` NHS HIGHLAND Significant Event Report Report to - Quality & Patient Safety Raigmore Management Team of Findings from Significant Event Review Meeting QPS040 26/10/2011 1.0 Outline of Significant Event 53 Year old lady, elective admission to surgical unit for revision of A-V Fistula and vein harvesting developed sacral pressure sore. Sore became infected. Necrotising fasciitis developed, patient died. 2.0 Background 53 year old lady Type 1 Diabetic since age 3 End stage renal failure on renal replacement therapy since 2006 Known ischemic heart disease and peripheral vascular disease, continued to smoke A number of recent admissions with vascular access problems including blown A-V Fistula, infected A-V fistula Nutritional issues as well as poor diabetic control Elective admission on 11/07/2011 for revision of A-V fistula R Arm. Admitted to ward 5C. Admission documentation not fully completed No evidence of skin care assessment or Waterlow scoring being performed. 12/07/2011 Patient at theatre for planned A-V fistula revision and vein harvesting. Technically challenging operation but no adverse events or difficulties 14/07/2011 Complaining of being unable to move lower legs. No sensation no reflexes 15/07/2011 06:45 hrs Patient noted to have bruising and marking to back and sacral area Patient down at renal unit when sacral area found to have open break. Noted to not be on air wave mattress at this time.
On return to ward area further entry re broken areas on sacrum and plan to transfer to pressure / air mattress when able 16/07/2011 limited description of pressure area in notes with further note re discoloration to heal of left foot 25/07/2011 transferred to ward 7C - Sacral wound being redressed daily or more often due to faecal soiling Daily Haemodialysis since 25/07/2011 27/07/2011 LP performed CSF non diagnostic MRSA screen from pressure sore Negative 9/07/2011 Further Neurology review 31/07/2011 Case note record by consultant surgeon sacral pressure sore has progressed to full thickness skin over a wide area, the surrounding skin looks a bit better. I would continue with current dressing regime and nurse her on either side as much as possible 01/08/2011 Moved from renal to GI side ward 7C 02/08/2011 08:30 cardiac arrest no DNACPR status recorded - resuscitated - No nursing note or observations documented for previous 12 hours. Found to be hyperkalaemic 8 mmol/l 02/08/2011 Transferred to MSCU HD performed 03/08/2011 Sacrel area noted to be necrotic over large area (Reviewed by 7C nurse and noted to be much worse from 3 days previously) Input from tissue viability nurse but unable to view for approx 10 days Surgical review and CT scan obtained demonstrates gas in soft tissue of back and buttock. D/W Surgical and Renal teams thought unlikely to recover. Following discussion with next of kin, commenced on Liverpool Care Pathway 3.0 Findings of the review group The group agreed the time line of events as summarised above. It was agreed that this patient was a particularly complex case, having undergone repeated complex procedures and surgical interventions in order to prolong and improve her quality of life. It was felt the patient had previously benefited from advanced medical and surgical intervention of the type undertaken on this admission. Further evidence of good practice was commencement of the Liverpool Care Pathway as soon as it was clear this was a likely terminal event for the patient.
It should also be noted that there is well documented evidence to demonstrate that the patient s family were kept informed of events and their wishes and opinions were taken into consideration. The review group discussed the issue of the patient developing a pressure ulcer which undoubtedly led to her death. It was felt that there were a number of contributory factors 1. Lack of skin care assessment, 2. Delay in using a pressure relieving dynamic mattress 3. The patients impaired sensation and lower limb mobility following surgery The group recognised that documentation of any assessment of the patient s skin & pressure areas on admission was lacking. Therefore we are unable to say with any degree of accuracy what condition the patients pressure areas were prior to theatre. It was agreed that this falls well below the standard of care expected for any patient being admitted to hospital. The tissue viability nurse specialist explained that the patient should have been assessed on admission and a skin care plan put in situ that would have included close monitoring of a very high risk individual and therefore frequent (up to 2hrly) monitoring and adaption of the skin care plan to respond to the evolving circumstances. It was acknowledged that there was insufficient documentation to confirm at what point in time the patient s skin became compromised. There was daily documentation of the pressure sore once it had been identified and a wound care plan had been completed. The Tissue viability nurse however felt that the wound charts were sketchy and lacked detail. She believed this to be due to a lack of training regarding tissue viability and wound care in general throughout NHS Highland. It was felt by the tissue viability nurse that the dressings used on the wound were inappropriate and conflicting in nature. She was asked what would have been the treatment of choice but could not be specific without more detailed information on the wound. In principle however she indicated that the following process should have been followed. A robust skin assessment should have been completed and documented on admission (Within 6 Hours) Waterlow score completed and documented MUST score completed and documented Provision of all pressure care equipment identified as being required Skin care bundle completed every 2/4/6 hours as appropriate depending on the risk rating of the patient Fluid and nutritional risk assessment completed and documented Reference was made to the new NHS Highland wound management guidelines and formulary as being the document to use when assessing wounds and for the selection of dressings etc. The vascular surgeon present was concerned that advice given by local nurse specialists was being identified as being wrong and that If this is the case it requires rectification with some urgency It was noted by the group and confirmed by the tissue viability nurse that Raigmore
hospital produces the largest number of these issue by dint of having by far the largest number of annual patient stays yet we have the services of the tissue viability nurse for 1 day a fortnight shared with the rest of northern NHS Highland The group believe strongly that there is a lack of tissue viability specialist service for Raigmore hospital and would urge NHS Highland to address this situation urgently It was agreed that pressure ulcers could be prevented by early assessment and interventions, but that education and resource are required to facilitate this. The group were informed that a 90 day rapid improvement plan is to be actioned shortly within Raigmore Hospital in relation to tissue viability and pressure ulcer prevention. There was further discussion around the choice of dressing used. In particular there was concern that the dressing used may have aided the spread and development of the wound. The tissue viability nurse felt that she was unable to give a conclusive answer to this, but felt that there was the possibility that bacteria may have penetrated and that this may have contributed to the deterioration of the wound. The group agreed that the use of digital photography to record pressure sores would clearly aid recording and documentation of wounds. Greater access on wards/departments to digital cameras and printers would aid this process. The tissue viability nurse agreed and added that it was important that photographs were taken correctly with arrows to show orientation and a measuring grid utilised to accurately demonstrate size of the wound. A date and time stamp was also important.. It was recognised that consent for photography and appropriate governance of the images was important. At this stage discussion turned to the possibility that the patients sudden restriction in movement and mobility caused by the loss of sensation and power to her lower limbs played a significant role in her deterioration and in particular the ongoing development of the pressure sore on her buttocks. It was felt that the loss of bowel control in all probability played a significant role in the wound becoming infected and that this was probably a result of the presumed spinal cord injury. The consultant pathologist confirmed that the bacteria present at post mortem (ecoli) were consistent with faecal contamination. The patient s medical notes confirmed that the dressing required changing several times on some days due to faecal soiling. The review group were keen to know if pathology had been able to diagnose a cause for the patient s sudden loss of power and sensation to her lower limbs. The consultant pathologist stated that she was still awaiting the neuro-pathology results in relation to this. The chair asked that when the relevant results were available could they be passed to the review group. It was agreed that this would be done. The supply of dynamic mattresses was of concern to some present at the meeting with a feeling that the current supply was not enough for the current demand. It was pointed out that there are ongoing issues with some wards/areas not following the current guidance for use of dynamic air mattresses and are requesting them unnecessarily. This leads to patients who require this level of pressure relieving equipment being left on inappropriate mattresses for longer than they should be. This was felt to be due to a lack of understanding and education in relation to the use of pressure relieving equipment
It was agreed that if any one area was utilising the majority of the current supply of dynamic pressure relieving mattresses consideration should be given to that area purchasing a separate supply. Discussion at this time turned to the cardiac arrest suffered by the patient three days prior to her dying. It was thought this was due to hyperkaleamia as the post cardiac arrest potassium was 8 mmol/l. The patient at this time had been receiving daily dialysis and as such was receiving gold standard renal replacement therapy. It was noted that biochemistry measurement was not being routinely performed post haemodialysis. It was explained that not all patients require frequent monitoring of biochemistry while undergoing renal replacement therapy. The patient s biochemistry had remained stable and was giving no cause for concern. It was pointed out that there was variation between renal physicians as to the criteria used to decide when bloods were taken for biochemistry. The group agreed that the renal team should review and standardise their practice. It was felt by the consultant nephrologists present that the high potassium level measured post cardiac arrest was likely the result of tissue breakdown caused by the narcotising fasciitis releasing a large amount of intracellular potassium in the context of renal failure. At this stage it was thought unlikely that this adverse event could have been anticipated or prevented. The issue of DNACPR not being in place at the time of the cardiac arrest was briefly discussed. It was agreed that consideration to this should have been given and documented at an earlier stage of this admission. However it was acknowledged that this had previously been discussed with this lady on a number of occasions and she had always made it known that she would wish resuscitation to be attempted. The group did not have time to discuss the issue of no nursing note or observations being documented in the 13 hour period prior to the patient suffering a cardiac arrest. It was agreed that this should be followed up by the nursing management team in the division concerned In conclusion the decision to undertake further invasive and difficult vascular surgery on this patient was multi disciplinary, well reasoned and with the informed consent of the patient. The review group agreed that the level of care following admission in relation to pressure area assessment as documented was below the standard required and contributed to the overall adverse outcome; it was acknowledged that there is evidence to demonstrate that the pressure ulcer was observed at an early stage of development and a plan of care put in place. The plan was not as robust as required and there was a delay in placing the patient on a dynamic air mattress. It has been agreed that significantly improved education around tissue viability and wound dressings are urgently required. The patient s wound became infected due to faecal soiling as a result of loss of sensation and bowel control. The cause of the neurological deficit is currently unknown, pending neuro-pathology results. Once NF had started to develop the situation had become unrecoverable and the decision to withdraw treatment and keep the patient comfortable was appropriate and well reasoned. The involvement of the next of kin at this stage demonstrated good end of life planning and care.
Following completion of the draft the neuro-pathology is now available. It has demonstrated that the patient had infarcted her lumbar spinal cord in the territory of the anterior spinal artery. This would have resulted in permanent loss of bowel control and sensation, movement of the patients lower limbs. 4.0 Recommendations Ratified 1. An appropriate Tissue Viability Service be developed for Raigmore Hospital, to include identification and education of link nurses in wards and departments 2. An education plan for Raigmore hospital in relation to wound care and tissue viability to be developed 3. Ward based digital photography to be developed for use in relation to tissue viability 4. A robust system and process for patient assessment in relation to skin care and tissue viability to be utilised throughout Raigmore Hospital 5. Raigmore Hospital to perform an assessment of need in relation to pressure area equipment/dynamic air mattresses and their availability and use, ensuring supply can match demand 6. The recently issued NHS Highland Wound Management Guidelines and Formulary requires widespread publicity to ensure all appropriate staff have ease of access 7. The present Highland Tissue Viability Service to widely publicise contact details and service availability 8. The circumstances of the operation to be critically reviewed by the surgical & anaesthesia team involved Compiled by - S Struthers/ Dr R Harvey Date 01/11/2011 5.0 Recommendations Ratified 1 An appropriate Tissue Viability Service be developed for Raigmore Hospital. 2. An education plan for Raigmore hospital in relation to wound care and tissue viability to be developed. 3. Ward based digital photography to be developed for use in relation to tissue viability. 4 A robust system and process for patient assessment in relation to skin care and tissue viability to be utilised throughout Raigmore Hospital. with modification
5 Raigmore Hospital to perform an assessment of need in relation to pressure area equipment/dynamic air mattresses and their availability and use, ensuring supply can match demand. 6 The recently issued NHS Highland Wound Management Guidelines and Formulary requires widespread publicity to ensure all appropriate staff has ease of access. 7 The present Highland Tissue Viability Service to widely publicise contact details and service availability. 8 The circumstances of the operation to be critically reviewed by the Surgical & Anaesthesia team involved. 9 The Highland Wound Formulary to be revised and re-issued in a form suitable for secondary care settings. 10 The Nursing Management Team for Medical Division to investigate reasons for lack of observation in the period prior to the cardiac arrest. 11 Identify if there is variation in the criteria for pre and post dialysis bloods between Renal Consultants and aim to reduce it where it occurs. Rejected as new evidence suggests current formulary not whole appropriate for Raigmore. Additional recommendation Additional recommendation Additional recommendation Compiled by - S Struthers Date 12/12/2011