09HDC01565 - Health and Disability Commissioner

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Health and Disability Commissioner 184. Ms Pirret, the nursing expert consulted by the legal representative for RN Ms I and RN Ms K, comments on this, noting that it ―risks sending messages to nursing staff that the respiration rate is of less importance when compared to other neurological observations‖. I agree. Ms Pirret further states that while respiration is an important vital sign, it has historically been poorly documented by nurses. My nursing expert, Ms Hewson, similarly notes that it has been found to be ―the most neglected vital sign‖. All the more reason, in my view, for CDHB to ensure its forms are designed to encourage, not discourage, the recording of respirations. 185. I note that the chart has since been redesigned to incorporate the Early Warning Score system, which includes respiratory rate, for the early identification of patients who are at risk or who are deteriorating. “Specialling” 186. CDHB states that it had become established practice for the ―specialling‖, or the close observation of SCU patients, to cease at the end of the first postoperative night (6am) or at the time of the morning nursing handover (6.45am), 36 rather than at the time of the morning medical review, which was usually at about 9am. This practice evolved in relation to patients who had experienced an uneventful first postoperative night. I consider that this practice was not acceptable. I note also that under this arrangement, a patient who had undergone surgery during the night would also have ceased to be ―specialled‖ at 6am, regardless of how long that patient had been in the SCU. 187. CDHB has now changed this practice, and patients continue to be ―specialled‖ until they have been medically reviewed. Postoperative monitoring regime 188. There is also the issue of the adherence by nursing staff to the postoperative monitoring regime documented by Dr F. Dr F‘s instruction was for neurological observations to be checked every 15 minutes for one hour, every 30 minutes for two hours, and then hourly. He did not specify when the hourly monitoring should end, but subsequently told HDC that if there were no concerns warranting an early review, ―in general‖, postoperative instructions are effective until medical review the next morning. However, Dr F also acknowledged that the nursing staff moved to twohourly monitoring overnight in accordance with the SCU protocol. 189. This protocol, contained in the ―SCU Clinical Information & Nursing Management Guidelines‖, sets out the regime for postoperative neurological observations following posterior fossa surgery: half-hourly observations for four hours, hourly observations for four hours, and then two-hourly observations for four hours or overnight until changed by medical staff. I have some concern that the wording of the instruction in this policy is potentially ambiguous in relation to the need for medical review. CDHB states that it was ―usual practice‖ in the unit to change to two-hourly monitoring overnight if there were no concerns. 36 The RCA report refers to 6am, while other correspondence to HDC refers to the time of nursing handover, ie, 6.45am. 5 September 2012 32 Names have been removed (except Canterbury DHB and the experts who advised on this case) to protect privacy. Identifying letters are assigned in alphabetical order and bear no relationship to the person’s actual name.
Opinion 09HDC01565 190. The decision to move to two-hourly observations overnight was therefore consistent with the SCU guideline and usual practice, but not with Dr F‘s documented regime for Mr A. Dr F‘s instructions should have taken priority. I would be more critical of the nursing staff in relation to this if it was clearer from Dr F‘s written instructions that hourly monitoring should continue until the next medical review, and if he had given some explanation as to why his proposed regime differed from the general guideline and usual SCU practice. 191. Given that there was no such explanation, the best course of action would have been for the nurse to seek clarification from Dr F or, if he was not available, from the oncall doctor. There is clearly potential for problems to arise if there is not a clear and shared understanding, documented in the relevant guidelines, in relation to what should occur when the postoperative monitoring regime prescribed for a particular patient differs from the generic instructions and usual ward practice. 192. The responses to my provisional opinion from Dr F, Dr E and CDHB have reinforced my view regarding the potential for confusion. Dr F states that in his experience it is usual for the documented orders (specific to the patient) to take priority where there is ―a (perceived) conflict‖, while Dr E refers to the ―overriding neurosurgical postoperative care protocol‖. CDHB states that Dr F‘s instructions were explicit and correct, and suggests there was no need for him to specify the end point for observations. However, CDHB has previously stated that Mr A was moved to twohourly monitoring in accordance with the SCU guideline and usual practice, while Dr F previously stated that postoperative instructions are generally effective until medical review the next morning. The differences between these understandings underline the need for clarity. 193. My neurosurgical expert, Dr Darrell Nye, states that his personal view is that hourly monitoring should have continued for a period of 24 hours postoperatively. Accordingly, he considers the decision to move to two-hourly observations overnight was inappropriate. However, he states further that this is his personal view, that the change to two-hourly observations was consistent with CDHB‘s neurosurgical guidelines, and that these guidelines are consistent with policies in the neurosurgical units in private and teaching hospitals in Melbourne. My primary concern about the decision to move to two-hourly observations overnight is that it was not consistent with Dr F‘s apparent intentions. 194. It appears to me that the communication between Dr F and nursing staff in relation to Mr A‘s postoperative monitoring regime was deficient. Handover practice 195. CDHB explains that where there were no concerns about a patient‘s status, it had become usual practice for the nurses responsible for the SCU to attend the ward‘s morning handover in the seminar room. It does not know why this practice started. RN Ms J states that it had already become usual ward practice by the time of her orientation to the SCU two years earlier. Afternoon and evening handovers for patients in SCU took place in SCU. 33 5 September 2012 Names have been removed (except Canterbury DHB and the experts who advised on this case) to protect privacy. Identifying letters are assigned in alphabetical order and bear no relationship to the person’s actual name.
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09HDC01565 - Health and Disability Commissioner

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