use of LMA and gave sedatives to calm her nerves (Seet et al. 2010 pp.602-607). The discharge safety was not proper, as the patient had not recovered from her anesthesia during her discharge (Phillips et al. 2013 pp.275-284). The patient had not been allowed to see her family members who were present in the hospital grounds, which further enhanced her distress.

The discussion above, points out the many mistakes of the perioperative care unit- including pre-procedural planning, safe positioning, intra operative nursing considerations, and pain management as well as importance of communication in a clinical care setting and the affect it has on the patient outcome. The patient outcome is dependent on the efficacy of the workforce in the healthcare institution. The clinical experience of the surgeon is not enough to determine the positive outcome of the patient. The surgical crew had many communication errors and management issues that lead to delay in surgery which could have been easily avoided. The patient’s previous insufflations, was rendered unimportant and the handovers were rushed and lacked attention and responsibility. The lack of time-out before operation could have solved all of these problems with proper communication, but the registered nurse was new to her profession but the supervisor also did not notice the fact. There was no investigative committee to look after this problem. This breaches the standard practice guidelines of the nursing and midwives board in Australia NMBA. The clause that state practice of safety procedures for patient safety was not supported. The communication in the team was not good which also breaches the code of conduct, which uphold communication. The ethical issues can also be analyzed in this situation, as the nursing staff is obligated to share every information and complain if another nurse is not standing true to their duty, but this was not reported at that time and needed mentioning. The clinical practice was very inefficient and patient engagement was very poor as she was not allowed to meet her family and was left distressed. This also breaks the ethical conduct and standard guidelines of NMBA.

References:
Alghanem, S.M., Massad, I.M., Rashed, E.M., Abu-Ali, H.M. and Daradkeh, S.S., 2010. Optimization of anesthesia antiemetic measures versus combination therapy using dexamethasone or ondansetron for the prevention of postoperative nausea and vomiting. Surgical endoscopy, 24(2), pp.353-358.
Apfel, C.C., Heidrich, F.M., Jukar-Rao, S., Jalota, L., Hornuss, C., Whelan, R.P., Zhang, K. and Cakmakkaya, O.S., 2012. Evidence-based analysis of risk factors for postoperative nausea and vomiting. British journal of anaesthesia, 109(5), pp.742-753.
Buck, D.L., Vester?Andersen, M. and Møller, M.H., 2013. Surgical delay is a critical determinant of survival in perforated peptic ulcer. British Journal of Surgery, 100(8), pp.1045-1049.
Chaudhuri, K., Storey, E., Lee, G.A., Bailey, M., Chan, J., Rosenfeldt, F.L., Pick, A., Negri, J., Gooi, J., Zimmet, A. and Esmore, D., 2012. Carbon dioxide insufflation in open-chamber cardiac surgery: a double-blind, randomized clinical trial of neurocognitive effects. The Journal of thoracic and cardiovascular surgery, 144(3), pp.646-653.
Eid, G.M., Brethauer, S., Mattar, S.G., Titchner, R.L., Gourash, W. and Schauer, P.R., 2012. Laparoscopic sleeve gastrectomy for super obese patients: forty-eight percent excess weight loss after 6 to 8 years with 93% follow-up. Annals of surgery, 256(2), pp.262-265.
Elwyn, G., Frosch, D., Thomson, R., Joseph-Williams, N., Lloyd, A., Kinnersley, P., Cording, E., Tomson, D., Dodd, C., Rollnick, S. and Edwards, A., 2012. Shared decision making: a model for clinical practice. Journal of general internal medicine, 27(10), pp.1361-1367.
Gustafsson, U.O., Scott, M.J., Schwenk, W., Demartines, N., Roulin, D., Francis, N., McNaught, C.E., MacFie, J., Liberman, A.S., Soop, M. and Hill, A., 2012. Guidelines for perioperative care in elective colonic surgery: Enhanced Recovery After Surgery (ERAS®) Society recommendations. Clinical nutrition, 31(6), pp.783-800.
Halverson, A.L., Casey, J.T., Andersson, J., Anderson, K., Park, C., Rademaker, A.W. and Moorman, D., 2011. Communication failure in the operating room. Surgery, 149(3), pp.305-310.
Hathorn, I.F., Habib, A.R.R., Manji, J. and Javer, A.R., 2013. Comparing the reverse Trendelenburg and horizontal position for endoscopic sinus surgery: a randomized controlled trial. Otolaryngology–Head and Neck Surgery, 148(2), pp.308-313.
Huffman, J.L. and Schenker, S., 2010. Acute acalculous cholecystitis: a review. Clinical Gastroenterology and Hepatology, 8(1), pp.15-22.
Jeyaseelan, L., Ward, J., Papanna, M. and Sundararajan, S., 2010. Quality of consent form completion in orthopaedics: are we just going through the motions?. Journal of medical ethics, 36(7), pp.407-408.
Jlala, H.A., French, J.L., Foxall, G.L., Hardman, J.G. and Bedforth, N.M., 2010. Effect of preoperative multimedia information on perioperative anxiety in patients undergoing procedures under regional anaesthesia. British journal of anaesthesia, 104(3), pp.369-374.
Krajewski, M.L., Raghunathan, K., Paluszkiewicz, S.M., Schermer, C.R. and Shaw, A.D., 2015. Meta?analysis of high?versus low?chloride content in perioperative and critical care fluid resuscitation. British Journal of Surgery, 102(1), pp.24-36.
Nygren, J., Thacker, J., Carli, F., Fearon, K.C.H., Norderval, S., Lobo, D.N., Ljungqvist, O., Soop, M. and Ramirez, J., 2012. Guidelines for perioperative care in elective rectal/pelvic surgery: Enhanced Recovery After Surgery (ERAS®) Society recommendations. Clinical nutrition, 31(6), pp.801-816.
Oszvald, Á., Vatter, H., Byhahn, C., Seifert, V. and Güresir, E., 2012. “Team time-out” and surgical safety—experiences in 12,390 neurosurgical patients. Neurosurgical focus, 33(5), p.E6.
Phillips, N.M., Street, M., Kent, B., Haesler, E. and Cadeddu, M., 2013. Post?anaesthetic discharge scoring criteria: key findings from a systematic review. International Journal of Evidence?Based Healthcare, 11(4), pp.275-284.
Riesenberg, L.A., Leisch, J. and Cunningham, J.M., 2010. Nursing handoffs: a systematic review of the literature. AJN The American Journal of Nursing, 110(4),. pp.24-34
Rothrock, J.C., 2014. Alexander’s Care of the Patient in Surgery-E-Book. Elsevier Health Sciences.
Seet, E., Rajeev, S., Firoz, T., Yousaf, F., Wong, J., Wong, D.T. and Chung, F., 2010. Safety and efficacy of laryngeal mask airway Supreme versus laryngeal mask airway ProSeal: a randomized controlled trial. European Journal of Anaesthesiology (EJA), 27(7), pp.602-607.
Tsimoyiannis, E.C., Tsimogiannis, K.E., Pappas-Gogos, G., Farantos, C., Benetatos, N., Mavridou, P. and Manataki, A., 2010. Different pain scores in single transumbilical incision laparoscopic cholecystectomy versus classic laparoscopic cholecystectomy: a randomized controlled trial. Surgical endoscopy, 24(8), pp.1842-1848.
Vather, R. and Bissett, I., 2013. Management of prolonged post?operative ileus: evidence?based recommendations. ANZ journal of surgery, 83(5), pp.319-324.

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