North Shore Hospital report - New Zealand Doctor

Opinion 07HDC21742appeared to be in pain. The clinical coach was employed to work after hours coachingthe ward nurses, with a view to improving their practice. The clinical coach wasconcerned about Mrs B‘s increased respiration and heart rate.At 4.30pm, Mrs B‘s NEWS score had increased from 1 to 2. The NEWS protocolstates that when the score is 3 or more, the nurse co-ordinator must be informed, thepatient reviewed by a house surgeon, and a minimum of one-hourly observationstaken. If the score remains at 3 or above over the next hour, it is mandatory for thepatient to be reviewed by a registrar within 30 minutes.The clinical coach discussed with Mrs B‘s son his concern that his mother wasdeveloping heart failure. They talked about using the morphine Mrs B had beenprescribed, to decrease her respiratory rate and effort. He agreed and Mrs B was given1mg of morphine. The clinical coach then paged the house officer again to ask him toreview Mrs B and speak to the family. Mrs B was given a further 1mg of morphine15 minutes later. At 5.30pm, the bureau nurse noted that she was more comfortable.At 6pm, Mrs B‘s NEWS score was 0.At 7pm, Mrs B‘s son went to the nurses‘ station to enquire when the doctor would seehis mother, and was told that the weekend on-call doctor had been paged. He said heleft the hospital at 7.15pm, ―somewhat disgusted, helpless and confused as what todo‖. He asked the nurse to keep him ―posted‖. The bureau nurse agreed to call him ifthere was any change in his mother‘s condition.The house officer, who had started work at 8am 34 and was covering all the medicalwards for the weekend, talked by telephone to the bureau nurse more than once to askabout Mrs B‘s condition. His usual practice is to tell the nursing staff when he thinkshe might be able to see a patient and ask them to let him know immediately if there isany deterioration. He was not aware that Mrs B was deteriorating. If he had been, hewould have seen her earlier, but he had other patients whom he thought it moreimportant to see first.At 8.30pm, Mrs B‘s NEWS score was 2.At 9.15pm the house officer arrived to assess Mrs B. His impression was that she was―definitely‖ in heart failure. The notes showed that her respiration rate had beenbetween 24 and 26 respirations per minute throughout the day, but when he saw hershe was breathing more rapidly at 44 respirations per minute.The bureau nurse recalls that when Mrs B was sat up for the house officer to assessher, the effort increased her respiratory rate to 42 respirations per minute. Prior to thattime, she had been resting and her respiration rate was 24 per minute.The house officer noted that Mrs B had been given a dose of frusemide, but heconsidered that she might have developed aspiration pneumonia. He believed that herheart condition had worsened. He ordered a chest X-ray and planned to re-assess herresponse to the frusemide. As Mrs B‘s oxygen saturation was satisfactory at 95%, the34 The house officer did not finish work until around 10.30pm that night.April 2009 19